Every finding on record at Focused Care at Allenbrook

Based on observations, interviews, and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food safety in that -The facility failed to ensure that dented cans were not stored with undented cans.The facility failed to ensure that one of 2 refrigerators in the dining room was free from expired food products. These failures placed residents at risk of foodborne illness.Findings included:Kitchen observation with Dietary Manager on 03/10/26 at 8:30AM revealed there was one 28 oz can, of tomato soup that was dented stored together with un-dented can goods. The Dietary Manager removed the dented can from the shelf and said it was supposed to be in the office for return.Observation of Refrigerator #1 in the dining room revealed-2-5 lbs. of containers of cottage cheese -expired 02/16/266-one-quart half and half milk with expired date of 03/04/262-Gallons of milk with expired date of 03/01/262-Gallons of milk with expired date of 03/08/26 andone gallon of milk with expired date of 03/09/26.The dietary Manager took all expired products out of the freezer.During an interview with Dietary Manager on 03/10/26 at 11:00AM, she said she usually checks all refrigerators and freezers for expired food products every Monday, but she was off Monday 03/09/26. She said all kitchen staff are supposed to check for expired food items in the freezer and refrigerators. She said expired food items and food products should not be served to anyone because serving expired food products may cause food born illness and sickness.During an interview with facility registered dietitian on 03/11/26 at 11:30AM, she said she worked 8 hours weekly at the facility and as needed. She said her focus was on the residents. She said from time to time, she would walk round the kitchen for general sanitation, provide education to staff and in-serviced staff in the areas that need improvement pending on her findings. She said no person should be served expired food products because expired food products can result in food born illness. She said she had done in-services on food rotation first in and first out and would do another in-service on food rotation.During an interview with facility Administrator on 03/11/26 at 4:00PM, she said expired food items and products should not be stored in the refrigerator or freezer for consumption. She said the Registered Dietitian would in-service all dietary staff on food rotation and ensure that all expired food items and products are removed from the refrigerators.Record review of facility's policy dated 04/2022 revised 02/2026 titled Food production.Policy: Left-over foods should be handled in a manner to prevent the spread of food borne illness. 6. Any foods that have a manufacturer's expiration or use-by date should be left in the original container and should be discarded according to this date.Definitions:Expiration date: when food is considered no longer safe to consume to avoid illnessUse by/Best by/Sell by date: guidelines provided by manufacturers indicating when a product will be at its best flavor and quality. It does not mean the product is unsafe to consume after this date. After the best by date, food is still safe to eat but its taste, texture and overall quality may decline. (Example: bread might be stale)Freeze by: dates refer to the recommended date to freeze a product to maintain quality. It does not indicate food safety.

Based on observation, interview, and record review, the facility failed to ensure that the medication error rates were not 5 percent or greater. During medication administration, a medication error rate of 7 percent was identified (2 errors out of 28 opportunities). These errors involved 2 of 9 residents (resident #20 and resident #52) and 1 of 2 MA (MA J) administering medications. 1. The facility failed to ensure that MA J did not attempt to administer divalproex sodium 500mg oral tablet to Resident #20 during the morning medication pass, when the physician's order indicated the medication was to be administered at bedtime. 2. The facility failed to ensure that MA J did not administer zinc sulfate oral tablet to Resident #52 when the physician's order specified zinc sulfate oral capsule resulting in administration of medication in a form inconsistent with the prescribed order. These failures placed residents at risk for medication errors and potential adverse outcomes.Findings include: Resident #20: Record review of Resident #20's face sheet, dated 3/12/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE], and readmitted on [DATE]. Her diagnoses included seizures (shaking), diabetes (high blood sugar level), hypertension (high blood pressure), hyperlipidemia (high lipid in the blood), mood disorder, and muscle weakness. Record review of Resident #20's quarterly MDS assessment, dated 12/17/2025, revealed a BIMS score of 6 out of 15, which indicated severe cognitive impairment. She required assistance from staff with activities of daily living care. Record review of Resident #20's care plan initiated on 4/11/25 revealed she was at risk of adverse consequences related to receiving anticonvulsants for treatment of mood disorder. Interventions were to give medications per order. Record review of Resident #20's Physician's orders dated 11/18/25 revealed an order for: Divalproex sodium oral tablet delayed release 500mg. Give 1 tablet by mouth at bedtime. During medication administration pass observation on 3/11/26 at 9:05 a.m., the surveyor observed MA J preparing medications for Resident #20. The MA J removed divalproex sodium (medication used to control seizure and helps to stabilize mood) 500mg from the blister pack and placed it into a medication cup with other medications intended for administration to Resident #20. Prior to administering the medication, the surveyor intervened and reviewed the medication blister pack. Upon review, it was determined that the medication removed from the blister pack was the medication ordered to be given at bedtime for Resident #20, indicating a medication administration error. Resident #52: Record review of Resident #52's face sheet, dated 3/12/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Malignant neoplasm (a harmful growth of abnormal cells in the body that can grow quickly and spread to other parts of the body), mood disturbance, anxiety (feeling very worried, uneasy, or afraid), hypertension (high blood pressure), muscle weakness, and lack of coordination. Record review of Resident #52's quarterly MDS assessment, dated 2/19/2026, revealed a BIMS score of 4 out of 15, which indicated severe cognitive impairment. She required assistance from staff with activities of daily living care. Record review of Resident #52's care plan initiated on 8/27/24 revealed she has potential for pressure injury. Interventions were to give medications per order. Record review of Resident #52's Physician's orders dated 2/19/26 revealed an order for: Zinc oral capsule 220 (50mg) zinc sulfate. Give 1 capsule by mouth every day. During medication administration observation on 3/11/26 at 9:30 a.m., the surveyor observed MA J preparing medications for Resident #52. The MA J administered Zinc sulfate (supplement that helps the body heal wounds, fight infections, and keep the immune system strong) 50mg tablets by mouth to Resident #52. During an interview with MA J on 3/11/2026 at 9:50 a.m., she stated that she verified the medication orders prior; however, she acknowledged that she assumed the medication was correct because multiple residents were receiving zinc sulfate. She confirmed that medication orders must be verified against the physician's order before administration. MA J further acknowledged that medication should not be administered if they are not consistent with the physician's order. She identified the potential risk to the resident as the possibility of adverse outcomes if medications are administered without a valid physician's order. Specifically, she stated that administering medications without proper authorization could result in the resident becoming ill or not receiving the prescribed medication as ordered for that day, which could negatively impact the resident's health and well-being. MA J also acknowledged that she popped the divalproex sodium medication from the package by accident. She acknowledged that if the medication had been administered, the resident could have received a higher dose than prescribed, which could potentially affect the resident's health. She stated that she was nervous at the time, which contributed to the mistake. During an interview with DON on 3/11/2026 at 10:04 a.m., DON stated that medication administration must follow established protocols, including verification of physician orders prior to administration. She indicated that both MA and nursing staff are expected to adhere to the Five Rights of medication administration (right resident, right medication, right dose, right route, and the right time). The DON reported that she was unable to determine why the MA did not verify the physician's order prior to removing the medication from the medication blister pack. She further stated that she was unable to explain why a zinc sulfate tablet was administered instead of zinc sulfate capsule as prescribed by the physician. She indicated that corrective action would include providing in- service education to MA and nursing staff to reinforce proper medication administration procedures and adherence to physician orders, with the goal of preventing future medication errors. She also confirmed that failure to verify medication orders prior to administration may place residents at risk for adverse effects. She stated that such errors could negatively impact the resident's condition, potentially resulting in a decline in health status and/or a delay in the resident's healing process. During an interview with LVN C on 3/12/2026 at 12:11 p.m., she stated that medication administration process includes verifying the physician's order, confirming the medication belongs to the correct resident, and ensuring the correct medication is administered according to the order. She confirmed that she would not administer a medication that differs from the physician's order. As an example, she stated that if the physician ordered a zinc capsule but only a tablet was available, she would not administer the tablet and would seek clarification first.She stated that different medication forms, such as capsules and tablets, may have different release mechanisms or effects, and administering the incorrect form could result in an adverse reaction or unintended effect for the resident. She reiterated that she verifies orders and seeks clarification before administering medications to ensure resident safety. During an interview with MA K on 3/12/2026 at 12:18 p.m., he stated that he follows the five rights of medication administration, including verifying the right resident, right medication, right dose, right route, and right time. He stated that he also verifies the physician's order before administering medications and ensures that the medication form (capsule, tablet, liquid, or powder) matches the order. He confirmed that he would not administer a medication that does not match the physician's order. When asked about potential risks to the resident if a tablet was administered when a capsule had been ordered, he stated that the medication could interact incorrectly with other medications or cause an adverse or allergic reaction, and therefore it is important to follow the physician's order exactly to ensure resident's safety. During an interview with MA L on 3/12/2026 at 1:03 p.m., she stated that prior to administering medications, she ensures adherence to the Five Rights of medication administration and verifies the medication against the physician's order. She reported that if a physician orders a zinc sulfate capsule and only zinc sulfate tablets are available in the facility, she would withhold the medication and immediately notify the nurse, rather than administer a medication that does not match the prescribed form. She confirmed that she would not administer medications in an incorrect formulation or dosage form that is inconsistent with the physician's order. She acknowledged that administering medications not in accordance with the physician's order may result in adverse reactions, potential drug interactions, and could negatively impact or deteriorate the resident's health status. Record review of facility's policy dated 09/2018 revised 08/2020 titled General Guidelines for Medication Administration. Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. At a minimum, the 5 rights- right resident, right drug, right dose, right route, and the right time- should be applied to all medication administration. Always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident MAR are compared with the medication label. Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review the facility failed to ensure the assessment accurately reflected the status for one (Resident #10) of 18 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #10's annual MDS assessment accurately reflected her lack of natural teeth in her oral cavity.This failure could place residents at risk for receiving inadequate care and services due to inaccurate assessments.The findings included: Record review of Resident #10's face sheet dated 03/11/26 indicated she was admitted to the facility on [DATE] and was re-admitted on [DATE]. Her diagnoses included Chronic obstructive pulmonary disease (lung disease), dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, essential hypertension ( high blood pressure), generalized anxiety disorder, chronic pain syndrome, major depressive disorder, lack of coordination, schizoaffective disorder and bipolar .Record review of Resident #10's annual MDS assessment dated [DATE] revealed her BIMS score was 4 out of 15 indicating severe cognitive impairment. Record review of the MDS section on oral dental, she was assessed as having obvious or likely cavity or broken natural teeth.Record review of Resident #10's care plan initiated 01/17/22 with a revision date of 01/17/26 indicated Resident #10 had oral/dental health problems, decayed missing teeth r/t Poor oral hygiene.Intervention: Resident #10 will be encouraged to comply with mouth care at least daily through review date. Date Initiated: 01/17/2022 Revision on: 01/08/2026.Observation on 03/11/26 at 12:20pm, revealed Resident #10 had mechanical-altered diet. She feeds herself and ate 100% of the meal served. Observation indicated she had no teeth in her oral cavity.In an interview on 03/11/26 at 2:00pm Resident #10 said she was tired and just wanted to rest. During an interview, she said she does not have any teeth in her oral cavity. She said she used to have dentures but lost them. She said she does not know where they were.Interview with MDS coordinator on 03/12/26 at 3:30PM, she said Resident #10 does not have any teeth in her oral cavity. She looked at the MDS and said the MDS assessment was an oversight. She said an inaccurate assessment may prevent residents from getting needed services. She said she would modify Resident #10's MDS assessment and update the care plan to reflect Resident #10's lack of natural teeth.During an interview with Facility DON on 03/12/26 at 3:10PM, she said all assessments should reflect Resident's condition. She said inaccurate assessment would delay residents from getting needed care and services.Facility's policy on accuracy of resident's assessment was requested on 03/13/26 at 10:20AM. MDS coordinator and Facility DON said the facility followed the RAI manual

Based on observation, interview and record review, the facility failed to ensure the environment remained as free from accidents as possible and that each resident received adequate supervision and assistance to prevent accidents for 1 of 30 residents (Resident #2) reviewed for adequate supervision.The facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering from his previous facility and eloped from this facility in 1/7/25. He was found by a good Samaritan in his wheelchair across the street from the facility.This noncompliance was identified as Past Non-Compliance. The IJ began on 1/7/2025 and ended on 1/8/2025. The facility corrected the noncompliance by conducting elopement assessments, updating care plans, providing in-services to staff on elopement, conducting elopement drills, and changing the door code for the secure unit. ---the facility failed to provide adequate supervision and put measures in place to prevent residents from eloping. Resident #2 had a history of exit seeking behaviors and wandering from his previous facility and eloped from this facility in 1/7/25. He was found by a good Samaritan in his wheelchair across the street from the facility. This noncompliance was identified as Past Non-Compliance. The IJ began on 1/7/2025 and ended on 1/8/2025. The facility corrected the noncompliance by conducting elopement assessments, updating care plans, providing in-services to staff on elopement, conducting elopement drills, and changing the door code for the secure unit. Findings include: Record review of Resident #2's face sheet revealed admission date 12/19/24 with diagnoses including encephalopathy (dysfunction of the brain), intracranial injury with loss of consciousness (temporary or permanent loss of awareness or response from a traumatic brain injury), muscle weakness (decreased muscle strength), paranoid schizophrenia (by persistent delusions and hallucinations), recurrent depressive disorders (persistent loss of interest in activities of daily life), cerebral infarction (interruption of blood flow to the brain), anxiety disorder (excessive worry and fear). Record review of Resident #2's admission MDS dated [DATE] revealed adequate hearing, speech, and vision; BIMS score of 10, indicating moderately impaired cognitive skills; limitation in range of motion in upper and lower extremities; moderate assistance required for personal hygiene; maximal assistance required for toileting, showering, and dressing; and occasionally incontinent of bladder and bowel. Record review of Resident #2's baseline care plan dated 12/19/24 revealed resident was an elopement risk, with special concerns to be in secure unit. Record review of Resident#2's admission elopement assessment dated [DATE] with a score of 9 indicated cognitive impairment, history of elopement, history of leaving without informing staff at sister facility. Interventions included secure unit, frequent monitoring, staff aware of wandering behavior. Recommendations included: if resident has exit seeking behaviors, increase supervision and consider electronic device. Record review of Resident #2's elopement assessment dated [DATE] with a score of 15 indicated cognitive impairment, expressions of a desire to go home to his mother's house, history of elopement, wandering aimlessly, with interventions including secured unit, frequent monitoring, use of a check in/out log, recreational activities, music, staff aware of wander risk. Recommendations included if resident has exit seeking behaviors, increase supervision and consider electronic device. Record review of Resident #2's most recent physician orders dated 6/2/25 revealed: may admit to Secured Unit for safety/security due to elopement risk . Record review of Resident #2's care plan dated 1/8/25 revealed: resident eloped from the unit and facility and was down the street at a Dr. office-was brought back to facility/unit without incident. (Resident got the code to the unit and let himself out). Intervention included wander guard bracelet to alert staff, monitor daily, 1/7/25- code to unit door changed, staff in-service to be more observant when residents by the door of the unit; structured activities- toileting, walking inside and outside, reorientation, signs, pictures, memory boxes. Record review of the incident report for Elopement, dated 1/7/25 at 4:44pm, revealed predisposing factors of the event were resident confused, impaired memory, active exit seeker and wanderer. Incident note: 3:00pm: “Good Samaritan called this facility to inform us that there is a resident that was coming from out direction, and he is sitting on his wheelchair with a cap on and is asking to be taken to his mother house. Good Samaritan wheeled patient to safety at the doctor's office across the street from this facility until staff can go verify if the patient is ours. Resident is confused and unable to give statement, staff [NAME] resident back into this facility, skin assessment done, no changes, vitals stable, RP made aware and MD, no new orders, no signs of distress noted. Staff in-service to be more observant when entering lock down unit when residents are sitting near the exit door, secure unit pass code changed, will continue to closely monitor.” Record review of the 24-hour report dated 1/7/25 to 1/8/25 revealed Resident Summary for Resident #2 including the above Incident Note at 4:44pm, a Social Service Note at 3:30pm, weekly skin assessment at 3:40pm and elopement assessment at 3:44pm, with a score of 15. Record review of the Provider Investigation Report dated 1/8/25 revealed the facility immediate action was staff brought the resident back to the facility, skin assessment was done with no changes, vital signs were stable, RP, MD, Ombudsman, Admin , DON, HHSC notified, in-services with staff on elopement and vigilance when entering the secure unit, pass code to secure unit changed, closely monitoring Resident #2 and all residents, in-services on elopement, elopement drills, rounding every 2 hours. Record review of the Incident/Accident report for 12/24 to 9/25 revealed no other elopements since the time of this incident on 1/7/25. Record review of in-services with all staff were as follows: 1/7/25: Resident Elopement, Elopement Policy; 1/8/25: Resident Rounding- Nurses and CNA's to make alternating resident rounds every 2 hours during shift. Observation of resident #2 on 9/3/25 and 9/4/25 revealed he was in the secure unit, with wander guard in place. Interview with ADON on 9/4/25 at 10am revealed the nurses check the wander guards to make sure they are working. She said there are 7 residents who have wander guards, and nurse check them daily to make sure they are working correctly. In a telephone interview with CNA A on 9/4/25 at 11:40am revealed she was working on the secure unit when Resident #2 eloped. She said she was watching residents in the back of the hall in the lounge area, and another aide was showering a resident at that time. She said they do watch out for residents who are close to the door, and do not enter the code if a resident is near the door. She said they do have elopement in-services, and the last one was after this incident with Resident #2. In a telephone interview with CNA B on 9/4/25 at 11:50am revealed she was at work on the secure unit when Resident 32 eloped, she was giving a shower to another resident. She said they have elopement in-services and the most recent was after Resident #2 left the facility. She said the staff on the secure unit always watch that no resident is si near the door when they put the code in to open the door. In a telephone interview with CNA E on 9/4/25 at 12:15pm revealed she works the 6 – 2 shift in the secure unit, so was not working when Resident #2 eloped. She said she used to work on the B Hall, and just started working in the secure unit recently. She said they do have in-services on abuse/neglect and elopement. In an interview with CNA C, in the secure unit, on 9/4/25 at 10am, she said she works the morning shift, so she was not here when Resident #2 eloped. She said they have in-services on elopement, just recently, and also on abuse/neglect. She said they watch to make sure there are no residents by the door when they enter the code to open the door. In an interview with CNA D, in the secure unit, on 9/4/25 at 10:15am, she said she was not working when Resident #2 eloped, and they do have elopement in-services. She said she will re-direct anybody near the door, and make sure the door is completely closed when she leaves the secure unit. In an interview with the Assistant Director of Clinical Operations on 9/4/25 at 11:05 am, she said Resident #2 was new in the facility, and came here from a sister facility, where he had a history of elopement and wandering. In this incident, he was taken to a dentist office across the street and brought back here by staff. He was assessed and had no injuries and was monitored. She said they have elopement drills, and take someone out of the facility, and go through the whole process of elopement investigation and follow-up. She said they have elopement and abuse/neglect in-services. In an interview with LVN A on 9/4/25 at 10:35am, she said they do have elopement drills, where they practice the entire elopement process. She said the staff will watch for anyone leaving the facility to ensure they are allowed. There is a sign-out book on the table by the door, for anyone to sign if they are leaving the facility In an interview with Director of Environmental Services on 9/4/25 at 4:00pm, she said they do have elopement in-services and elopement drills regularly. In an interview with LVN B on 9/4/25 at 4:05 pm, she said they do have in-services on elopement, including elopement drills every 3 months. The DON was provided the PNC IJ template on 9/3/25 at 5:31 pm. A Plan of Removal was not requested. The non-compliance began on 1/7/25 and ended on 1/8/25. The facility had corrected the non-compliance before the investigation began. The following interventions were implemented prior to surveyor entrance and surveyor confirmed the Past Noncompliance. 1. Resident # 2 was immediately assessed 2. Resident # 2 was placed on 1:1 supervision 3. Resident #2's care plan was updated for elopement risk 4. Facility notified RP, MD, Administrator, DON, Ombudsman, HHSC 5. In-services on elopement, abuse/neglect, including staff and management recognizing and reporting abuse/neglect and elopement. 6. In-services with staff (nurses & CNAs on alternate resident rounding every 2 hours). An ad-Hoc QAPI meeting was held on 1/7/25 with the following addressed: 1. Incident/accidents-elopement reviewed 2. Secure unit code changed 3. Alternating rounds every 2 hours 4. Elopement drill 5. In-services on alternating rounding during shift for CNAs 6. In-services on alternating rounding during shift for nurses. There have been no elopement since this incident. Record review of the facility Elopement, effective 11/1/2019, revealed, in part: “a prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly…” Findings include: Record review of Resident #2's face sheet revealed admission date 12/19/24 with diagnoses including encephalopathy (dysfunction of the brain), intracranial injury with loss of consciousness (temporary or permanent loss of awareness or response from a traumatic brain injury), muscle weakness (decreased muscle strength), paranoid schizophrenia (by persistent delusions and hallucinations), recurrent depressive disorders (persistent loss of interest in activities of daily life), cerebral infarction (interruption of blood flow to the brain), anxiety disorder (excessive worry and fear). Record review of Resident #2's admission MDS dated [DATE] revealed adequate hearing, speech, and vision; BIMS score of 10, indicating moderately impaired cognitive skills; limitation in range of motion in upper and lower extremities; moderate assistance required for personal hygiene; maximal assistance required for toileting, showering, and dressing; and occasionally incontinent of bladder and bowel. Record review of Resident #2's baseline care plan dated 12/19/24 revealed resident was an elopement risk, with special concerns to be in secure unit. Record review of Resident#2's admission elopement assessment dated [DATE] with a score of 9 indicated cognitive impairment, history of elopement, history of leaving without informing staff at sister facility. Interventions included secure unit, frequent monitoring, staff aware of wandering behavior. Recommendations included: if resident has exit seeking behaviors, increase supervision and consider electronic device. Record review of Resident #2's elopement assessment dated [DATE] with a score of 15 indicated cognitive impairment, expressions of a desire to go home to his mother's house, history of elopement, wandering aimlessly, with interventions including secured unit, frequent monitoring, use of a check in/out log, recreational activities, music, staff aware of wander risk. Recommendations included if resident has exit seeking behaviors, increase supervision and consider electronic device. Record review of Resident #2's most recent physician orders dated 6/2/25 revealed: may admit to Secured Unit for safety/security due to elopement risk . Record review of Resident #2's care plan dated 1/8/25 revealed: resident eloped from the unit and facility and was down the street at a Dr. office-was brought back to facility/unit without incident. (Resident got the code to the unit and let himself out). Intervention included wander guard bracelet to alert staff, monitor daily, 1/7/25- code to unit door changed, staff in-service to be more observant when residents by the door of the unit; structured activities- toileting, walking inside and outside, reorientation, signs, pictures, memory boxes. Record review of the incident report for Elopement, dated 1/7/25 at 4:44pm, revealed predisposing factors of the event were resident confused, impaired memory, active exit seeker and wanderer. Incident note: 3:00pm: “Good Samaritan called this facility to inform us that there is a resident that was coming from out direction, and he is sitting on his wheelchair with a cap on and is asking to be taken to his mother house. Good Samaritan wheeled patient to safety at the doctor's office across the street from this facility until staff can go verify if the patient is ours. Resident is confused and unable to give statement, staff [NAME] resident back into this facility, skin assessment done, no changes, vitals stable, RP made aware and MD, no new orders, no signs of distress noted. Staff in-service to be more observant when entering lock down unit when residents are sitting near the exit door, secure unit pass code changed, will continue to closely monitor.” Record review of the 24-hour report dated 1/7/25 to 1/8/25 revealed Resident Summary for Resident #2 including the above Incident Note at 4:44pm, a Social Service Note at 3:30pm, weekly skin assessment at 3:40pm and elopement assessment at 3:44pm, with a score of 15. Record review of the Provider Investigation Report dated 1/8/25 revealed the facility immediate action was staff brought the resident back to the facility, skin assessment was done with no changes, vital signs were stable, RP, MD, Ombudsman, Admin , DON, HHSC notified, in-services with staff on elopement and vigilance when entering the secure unit, pass code to secure unit changed, closely monitoring Resident #2 and all residents, in-services on elopement, elopement drills, rounding every 2 hours. Record review of the Incident/Accident report for 12/24 to 9/25 revealed no other elopements since the time of this incident on 1/7/25. Record review of in-services with all staff were as follows: 1/7/25: Resident Elopement, Elopement Policy; 1/8/25: Resident Rounding- Nurses and CNA's to make alternating resident rounds every 2 hours during shift. Observation of resident #2 on 9/3/25 and 9/4/25 revealed he was in the secure unit, with wander guard in place. Interview with ADON on 9/4/25 at 10am revealed the nurses check the wander guards to make sure they are working. She said there are 7 residents who have wander guards, and nurse check them daily to make sure they are working correctly. In a telephone interview with CNA A on 9/4/25 at 11:40am revealed she was working on the secure unit when Resident #2 eloped. She said she was watching residents in the back of the hall in the lounge area, and another aide was showering a resident at that time. She said they do watch out for residents who are close to the door, and do not enter the code if a resident is near the door. She said they do have elopement in-services, and the last one was after this incident with Resident #2. In a telephone interview with CNA B on 9/4/25 at 11:50am revealed she was at work on the secure unit when Resident 32 eloped, she was giving a shower to another resident. She said they have elopement in-services and the most recent was after Resident #2 left the facility. She said the staff on the secure unit always watch that no resident is si near the door when they put the code in to open the door. In a telephone interview with CNA E on 9/4/25 at 12:15pm revealed she works the 6 – 2 shift in the secure unit, so was not working when Resident #2 eloped. She said she used to work on the B Hall, and just started working in the secure unit recently. She said they do have in-services on abuse/neglect and elopement. In an interview with CNA C, in the secure unit, on 9/4/25 at 10am, she said she works the morning shift, so she was not here when Resident #2 eloped. She said they have in-services on elopement, just recently, and also on abuse/neglect. She said they watch to make sure there are no residents by the door when they enter the code to open the door. In an interview with CNA D, in the secure unit, on 9/4/25 at 10:15am, she said she was not working when Resident #2 eloped, and they do have elopement in-services. She said she will re-direct anybody near the door, and make sure the door is completely closed when she leaves the secure unit. In an interview with the Assistant Director of Clinical Operations on 9/4/25 at 11:05 am, she said Resident #2 was new in the facility, and came here from a sister facility, where he had a history of elopement and wandering. In this incident, he was taken to a dentist office across the street and brought back here by staff. He was assessed and had no injuries and was monitored. She said they have elopement drills, and take someone out of the facility, and go through the whole process of elopement investigation and follow-up. She said they have elopement and abuse/neglect in-services. In an interview with LVN A on 9/4/25 at 10:35am, she said they do have elopement drills, where they practice the entire elopement process. She said the staff will watch for anyone leaving the facility to ensure they are allowed. There is a sign-out book on the table by the door, for anyone to sign if they are leaving the facility In an interview with Director of Environmental Services on 9/4/25 at 4:00pm, she said they do have elopement in-services and elopement drills regularly. In an interview with LVN B on 9/4/25 at 4:05 pm, she said they do have in-services on elopement, including elopement drills every 3 months. The DON was provided the PNC IJ template on 9/3/25 at 5:31 pm. A Plan of Removal was not requested. The non-compliance began on 1/7/25 and ended on 1/8/25. The facility had corrected the non-compliance before the investigation began. The following interventions were implemented prior to surveyor entrance and surveyor confirmed the Past Noncompliance. 1. Resident # 2 was immediately assessed 2. Resident # 2 was placed on 1:1 supervision 3. Resident #2's care plan was updated for elopement risk 4. Facility notified RP, MD, Administrator, DON, Ombudsman, HHSC 5. In-services on elopement, abuse/neglect, including staff and management recognizing and reporting abuse/neglect and elopement. 6. In-services with staff (nurses & CNAs on alternate resident rounding every 2 hours). An ad-Hoc QAPI meeting was held on 1/7/25 with the following addressed: 1. Incident/accidents-elopement reviewed 2. Secure unit code changed 3. Alternating rounds every 2 hours 4. Elopement drill 5. In-services on alternating rounding during shift for CNAs 6. In-services on alternating rounding during shift for nurses. There have been no elopement since this incident. Record review of the facility Elopement, effective 11/1/2019, revealed, in part: “a prompt investigation and search will be conducted if a patient/resident is considered missing. Elopement drill will be held quarterly…”

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. -The facility failed to label, and date left over food items stored in the walk-in cooler. -The facility failed to ensure dented cans were not stored together with undented cans. These failures could place residents at risk for food contamination and foodborne illness due to cross contamination. The findings included: Initial kitchen observation on 12/09/24 at 8:40 AM revealed the following - (All food items were identified by the Dietary Manager) observation of the walk-in freezer in the kitchen revealed. -an open bag of chicken parties which was unlabeled and undated, -a half bag of chicken strips was un-labeled and undated. -3 full bags of chicken parties were unlabeled and undated. -chicken parties in a plastic bag were not sealed, were unlabeled and undated Observation of the dry goods storage revealed one 6 Ibs dented can of sliced apple and one 6.2 Ibs. of dented fancy tree beans. In an interview with the Dietary Manager, on 12/09/24 at 9:00 AM, she said the dented cans were supposed to be kept in her in her office for credit. She said she was sick and today 12/09/24 was her first day back. She said she expected all food items out of the original box\containers to be labeled and dated with a used by date. She said inappropriate food storage could lead to cross contamination and food poisoning. Record review of the facility's policy, dated May 2020, entitled Labeling and Dating Foods. Policy statement read in part- Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure: Date marking for refrigerated storage food items. -Unopened cases of refrigerated food items will be dated with the date the item was received into the facility and will be stored using the first in - first out method of rotation. -Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first in - first out method of rotation. -Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date.

Based on interview and record review the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, within 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 1 of 18 residents (Resident #47) reviewed for comprehensive annual assessments. The facility failed to ensure Resident #47's Annual MDS Assessment was completed within 14 days of the ARD. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services. The findings include: Record review of Resident #47's Admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls, major depressive disorder (persistently depressed mood), alcohol dependence, insomnia (persistent problem falling or staying asleep), mood disorder (different psychiatric conditions that cause changes in a person's emotional state), psychosis (a psychiatric condition that causes a person to lose touch with reality), adjustment disorder with depressed mood (mental health condition when someone has difficulty coping with major stressors or changes in life), quadriplegia (partial or total paralysis in all four limbs and the torso), and alcohol dependence with alcohol induced persisting dementia (a condition that results from chronic alcohol consumption and the resulting brain damage). Record review of Resident #47's Annual MDS with an ARD of 05/20/2024, revealed Section Z of the MDS, Z0500. Signature of RN Assessment Coordinator Verifying Assessment Completion revealed sections A, B, C, D, E, F, GG, H, I, J, K, L, M, N, O were signed as completed by MDS Coordinator A on 06/06/2024. Requested a copy of Resident #47's Annual MDS from MDS Coordinator A prior to exit and was provided a copy that only included sections A-I, instead of A-Z. Record review of screen shot of Annual MDS revealed it was signed on 06/06/2024 and highlighted red. Interview on 12/11/24 at 11:14 AM with MDS Coordinator A, who said she was not aware the annual MDS, dated [DATE], for Resident #47 was late and could not account for why it was late. She looked at the EMR and said the date 6/6/24 was highlighted in red because it was late. She said it was possible she was out on leave or PTO or the DON may have signed the MDS late. She said the DON signed all the facility MDS' for completion and the MDS should be completed within 14 days of the ARD date so if the ARD was 5/20/24 and the MDS was not completed until 6/6/24 it was actually 17 days and late. MDS Coordinator A said she was responsible for ensuring MDS assessments were submitted on time. She said she used the RAI manual as her policy and procedure for completing the MDS. Interview with the DON on 12/11/24 at 11:29 AM, who said he signed the MDS' for the facility for completion. He said he did not know why or how Resident #47's Annual MDS, dated [DATE], had been completed late. He said in his absence corporate may sign and review or audit MDS'. He said PASRR forms were the sole responsibility of MDS Coordinator A. Record review of CMS's RAI Version 3.0 Manual CH 2: Assessments for the RAI October 2019 Page 2-22 Assessment Management Requirements and Tips for Annual Assessments: o The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) completion date, but not later than.

Based on interview and record review, the facility failed to ensure the assessments accurately reflect the resident's status for 1 of 5 residents (Resident #24) reviewed for accurate assessments. The facility failed to ensure Resident #24's MDS accurately reflected the resident's falls. This failure could place residents at risk for not receiving needed services or receiving improper or incorrect care and services necessary for their physical, mental and psychosocial well-being. The findings include: Record review of Resident #24's face sheet reflected a [AGE] year-old male with an admitted [DATE]. Resident #24 had diagnoses which included Displaced Intertrochanteric Fracture of Left Femur (Broken Hip), Unspecified Dementia (decline in mental abilities that affects daily life), Schizophrenia (chronic mental illness that affects how one thinks, feels, and behaves), Muscle Weakness, Difficulty in Walking, Unspecified Lack of Coordination, and Repeated Falls. Record review of Resident #24's Quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment. Resident #24's fall on 9/20/2024 was not reflected in section J, Health Conditions in the MDS. Section J1800 which asked Has the resident had any falls since admission/entry or reentry or the prior assessment on the quarterly comprehensive assessment, dated 11/12/2024, did not reflect any falls. Record review of Resident #24's nurse progress notes reflected documentation of a fall on 9/20/2024. It was documented that the nurse went into Resident's #24's room around 7 a.m. to administer as needed pain medication. Resident #24 reported to the nurse that he fell out of bed onto the floor about 30 minutes prior. Resident #24 reported he hit the right side of his head. Resident #24 also reported pain to his right hand and hip. The nurse assessed Resident #24 for injuries, and none were noted. Resident #24 was sent to the hospital for evaluation. Record review of Resident #24's incident report, dated 9/20/2024, reflected a fall was documented,. on 9/20/2024 Resident #24 informed a nurse he fell out of bed onto the floor about 30 minutes prior to notifying the nurse at 7 a.m., when she went to administer requested pain medication. Resident #24 stated he hit his head, and his right hand and hip hurt. The nurse assessed the resident for injuries, but none were noted . During an interview on 12/10/24 at 8:33 a.m., the DON said Resident #24 had a fall which occurred on 9/20/24 . During an interview on 12/11/24 at 3:00 p.m., the Clinical Reimbursement Coordinator stated she completed the MDS assessments. The Clinical Reimbursement Coordinator said falls were noted in section J of the MDS and if there was a fall with no significant change then it would be noted on the next MDS. This should be completed . During an interview on 12/11/24 at 3:03 p.m., the DON named the MDS Coordinator who was the same as the Clinical Reimbursement Coordinator as the person who completed the MDS assessments. The DON said he signed the MDS after being notified it was completed. Record review of the facility policy, MDS Completion Accuracy and Timeliness, reflected the facility must follow most updated MDS RAI rules and regulations for completing each MDS accurately and timely. Also, that each facility must also utilize most updated Texas TAC rules for MDS accuracy.

Based on interviews and record review, the facility failed to were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening Based on interview and record review, the facility failed to refer a resident with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review for reviewed for 2 of 3 residents (Resident #47 and Resident #25) reviewed for resident assessments. The facility failed to update the PASRR Level 1 forms for Resident #47 and Resident #25 to indicate mental health illness. This failure could place residents at risk of not having their special needs assessed and met by the facility. Findings included: 1. Record review of Resident #47's Admission Record, dated 12/11/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #47 had with diagnoses which included fracture of right femur (broken thigh bone), dysphagia (difficulty swallowing), repeated falls, major depressive disorder (persistently depressed mood), alcohol dependence, insomnia (persistent problem falling or staying asleep), mood disorder (different psychiatric conditions that cause changes in a person's emotional state), psychosis (a psychiatric condition that causes a person to lose touch with reality), adjustment disorder with depressed mood (mental health condition when someone has difficulty coping with major stressors or changes in life), quadriplegia (partial or total paralysis in all four limbs and the torso), and alcohol dependence with alcohol induced persisting dementia, (a condition that results from chronic alcohol consumption and the resulting brain damage). Continued record review revealed Resident #47's diagnosis of psychosis was dated from his admission 3/28/22. Record review of Resident #47's PASRR Level 1, dated 2/21/22,-section C0100 Mental illness Is there evidence or indication this is an individual that has a Mental Illness? and the answer was documented as No. Record review of Resident #47's Annual MDS, dated [DATE], Section I Active Diagnoses read in part: 15950. Psychotic Disorder (other than schizophrenia). 2. Record review of Resident #25's Admission Record, dated 12/11/24, revealed a [AGE] year old male who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25 had diagnoses which included: delusional disorder (psychotic condition characterized by persistent false beliefs), obsessive-compulsive disorder (excessive thoughts that lead to repetitive behaviors), adjustment disorder with mixed anxiety and depressed mood (mental health condition that involves experiencing both symptoms of anxiety and depression), and major depressive disorder recurrent severe with psychotic symptoms (a serious mental illness that involves both depression and psychosis or loss of touch with reality). There was no diagnosis of dementia. Record review of Resident #25's PASRR Level 1 Screening, dated 8/19/2020, indicated .Mental illness .Is there evidence or an indicator this is an individual that has a Mental Illness .No Record review of Resident #25's Annual MDS, dated [DATE], Section I Active Diagnoses read in part: 15900. Bipolar Disorder. 15950. Psychotic Disorder (other than schizophrenia). During an interview on 12/11/24 at 11:14 AM, with MDS Coordinator A who said she was not aware of Resident #25 and Resident #47's mental illness diagnoses from admission did not have primary diagnoses of dementia. She said she had worked at the facility for the last 4 years but had not ever completed any audits of previous PASSR Level 1 evaluations for accuracy, because she did not know she had to. MDS Coordinator A had not really used the 1012 form for Mental Illness before and did not know of any sister facilities that had completed them or used them. MDS Coordinator A said both Resident #25 and Resident #47 had potentially qualifying MI diagnoses and she would look at each of their PL-1's and complete a 1012 form for each of them. MDS Coordinator A said she used the RAI manual to complete MDS's and PASRR requirements as the policy and procedure she followed. Follow up interview with MDS Coordinator A on 12/11/24 at 11:53 AM, she said the potential risk to a resident for not having the corrected referral submitted to identify mental health illness, would be the resident would not receive the necessary services they may qualified for. She provided copies of undated 1012 forms For Mental Illness/Dementia Resident Review for Resident #25 and Resident #47 . The MDS Coordinator A said she was unsure if Resident #25 and Resident #47 should have had an updated PASRR or if a form 1012 should have been completed for each of them. The MDS Coordinator A said that she was ultimately responsible for any PASRR updates. Interview with the Administrator on 12/11/24 at 1:08 PM, he said there was a Corporate MDS Coordinator who could provide oversight for MDS Coordinator A, but he was unsure what her name was and said he would provide her contact information. The Administrator said he would do some in-service education with MDS Coordinator A. The Administrator said he was unsure who conducted audits of PL-1's but he said he knew what a form 1012 was and when it should be used ,which was when a resident was later discovered to have a potentially qualifying MI diagnosis. The State Surveyor requested information for the Corporate MDS Coordinator but did not receive it prior to exit. Record review of the Texas Health and Human Services Commission Purpose of form 1012, read in part: When to Prepare: Form 1012 assists nursing facilities (NF ) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level I (PL1 ) Screening form submitted into the Long-Term Care (LTC) Portal, needs further evaluation for Mental Illness (MI). This form is used to determine whether the individual has a primary dementia diagnosis or if the individual has a mental illness diagnosis. This form also serves as the NF's documentation for the individual's medical record as to why further evaluation was or was not completed .

Based on interviews, and record reviews the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice for CR#1 reviewed for quality of care. The facility failed to monitor and ensured CR#1 received proper dressing changes on the Intra right jugular Vein (Central Line) on CR#1's neck. The facility failed monitor and ensured CR#1 received proper dressing changes on CR#1's Cholecystectomy tube. This deficient practice could affect residents by diminishing their quality of care. Findings Included: Record review of CR #1's undated Face Sheet reflected she was admitted to the facility on [DATE] and readmitted on [DATE]. She was a [AGE] year-old female with the following diagnoses: heart failure (heart fails to pump blood to give body a normal supply), hypertension (high blood pressure), peripheral vascular disease (poor circulation in blood vessels), gastroesophageal reflux disease (stomach acid repeatedly flows back up into the tube connecting the mouth and stomach called the esophagus) , viral hepatitis (liver infection), diabetes (too much sugar in the blood stream) , stroke (blood to brain is blocked), pneumonitis (lung swelling) due to inhalation of food and vomit, IV tube feeding for medication, nutrition and fluids. Record Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 11, which suggest cognitive skills are moderate impaired; receives more than 51% of calories through IV tube feeding for medication, nutrition and fluids. Record Review of CR#1's CPCP (Document that summarizes health conditions, treatments and other important information) dated 8/2/2024 (Revision 8/6/2024) revealed, CR#1 had a potential for dehydration r/t diuretics/NPO (nothing by mouth) status. Administer medications as ordered. Monitor/document for side effects and effectiveness; Has a swallowing problem r/t aspiration and all staff to be informed of resident's special dietary and safety need; resident is totally dependent on staff for ADL; an altered endocrine status R/T gallbladder disease, which required monitoring the JP drainage (an opening into the stomach from the abdominal wall and a tube is inserted to allow air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food to the patient). Record review of Admission Summary progress note dated 8/2/2024 at 7:55pm by LVN A revealed, Resident AxOx3 (Alert and Oriented, times 3) Dx: asp pna arrived at facility via stretcher from Houston Methodist hospital accompanied by 2 EMT staff, returned with orders that was verified by MD via Celo and ok to continue per MD, obtain vitals 128/72 68 97.9 20 N/C @2L, resident returned NPO with peg tube to left mid-abdomen and order for Diabetic source but will use Glucerna Carbsteady 1.2 @55ml/hr water flush @50ml/Q12hr until original feeding is available, all medication administered via peg tube, gall bladder drain at right abdomen replaced while at hospital stay no drainage at this time, 02 @2L n/c no acute distress noted, denies pain or discomfort noted respiration even and labored, resident has order for Meropene (antibiotic used to treat bacterial infections) lg q8hr X 6days r/t asp pna vial IJ triple lumen to right side of neck, accuchecks (blood glucose monitoring) monitoring d/t enteral feeding, notified RP of resident's arrival, continue to provide care Record review of Resident#1's physician's order dated 8/2/2024 revealed cleanse site around Cholecystectomy tube ( A catheter that drains excess bile and fluids from the gallbladder) every night and PRN every night shift and monitor output every shift; Cleanse stoma site with NS or wound cleanser pat dry, apply split dressing between skin & disk every night shift; Glycolax Powder - Give 17 gram via G-Tube one time a day for constipation; Famotidine Give 1 tablet via G-Tube one time a day for acid reducer; Intra right jugular Vein IV site clean every week and PRN if needed. One time a day every Sat for change weekly; Eternal Feed Order every shift auto water flush 100ML Q 6 hrs; Perform weekly skin assessment every day shift every 7-day(s) document C for Clear and A for Abnormal (D/C 8/3/2024); Monitor PICC Line for S/S of infection every shift (every shift for 6 days); Normal Saline Flush Solution. Use 10 ml intravenously every 8 hours for aspiration pneumonia PICC LINE-Flush with 10 Normal Saline every 8 hours if not used with the same frequency for medication administration; Cleanse site around Cholecystectomy tube every night and PRN as needed. Record review of progress note dated 8/12/2024 at 1:19pm revealed resident has completed IV abx and has central line to right IJ catheter is stitched in place per DON and stated resident may have to send to ER to remove, notified MD via CELO, awaiting MD response. Record review of Hospital ER notes dated 6/3/2024 at 8:41pm revealed CR#1 was transported to hospital, via ambulance, and admitted [DATE] at 1:14am. CR#1 had an admittance diagnosis of Pyelonephritis [N12]. The primary diagnosis was aspiration pneumonia of right lung, which included chronic airway obstruction, palliative care. On 6/14/2024 an open drain right; upper abdomen was placed in the abdomen (stomach) which the dressing last changed 4 days prior, 6/12/2024 a CVC triple Lumen Non-tunneled right internal jugular vein, which the last dressing changed 3 days prior. On 6/15/2024 at 12:06pm, CR#1 was discharged from hospital and the instructions were Cholecystostomy tube must remain in place for a minimum of 6 weeks or until cholecystectomy is performed; Tube should be exchanged every 8-12 weeks; tube should be flushed twice daily with 10cc normal saline; tube should remain to gravity bag drainage at all times; and consider placing patient on ursodiol. Record review of facility's Quality of Care policy dated 02/2017 and revised 01/2023 revealed, Quality of care is a fundamental principle that applies to all treatment and care provided to community residents. *Colostomy, Urostomy, or ileostomy care. The community will ensure residents who require colostomy, urostomy, or ileostomy services, received such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Record review of LVN A progress note on 6/3/2024 at 10:04 revealed, revealed resident was observed lying in bed with eyes closed not easily to arouse verbally but slowly awaken with sternal rub, resident lethargic did not eat breakfast or drink fluids with assistance this am, obtained vitals 122/93 92 97.7 20 93% @3L n/c, resident is not her usual self, notified MD via Celo (Communication line with medical doctors) sent recent labs via Celo for MD to review as well, [NAME] gave order for meropenem lg iv q 8hr x 7 days, called and spoke with RP-FM he gave verbal consent for PICC insertion, cont. to provide care. Record Review of the Skilled Charting forms dated between the dates of 8/2/2024 and 8/9/2024, revealed the nurses on all shifts completed assessments; however, failed to address the PICC line, which was not assessed for any condition. Review of text message and video texted from FM A revealed a photo time stamped 7/9/2024 at 8:25am showing the tube in a body area of a resident and a bandage with the date of 6/14; Second photo time stamped 8/12/2024 showing what appeared to be a bandage dated 7/30/2024 and a blue tab and the dressing dirty and coming up off the residents' body. During a telephone interview with FM A on 9/10/2024 at 9:48am it was revealed on 6/4/2024, he was notified by the facility that CR#1 was rushed to the Hospital ER. FM was informed by the Hospital ER that CR#1 had severe pneumonia, bilateral kidney infection, a gallbladder infection, and a UTI. After 3 weeks in the hospital, she was discharged with a gallbladder drain tube. FM A provided additional instances of concerns. o FM A stated on 7/9/2024, he visited CR#1 and noticed the dressing on her gallbladder drain tube had not been changed since 6/14/2024, which was the day prior to being released from the hospital during her 6/4/2024 visit. Furthermore, the dressing that was supposed to be around the gallbladder drain tube; however, was visibly off CR#1's body and the tube that was inserted in the stomach was coming out. FM spoke with CNA B who went to get the charge nurse. o FM A revealed CR#1 had another hospital ER visit on 7/29/2024, and while she was in the hospital, a Central Line (PICC line) was placed in her neck area for medications and along with the G-tube inserted for feeding and hydration, to help mitigate the risk of aspiration. CR#1 returned to the facility 7/30/2024. o FM A stated during another visit at the facility on 8/6/2024, at 8:30 AM. CR#1 began complaining of something biting her and itching. FM A called CNA A to come to the room to look at the mattress. CNA A rolled CR#1 on her side to see what was going on in the area his mom was lying. The bed was covered with live ants. FM stated CNA A went to get Maint. and another staff member for assistance. Both staff members assisted in getting CR#1 out of bed, cleaned up, and our of the room while the Maint. Sprayed the room with disinfectant which may have caused breathing issues. o FM A stated during another visit on 8/12/2024 it was observed that CR#1's Central Line (PICC) had not been changed since she returned to the facility on [DATE]/30/2024 from the hospital visit on 7/29/2024, which was 14 days prior. It was noted that the dressing was in an extremely unsanitary condition. o FM A stated on 8/21/2024 CR#1was again sent to the Hospital ER with breathing difficulties and diagnosed with sepsis (the body responds improper to the bacteria infection that affect the immune system) and a MRSA (a germ resistant to antibiotics and causes infection in different parts of the body. It is contagious) infection in her bloodstream. Her condition had significantly worsened due to, in FM A's opinion, the lack of proper care at the facility. On 9/10/2024 at 2:55pm during a telephone interview with RA witnessed ants CR#1's bed on 8/6/2024 . RA stated she reported this incident to Maint and LVN A. She stated she and another aide (Can't remember the name) got the resident out of bed and cleaned her up fast along with sanitizing the mattress and putting new bedding on. RA further confirmed the conversation with FM A regarding the unsanitary condition of CR#1's Central Line and that it had not been changed in 14 days. RA stated she did not look at the area; however, immediately went and got LVN A who accompanied her to CR#1's room. On 9/10/2024 at 3:11pm during an interview with LVN B it was revealed she had she been aware of report that the FM A had found ants in CR#1's bed by LVN A during shift change where staff exchange information regarding what issues, if any, occurred on their shift. LVN B stated CR#1 should have immediately been assessed to ensure there weren't any bites or other conditions; ensured the Maint was called and moved the bed from the window area if necessary and finally a notation would and should have been reported in PCC. Regarding the Central PICC, LVN B stated she was aware CR#1 had a Central PICC line on the right side of her neck and should have been flushed each shift. She further stated there is a kit in the medication room, which provide items to remove dressing, and re-apply adhesive around the outer side to prevent infection. LVN B stated this should be completed once weekly. She stated the dressing change on the PICC line was according to the order, to be changed on the weekends (Saturday). LVN B stated she did not clean or flush the PICC line because the order was for every Saturday and CR#1 never complained about the area. On 9/10/2024 at 4:30pm during an Interview with Maint revealed he was called to CR#1's room by the RA during the morning shift because there were ants in the bed. Maint witnessed about 3 ants (sugar ants according to Maint) and there were some cookie crumbs in the bed. At that time, CNA's helped the resident out of bed, stripped the bed, the resident was cleaned and placed in her wheelchair in the hall while he sprayed the room. The ants were also seen on the windowsill in the room. Maint stated there are no concerns of sugar ants and they come in the facility when it rains. He stated pest control comes monthly to spray but could not give an indication of all areas of applications other than internal applications. On 9/10/2024 at 5:00pm during an interview with LVN A stated she was aware of the gallbladder tube in CR#1's stomach and orders were to monitor drainage and tube base to make sure it's clean or dry. She confirmed she changed the dressing of the resident when FM brought it to her attention that the dressing was unsanitary and hadn't been changed. She stated CR#1's dressing should have been changed every 7 days. LVN A stated she completed on-going assessments of CR#1's gallbladder tubing area but did not notice the date nor change the dressing until it was brought to her attention . LVN A stated when dressing isn't changed it could cause infection and create a problem with the functioning of the tube. LVN A stated she was working on 8/12/2024 and was aware the resident had a Central Line but does not remember FM A informing her about the condition of the dressing (unsanitary and dirty). She stated she flushed the line and ensured the medication was flowing like it was supposed to. With the line being in an unsanitary condition, it could cause the resident to have a risk of serious infection. LVN A stated when CR#1 returned from the hospital on or around the 7/30/24 she completed a head-to-toe assessment , noted orders from the hospital, took vital signs, reconciled medications with doctor for approval and completed documentation in PCC. The PICC line was not checked, and she stated she thought she had checked it. She stated when she failed to check the PICC line it did not populate in the orders and therefore nursing staff was unaware of the requirements for checking the PICC line area daily. LVN A stated she was never notified about ants in the resident's bed and was never notified of this fact. If she had been notified, she would have completed a head-to-toe assessment on CR#1for ant bites. On 9/11/2024 at 11:00am during an interview with DON who stated CR#1 returned to the facility on [DATE] with a Central Line (PICC). She was not considered a Skilled Charting (An assessment of a high-risk resident on each shift for a period of time) resident , which would require a head-to-toe assessment each shift, which would have noted the nursing staff addressed the PICC line. The DON stated CR#1 was not considered a Skilled Charting resident and was unable to explain the reason other than residents on a Skill Charting level is determined by the business office. He further stated residents stay on Skill Charting only a certain number of times. The DON was unable to give an exact date resident was on Skill Charting or removed. The DON stated the nursing staff requirement for tube care for a resident who has a Central Line (PICC), colostomy bag, cholecystectomy tube or any type IV insertion, the area must be checked for any drainage amount and check for s/s of infection and continue to monitor that the tube stays intact. The DON stated failure to ensure the tube was intact could result in the tube leaking inside resident, which could very well cause sepsis. It was further stated the dressing around the area should not be dirty and the nurses are expected to keep that area clean. However, if the gallbladder dressing isn't dirty or draining there is no reason to bother it regardless of how long it's been there. She also stated it was not a problem if the dressing appeared to come off the tube; it just showed it needed to be changed. The DON stated the PICC line dressing should be changed every 7 days and it is unacceptable if it wasn' t. The DON stated the risk is the resident would get an infection. The DON reiterated that each Saturday the dressing should have been changed during day shift (6am - 2pm); however, the order went in on August 2nd at 8:20pm and since the resident came in with a PICC line from the hospital the dressing is clean and the nurses would not have change it. On 9/10/2024 at 3:11pm during an interview with LVN B Nurse stated she was informed during shift change by LVN A that FM found ants in CR#1's bed. LVN B stated CR#1 should have immediately received a head-to-toe assessment . LVN B stated she was aware of CR#1's Central PICC line on the right side of her neck and should be flushed each shift. However, the only order for the PICC line was to be cleaned and dressing changed on weekends (Saturday). LVN B stated when the resident returned to facility from the hospital, if the PICC line had been checked, it would have populated the cleaning along with the weekly dressing change for all shifts. On 9/11/2024 at 3:55pm during an Interview with Admin revealed he assumed the nursing staff were changing the dressing on the gallbladder and the dressing on the Central PICC line for CR#1. He stated the nursing staff should have completed and on-going monitoring of the two areas to ensure there were no signs or symptoms of infection. He stated he will ensure staff received in-service training and education on skin assessments, environmental. In reference to the ants, he stated an assessment of CR#1 should have been completed. He stated there is an ongoing pest control application. There was an application on 8/5/2024. He stated to his knowledge there isn't an ant problem. On 9/27/24 at 7:24am during a telephone interview with MD - revealed CR#1 had a central line (PICC) at some point in the past, but what CR#1 had at the facility was a CVC (used for short-term access. A needle puncture to the vein in the neck, groin or upper chest) used to administer drugs, and fluids. MD stated CR#1 is still his patient even at her current facility. MD stated in June CR#1 went to the hospital for gallbladder issue, but the risk of surgery was to high based on her physical condition. MD stated that CR#1 has had several PICC lines in the past. However, the PICC lines can't stay in too long because of her historical health. MD stated this facility is a good community that continues to communicate with him regarding all his patients, especially CR#1. MD stated the facility calls often regarding concerns with CR#1's condition. MD stated he has had no problem with the care the facility gave CR#1. MD stated the correlation between Mrsa and the bandage is with mrsa there would have been a large abscess in the area if the bandages had infected the resident. MD stated CR#1 had colonization on her skin and changing the bandage too often would have created a secondary cross-contamination, which is what medical personnel wanted to avoid. MD stated that the bandage being dirty was not an issue at this time for CR#1, unless it was saturated with blood that was visible, had a foul odor and/or was really wet, which was not the case with her. MD stated the facility monitored CR#1 very closely and he was aware of her conditions and/or changes immediately. MD stated CR#1 has an enormous amount of risk factors for infection. MD stated CR#1 was recently released from the hospital to her current nursing facility and has had to be returned to the hospital for other medical issues. MD stated CR#1 will always have infections and other health issues and go back and forth to the hospital due to her medical condition. MD reiterated he had no concerns with her treatment at the facility and was always aware of CR#1 health issues when they occurred.

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (Resident #1) of six residents reviewed for accidents, hazards, and supervision. The facility interventions did not prevent 18 unwitnessed falls and 16 witnessed falls with multiple injuries and hospitalization . The facility failed to implement the physician order for a use of a helmet to prevent injuries from falls. Facility staff, the NP and the Rehab Director were unaware of this physician order. These failures placed residents who are dependent on staff for activities of daily living, supervision, and bed mobility at risk of not being adequately supervised, no adequate intervention, not putting appropriate devices in place, worsening of existing wounds, decline in quality of care, and experiencing pain. Findings include: Record review of Resident #1's face sheet dated 11/29/23 revealed original admitted to facility was 5/9/23 and was readmitted on [DATE]. Resident was diagnosed with dementia with other behavioral disturbance, Urinary Tract infection, bilateral cataract, fracture of right pubis, osteoporosis (bone disease that develops when bone mineral density and bone mass decreases), intertrochanteric fracture of left femur, mood disorder, history of falling, type 2 diabetes (high blood sugar), insomnia, dysphagia (swallowing difficulty), fracture of unspecified part of neck of right femur, anxiety, lack of coordination, repeated falls, disorientation, abnormalities of gait and mobility and pain in right hip. Record review of Resident #1's Quarterly MDS signed on 11/28/23 revealed the resident was rarely/never understood and had severe cognitive impairment and she was dependent on staff and the helper does all of the effort for toileting hygiene, and putting on/taking off footwear, and sit to stand and tub/shower transfer. Resident #1's bed mobility, transfer, walking, dressing, eating and/or swallowing score was 0 for the number of days restorative programs were performed. Resident #1 was not rated on mobility. Record review of Resident #1's undated care plan revealed resident was at risk for falls and fractures as evidence by: History of Falls, Cognitive Impairment Interventions: 04/21/2023 - Per MD .it was determined that despite all attempted interventions, due to Resident's overestimation of abilities, noncompliance, and advancement of disease processes, Resident's incidences of falls is unavoidable and anticipate needs, provide prompt assistance. Date Initiated: 11/21/2022. Assure lighting is adequate and areas are free of clutter, Encourage resident to ask for assistance of staff, Encourage socialization and activity attendance as tolerated, Ensure call light is in reach and answer promptly, Therapy to evaluate and treat per orders, Resident #1 was identified again for falls: High risk for increased falls and fractures as evidence by: Confusion, Deconditioning, Unaware of safety needs 10/25/2022 - Hit by door when roommate's spouse tried to open the door . Interventions: 10/25/2022 - Move Resident away from door and move Resident's roommate and roommate's spouse to larger area, fall mat beside bed, bed in lowest position , Anticipate and meet The resident's needs, Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, Follow facility fall protocol, Pt evaluate and treat as ordered or PRN, the resident uses a scoop mattress. Ensure the device is in place as needed. Focus: 8/6/22-I have had an actual fall with no injury r/t Poor Balance, Poor communication/comprehension. 9/14/22- witnessed fall with no injury, transferring self 9/24/22- self report of a fall with bump to back of head 11/4/22- unwitnessed fall with injury returning from bathroom 1/4/2022 unwitnessed fall w/no injury 11/5/22- witnessed fall w no injury 11/17/22 - witnessed fall w no new injury 11/21/22- witnessed fall w injury to head 12/5/22- witnessed fall w skin tear(lost balance while standing unassisted) 2/12/23- witnessed fall w skin tear to elbow 2/27/23-unwitnessed fall w no injury 2/27/23- unwitnessed fall w no injury 3/13/23- witnessed fall w no injury-slid out of w/c 3/15/23- UNWITNESSED slid out of chair no injury 4/27/23- witnessed fall with major injury 5/16/23 fall with a skin tear 5/25/23- unwitnessed fall with no injury 7/15/23-witnessed fall with no injury Date Initiated: 10/20/2022 Revision on: 07/17/2023 Interventions: 02/12/2023 - PT to eval/treat; remind to call for assistance; staff to monitor/encourage resident to call for assistance; Tx performed r/t s/t; Resident continues to refuse to wear helmet r/t falls; Resident pushing w/c instead of using w/c to ambulate Date Initiated: 02/14/2023 Revision on: 04/27/2023. 11/17/2022 - Remind Resident to call for assist with transfer; mat to remain at bedside; Ensure non-skid socks are in place 11/21/22- sent to ER for eval Date Initiated: 11/21/2022. 11/4/22-Sent to ER to eval & treat Date Initiated: 11/04/2022 Revision on: 04/04/2023. 11/5/22-PT to eval/treat; Remind & encourage Resident to use assistive device Date Initiated: 11/05/2022 Revision on: 04/04/2023. 12/5/22-Helmet Date Initiated: 12/07/2022 Revision on: 04/04/2023. 2/27/23-PT to eval/treat; remind to call for assistance; staff to monitor/encourage resident to call for assistance; Resident continues to refuse to wear helmet r/t falls; Resident continues to push w/c instead of using w/c to ambulate Date Initiated: 02/28/2023 Revision on: 04/27/2023. 3/13/23-PT to eval/treat; Resident continues to refuse to wear helmet r/t falls; Resident continues to push w/c instead of using w/c to ambulate; pharmacy medication review Date Initiated: 03/14/2023 Revision on: 04/27/2023. 3/15/2023 Check me for range of motion; Resident continues to refuse to wear helmet r/t falls; Resident continues to push w/c instead of using w/c to ambulate; Resident being considered for unavoidable falls Date Initiated: 10/20/2022 Revision on: 04/27/2023. 4/27/23- sent to ER for eval (Hip FX). Initiated: 04/27/2023 Revision on: 04/28/2023. 5/16/23- Resident has high incidence of falls and refuses to wear helmet to provide protection for falls. PT to evaluate and treat as indicated, and staff to encourage, remind, and monitor for Resident to call for assistance. Date Initiated: 05/16/2023 Revision on: 11/22/2023. 7/15/23- ensure needed items are in reach Date Initiated: 07/17/2023. 9/14/22- remind to ask for assist with transfers Date Initiated: 10/20/2022 Revision on: 10/20/2022. 9/24/22-Neuros and head/skull X-rays ordered; PT to eval/treat; Resident reminded to call for assistance as needed; staff to monitor/encourage resident to call for assistance when completing ADL tasks, Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation, Neuro-checks x 72 hrs., Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound, PT consult for strength and mobility, Focus: 8/3/23-I have had an actual unwitnessed fall with no injury r/t Poor Balance, Unsteady gait 8/20/23- witnessed fall no injury 9/3/23- witnessed fall with no injury 9/3/23- unwitnessed fall with injury-s/t to eyebrow 9/17/23- unwitnessed fall 9/29/23- unwitnessed fall with no injury 10/1/23- fall with no injury 10/10/23- unwitnessed fall with no injury 10/24/23- unwitnessed fall with skin tare and bump to head Date Initiated: 08/03/2023 Revision on: 10/24/2023. Interventions: 10/24/23-PT eval and treat for safety awareness and gait training. Maintain 1/2 siderail and bed lowest position when in bed and x1 mat Date Initiated: 10/24/2023 Revision on: 11/22/2023. 8/3/23- remind to ask for assistance when needing to get up Date Initiated: 08/04/2023. 9/17/23-Continue safety measures such as, low bed, floor mat and dycem in wheelchair. Date Initiated: 09/22/2023 Revision on: 09/22/2023. 9/29/23- continue current safety measures perimeter top to his mattress Date Initiated: 10/03/2023 Revision on: 10/05/2023. 9/3/23-resident educated on the importance of sitting properly in her chair so that she won't fall to the floor and cause injury to self. note resident states prefers to scoot down in her chair. it's comfortable to me. note medi-non slip padding was in use. 9/3/23-Continue safety measures such as, low bed, floor mat and dycem in wheelchair Date Initiated: 09/05/2023 Revision on: 09/22/2023. Check range of motion Date Initiated: 08/03/2023 Revision on: 08/03/2023. Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 08/03/2023 Neuro-checks x's 72 hrs. Date Initiated: 08/03/2023 Revision on: 08/03/2023 PT consult for strength and mobility. Date Initiated: 08/03/2023. Focus: 11/19/23- I have had an actual unwitnessed fall with injury (cut to forehead L) r/t Poor Balance, Unsteady gait, will get up unassisted repeatedly. 11/28/23- fall with injury, propelling self leaning forward and fell , -Intervention: pt transferred to Methodist ER for eval/management s/p fall W/injury per in house MD Record Date Initiated: 11/22/2023. 11/28/23- Sent to ER for evaluation, Check range of motion Date Initiated: 11/20/2023 Revision on: 11/20/2023 Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks x 72 hrs., PT consult for strength and mobility, Focus: Resident #1 is an elopement risk/wanderer and is at risk for possible injury r/t impaired safety awareness and diagnosis of dementia. 10/2/22- Has made multiple attempts to go out front door, frequent redirection and when redirected she lashes out at any and all staff within reach, Interventions: Assess for fall risk, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or books, Provide structured activities: Toileting, walking inside and outside, reorientation strategies, including signs, pictures and memory boxes, Wander guard placed for resident's safety, bracelet will alert staff if and when resident attempts to exit doors of facility. Staff to monitor daily. Record review of Resident #1's Physician Orders dated 11/29/23 revealed: -May have bedside mat for safety date 11/4/22 -May have Helmet to head as needed for safety dated 10/25/2023 -Send pt to [local hospital] ER for Eval s/p fall with injury dated 11/28/2023 -Signal device (Wander guard) in place due to (reason) for safety awareness dated 07/28/2023 Record review of Resident #1's Incidents dated 11/29/23 at 12:28 p.m. with date range 5/1/22 to 11/29/23 revealed: -16 Witnessed Fall Incidents 7/25/22 at 7:30 a.m. Closed fracture of right hip 9/14/22 at 4:24 p.m. 11/4/22 at 2:30 p.m. 11/17/22 at 2:26 p.m. 12/5/22 at 11:30 a.m. 2/12/23 at 9 a.m. 3/13/23 at 10:20 a.m. 4/27/23 at 9:50 a.m. pain to back of head and left hip 911/Left femur fracture 7/15/23 at 8 p.m. Fracture of right pubis 8/20/23 at 2:02 p.m. 9/3/23 at 3:22 a.m. 9/3/23 at 10:30 a.m. 9/17/23 at 1:50 p.m. 9/29/23 at 6:29 p.m. 10/1/23 at 8 p.m. 11/28/23 at 12:38 p.m. -18 Unwitnessed Fall Incidents 5/16/22 at 1 p.m. 8/6/22 at 11 a.m. 9/24/22 at 2:44 a.m. 11/4/22 at 2:01 a.m. 11/5/22 at 11:28 a.m. 2/27/2 at 11:31 a.m. 2/27/23 at 2:02 p.m. 3/15/23 at 12:30 p.m. 5/16/23 at 5:43 a.m. 5/26/23 at 11:30 a.m. (pain to right knee) 8/3/23 at 12:30 a.m. 8/5/23 at 10:15 p.m. 8/25/23 at 8:30 a.m. Record review of incidents and accidents did not include Resident #1's unwitnessed falls on 11/19/23 and 11/28/23 where Resident #1 was taken to the hospital, and she did obtain hematoma to head on 11/19/23 and reinjured the same forehead hematoma on 11/28/23. Record review of Resident #1's Nurses notes dated 4/27/23 at 9:59 a.m. revealed Called into locked unit by aides. Resident [Resident #1] was being assessed by opposite nurse and vital signs taken by opposite nurse while walking into unit. Resident [Resident #1] had fell on floor laying flat on back. witnessed by hospitality aide. Resident [Resident #1] had no complaints or pain noted at this time. Some redness noted to back of head no hematoma. Hospitality aide communicated that resident had hit back of head on floor. Assisted resident back into w/c and resident able to maneuver w/c without complications. Record review of Resident #1's SBAR Summary written by LPN A dated 4/27/23 at 10:25 a.m. revealed Situation : The Change In Condition/s reported on this Evaluation are/were: Falls. Resident did have pain, other neurological symptoms, recommendations were to send resident out to hospital for evaluation. Record review of Resident #1's Local Hospital records dated 5/1/23 revealed principal diagnosis: left femur fracture and transferred by ambulance. Resident #1's mental status was disoriented and she was partial weight bearing and skin integrity type was incision on left hip. [AGE] year-old female with Progressive macular hypo melanosis of dementia (skin disorder- non-scaly spots on the trunk), hypothyroidism (abnormally low activity of the thyroid), Diabetes Mellitus, recurrent falls, dementia, right hip fracture s/p intramuscular injection nailing (installing medications into the depth of the muscles) 7/2022, seizure, HTN (hypertension) .presents to ER with left hip pain s/p mechanical fall. Patient with history of dementia .No family at bedside at this time. Per report, Resident #1's family member noted patient unable to move left leg and c/o left hip pain while visiting her at the nursing home today. Apparently patient lost her balance twisted her left hip and fell . Reports left hip pain, severe, achy pain with movement since yesterday, no pain at rest. Who had her right hip nailing last year on July low dose with a past medical history .Imaging Procedure lower extremity without contrast left collected 4/27/23 at 2:26 p.m. Clinical history: Fracture femur Impression: 1. Acute comminuted intertrochanteric fracture of the left hip with various angulation. Significant communication of the greater trochanter. Displaced lesser trochanter fragment. The lateral wall of the proximal femoral shaft intact. Record review of Resident #1's SBAR for Change in Condition written by LPN B dated 5/16/23 at 6:43 a.m. revealed: The Change in Condition/s reported on this Evaluation are/were: Falls. Record review revealed no documentation of injury. Record review of Resident #1's progress notes dated 5/26/23 at 11:35 a.m., written by LPN A revealed: Called into locked unit by hospitality aide that resident had fallen. Went into locked unit, found resident in bed. resident was in bed in lowest position with head and knees raised to create a cradled position. assessed resident for any skin alterations, none noted at this moment. resident communicated pain to right knee. assessed legs and no alterations noted. Knee had no swelling or redness to area. Administered PRN Norco and adjusted resident in bed to comfortably eat lunch. Notified MD about situation and no new orders made. Notified family about situation. Plan of care continues. Record review of Resident #1's local Inpatient Physician Progress note dated 11/8/23 revealed, Chief Complaint Anxiety/agitation, 80 y/o female with past medical history of hypertension (high blood pressure), hyperlipidemia (high cholesterol), hypothyroidism (thyroid gland does not make enough thyroid hormones), presented to the hospital with right hip pain post mechanical fall , computed tomography scan of the pelvis revealed a nondisplaced inferior pubic ramus fracture. Seen and evaluated by ortho, no surgical intervention needed, advised extensive physical therapy in a rehab .transferred to SNF for continuation of skilled services and further rehab. Doing well discussed with nursing has had evaluation with PT and OT tolerating medications routine labs ordered for monitoring and wound care assessment screening is done, reviewed medications to limit falls in facility. Will closely monitor. Record review of Resident #1's Local Hospital Record dated 11/20/23 and date of Admission 11/19/23 revealed physical examination .skin: contusions (bruises) along forehead and face . Record review of Resident #1's Morse Fall Scale dated 11/21/23 at 9:58 p.m. revealed: Resident #1 has fallen before, ambulatory aids were none/bedrest/wheelchair/nurse assist .overestimates or forgets limits . Record review of Resident #1's Nurse notes dated 11/28/23 at 12:03 p.m. written by the ADON revealed, This nurse was called down to C hall by housekeeping staff, noted resident lying on the floor in the hallway on her back with her wheelchair beside her, existing abrasion from previous fall noted bleeding this nurse applied pressure to site, and charge nurse obtained vital signs . and Range of Motion performed without any abnormalities. Per housekeeper resident fell straight forward out of her wheelchair head first to the floor. Resident [Resident #1] stated that her head was hurting, MD notified and 911 called for resident to be taken to hospital for further evaluation. This nurse and charge nurse assisted resident [Resident #1] to her wheelchair then to her room and laid her in bed. Stayed with resident and continued to apply pressure to site, once bleeding stopped 2 steri-strips was applied to site 911 arrived at 12:10 pm. Resident left alert without any sign of distress. Record review of Resident #1's Nurse note dated 11/28/23 at 12:15 p.m. written by the ADON revealed, Notified RP that resident had fell and reopened the abrasion to forehead and that she was sent out 911 for further evaluation. Record review of Resident #1's Local Hospital Record dated 11/28/23 at 12:32 p.m. revealed: Previous Emergency Department Visits: 11/19/23 Fall, 6/15/23 Arm Pain-Superficial bruising of arm, left, initial encounter, 4/27/23 Fall-closed displaced intertrochanteric fracture of left femur, 11/21/22 Wound Assessment- scalp hematoma, 11/21/22 Fall- Hematoma of scalp, 11/4/22 Fall- Fall .7/4/22 Hip pain- closed fracture of right hip, 6/11/22 Pain- intractable pain. Chief Complaint: Fall- patient from [facility], fell approximately 12 p.m. today from wheelchair with laceration to forehead. Per EMS patient had a fall approximately 1 week ago also and hit same spot on head. Emergency Department final diagnosis Fall, initial encounter- contusion of face. Record review of Resident #1's SBAR Summary dated 11/28/23 at 12:55 p.m. written by DON revealed: Situation : The Change In Condition/s reported on this Evaluation are/were: Falls, Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Increased confusion (disorientation) Memory loss (new or worsening), Functional Status Evaluation: Fall, Primary Care Provider recommendations were to send to ER. Observation and attempted interview on 11/22/23 at 1:40 p.m. with Resident #1 revealed both eyes were purple underneath, with a green bruise under her chin. Observation revealed there was a raised open sore in the middle of her forehead by Resident #1's scalp. Further observation revealed bruises on Resident #1's hands. Resident #1's bed was positioned on the wall by the window and she had a bolster mattress on bed and a fall mat on the other side of the bed on the floor. Observation revealed pillows all around Resident #1's bed and on the side by the floor mat Resident #1 had 2 pillows under the sheet to attempt to bolster resident from falling. Resident #1 was attempted to be interviewed but continued falling back to sleep. Observations did not reveal a helmet or wander guard on Resident #1. In an interview with Resident #1's family member on 11/22/23 at 1:47 p.m. she stated she came to see Resident #1 daily. She stated on Sunday night, 11/19/23 she received a call saying Resident #1 had fallen and no one saw her. The Family member stated the facility called 911 and they just got back at 9pm on 11/21/23. She stated the phone call (Unknown staff) said Resident #1 was at the nurses station in the front and Resident #1 fell and no one saw it. Resident #1's Family member stated on 11/19/23 under Resident #1's left eye was really swollen, black and blue and the right eye popped up after. She stated Resident #1's forehead was still bleeding. The Family member stated the fall was on 11/19/23 at around 12:15 p.m. when she was called. In an interview on 11/22/23 at 2:00 p.m. with LVN C she stated Resident #1 was on B hall and she was passing her meds and the RN supervisor calling her from the Nurse Station and LVN C stated the RN Supervisor saw Resident #1 on the floor lying on her left side. The RN supervisor said she did not see what happened, but she saw Resident #1 on the floor. She stated there was a big bump on Resident #1's head and she was bleeding, and the RN Supervisor let the Doctor know and the family and Resident #1 went by 911 10 min later to the hospital. LVN C stated Resident #1 tried to get up and walk from her chair. In an interview on 11/29/23 at 10:30 a.m. with Resident #1 she shook her head saying she was okay. Observation revealed Resident #1 had bruises under both eyes, a raised bruise on the forehead covered with a white strip bandage. Observation revealed Resident #1 was not wearing a helmet and did not have wander guard. Observation revealed Resident #1 moving her legs up and down exercising. Observation revealed a pillow under the sheet on the side of the bed to keep her from rolling out. Observation revealed low bed. In an interview on 11/29/23 at 10:45 a.m., Resident #1's roommate stated Resident #1 keeps falling and 911 people come to get her. Resident #1's roommate stated the facility never offer Resident #1 a helmet that she ever hears of. She stated Resident #1 never wore a helmet since she has been her roommate for at least 3 months. She stated more recently the facility staff have been keeping Resident #1 on a low bed and it made more sense. In an observation and interview on 11/29/23 at 11:00 a.m. with CNA A she stated she assisted Resident #1. CNA A stated Resident #1 was a fall risk and she was going to check on Resident #1 again. CNA A stated Resident #1 was a fall risk and cannot stay still. She stated Resident #1 was in Memory Care because she was always a fall risk and moved a lot. CNA A stated she did not know if Resident #1 had dementia. CNA A stated Resident #1 slides in her wheelchair, so they do not want to put Resident #1 in the wheelchair anymore. CNA A stated Resident #1 leans back and slides off of the wheelchair. She stated the facility had Resident #1 in a low bed. She stated the facility used pillows, and the fall mat for Resident #1. CNA A stated Resident #1 did not have a helmet and observation revealed Resident #1 did not have a helmet on. She stated she was wondering if they would ever use a helmet with Resident #1. CNA A stated in Resident #1's bed she tried to slide down, but they position Resident #1 at a 30 degree angle in the bed sometimes. CNA A stated Resident #1's family member did not want Resident #1 in the bed, she wanted her to be in the wheelchair. She stated they keep telling Resident #1's family member that if they put her in the wheelchair Resident #1 would keep falling. CNA A stated most of Resident #1's falls have been when she was in the wheelchair. She stated Resident #1 had been on C hall for since August 2023. CNA A stated she talked to the Nurses and the Therapist and they tell her what Resident #1 needed when asked about having access to Resident #1's care plan. CNA A stated Resident #1 was a 1 person assist, but when it comes to keeping her on the wheelchair there has to be 2 people watching Resident #1. Observation with CNA A revealed Resident #1 did not have wander guard. In an interview and record review of Resident #1's Nurse notes on 11/29/23 at 11:37 a.m. with LVN D she stated Resident #1 liked to move herself around in the facility. LVN D stated Resident #1 sometimes tried to get up and she forgot she cannot walk. LVN D stated Resident #1 will say yes but other than that she does not answer your questions. LVN D stated Resident #1 tried to get out of bed herself and she was really active and alert. LVN D stated Resident #1 had fall mats, bed in lowest position, call light in reach, they get Resident #1 up for meals so they can watch her in the dining room. She stated when Resident #1 was out in the community sometimes she got away and tried to get up and there goes the falls. LVN D stated on 11/28/23, Resident #1 fell at around this time when staff were busy checking blood sugars and CNA's were getting residents to the dining room. She stated the facility could not keep an eye on her 24/7. She stated she did not know what could be done unless Resident #1 had one on one supervision. LVN D stated sometimes they did short term one on one when there were things going on with residents. LVN D stated Resident #1's family member came to check on Resident #1 daily in the evenings mostly. LVN D stated Resident #1 had a helmet and Resident #1 takes it off and does not want to wear it. LVN D stated Resident #1 did have a wander guard and was in the memory care unit a couple months ago but they took her out of the secure unit. LVN D stated Resident #1 still had the wander guard on and so if she went to the front door, it would go off. LVN D stated the wander guard was on Resident #1's legs. LVN D stated record review of Resident #1's physician orders say check wander guard placement, but the wander guard was on one of her ankles. In an interview on 11/29/23 at 11:46 a.m. with CNA A she stated Resident #1 did not have any wander guards on. She stated Resident #1 used to have a wander guard but she did not know what they did with it. CNA A stated since she has been working with Resident #1 she had not had a wander guard. She stated since she had been working with Resident #1 she had not had a wander guard or a helmet. CNA A stated she had been working at the facility since July 2023, but not always with Resident #1 but they move the CNA's around. CNA A stated when she had Resident #1 on A hall she had wander guard on her right ankle. CNA A stated she did see that Resident #1 needed a helmet and the wander guard to make the alarm. In an interview on 11/29/23 at 11:54 a.m. with the NP she stated Resident #1 was a long-term resident and she has been seeing patients here since February 2023. The NP stated she had dementia. She stated recently Resident #1 had fallen and was confused. The NP stated Resident #1 got in her wheelchair and had a recent fall from the wheelchair, hit her face and had to go to the hospital. The NP stated since Resident #1 has come back from hospital the facility had monitoring in place. She stated Resident #1 had a UTI and was receiving antibiotics for that. The NP stated they are monitoring Resident #1, making sure the bruises go away and they are holding blood thinners right now. She stated there were a few NP's that come to the facility so she does not always see all the residents. The NP stated one of Resident #1's bruises opened when she fell and the nurses need to make rounds, fall mat on the ground, neuro checks every 4 hours, make sure she was not agitated and trying to get up. The NP stated Resident #1 should have wander guard but she is not 100% sure. The NP stated she was not aware Resident #1 had orders for a helmet right now because there were a few NP's that see the residents. The NP stated Resident #1 should have the helmet on when out of bed and even when sitting in a chair. In an interview on 11/29/23 at 12:01 p.m. with Hospitality Aide A he stated Resident #1 was a busy body, does not like to stay still, was constantly trying to walk and kept hurting herself. Hospitality Aide A stated Resident #1 stuck to herself. He stated Resident #1 had falls when she was in A Hall in Memory Care also. Hospitality Aide A stated Resident #1 tried to stand and walk. He stated Resident #1 did not have a wander guard that he knew of and she never wore a helmet that he knew of. Hospitality Aide A stated he had been working at the facility for 2 1/2 to 3 years. In an interview on 11/29/22 at 12:05 p.m. with CNA B she stated she remembered helping Resident #1 around the building. CNA B stated Resident #1 did not have a wander guard when she was on A hall in Memory Care. CNA B stated she did not remember if Resident #1 wore a helmet. In an interview and record review on 11/29/23 at 12:19 p.m. with the ADON she stated Resident #1's Clinical record shows that she had 16 witnessed falls and 18 unwitnessed falls at the facility. The ADON stated on November 4, 2022 Resident #1 had an unwitnessed fall and Resident #1's progress notes say that a CNA (unknown name) came to RN (unknown name) at 2 a.m. and said Resident #1 was on the floor. Resident #1 was noted with walker and was laying by bathroom door wearing non skid socks, and the intervention was to go to the ER for evaluation because Resident #1 had a hematoma to the back of the head. The ADON stated the facility had to order the helmet back in December 2022 but Resident #1 kept taking it off. The ADON stated they care planned the helmet and she continued taking the helmet off. The ADON stated the facility care planed that Resident #1 was unavoidable for falls and she just wheels herself around the facility because that was what Resident #1 liked to do. She stated Resident #1 had body strength, a dycem on her wheelchair (non-slip material placed in wheelchair to prevent sliding out), bolster mattress, low bed, floor mats. The ADON stated the facility took Resident #1's wander guard off when they sent her to the hospital. She stated the facility had Resident #1 on one on one when she was having the falls, they asked the family to help with one on ones but they could not do it all the time. The ADON stated if Resident #1 would keep the helmet on that would be good because she keeps hitting her head. She stated the CNA's should know about the helmet. In an interview on 11/29/23 at 12:43 p.m. with the Rehab Director she stated Resident #1 was on PT and they worked on strengthening her muscles and mobility with transferring and getting in and out the wheelchair. The Rehab Director stated there was a dycem on Resident #1's wheelchair seat and it was a non-slip material to decrease her slipping out the chair. She stated there was also anti-tilt to prevent Resident #1 from titling back and the chair was tilted to prevent her from falling out the wheelchair. The Rehab Director stated she was not aware of the helmet being an intervention. In an interview on 11/29/23 at 12:50 p.m. with the Administrator he stated Resident #1 had a low bed, fall mat, no staffing issues, the ratio was perfect, and Resident #1's supervision was where it needed to be. The Administrator stated they put the wheels on Resident #1's wheelchair so it could not tip over, and they have all the therapeutic devices in place. He stated the facility did not have one on one supervision capability in this facility. In an interview on 11/29/23 at 1:04 p.m. with the DON she stated Resident #1 had falls when she was at home and that was why she came to the facility. The DON stated with Resident #1's dementia advancing she was around the 6th to 7th stage of dementia. The DON stated they were trying to get Resident #1 out of bed daily. The DON stated Resident #1 had a fall on 11/28/23. She stated Resident #1's bed was in the lowest position, and on her bed window frame they have little transparent stuff that spins to help to distract Resident #1. She stated there was a p [TRUNCATED]

Based on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen: -The facility failed to ensure that the kitchen floors were clean and free of food particles. -The facility failed to ensure that food preparation equipment was clean and free of grease build up. -The facility failed to ensure food items in the refrigerator\freezer were dated, labeled, and appropriately sealed. These failures placed all residents who ate food served by the kitchen at risk of food-borne illness. Findings included: Observation on 10/31/23 from 9:15AM to 9:30AM, revealed the following: *the kitchen floor was dirty with food particles and grease around the cooking area and behind the stove. *One of two cooking stoves had grease built up inside and around outer part of the stove. * one of one commercial can opener in the kitchen revealed had grease and dark looking substance around the cutting blade and the blade holder. * freezer #1 revealed the floor of the freezer had food particles and the door had grease build up. Inside the freezer were open half bag of French fries, a half bag of frozen biscuit, left over hot dog meat in a plastic bag, left over pork sausage. All food items were unlabeled and undated. All food items were identified by the Dietary Manager. * freezer #2 revealed left over hamburger meat, chicken party, and chicken parts all in plastic bags undated and unlabeled. During an interview on 10/31/23 at 10:10Am, the dietary Manager said all food out of their original packet should be labeled and dated with used by date. She said the kitchen should be clean daily after meal preparation and at the end of the day. She said preparing food in an unclean environment can lead to food born illness and violations of food establishment codes. She said she would have an in-service and have the kitchen cleaned. Record review of the facility's policy entitled Food Storage, Food Safety in Display and Service Policy dated 1/20/2018, revised 04/11/2022, read in part- documented: The receiving date is written on the top of all food cases or containers. All food in its original containers, will have the expiration date written on it. All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws, and regulations. Food will be handled in a safe and sanitary method to prevent contamination and food-borne illness. #9 Opened package or leftover food is to be tightly wrapped or covered in airtight, clean containers. It should be labeled, dated with the opened or use by date. Do not keep leftovers in the refrigerator for more than 7 days. The policy did not address kitchen cleaniness

Based on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible, for 1 of 6 residents (Resident #62) reviewed for nutritional status, in that; Resident #62 who admitted to the facility with poor nutrition was not provided prompt intervention to prevent severe weight loss of -16.85 pounds in 6 months. This failure could affect all residents in the facility with weight loss at increased risk of weight loss. Findings included: Record review of Resident #62's admission sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, unspecified abnormalities of gait and mobility (a change to your walking pattern), depression, dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes. Record review of Resident #62's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 06 indicating severely impaired. Record review of Resident #62's Care Plan dated under focus revealed weight loss as evidence by 10.0 % change over 180 days. Resident #62 is refusing eat at times 8/10/2022, current weight is 125. Weight loss noted while in the hospital. 8/3/22 119.5 lbs., 9/2/2022 118.3 lbs. -5.36%/30dyas, 10/19/2022-readmit weight of 114.0 lbs., 1/9/2022 113.2 1bs., 4/10/2023 99.2 lbs., 5/8/2023 106.2 lbs., 7/21/2023 92.2 lbs. 7.5 % change comparison weight 5/8/2023 106.2 lbs., 9/9/203-9 lbs. Goal: Resident will stay within 3-5 1lbs of baseline weight over the 90 days. Resident will be encouraged to eat 50%-100% of her meals over the next 90 days. Target date 1/25/2024. Interventions: Assess resident for food preferences, serve resident food preferences. Record review of Resident #62's comprehensive care plan date 5/1/2023, did not address any plan of care for her nutrition regarding supplements until 4/10/23 and the weight loss and poor diet was first noticed on 8/10/2022. Appetite stimulant was not added until 6/5/2023. Record Review of Resident #62's Diet Type Report revealed, her diet type was carb controlled/no added salt, diet texture was mechanical soft, and her fluid consistency was regular. Dietary - Supplements was a health shake, administer one (1) health shake two (2) times a day with lunch and dinner. Record Review of Resident #62's Monthly Weight Report revealed, in April 99.7 Lbs., May 106.2 Lbs., June 89.0 Lbs., July 92.5 Lbs., August 90.0 Lbs., September 90.5 Lbs., and October 86.2 Lbs . Record Review for Weight Variance Report for September 2023 revealed, 30 days (+0.56%), 90 days (+1.69%) and 180 days 15.66%. Record Review for Weight Variance Report for October 2023 revealed, 30 days (4.75%), 90 days ((6.81%), and 180 days 13.54%. Observation on 11/1/2023 at 12:10p.m., revealed CNA D bringing Resident #62 her tray. She adjusted Resident #62's bed. CNA D asked Resident #62 how she wanted her bed positioned but she did not respond. CNA D placed bed tray over Resident #62 with food on a plate. Resident #62 grabbed the cup off the tray and drank it. She did not touch the food. The food was not in reach of Resident #62, and she was lying flat on her back. Observation and on 11/1/2023 at 12:15p.m., revealed the Resident #62 lying low. Her tray was out of reach and there was no one assisting her to eat. Resident #62 was able to reach her cornbread that was sitting close to her on the bed tray. Resident #62 was not able to push her tray close to her. The health shake was not present on the tray. Observation on 11/1/2023 at 12:30p.m., revealed the Resident #62 taking her foot attempting to push the tray out of her way. There was no CNA present to assist Resident #62. During an interview on 11/1/2023 at 12:13p.m. with CNA D said she usually fed Resident #62 because she was supposed to have assistance with feeding, but sometimes she will not allow it to happen. She said she did not ask Resident #62 if she would like to feed herself because Resident #62 grabbed the spoon, and she believed she wanted to eat on her own. During an interview on 11/1/2023 at 12:00p.m. with the DOR said she saw Resident #62 for SOC (start of care) because she was pocketing food. She said a family member brought it to the nursing staff's attention that Resident #62 was pocketing food. She said they have had morning meetings and care plan meetings with Resident 62's family member. She said a family member brought food to the resident and sometimes it was a matter of if the resident was going to eat the food. She said staff should be feeding her in the room or the dining room. She said the speech therapist put in the percentage of how much Resident #62 ate. She said she was not sure of the time frame from when the resident had a one on one to assist here with feeding. She Resident #62 was on a mechanical soft diet and thin liquids. During a follow-up interview on 11/1/2023 at 12:35p.m. with CNA D said she documented the meals how much the residents eat. She said if Resident #62 eats everything she will document100 percent. She said if it is most of her food but not all of it, she will document 75 percent. She said it depends on the amount of food the Resident #62 eats. During a follow-up interview on 11/1/2023 with the DOR at 1:30p.m., said to make changes regarding Resident #62 meals, they can probably have a morning meeting, update the care plan to make sure someone was consistently helping Resident #62 whether it is in the dining room or her bedroom. She said they would work on educating staff and have in-services completed. During an interview on 11/1/2023 at 3:14p.m., with the dietician, he said he checked for residents weights every 30 days, 90 days, and 180 days to see the weight differential. He said Resident #62's weight for the 180 days in April to October triggered. He said the 30 day was 4.75, the 90 day was 6.81 and the 180 day was 13.5 and it triggered just for that day. He said Resident #62's weight loss had slowed down. He said he ordered a health shake with meals for breakfast, lunch, and dinner. He said he would come to the facility on ce a week. He said he would make a recommendation if something triggered for him, to the ADON, DON, and the Administrator. He said he does a follow-up to make sure residents have received what he recommended. He said Resident #62 was getting the health shake BID. He said he does not physically see what was on the Resident #62's tray every day. He said he weighed the resident every month. During an interview on 11/2/2023 at 3:33p.m., with the DON, said 4 weeks ago she put Resident #62 on weight variance. She said she viewed her diagnosis and ordered a stat lab. She said she wanted to increase her medication, but her daughter said no. She said the SBAR was completed on October 23rd. She said Resident #62 was holding food in her mouth. During a follow-up interview on 11/2/2023 at 4:04p.m., the DON, said she would notify the doctor and the doctor will know when Resident #62 has not been receiving supplement. She said she can notify the doctor and inform him Resident #62 doctor supplement might need to be increased. She said she followed up with kitchen to find out why it was not provided. She said also talked to nurses and CNAs. She said the resident could have electrolyte imbalance. She said Resident #62 had compromised health complications, skin breakdown, because the shake has protein in it. She said if residents have issues with weight, she will go by the weight loss list. She said they discuss weight loss in the morning meetings. She said it should be care planned because if they lose weight you have to care plan to show what you are doing for the resident and if it is working. She said when she checked the facility systems Resident #62's weight because it triggered in the system. She said she checks the weight on a weekly basis. She said she started working at the facility on 10/9/23 and ordered a lab and chest x-ray. She said she decided to have a care conversation with Resident #62's family member. She said she told staff to get Resident #62 out of bed because she is high risk for aspiration. She said the nurses are supposed to make sure the interventions are being followed. She said the nurses should be able to notice the decline with the residents. She said no one did anything regarding Resident #62's weight for a while because she was told the resident went to the hospital, and she had COVID. She said she will have to look into it and find out what the policy says regarding weight loss. During an interview on 11/2/2023 at 4:26p.m., with CNA E, said she has assisted Resident #62 in eating and sometimes her sister assisted her with eating. She said usually she stayed with Resident #62 to watch her eat. She said she ate regular diets. She said sometimes Resident #62 received milkshakes or magic cups. She said the milkshake did not come with every meal. She said sometimes it did not have the shake or the magic cup, but you can go to the kitchen and ask. She said Resident #62 would eat by herself. She said she would sit her up and she feed herself. She said the Resident #62 would eat in her chair, in the room or sometimes she would eat on her bed. She said she accepted to in the dining room. She said she received in-service on feeding when she first became a CNA. During an interview on 11/2/2023 at 4:33pm the ADON she said she has been working at the facility since 2010. She said the dietician comes and weighted the residents monthly. She said it is done weekly when they first enter the facility. She said if someone wants to add a supplement. She said the nurses can request it. She said the DON is over the weight system. She said Nurse can ask doctor if they notice a weight issue with the resident. She said [NAME] does monthly and weekly weights and report it to the DON. She said Resident #62 did not trigger for weight loss back in April. She said Resident #62 was on the health shake April or May twice a day and was recently increased to 3 times a day. She was put on Remeron for appetite simulate. She said supplement may be a change in intake or not taking meals. She said they check the tray card and the nurse check the tray as well. She said they could continue to lose weight if they we're not receiving the supplements. Record Review of the facility's policy titled Nutrition Management revised on 06/2018 read in part . The purpose of this policy is to establish facility guidelines on how and when the facility obtains and documents residents weights. This policy is also to ensure that residents with significant weight loss or weight gain are rapidly identified to ensure that the resident maintains the highest quality of life and wellness in the facility. Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical demonstrates that this is not possible; and receives a therapeutic diet when there is a nutritional problem. It is best practice to use the same scale each time to weight the residents. Ensure the resident is weighed, if possible, during the same time of day. The following percentages of weight loss are considered significant: 5% in 30 days or less, 7.5% in 90 days, and 10% in 180 days. Any resident who experiences a significant weight loss or gain must be placed on the Weight Surveillance program .

Based on interview and record review the facility failed to ensure a post-discharge plan of care was developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment and the post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services for 1 of 4 residents (CR # 1) reviewed for an effective discharge process. The facility failed to complete a discharge summary prior to and after CR#1's discharge. This failure could place residents at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents and failures in the continuity of care for residents. Findings include: Record review of the undated admission sheet for CR # 1 revealed a [AGE] year-old female who was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. Her diagnoses included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), stage 4 pressure ulcer (an injury to skin and underlying tissue resulting from prolonged pressure on the skin , staged 1-4 with 4 being the most extensive), hypotension (low blood pressure) pressure ulcer of the sacral region stage 2 (injury to the skin and underlying tissue located in or around the large heavy bone at the base of spine and buttock), pain (an unpleasant sensory sensation that can range from mild, localized discomfort to agony and has both physical and emotional components) and adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). Record review of CR#1's EMR on 10/31/23 at 10:00 AM under the census heading revealed CR #1 discharged on [DATE]. There was no discharge order. Record review of CR#1's EMR on 10/31/23 at 10:02 am revealed there was no discharge summary. Record review of CR#1's EMR on 10/31/23 at 10:03 am revealed in there was no discharge note on 10/18/23, indicating what time CR#1 left the facility, how CR #1 left the facility, the location CR#1 discharged to, or the condition CR #1 was in when she left the facility. Record review of CR#1's EMR on 10/31/23 at 10:04 am revealed the discharge Minimum Data Set (MDS) dated [DATE] revealed it was coded as a Discharge-return anticipated. Record review of CR#1's EMR revealed social worker note dated: 10/18/2023 at 3:08 SW spoke to staff member with Facility B. Stated that CR#1 contacted them about a possible transfer. Spoke with CR#'1's family member who confirmed they want to see if facility will accept and transfer her. SW notified medical records to send clinicals for review. Record review of CR#1's EMR revealed nurses progress note dated 10/19/2023 at 5:50pm CR#1's family member here to pick up CR#1's belongings. Author: LVN C-LVN. (e-Signed). Interview on 11/2/23 at 3:08pm with CR#1's family member who said that they communicated with Former Administrator that CR#1 was discharging from the facility after care complaints. CR#1's family member said that CR#1 went to the hospital on 10/18/23 for a central line removal and they had the hospital case managers request CR#1's paperwork to forward to another facility and that CR#1 was accepted and admitted to the other facility from the hospital. CR#1's family member said they never received any discharge paperwork from the facility and never heard back from anyone at the facility about CR#1's discharge. The family member said they went to the facility the next day, to collect CR#1's belongings and no facility member said anything to him or had him sign anything and no one asked what happened to CR#1 or where she went. Interview with the MDS Coordinator who said they did not know why CR#1 had no discharge summary and did not know who was responsible for completing a discharge summary. Interview with SW on 11/1/23 at 11:30 am the SW said that she knew CR#1 was going to the hospital for a procedure but did not know when or exactly what time the resident left the facility. The SW said she did receive a call from another facility requesting medical records for transfer and she believed CR#1 transferred to that other facility. She said the IDT meets daily and discusses admissions and discharges. The SW said she was unsure if or when CR#1 was discussed but believed the IDT had discussed it. The SW said she did not know who was responsible for the discharge summary. Interview and record review on 11/1/23 at 11:32am with the DON she said there should have been a nursing progress note on 10/18/23 when CR#1 left the facility. She said there was no discharge summary because CR#1 left the facility to go to the hospital to have her Central Line (Central venous catheter used by doctors to give medicines, fluids, blood and or nutrition) removed. The DON said that the IDT meets daily in the morning to discuss resident changes, including admissions and discharges. She said that the nurses should have documented where CR#1 went and if she was not returning to the facility. She said she was working at the facility as the DON on 10/18/23 when CR#1 was discharged . She said that there was a note dated in September that referenced CR#1's 10/18/23 discharge to the hospital. Record review in CR#1's EMR: 10/9/2023 1:09 Nurses Note. Note Text: This writer followed up with the radiology dept at Hospital A regarding an appt for the resident to get her central line removed. Appt is on 10/18/23 at 1pm. Transport is set up with Transportation Company A with a pickup time at 1245PM. The DON said she did not know why the nurses did not write a discharge note or any note regarding CR#1's discharge to the hospital or why CR#1 did not return. Telephone interview with Regional Director of Reimbursement Services on 11/1/23 at 11:48 AM she said that any resident who was discharged from the facility, should have a discharge note indicating when the resident discharged and where the resident discharged to. Interview with DON on 11/1/23 at 5:00pm she said that CR#1 should have had a discharge note and discharge summary and that she did not know why they had not been completed. The DON said that she had only been working at the facility for a few weeks and did know who was previously assigned as being responsible for the completion of the discharge summary. She said the charge nurses were responsible for completing the discharge progress notes and discharge summary. There was no discharge summary for CR#1 provided prior to survey exit. Record review of facility provided policy and procedure dated as revised December 2016 and titled: Transfer or Discharge, Preparing a Resident for read in part: Residents will be prepared in advance for transfer. 3. Nursing services is responsible for: a. Obtaining orders for discharge or transfer . b. Preparing the discharge summary .d. Providing the resident or representative (sponsor) with required documents (i.e., Discharge Summary and Plan). h. Completing discharge note in the medical record.

Based on interview, observation and record review the facility failed to revise the comprehensive care plan for 1 of 6 residents (Resident #62) reviewed for care plans in that: Facility failed to revise Resident #62's care plan to have assistance with feeding during each meal. This failure could place all residents at risk of not having their individually needs met and place them at risk of not receiving proper nutrition. Findings include: Record review of Resident #62's admission sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included muscle weakness, unspecified abnormalities of gait and mobility (a change to your walking pattern), depression, dementia (a group of thinking and social symptoms that interferes with daily functioning), and type 2 diabetes. Record review of Resident #62's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 06 out of 15 indicating severely impaired. Record review of Resident #62's Comprehensive Care Plan revealed resident is able to feed self with set up supervision and cueing. Date initiated 10/20/2022, revision on 10/20/2022. Record review of Resident #62's MDS revealed in section GG regarding eating, number 05 which said, set up or clean up assistance: Helper sets up or clean up; resident completes activity. Helper assists only prior to or following the activity. Eating, the ability to use suitable utensils to bring food and or/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Observation on 11/1/2023 at 12:10p.m., CNA D brought Resident #62 her tray. She adjusted Resident #62's bed. CNA D asked Resident #62 how she wanted her bed positioned but she did not respond. CNA D placed bed tray over Resident #62 with food on a plate. Resident #62 grabbed the cup off the tray and drank it. She did not touch the food. The food was not in reach of Resident #62, and she was lying flat on her back. Observation and on 11/1/2023 at 12:15p.m., revealed Resident #62 lying low and not high enough to eat her meal properly. Her tray was out of reach and there were no staff member present in the room and no staff member assisted her to eat. Resident #62 was able to reach her corn bread that was sitting close to her on the bed tray. Resident #62 was not able to push her tray close to her. Observation on 11/1/2023 at 12:30p.m., revealed the Resident #62 took her foot attempting to push the tray out of her way. There was no CNA or staff member present to assist Resident #62. During an interview on 11/1/2023 at 12:13p.m. with CNA D said she Resident #62 is usually fed during her meals because she is supposed to have assistance with feeding, but sometimes she will not allow it to happen. She said she did not ask Resident #62 if she would like to feed herself because Resident #62 grabbed the spoon, and she believed she wanted to eat on her own. During an interview on 11/1/2023 at 12:00p.m. with the DOR said she saw Resident #62 for SOC (start of care) because she was pocketing food. She said a family member brought it to the nursing staff's attention that Resident #62 was pocketing food. She said they have had morning meetings and care plan meetings with Resident 62's family member. She said a family member brought food to the resident and sometimes it was a matter of if the resident was going to eat the food. She said staff should be feeding her in the room or the dining room. She said the speech therapist put in the percentage of how much Resident #62 ate. She said she was not sure of the time frame from when the resident had a one on one to assist here with feeding. She Resident #62 was on a mechanical soft diet and thin liquids. During a follow-up interview on 11/1/2023 at 12:35p.m. CNA D said she documented the meals how much the residents eat. She said if Resident #62 ate everything she will document 100 percent. She said if it was most of her food but not all of it, she will document 75 percent. She said it depends on the amount of food the Resident #62 ate. During a follow-up interview on 11/1/2023 with the DOR at 1:30p.m., said to make changes regarding Resident #62 meals, they can probably have a morning meeting, update the care plan to make sure someone was consistently helping Resident #62 whether it was in the dining room or her bedroom. She said they would work on educating staff and have in-services completed. During an interview on 11/2/2023 at 4:26p.m. CNA E, said she has assisted Resident #62 in eating and sometimes her family member assisted her with eating. She said usually she stayed with Resident #62 to watch her eat. She said she ate regular diets. She said sometimes Resident #62 received milkshakes or magic cups. She said the milkshake did not come with every meal. She said sometimes it did not have the shake or the magic cup, but you can go to the kitchen and ask. She said Resident #62 would eat by herself. She said she would sit her up and she fed herself. She said Resident #62 would eat in her chair, in the room or sometimes she would eat on her bed. She said she received in-service on feeding when she first became a CNA. Record Review of an in-service training report dated 11/1/2023 revealed, Employee: CNA D. Topic: Melas, trays, assistance with feeding. The contents or summary session: When a resident requires assistance with feedings, you do not leave the tray in the room. You do not put tray in the room until you are ready to assist that resident with feeding. Explain what you are about to do, make sure residents are properly positioned with head of bed. Record Review of an in-service training report dated 11/1/2023 revealed, Employe: Nurses, CNAs, CMAs. Topic Meals, trays, assistance with feeding. Contents or summary: You are to put a tray in the room with a resident requiring assistance with feeding until you are ready to assist them. Record Review of the facility's policy for care plan was not available.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe and sanitary environment and to help prevent the development and transmission of diseases and infections for 4 (Residents #1, #2, #46, #49) out of 4 residents reviewed for infection control. In that: 1. MA B failed to sanitize blood pressure machine being used for multiple residents. 2. Facility failed to ensure Resident #46's nephrostomy catheter bag was kept in a safe and sanitary place away from the trash. These failures could place residents at risk of cross contamination and infection. Findings include: 1. Resident #46 Review of Resident #46's face sheet reflected the resident was a [AGE] year old male admitted to the facility on [DATE]. Resident' #46'sdiagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/23/2022 at 10:07 AM the surveyor observed Resident #46 in bed in his room. He had a nephrostomy with catheter bag. The Surveyor observed the catheter bag was placed in the trash container where there was trash. Resident #46 stated he dropped the catheter bag in the trash can because it was leaking. De stated he did not want it to mess up his bed. Review of Resident #46's skin assessment reflected he currently had a hip wound which had been previously infected. On 08/23/2022 at 10:10 AM the Surveyor called the nurse on the floor LVN C who stated the resident had been told not to place the bag in the trash but he refused and still wanted to do it his own way. She said the resident would always drop the catheter in the trash can. LVN C said she worked the floor regularly but never heard the catheter bag was leaking. She stated she would provide another clean container for the patient to place the catheter bag so it would be away from the trash. LVN C stated the deficient practice could place the resident at risk for infection. On 08/25/2022 at 1:55 PM during an interview with the DON, she stated the deficient practice increased risk for infection for the resident. The DON said she was going to do in-service on the deficient practice. 2. Resident #2 Review of Resident's face sheet reflected resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2'ss diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/24/2022 at 11:07 AM, MA B was observed with three different blood pressure machines on the medication cart, each machine had a different cuff size (wrist cuff, upper arm medium cuff and upper arm large cuff). MA B was observed using the wrist-size cuff for Resident #2 after which he dropped the blood pressure machine on the medication cart among two other blood pressure machines. MA B failed to sanitize the equipment before and after using it on the resident. 3. Resident #1 Review of Resident #1's face sheet reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/24/2022 at 11:18 AM, MA B was observed using medium-size cuff machine to measure Resident #1's blood pressure, after which he dropped it on the medication cart among two other two blood pressure machines. MA B failed to sanitize the equipment before and after using it on Resident #1. 4. Resident #49 Review of Resident #49's face sheet reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/24/2022 at 11:28 AM, MA B was observed entering Resident #49's room to check his blood pressure using a large-size cuff machine. MA B removed the cuff from the resident and stated probably that was too big. MA B came out of resident's room and placed the cuff on the medication cart with the others. He then took the medium-size blood pressure cuff (same cuff he used for Resident #1 and used it for Resident #49, after which he placed it on the medication cart among two other blood pressure machines. MA B, failed to sanitize the equipment before and after using it on the resident. On 08/24/2022 at 11:47 AM during an interview with MA B, he stated he understood the deficient practice could place residents at risk for cross contamination because germs could have been transferred from one resident to another through the blood pressure machine he failed to sanitize. MA B stated he had been working with the facility for many years and had received trainings about prevention of infection. He also stated they had infection control training couple of times every month. On 08/25/2022 at 1:55 PM during an interview with the DON, she stated the residents were placed at risk for infection. She also stated they usually trained all their staff and they were also constantly having in-services on infection control and prevention. The DON said she was going to do an in-service related to infection control. On 08/24/2022 at 1:55 PM during interview with the Administrator, she stated they did not have policy that addressed sanitization of blood pressure cuff, she stated they were only following the best practice which was to sanitize equipment used for multiple residents.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate dispensing and administration of all drugs or biologicals) to meet the needs of each resident and ensure expired and discontinued drugs or biologicals were not available for use in 1of 2 nurses med cart (LVN B) and one of one medication room, reviewed for pharmacy services. The facility failed to ensure an opened [MEDICATION(S)] 1% multi-dose vial partially used, and without an open date or resident name, was removed from the nurse's med cart (LVN B). The facility failed to ensure discontinued meds were not stored next to mixed supplies of foley catheter, wound care supplies, suture removal and foley anchor kits, and a 30 pack of beer cans, in the one Med Rm. The facility failed to ensure the intravenous (IV) emergency kit was sealed and secured, and the Med Room sink without rust stains and clean. These failures could place all residents at risk of not receiving the intended therapeutic benefit of their medications, and the potential to facilitate drug diversions. Findings included: During observation on [DATE] at 1:35 p.m. of LVN B's med cart revealed an opened [MEDICATION(S)] 1% multi-dose injectable vial, partially used and without an open date. Observed no resident name on the accessed multi-dose vial. During observation on [DATE] at 1:45 p.m. of the Med Room revealed 2 medium sized containers of discontinued meds were stored next to a 30 pack beer cans and 3 medium sized cardboard boxes with mixed supplies of suture removal kits, wound care supplies, foley catheter and foley anchor kits. Further observation on [DATE] at 1:45 p.m. of the Med Room revealed an unsealed IV emergency-kit and an unsealed clear plastic container labeled emergency-kit with contents of a box of insect wipes and 5 syringes. The Med room sink was observed to have rust stains and was dirty with dust. During an interview on [DATE] at 1:55 p.m. LVN B confirmed the [MEDICATION(S)] 1% multidose vial was opened and accessed, but she did not know which resident it was used on. She stated the multidose vial was partially used, with no open date or resident name on it. LVN B stated that nurses were responsible to dispose of unlabeled, opened multidose vials and to ensure meds labeled properly. She stated she knew it should have been removed from the med cart. During an interview on [DATE] at 1:55 p.m. LVN B stated that the unsealed clear plastic container was not an E-kit although labeled emergency kit. She stated however the IV emergency-kit should have been sealed and she knew the process. She stated that we have the NYXIS (automated dispensing) for meds, which required a password from nurses. During an interview on [DATE] at 2:00 pm LVN C stated the 30 pack of beer cans found was ordered for a resident, therefore it was in the Med room. She stated she would remove the plastic container labeled emergency kit, which was not an E-kit. She stated that she did not know who placed a box of insect wipes, with the syringes on it, and she will remove the excessive boxes with mixed supllies next to discontinued meds. During an interview on [DATE] at 10:00 a.m. the ADON stated the opened [MEDICATION(S)] 1% multidose vial could be from a discharged resident on completed antibiotic, but she did not know which resident it was used on. The ADON stated an opened or accessed multidose vial should have an open date and must have a resident name if entered and used in resident's room. She stated she would in-service staff including topics on E-kit proper procedures and notifying the pharmacy. During an interview on [DATE] at 2:30 p.m. ADON stated CS staff was in the process of removing the excessive boxes in the Med room. She stated the CS staff started re-organizing the Med room and labeling the shelves. She stated we have not used the sink, maintenance cleaned the rusts around the sink and were working on replacing it. During an interview on [DATE] at 3:00 p.m. the Administrator stated moving forward we would follow up all issues on meds and the Medication room with QAPI. Record review of facility provided policy titled, Storage of Medications dated [DATE] reflected in part, medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medication storage areas are kept clean, well lit, and free of clutter and extreme temperatures. Once opened, these products will be acceptable to use until the manufacturer's expiration date is reached unless the medication is in a multi-dose injectable vial.

Intake ID # 2 Based on interview and record review the facility failed to permit one of three (CR #!) residents to return to facility after being hospitalized . The facility failed to permit CR #1 to return to the facility after hospitalization . This failure could place residents at risk of being denied readmission. Findings include: Record review of CR #1's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE], discharged with return anticipated on 07/14/22. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's discharge MDS dated [DATE] revealed a discharge date of [DATE] to a psychiatric hospital. Returned anticipated. Record review of CR#1's quarterly MDS assessment dated [DATE]revealed a BIMs score of 2 indicating he was severely impaired cognitively. Section on mood was coded as 00 meaning the facility was unable to complete CR #1's mood. Section on behavior was coded as 2 which indicated behavior occurrences multiple times. Record review of CR #1's care plan dated 05/12/20 with multiple revision dates revealed - 5/12/20- has potential to be physically aggressive (hitting) r/t Dementia, Poor impulse control-Physical aggression towards another resident after other resident threw a soiled brief at him. 12/20/20- Physical aggression towards another resident because the other resident was in his bed. 7/30/21- Physical behavior towards staff with no injury 8/25/21- Physical aggression towards another resident with no injury (pushed another resident) 9/1/21- Physical aggression towards another resident. He was hit with a spoon and this resident punched her in the eye 12/18/21- Behavior of stacking dressers on top each other, picking up chairs and threating to throw them. 1/25/22- physical behavior- hit another resident in back. 6/25/22-physical aggression towards another resident. 07/13/2022 - Physical aggression toward another Resident. 07/13/2022 - Physical aggression toward of resident rejecting care and being agitated. Interventions: Resident placed on 1:1 supervision with family member until transfer to behavioral hospital for further evaluation. Date Initiated: 7/13/2022 - Resident placed on 1:1 supervision with family member until transfer to behavioral hospital for further evaluation. 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 CR#1's nurse's documentation, reflect in parts - 7/22/2022 12:10 AM: The SW spoke with the hospital about discharge concerns. CR #1 was physically aggressive with multiple residents and staff. At this time, it was not safe for him to return to the secured unit for the safety of all residents and staff . Record review of Social Worker's note dated 07/22/22 reflect in part-The SW also spoke with the RP about safety concerns. The RP was informed that due to CR #1's aggressive behavior, the IDT has recommended that CR #1 should not return to the secured unit and a long-term Geri-psych unit may be best for his current needs. The RP was working with the hospital to find long term placement for CR #1. 7 /13/2022 9:18PM: Family member at the resident's' side. No aggression was noted at this time. 7 /14/2022 12:25 AM EMS arrived at facility to transport the resident to local psychiatric hospital, resident was transported via stretcher. The DON/Administrator/family member were notified about transfer. In an interview with the DON on 08/23/22 at 1:28 PM, she said, she started working at the facility in February of 2022. She said CR #1 had become physically aggressive with other residents and the frequency of incidents was increasing. She said CR #1 was sent out twice to a local psychiatric hospital in July of 2022, and the 2nd time CR #1 was not allowed to return to the facility due to the safety of other residents During an interview with the facility Administrator and the DON on 08/25/22 at 1:30PM, the Administrator said the facility did not re-admit CR #1 back, due to the safety of other residents at the facility. The Administrator said there was no policy on permitting residents back into the facility. The DON said CR #1 was not assessed and re-evaluated, but he was directed and re-directed according to his care plan. Record review of the facility's Admission packet did not address readmitting resident back to the facility after admission to psychiatric hospital.

Based on interview and record review, the facility failed to ensure residents who use antipsychotic drugs receive gradual dose reduction, and behavioral interventions, unless clinically necessary contraindicated, in an effort to discontinue these drugs for 1 of 14 residents ( Residents #15) reviewed for unnecessary [CONDITION(S)] meds. The facility administered an antipsychotic medication without adequate indications for use and did not obtain a rationale for continuing the concurrent use of the [CONDITION(S)] for Residents #15. This failure could place any resident on psychoactive medications and those with a diagnosis of dementia administered with antipsychotic meds, at risk for receiving unnecessary drugs and adverse reactions. Findings included: Record review of Resident #15's clinical record revealed an [AGE] year old male admitted to the facility on [DATE] with diagnoses of dementia without behavioral disturbance, anxiety disorder, [CONDITION(S)], conductive hearing loss, bilateral and [CONDITION(S)]. Record review of Resident #15's quarterly MDS assessment, dated 6/10/22 revealed Active Diagnoses did not have a check by the disorders Depression, [CONDITION(S)], Psychotic disorder or [CONDITION(S)]. Mood interview with total severity score=0. No hallucination or delusion. Resident with severely impaired cognition. He required 1 staff supervision most ADLs. Further noted he sometimes understood, and sometimes understands. Record review of undated Resident #15's care plan, revealed he had impaired thought processes related to dementia, and taking [CONDITION(S)] meds related to anxiety. The resident was at risk of experiencing adverse consequences and to monitor for side effects and effectiveness from [CONDITION(S)] drug use. Ask yes/no questions in order to determine resident's needs. Anticipate and meet needs. Record review of Resident #15's Physician's Orders dated August 2022, revealed give [MEDICATION(S)] ([MEDICATION(S)]) 1 mg 1 tab po at bedtime, for severe mood disorder, start date 8/02/22.; and [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg tab po q day, for severe mood disorder, start date 8/02/22. Further noted, reflected dx: Unspecified mood affective disorder. Record review of Resident #15's MAR dated August 2022 revealed Resident received [MEDICATION(S)] ([MEDICATION(S)]) 1 mg 1 tab po at bedtime, for severe mood disorder, start date 8/02/22 and [MEDICATION(S)] ([MEDICATION(S)]) 0.5 mg tab po q day, for severe mood disorder, start date 8/02/22. Further note reflected dx: Unspecified mood affective disorder; Antipsychotic/ Antimanic. Record review of Resident #15's, Behavior Monitoring, dated August 2022, revealed no behaviors noted. Monitoring for behaviors of yelling, screaming, cursing, hallucinations. dx severe mood disorder with psychotic symptoms. Episodes: zero. No documentation of hallucinations or delusions. During interview on 8/23/22 at 2:00 p.m. CNA E stated that Resident #15 was pleasantly confused and redirectable most of the time. She stated she had not seen him with any verbal aggression but was a sundowner (state of confusion occurring in the late p.m). During interview on 8/23/22 at 2:30 p.m. the DON stated Resident #15 had an attempted elopement behavior, a day after he tested Covid-19 (+) 7/23/22 and which could be related to increased confusion with the room change. She further stated the ADON was responsible for overseeing psych meds and ensuring with appropriate indication for its use or proper dx. During interview on 8/25/22 at 10:00 a.m. the ADON stated Resident #15 received the anti-psychotic [MEDICATION(S)] for dx of unspecified mood affective disorder; Antipsychotic/ Antimanic. She stated she would re-educate the staff, that antipsychotic/antimanic was a medication classification and not the dx. The ADON stated she was responsible to follow-up on [CONDITION(S)] meds, and she would continue monitoring them. The ADON stated the new psychological services or group just started on 8/01/22, and psych consult was called yesterday 8/24/22, to review Resident #15's [CONDITION(S)] meds. During interview on 8/25/22 at 2:30 p.m. LVN C stated the psychiatry NP consult was called and the NP ordered today to discontinue Resident #15's [MEDICATION(S)] and would be starting him on [MEDICATION(S)] (mood stabilizer) medication for dx. of mood disorder. In an interview on 8/25/22 at 3:00 p.m. the Administrator stated they would follow-up all issues on medications with QAPI. Record review of the facility's policy titled, Antipsychotic Medication Use for Residents with Dementia dated 11/01/219 reflected in part, Residents receiving antipsychotic meds for [NAME] fide psychiatry dx will be evaluated regularly according to regulation. Facility will have processes in place to monitor specific behavioral symptoms and are encouraged to use tools that enable the facility to identify changes to the specific behaviors overtime as the person with Dementia progresses in his/her disability and or situation.

Based on observation, interview and record review, the facility failed to ensure care plan were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents reviewed for care plan accuracy. (Resident # 34) --Resident #34 was care planned for IV antibiotics, he was no longer receiving. This failure placed residents at risk of receiving inappropriate care and not having their needs identified or addressed. Findings include: Record review of Resident #34's face sheet revealed a [AGE] year-old male with admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #34's quarterly MDS dated [DATE] revealed BIMS summary score of 6 indicating impaired cognitive skills for daily decision making and extensive assistance required for ADL's. Record review of Resident #34's undated care plan revealed on antibiotics X 14 days related to left ankle wound infection. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 3/30/22 at 10:00 a.m., Resident #34 was sitting in a wheelchair in his room, watching TV. There was no IV pole noted in his room. Resident #34 said his ankle is getting better, and they change the dressing every day. He said he used to have to get medicine through a tube in his arm but not now. He stated his ankle did not hurt like it used to, but the only time it did hurt was when they took the dressing off, but only for a short time. In an interview on 3/30/22 at 11:20 a.m., LVN M stated Resident #34 was on IV antibiotics for about 10 days for an infection of his ankle wound, but the antibiotics are finished, and his ankle wound is healing. In an interview on 3/31/22 at 1:00 p.m., the MDS nurse said the care plan for Resident #34 needed to be changed and the IV antibiotics taken off, since he is not on them now. She said the MDS nurses update the care plans with information from the interdisciplinary team, but this one might have been overlooked. In an interview on 3/30/22 at 2:15 p.m., the ADON stated there were no residents receiving IV medications. She said Resident #34 was on IV antibiotics for an infection to his left ankle arterial wound, but the order was for 10 days, and is completed. She said the wound is healing and it is not infected. Record review of the Wound Care progress notes dated 3/24/22 revealed Resident #34's left ankle arterial wound was healing and there was no infection. Facility Care Plan policy was requested form MDS nurse, but was not available by the time of the exit.

Based on interview and record review, the facility failed to conduct a comprehensive assessment within the required 14 calendar days after admission for 1 of 20 residents reviewed for assessments. (Resident # 70) Resident #70's comprehensive MDS assessment was not completed timely. This failure could place residents at risk of receiving inappropriate care, having an incomplete record, and not having their assessments transmitted in a timely manner. Findings included: Record review of a face sheet indicated Resident #70 was a [AGE] year-old male who was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #70's MDS assessment dated [DATE] was signed as completed on 09/22/21, 2 days past the 14 day requirement. Record review of CMS Submission Report, MDS 3.0 NH Final Validation Report dated 2/9/22 indicated Resident #70's Entry MDS was submitted on 9/22/21, Record Submitted Late: The submission date was more than 14 days after A1600 (Code refers to the entry date 9/6/21). During an interview on 3/29/22 at 1:58 p.m., the MDS Coordinator B said the DON resigned and there was no RN to sign the MDS. She said she was aware that the MDS had to be signed as complected by the RN before or by the 14th day of admission. Policy on completion of MDS was requested from the Administrator. None was not provided. The MDS coordinator said the facility follows guidelines set by CMS.

Based on observation, interview 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 and worsening of pressure ulcers to 3 of 7 residents (Resident #1, CR #2 and Resident #3) reviewed for pressure ulcers in that; -The facility failed to ensure proper monitoring of Resident #1's skin to avert the development and worsening of a pressure ulcer. As a result, Resident #1 developed a sacral St IV facility acquired pressure ulcer. -The facility failed to implement and follow Resident #1's care plan and did not turn the resident every two hours resulting in her pressure ulcer worsening from a stage II to a stage IV. -The facility failed to ensure CR #2 was properly assessed and treated for [REDACTED]. As a result, the St II sacral pressure ulcer progressed to a St III, and he developed a Stage I on his left heel and non-blanchable DTI to his right heel resulting in hospitalization . -The facility failed to ensure weekly skin assessments were accurately completed to reflect Resident #1, CR #2, and Resident #3's current skin conditions. -The facility failed to identify and treat Resident #3's 5 pressure ulcers.The facility failed to provide Resident #3 with a turning a repositioning schedule when he was left for long periods of time on his back. Resident #3's wound to his sacral pressure sore was not protected with a dressing as ordered. These failures resulted in an immediate jeopardy on 7/11/19. While the IJ was removed on 7/13/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 3 residents causing worsening pressure ulcers and placed them at risk for decline in health, infections, pain and hospitalization . Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female originally admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record Review of Resident #1's Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for ADL care requiring two or more persons for physical assist. It further revealed she had 1 stage VI pressure ulcer and treatments included pressure reducing device and pressure ulcer care. Record review of Resident #1's Care plan read in part, Focus Resident #1 has a stage 4 pressure area on the sacrum due to immobility, incontinent of bowel. Date Initiated: 01/03/2019, Goal, The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Date Initiated: 12/07/2018 Revision on 04/23/2019, Interventions Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: 12/07/2018, Woundcare as ordered per MD Date Initiated: 01/03/2019 Revision on: 01/-3/2019. Further review of Resident #1's Care plan read in part, Focus Resident has unavoidable pressure injury to buttock and at risk for deterioration of current stage (4) pressure injury areas to (SPECIFIC L[NAME]ATION) due to the following risk factors: [DIAGNOSES REDACTED].Assess/record/monitor wound healing weekly per policy .Turn/reposition resident every 2 hours, Weekly skin assessment by licensed nurse and record in resident's chart Date Initiated: 01/31/2019. Record review of Resident #1's weekly skin assessments revealed an onset date of 12/06/18 to the left buttock St II measuring 1.5 cm x 0.5 cm, depth unable to determine. There were no skin assessments documented between the onset date of 12/06/18 until 06/06/19 for the left buttock pressure ulcer. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 12/07/2018 revealed a Braden score of 11 indicating the resident was HIGH RISK for developing pressure sores. Record review of Resident #1's weekly skin assessment revealed a new sacral pressure wound with an onset date of 12/13/2018. There was no staging or measurements documented on the dates of 12/13/2018, 12/20/2018, 12/27/2018 and 12/29/2018. Record review of Resident #1's TAR for the month of (MONTH) (YEAR) revealed on 12/15/18, 12/16/18, 12/18/18, 12/23/18 no documentation for the daily wound care to buttock as ordered with a start date of 12/7/18; clean wound with NS, pat dry, apply [MEDICATION NAME] dressing, until healed every day shift. The order was discontinued on 1/3/19. Record review of Resident #1's weekly skin assessment revealed a new coccyx unstageable pressure ulcer on 01/02/2019 measuring 6.1 cm x 9.6 cm x 0.3 cm. By 01/09/2019, the coccyx pressure wound was changed from unstageable to a St IV pressure ulcer and had increased in size measuring 7.7 cm x 2.5 cm x 2.5 cm. Record review of the wound care physicians' notes dated 01/03/19 revealed a consult for wound care to manage the resident's wounds. Further record review of the wound care physicians' notes revealed the modifying factors for the patients wound as Failure to offload. Documentation in the assessment read in part, General notes: Per TN, the facility had been treating the wound prior to consulting our service. Family member have been cleansing wound with various compounds and have changed the dressing on the wound, using dressings not recommended by the facility. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 01/17/19, 01/19/19, 01/23/19, and 01/27/19 no documentation for daily wound care to the residents' sacrum as ordered; Santyl ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to SACRUM topically ever day shift for Wound Healing related to muscle wasting and atrophy, not elsewhere classified, multiple sites (M62.59)Cleanse unstageable to sacrum with Dakin solution, pat dry apply Santyl oint, apply calcium alginate rope and cover with dry dressing daily and as needed for dislodgement. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 02/17/19 night shift, 02/18/19 night shift, 02/20/19 night shift, 02/22/19 night shift, 02/24/19 night shift, 02/25/19 day, evening and night shift, 02/26/19 day shift, and 02/28/19 night shift no documentation for monitoring wound vac for placement and running at 125 mmHg to the sacral wound every shift as ordered with a start date of 2/16/19. The order was discontinued on 3/5/19. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 03/5/19 night shift, 03/11/19 evening and night shift, 03/13/19 evening and night shift, and 03/18/19 night shift, no documentation for monitoring wound vac for placement and running at 125 mmHg to the sacral wound every shift as ordered. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 04/15/19 no documentation that the wound vac was changed to the sacral wound as ordered. Further record review revealed on 04/18/19 there was no documentation for sacral wound; cleanse the wound with NS, pat dry, apply calcium alginate and cover with dry dressing Thurs-Sunday every shift for sacral wound. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 06/14/19 at 9:00AM no wound care documentation for left buttock wound to clean with NS and apply [MEDICATION NAME] daily one time daily for wound healing and for the sacral wound to clean sacrum with NS then apply Santyl and cover with calcium alginate and secure with tape daily one time a day for wound healing. Record review of Resident #1's weekly skin assessment revealed the following, by 05/09/19 the sacral wound began to deteriorate measuring 5.0 cm x 2.1 cm x 1.5 cm. By 06/13/19 the wound had further increased in size measuring 8.2 cm x 10.7 cm x 3.3 cm. Record review of the weekly skin assessments revealed the St II unstageable pressure ulcer of the left buttock deteriorated measuring 3.4 cm x 3.2 cm x 0.1 cm on 06/06/19 and by 06/27/19 it progressed to a St IV measuring 4.2 cm x4.8 cm, depth unable to determine. Record review of the wound care physicians' notes dated 06/06/19, the wound care Objective notes read in part, . the wound is deteriorating. The Patient Assessment notes read in part, Re-Debridement Rationale: . General notes: Rec facility adhere to recommended treatment; also advised family and DON to review VAC technique w/staff. New wound to L buttock may combine w/sacral wound. Record review of the wound care physicians' notes dated 6/20/19 read in part, Objective .Integumentary (Hair, Skin) Wound #1 Sacrum is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not healed .Wound #2 Left Buttock is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received an outcome of Merged. Record review of Resident #1's weekly skin assessments revealed there was no documentation for the St IV coccyx pressure ulcer from 1/9/19 to 06/26/19. On 6/27/19 the wound measured 5.5 cm x 10.6 cm x 3.2 cm. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 07/02/2019 revealed the resident was scored as high risk for developing pressure ulcers. Record review of the facility's weekly Pressure wound QI log dated 7/9/19 revealed Resident #1 developed a facility acquired pressure ulcer. On 07/9/19 the wound was characterized as a St IV pressure ulcer measuring 6 cm in x 11 cm in x 3.5 cm. The sacral wound increased in size from the previous week of 07/5/19 with the wound measuring 5.5 cm x 10 cm x3.2 cm. Observation on 07/10/19 at 10:50 AM of Resident #1 revealed, the resident was asleep, lying supine (on her back) on a low air mattress with continuous tube feeding via a PEG tube. The head of bed was elevated approximately 30 degrees. The resident had small white cloths folded in her hands due to bilateral upper extremity contractures. A Foley catheter was in place. Observation and interview on 07/10/19 at 11:14 AM with the Treatment nurse revealed she was in the residents' room setting up her supplies to perform wound care. The resident was lying supine and the TF was turned off. When asked if she knew why the residents' wound had increased in size over a matter of a week, the wound care nurse stated the wound was getting worse for a couple of weeks. She said she informed the DON that the wound was not improving about five weeks ago when there was no treatment nurse at the time, but no one did anything. She stated staff did not turn the resident every two hours like they were supposed to, further stating staff did not change the dressing and staff did not bathe or dress the resident. She said she would come into the residents' room and she would be in the same position she was in when she left her. She stated she had been completing the wound care treatments for Resident #1 for a little under a month. She stated all the residents who had pressure ulcers were facility acquired. Further observation and interview on 07/10/19 at 11:14 AM revealed the the resident was repositioned to her left side by the treatment nurse for wound care. The treatment nurse removed the dressing from the residents' sacrum and exposed the wound. The wound was located on her sacrum, left and right buttock and had a mild odor, it measured approximately 6 cm x 11 cm x 3.5 cm and was draining a moderate amount of serosanguinous fluid, the edges were rolled over with the surrounding skin black and non-blanchable. The wound base was pink with exposed bone and muscle, the left and right wound merged into one large wound with a piece of skin in the center of the two wounds remaining on the outside. The treatment nurse was able to place her finger in the left side of the wound and continue through to the right side. She stated if the skin in the center deteriorates, it would be one large opened wound. She removed the soiled calcium alginate packed into the wound and cleansed the inside with Dakin's solution. The wound was packed with calcium alginate and covered with a large dry adhesive dressing. The treatment nurse did not label the dressing stating it was facility policy not to date or initial the dressing. She further stated she did not agree with the policy because she was always taught to label the dressing so other nurses would know when the dressing was changed. She stated she was recently told by the DON and corporate office staff to stop putting the date and her initials on the dressing. The resident was positioned supine after treatment. Interview on 07/10/19 at 12:16 PM with the DON, when asked how Resident #1's wound worsened and if she was notified, the DON reported the resident's wound worsened because the previous treatment nurse did not notify her of the changes and deterioration. She further stated she did not find out about the wound worsening until she was doing weekly rounds with the wound care physician the following week. When asked if it was a facility policy not to date or initial dressings once treatment was completed, she stated, yes, it has always been a policy. Observations of Resident #1 on 07/10/19 at 12:54 PM, 1:35 PM and 2:57 PM revealed the resident was not repositioned during the observed times and remained lying supine from 12:54 PM until 4:34 PM. Further observation of Resident #1 at 4:34 PM revealed she was awake and repositioned to her right side with pillow support to her back and between her knees. The HOB was elevated approximately 30 degrees, Tube feeding was infusing. Resident was non-verbal and unable to be interviewed. CR #2 Record review of CR #2's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He discharged to the community on 5/28/19. Interview with CR #2's family member on 06/12/2019 at 3:37 PM, she stated the resident's wounds were not being treated while he was at the facility. She said she had to take him to the hospital after he was discharged from the facility because his wounds had worsened. Record review of hospital discharge physician orders [REDACTED].#2 had bilateral buttocks St II pressure ulcers. Record review of the facility's Admit/Readmit Screener dated 5/19/2019 revealed CR #2 had maceration to the residents' coccyx. Record review of CR #2's weekly wound assessment dated [DATE] revealed documentation of a St II pressure ulcer to the buttocks with moderate, bloody, clear exudate. Wound bed red with rolled under margins, surrounding skin macerated. No wound measurements were documented. Interventions listed as skin protectant daily. There was no documentation that the physician was notified of the residents wound. Record review of CR #1's Baseline Plan of Care dated 05/19/2019 revealed documentation the resident had skin risk and current skin integrity issues with the specific skin integrity issue documented as wounds. Further review of the Baseline plan of care (BCP) summary read in part, Resident bedbound and needs assistance for all ADL's. Resident goal is to dc back home. No further documentation for wound treatment or resident's goals were documented. Record review of CR #2's hospital admission wound properties dated 05/28/2019 revealed a right and left buttock deep tissue injury St 3 present on admission. Further record review of hospital admission wound properties revealed a left heel stage 1 and a right heel non blanchable pressure ulcer suspected deep tissue injury with a purple wound base present on admission. Interview on 06/13/19 at 10:34 AM with the Treatment nurse, she stated the treatment nurse quit a couple of weeks ago and that she was now doing the wound care. She said before, she was only working on the weekends. She stated CR #2 was not receiving any wound care and the resident was not being repositioned every two hours. She said when she would enter his room, his feet would be touching the foot board. She further stated that someone may have dropped the ball because the resident came to the facility with wounds, but they were not being treated while at the facility. Interview on 06/13/19 at 11:09 AM with LVN B, she stated she was the admitting nurse and CR #2 was admitted to the facility for antibiotic treatment and had Unna boots (Zinc Oxide compression bandages)on his lower legs. She stated she could not remember if he had any pressure wounds on admission, stating she saw excoriations on his buttocks, but could not recall if he had a St II pressure ulcer to his sacrum. Interview on 06/13/19 at 11:22 AM with the Treatment nurse, she stated she was not CR #2's admission nurse, so she did not complete an initial skin assessment. She said the nurse who admitted the resident should have completed a skin assessment which would have then been followed up by the DON. She further stated the resident's skin looked as if someone took a cheese grater and rubbed it across his bottom. She stated there were no orders for wound care and the CNA's were only applying a barrier cream to the affected area. She said the DON was aware of the residents' wounds and there should have been orders for wound care. Record review of CR #2's physician orders [REDACTED]. Record review of CR #2's TAR for the month of 05/19 revealed, on 05/20/19, LVN B documented a check mark for completion of the skin assessment and a 0 for the skin. There was no documentation of C for Clear or A for abnormal skin. Interview on 06/13/19 at 12:04 PM with CNA A, she stated (CR #2) had something on his buttocks, and there was some bleeding on the right side. She stated all nurses were aware and that she was applying a barrier cream to his buttock when he was changed because it was the facility's policy. Interview on 06/13/19 at 12:07 PM with LVN B, she stated she thinks she was CR #2's admitting nurse, further stating she did not do an initial skin assessment because he came in late. She said the facility had a treatment nurse at the time and the treatment nurse usually did the assessment. Further interview on 06/14/19 at 9:16 AM with LVN B, she stated she was the admitting nurse for CR #2, stating he had some wounds, but the resident did not want to be moved, so she did not assess any skin that was not exposed or that she could not visualize. When asked if she reviewed the hospital physician orders [REDACTED]. She said she contacted the on-call NP because it was late, and she informed the NP the resident was admitted with wraps to his legs and she reviewed the residents' medication list. She said she could not get orders for his wounds because she did not assess the wounds. She further stated she could not recall if the residents skin was assessed during his stay at the facility. Record review of CR #2's nursing progress notes dated 5/19/19 by LVN B read in part, Health team called back and orders where confirmed with the NP for Team Health. Resident awake, and alert x 3 multiple wounds noted denies any pain. Team Health Np to call in medication [MEDICATION NAME] 10/325 mg tablet. Called and spoke to representative from Pharmacy abt orders faxed. O2 on at 2 liters nasal cannula. Resident transferred from (hospital) by ambulance 3 attendants 97.4 78 18 136/75. Further record review of CR #2's nursing progress notes revealed the following, from admission on 05/19/19 until discharge on [DATE], there was no documentation on residents St II pressure wounds or any treatment. Interview on 06/13/19 at 12:18 PM with the DON, she stated CR #2 had macerated skin when she assessed him. She stated she completed the initial admission skin assessment, stating the resident had Unna boots to his BLE and they were put on by the hospital. When asked if she notified the resident's admitting physician about the St II pressure ulcer to the residents' buttocks, she said the resident was only at the facility for a week, so the physician was not contacted. She further stated it is the facility's policy to treat wound(s) if it was a St II or less with a topical barrier cream/zinc oxide and if the wound worsened and/or did not improve in two weeks, then she would notify the wound care physician, so the wound could be treated. She stated the wound care physician would be contacted for treatment only if a resident was admitted to the facility with a St III or IV, or with wounds that were not healing. She further stated the facility must show that the wound was not healing, and the treatment was not working before calling the wound care physician. Further interview with the DON on 06/13/19 at 12:18PM, she stated CR #2 had bleeding when his buttock was wiped, or anytime the skin was manipulated it would bleed, further stating which is good, it shows the skin is viable. She said she only saw the resident on that Saturday, Sunday and Monday stating the treatment nurse should have assessed the resident. Interview on 06/14/19 at 11:15 AM with Physician A, CR #2's PCP at the facility, she stated she was never notified the resident had a St II pressure ulcer. She said she saw the resident before he left but did not do a skin assessment, so she was not aware of any wounds. She further stated typically she would not turn the resident and assess the skin unless the nurses at the facility notified her there were wounds. She said she thinks if a resident has a St II with or without bleeding, they should contact the physician for wound care orders. She stated the facility has a wound care physician and he could have been contacted. Resident #3 Record review of the medical record face sheet revealed Resident #3 was [AGE] years old and admitted on [DATE] with Full Code Status. [DIAGNOSES REDACTED]. Record review of the Wound Care Physician's skin assessment Progress note dated 6/20/19 for Resident #3 revealed in part: *initial consult 6/20/19, Integumentary: wound #1 Left Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Measurements are 7.4cm length X 12.1cm width with no measurable depth there is no amount of drainage noted. Wound #2 Sacrum is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer Measurements are 6.9cm length 7.7cm width X 0.1cm depth. There is a moderate amount of drainage noted which has no odor. *Wound orders: Wound #1 Left heel wound cleansing & dressings: Cleanse/Irrigate wound with NS/water - skin prep every day, Wound #2 Sacrum Wound Cleansing & Dressings: Cleanse/Irrigate wound with NS/water, apply Santyl ointment, apply Calcium Alginate, Cover with dry dressing, change dressing every day and as needed. Additional Orders: Implement pressure relieving measures and offloading as tolerated. Record review of the Wound Care Physician's skin assessment Progress note dated 6/27/19 for Resident #3 revealed in part: * Integumentary: wound #1 Left Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Measurements are 5.2cm length X 10.8cm width with no measurable depth there is a none amount of drainage noted which has no odor. Wound #2 Sacrum is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer Measurements are 7.1cm length 8.3cm width X 0.4cm depth. There is a moderate amount of drainage noted which has no odor. Procedures: Wound #2 surgical debridement Subcutaneous was removed along with devitalized tissue:necrotic/eschar and slough. Post Debridment Measurements: 7.1cm length X 8.3cm width X 0.5cm depth. *Wound orders: Wound #1 Left heel wound cleansing & dressings: Cleanse/Irrigate wound with NS/water - skin prep every day, Wound #2 Sacrum Wound Cleansing & Dressings: Cleanse/Irrigate wound with NS/water, apply Santyl ointment, apply Calcium Alginate, Cover with dry dressing, change dressing every day and as needed. Additional Orders: Implement pressure relieving measures and offloading as tolerated. Record review of facility weekly wound logs dated 6/20/19, 6/27/19 and 7/5/19 revealed in part; Resident #3's wounds: *left heel was unstageable-deep tissue injury, facility acquired 6/18/19 *sacrum was Unstageable-slough and/or eschar, facility acquired 6/18/19 Record Review of Resident #3's undated care plan revealed no Care plan for Skin Breakdown, Prevention or risks. The review was conducted on 7/4/19. Observation and interview during wound care treatment of [REDACTED].#3 was laying on a regular mattress, slightly turned to his right side, with his head down and a positioning pillow in his back. Resident #3 was sleeping with a sheet covering him with his feet exposed and a kerlix dressing to his left foot. Resident #3 did not have his feet elevated and did not have any heel protectors on. His feet were not off-loaded and were resting on the mattress. When Treatment Nurse 2 called his name and was explaining what she was going to do to him Resident #3 responded in a unclear slurred speech with a decreased L[NAME]. Treatment Nurse 2 stated to surveyor that the only Pressure Ulcer needing care today was the left heel and that Resident #3 had a sacral wound but the treatment was not due today. Treatment Nurse 2 set-up her supplies. In a continued observation on 7/4/19 at 10:00am, CNA Y raised Resident #3's left leg, Treatment Nurse 2 removed kerlix from left foot and exposed a non-odorous, purple, non-draining DTI on the posterior area of heel. After the Treatment Nurse finished the Treatment to the heel surveyor requested to see the rest of Resident #3s skin since left heel was not source of malodorous smell. Resident #3 had a Blister to his right heel that was pink in color and not blanching and both his calves had pink to red patches resembling a rash. Treatment Nurse 2 stated the resident has had these rashes and that there was no order for the blister DTI to right heel. CNA Y and Treatment Nurse then rolled Resident #3 to his right side removed his urine soiled brief and the malodorous foul smell was stronger. On Resident #3's sacral area was a non-dated foam dressing centered on necrotic tissue, that was not covering approximately a 2-inch border of the necrotic wound. Treatment Nurse 2 stated this is not the type of dressing that should be on here, it's not even covering the whole wound she further stated that feces could get in the wound and cause infection. Treatment Nurse 2 described wounds as follows: #1 half-dollar size, necrotic, leathery, macerated white edges 0.5cm; #2 Intergluteal cleft area, nickel size, brown black necrotic, drainage, hard to touch with macerated edges; #3 right buttock, dime size, black necrotic, draining, hard to touch with macerated edges; #4 Lower right buttock area, hard, slime drainage, quarter size, slough, brown and yellow color; Treatment Nurse 2 stated the wound smells bad, looks bad and possibly infected because there is about 3-4 inch border around the whole wound that is red and warm to touch. Interview on 7/4/19 at 10:33am with Treatment Nurse 2 revealed she was PRN and not the regular treatment nurse and that she has been doing wounds for 3 days and has not had any formal training in wound management as Treatment nurse. When asked if she had a guide where she would refer to when treating pressure sores or wounds, she said No, she would go to the DON for treatment or call the doctor. She further said that CNA's could go to her or the charge nurses to notify any new skin conditions. She stated that she has asked the DON for some training but she has not gotten back with her about it. Interview on 7/4/19 at 12:04pm with the DON revealed she called the MD for Resident #3 and was started on Santyl for odor and discontinued the duoderm dressing, and to clean the wound with dakins solution apply calcium alginate and cover with dressing daily. She stated she had not seen the wound and agreed to go see it with surveyor. Observation and Interview with DON on 7/4/19 at 12:45pm DON said Resident #3's sacral wound did not meet criteria for a duoderm. She said it was macerated with eschar and she removed the duoderm dressing dated 7/4/19. DON stated that wound staging was done by her or the Doctor and that the nurses do not stage wounds, and that wound rounds were done weekly on Thursdays with herself and the Doctor. DON said Resident #3's right buttock wound had a foul odor and it was macerated, red outer edges, coccyx area necrotic and draining. She said there was slough unstageable to lower right buttock area, she stated stage 2 open area 0.5cm circle to right and left lower buttock. She counted out 5 wounds when asked how many wounds on the sacral area. DON stated the left heel had an unstageable, black DTI, Right heel had non-blanchable DTI Blister. DON also noted the Resident #3 had MASD between his legs and groin creases and scrotum. DON stated Resident #3 had a stage 2 to his left ear. In a phone interview on 7/4/19 at 1:50pm with the PCP for Resident #3 revealed she was not aware of Resident #3 wounds and did not know he had that many. She stated that she knew there was a wound care doctor that visited the facility weekly and she did not know what he was doing. She stated that it sounded like the wound on the sacral area was infected and would get the facility to take a picture of it and send it to her so that she could give orders and go from there. Record Review of Facility hand typed List of Residents with Pressure ulcers provided to surveyor on 7/4/19 revealed Resident #3 had a Left heel DTI and Sacral Pressure. There was no record of Resident #3's Stage 1 Blister/DTI to his right heel or the Stage 2 to his left ear. Record review of facility weekly wound logs dated 7/5/19 revealed no documentation of the resident's right heel DTI or Stage 2 to left ear. On 7/10/19 Record review of CR #3's undated care plan revealed in part: -Resident #3 had two un-stageable DTI's to right heel, an un-stageable pressure injury to left heel, pressure ulcer to buttock/sacrum -Interventions: Administer treatments as ordered and monitor for effectiveness. Report improvements and declines to the MD. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Report loose dressing to Treatment Nurse. Turn and repositio

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 4 of 8 residents reviewed for neglect (Resident #1, CR #2, Resident #4 and Resident #3). -The facility failed to have an effective wound management and prevention program to ensure residents do not develop pressure ulcers or have pressure ulcers worsen. Resident #1 had a facility acquired stage IV pressure wound and CR #2's wound worsened to a stage III. - The facility failed to ensure there was procedures in place to accurately and timely assess and treat resident's skin conditions. CR #2 did not receive treatment for [REDACTED]. Resident #4 was not assessed on readmission and 14 staples remained in the resident's scalp for a total of 27 days. Resident #3's wound treatment orders were not followed and his skin was inaccurately assessed. - The facility failed to ensure there was effective training to educate LVN staff to monitor, assess and accurately treat pressure wounds in the absence of a treatment nurse. - The facility failed to have a policy and procedure for prevention of skin breakdown and failed to have a system in place to reposition residents who were at risk of or had pressure ulcers. -The facility failed to ensure physician's orders were obtained and followed for necessary care and treatment for [REDACTED].#2, Resident #3 and Resident #4. These failures resulted in an immediate jeopardy on 7/11/19. While the IJ was removed on 7/13/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 4 residents and placed them at risk of further neglect, pain, decline in health and/or hospitalization . Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female originally admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record Review of Resident #1's Quarterly MDS dated [DATE] revealed the resident was totally dependent on staff for ADL care requiring two or more persons for physical assist. It further revealed she had 1 stage VI pressure ulcer and treatments included pressure reducing device and pressure ulcer care. Record review of Resident #1's Care plan read in part, Focus Resident #1 has a stage 4 pressure area on the sacrum due to immobility, incontinent of bowel. Date Initiated: 01/03/2019, Goal, The resident will have intact skin, free of redness, blisters or discoloration by/through review date. Date Initiated: 12/07/2018 Revision on 04/23/2019, Interventions Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: 12/07/2018, Woundcare as ordered per MD Date Initiated: 01/03/2019 Revision on: 01/-3/2019. Further review of Resident #1's Care plan read in part, Focus Resident has unavoidable pressure injury to buttock and at risk for deterioration of current stage (4) pressure injury areas to (SPECIFIC L[NAME]ATION) due to the following risk factors: [DIAGNOSES REDACTED].Assess/record/monitor wound healing weekly per policy .Turn/reposition resident every 2 hours, Weekly skin assessment by licensed nurse and record in resident's chart Date Initiated: 01/31/2019. Record review of Resident #1's weekly skin assessments revealed an onset date of 12/06/18 to the left buttock St II measuring 1.5 cm x 0.5 cm, depth unable to determine. There were no skin assessments documented between the onset date of 12/06/18 until 06/06/19 for the left buttock pressure ulcer. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 12/07/2018 revealed a Braden score of 11 indicating the resident was HIGH RISK for developing pressure sores. Record review of Resident #1's weekly skin assessment revealed a new sacral pressure wound with an onset date of 12/13/2018. There was no staging or measurements documented on the dates of 12/13/2018, 12/20/2018, 12/27/2018 and 12/29/2018. Record review of Resident #1's TAR for the month of (MONTH) (YEAR) revealed on 12/15/18, 12/16/18, 12/18/18, 12/23/18 no documentation for the daily wound care to buttock as ordered with a start date of 12/7/18; clean wound with NS, pat dry, apply [MEDICATION NAME] dressing, until healed every day shift. The order was discontinued on 1/3/19. Record review of Resident #1's weekly skin assessment revealed a new coccyx unstageable pressure ulcer on 01/02/2019 measuring 6.1 cm x 9.6 cm x 0.3 cm. By 01/09/2019, the coccyx pressure wound was changed from unstageable to a St IV pressure ulcer and had increased in size measuring 7.7 cm x 2.5 cm x 2.5 cm. Record review of the wound care physicians' notes dated 01/03/19 revealed a consult for wound care to manage the resident's wounds. Further record review of the wound care physicians' notes revealed the modifying factors for the patients wound as Failure to offload. Documentation in the assessment read in part, General notes: Per TN, the facility had been treating the wound prior to consulting our service. Family member have been cleansing wound with various compounds and have changed the dressing on the wound, using dressings not recommended by the facility. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 01/17/19, 01/19/19, 01/23/19, and 01/27/19 no documentation for daily wound care to the residents' sacrum as ordered; Santyl ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to SACRUM topically ever day shift for Wound Healing related to muscle wasting and atrophy, not elsewhere classified, multiple sites (M62.59)Cleanse unstageable to sacrum with Dakin solution, pat dry apply Santyl oint, apply calcium alginate rope and cover with dry dressing daily and as needed for dislodgement. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 02/17/19 night shift, 02/18/19 night shift, 02/20/19 night shift, 02/22/19 night shift, 02/24/19 night shift, 02/25/19 day, evening and night shift, 02/26/19 day shift, and 02/28/19 night shift no documentation for monitoring wound vac for placement and running at 125 mmHg to the sacral wound every shift as ordered with a start date of 2/16/19. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 03/5/19 night shift, 03/11/19 evening and night shift, 03/13/19 evening and night shift, and 03/18/19 night shift, no documentation for monitoring wound vac for placement and running at 125 mmHg to the sacral wound every shift as ordered. The order was discontinued on 3/23/19. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 04/15/19 no documentation that the wound vac was changed to the sacral wound as ordered. Further record review revealed on 04/18/19 there was no documentation for sacral wound; cleanse the wound with NS, pat dry, apply calcium alginate and cover with dry dressing Thurs-Sunday every shift for sacral wound. Record review of Resident #1's TAR for the month of (MONTH) 2019 revealed on 06/14/19 at 9:00am no wound care documentation for left buttock wound to clean with NS and apply [MEDICATION NAME] daily one time daily for wound healing and for the sacral wound to clean sacrum with NS then apply Santyl and cover with calcium alginate and secure with tape daily one time a day for wound healing. Record review of Resident #1's weekly skin assessment revealed the following, by 05/09/19 the sacral wound began to deteriorate measuring 5.0 cm x 2.1 cm x 1.5 cm. By 06/13/19 the wound had further increased in size measuring 8.2 cm x 10.7 cm x 3.3 cm. Record review of the weekly skin assessments revealed the St II unstageable pressure ulcer of the left buttock deteriorated measuring 3.4 cm x 3.2 cm x 0.1 cm on 06/06/19; and by 06/27/19 it progressed to a St IV measuring 4.2 cm x4.8 cm, depth unable to determine. Record review of the wound care physicians' notes dated 06/06/19, the wound care Objective notes read in part, . the wound is deteriorating. The Patient Assessment notes read in part, Re-Debridement Rationale: . General notes: Rec facility adhere to recommended treatment; also advised family and DON to review VAC technique w/staff. New wound to L buttock may combine w/sacral wound. Record review of the wound care physicians' notes dated 6/20/19 read in part, Objective .Integumentary (Hair, Skin) Wound #1 Sacrum is a Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not healed .Wound #2 Left Buttock is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received an outcome of Merged. Record review of Resident #1's weekly skin assessments revealed there was no documentation for the St IV coccyx pressure ulcer from 1/9/19 to 06/26/19. On 6/27/19 the wound measured 5.5 cm x 10.6 cm x 3.2 cm. Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk dated 07/02/2019 revealed the resident was scored as high risk for developing pressure ulcers. Record review of the facility's weekly Pressure wound QI log dated 7/9/19 revealed Resident #1 developed a facility acquired pressure ulcer. On 07/9/19 the wound was characterized as a St IV pressure ulcer measuring 6 cm in x 11 cm in x 3.5 cm. The sacral wound increased in size from the previous week of 07/5/19 with the wound measuring 5.5 cm x 10 cm x3.2 cm. Observation on 07/10/19 at 10:50 AM of Resident #1 revealed, the resident was asleep, lying supine (on his back) on a low air mattress with continuous tube feeding via a PEG tube. The head of bed was elevated approximately 30 degrees. The resident had small white cloths folded in her hands due to bilateral upper extremity contractures. A Foley catheter was in place. Observation and interview on 07/10/19 at 11:14 AM with the Treatment nurse revealed she was in the residents' room setting up her supplies to perform wound care. The resident was lying supine and the TF was turned off. When asked if she knew why the residents' wound had increased in size over a matter of a week, the wound care nurse stated the wound was getting worse for a couple of weeks. She said she informed the DON that the wound was not improving about five weeks ago when there was no treatment nurse at the time, but no one did anything. She stated staff did not turn the resident every two hours like they were supposed to, further stating staff did not change the dressing and staff did not bathe or dress the resident. She said she would come into the residents' room and she would be in the same position she was in when she left her. She stated she had been completing the wound care treatments for Resident #1 for a little under a month. She stated all the residents who had pressure ulcers were facility acquired. Further observation and interview on 07/10/19 at 11:14 AM revealed the resident was repositioned to her left side by the treatment nurse for wound care. The treatment nurse removed the dressing from the residents' sacrum and exposed the wound. The wound was located on her sacrum, left and right buttock and had a mild odor, it measured approximately 6 cm x 11 cm x 3.5 cm and was draining a moderate amount of serosanguinous fluid, the edges were rolled over with the surrounding skin black and non-blanchable. The wound base was pink with exposed bone and muscle, the left and right wound merged into one large wound with a piece of skin in the center of the two wounds remaining on the outside. The treatment nurse was able to place her finger in the left side of the wound and continue through to the right side. She stated if the skin in the center deteriorates, it would be one large opened wound. She removed the soiled calcium alginate packed into the wound and cleansed the inside with Dakin's solution. The wound was packed with calcium alginate and covered with a large dry adhesive dressing. The treatment nurse did not label the dressing stating it was facility policy not to date or initial the dressing. She further stated she did not agree with the policy because she was always taught to label the dressing so other nurses would know when the dressing was changed. She stated she was recently told by the DON and corporate office staff to stop putting the date and her initials on the dressing. The resident was positioned supine after treatment. Interview on 07/10/19 at 12:16 PM with the DON, when asked how Resident #1's wound worsened and if she was notified, the DON reported the resident's wound worsened because the previous treatment nurse did not notify her of the changes and deterioration. She further stated she did not find out about the wound worsening until she was doing weekly rounds with the wound care physician the following week. When asked if it was a facility policy not to date or initial dressings once treatment was completed, she stated, yes, it has always been a policy. Observations of Resident #1 on 07/10/19 at 12:54 PM, 1:35 PM and 2:57 PM revealed the resident was not repositioned during the observed times and remained lying supine from 12:54 PM until 4:34 PM. Further observation of Resident #1 at 4:34 PM revealed she was awake and repositioned to her right side with pillow support to her back and between her knees. The HOB was elevated approximately 30 degrees, Tube feeding was infusing. Resident was non-verbal and unable to be interviewed. CR #2 Record review of CR #2's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. He discharged to the community on 5/28/19. Interview with CR #2's family member on 06/12/2019 at 3:37 PM, she stated the resident's wounds were not being treated while he was at the facility. She said she had to take him to the hospital after he was discharged from the facility because his wounds had worsened. Record review of hospital discharge physician orders provided by the facility dated 05/19/2019 revealed CR #2 had bilateral buttocks St II pressure ulcers. Record review of the facility's Admit/Readmit Screener dated 5/19/2019 revealed CR #2 had maceration to the residents' coccyx. Record review of CR #2's weekly wound assessment dated [DATE] revealed documentation of a St II pressure ulcer to the buttocks with moderate, bloody, clear exudate. Wound bed red with rolled under margins, surrounding skin macerated. No wound measurements were documented. Interventions listed as skin protectant daily. There was no documentation that the resident's physician was notified of the residents wound. Record review of CR #1's Baseline Plan of Care dated 05/19/2019 revealed documentation the resident had skin risk and current skin integrity issues with the specific skin integrity issue documented as wounds. Further review of the Baseline plan of care (BCP) summary read in part, Resident bedbound and needs assistance for all ADL's. Resident goal is to dc back home. No further documentation for wound treatment or resident's goals were documented. Record review of CR #2's hospital admission wound properties dated 05/28/2019 revealed a right and left buttock deep tissue injury St 3 present on admission. Further record review of hospital admission wound properties revealed a left heel stage 1 and a right heel non blanchable pressure ulcer suspected deep tissue injury with a purple wound base present on admission. Interview on 06/13/19 at 10:34 AM with the Treatment nurse, she stated the treatment nurse quit a couple of weeks ago and that she was now doing the wound care. She said before, she was only working on the weekends. She stated CR #2 was not receiving any wound care and the resident was not being repositioned every two hours. She said when she would enter his room, his feet would be touching the foot board. She further stated that someone may have dropped the ball because the resident came to the facility with wounds, but they were not being treated while at the facility. Interview on 06/13/19 at 11:09 AM with LVN B, she stated she was the admitting nurse and CR #2 was admitted to the facility for antibiotic treatment and had Unna boots (Zinc Oxide compression bandages) on his lower legs. She stated she could not remember if he had any pressure wounds on admission, stating she saw excoriations on his buttocks, but could not recall if he had a St II pressure ulcer to his sacrum. Interview on 06/13/19 at 11:22 AM with the Treatment nurse, she stated she was not CR #2's admission nurse, so she did not complete an initial skin assessment. She said the nurse who admitted the resident should have completed a skin assessment which would have then been followed up by the DON. She further stated the resident's skin looked as if someone took a cheese grater and rubbed it across his bottom. She stated there were no orders for wound care and the CNA's were only applying a barrier cream to the affected area. She said the DON was aware of the residents' wounds and there should have been orders for wound care. Record review of CR #2's physician orders dated 05/20/2019 read in part, Nursing to perform weekly skin assessment every day shift every 7 days(s) Document C for Clear and A for abnormal. Record review of CR #2's TAR for the month of 05/19 revealed, on 05/20/19, LVN B documented a check mark for completion of the skin assessment and a 0 for the skin. There was no documentation of C for Clear or A for abnormal skin. Interview on 06/13/19 at 12:04 PM with CNA A, she stated (CR #2) had something on his buttocks, and there was some bleeding on the right side. She stated all nurses were aware and that she was applying a barrier cream to his buttock when he was changed because it was the facility's policy. Interview on 06/13/19 at 12:07 PM with LVN B, she stated she thinks she was CR #2's admitting nurse, further stating she did not do an initial skin assessment because he came in late. She said the facility had a treatment nurse at the time and the treatment nurse usually did the assessment. Further interview on 06/14/19 at 9:16 AM with LVN B, she stated she was the admitting nurse for CR #2, stating he had some wounds, but the resident did not want to be moved, so she did not assess any skin that was not exposed or that she could not visualize. When asked if she reviewed the hospital physician orders which showed documentation of St II pressure ulcers to his left and right buttock, she stated she could not recall. She said she contacted the on-call NP because it was late, and she informed the NP the resident was admitted with wraps to his legs and she reviewed the residents' medication list. She said she could not get orders for his wounds because she did not assess the wounds. She further stated she could not recall if the residents skin was assessed during his stay at the facility. Record review of CR #2's nursing progress notes dated 5/19/19 by LVN B read in part, Health team called back and orders where confirmed with the NP for Team Health. Resident awake, and alert x 3 multiple wounds noted denies any pain. Team Health Np to call in medication [MEDICATION NAME] 10/325 mg tablet. Called and spoke to representative from Pharmacy (about) orders faxed. O2 on at 2 liters nasal cannula. Resident transferred from (hospital) by ambulance 3 attendants 97.4 78 18 136/75. Further record review of CR #2's nursing progress notes revealed the following, from admission on 05/19/19 until discharge on [DATE], there was no documentation on residents St II pressure wounds or any treatment. Interview on 06/13/19 at 12:18 PM with the DON, she stated CR #2 had macerated skin when she assessed him. She stated she completed the initial admission skin assessment, stating the resident had Unna boots to his BLE and they were put on by the hospital. When asked if she notified the resident's admitting physician about the St II pressure ulcer to the residents' buttocks, she said the resident was only at the facility for a week, so the physician was not contacted. She further stated it is the facility's policy to treat wound(s) if it was a St II or less with a topical barrier cream/zinc oxide and if the wound worsened and/or did not improve in two weeks, then she would notify the wound care physician, so the wound could be treated. She stated the wound care physician would be contacted for treatment only if a resident was admitted to the facility with a St III or IV, or with wounds that were not healing. She further stated the facility must show that the wound was not healing, and the treatment was not working before calling the wound care physician. Further interview with the DON on 06/13/19 at 12:18PM, she stated CR #2 had bleeding when his buttock was wiped, or anytime the skin was manipulated it would bleed, further stating which is good, it shows the skin is viable. She said she only saw the resident on that Saturday, Sunday and Monday stating the treatment nurse should have assessed the resident. Interview on 06/14/19 at 11:15 AM with Physician A, CR #2's PCP at the facility, she stated she was never notified the resident had a St II pressure ulcer. She said she saw the resident before he left but did not do a skin assessment, so she was not aware of any wounds. She further stated typically she would not turn the resident and assess the skin unless the nurses at the facility notified her there were wounds. She said she thinks if a resident has a St II with or without bleeding, they should contact the physician for wound care orders. She stated the facility has a wound care physician and he could have been contacted. Resident #4 Record review of Resident #4's face sheet revealed she was [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of hospital wound notes dated 06/11/2019 revealed Resident #4 had a posterior laceration to her head in three directions with a total of 14 staples placed. Record review of Resident #4's Admit/Readmit Screener dated 06/14/2019 revealed no documentation of staples to resident's scalp. Further record review of the resident's weekly skin assessments dated 06/17/19, 06/24/2019, 07/01/2019, and 07/08/2019 revealed no documentation of staples to residents' scalp. Record review of Resident #4's nursing progress notes dated 06/14/2019 at 2:53PM read in part, client readmitted to facility arrived via w/c in stable condition client is awake and alert no signs and symptoms of distress noted no c/o pain resp are even and unlabored cvs 142/84 97.2 84 22 MD notified of arrival and all medication verified client currently walking down hallway in unit pleasant mood noted will cont to observe. Note documented by LVN C. There was no documentation of staples to resident's scalp. Further record review of nursing progress notes dated 07/8/2019 at 1:06PM read in part, SW met briefly with resident's (family member) who wanted to know why staples were still in the resident's head. Also noted (family member) stated those should have been out long-time ago. SW informed (family member) that she would inform DON. SW informed DON who would resolve issue of concern . Record review of Resident #4's Care plan revealed she was at risk for falls, date initiated 02/07/2019. The care plan was not updated to reflect the resident's actual fall on 06/11/2019, or staples to her head after re-admission to the facility on [DATE]. Interview on 07/09/19 at 10:26 AM with LVN D, she stated she only works PRN and does not work on the locked unit all the time. She stated she was not working the day the resident had a fall, but she was made aware about the staples prior to last week. When asked how long should staples normally remain in place and who removed them at the facility, she stated usually 10 days to 2 weeks and the DON or treatment nurse would remove them. Further interview with LVN D at 10:26 AM, she stated normally the physician would assess the resident once admitted and they would write the orders for the staple removal. She then stated the nurse who completed the admission assessment should have assessed the residents skin and documented the staples and if there were no orders to remove the staples, the nurse should have followed up with the physician to obtain the orders. She stated the resident's nurse was responsible for completing skin assessments and should notify the physician if the staples were not removed after two weeks. Observation on 07/09/19 of Resident #4 at 10:34 AM, the resident was observed on the locked unit ambulating down the hall. She was not interviewable. There were small scabs noted on the skin of the resident's scalp where the staples were removed. Interview on 07/09/2019 at 10:50 AM with the DON, she stated the staples were not removed from Resident #4's scalp because the physician thought the NP had removed them, further stating the physician thought she had put in orders for the staple removal. When asked how long should staples remain in skin, she stated normally they are left in for 10-14 days. She said if there was dehiscence (wound separation) then the staples would remain in place. When asked what should have happened to prevent the staples from being left in the resident's scalp, she stated the nurse should have assessed the resident' skin per policy and informed the physician there were no orders for removal. Interview on 07/09/19 at 11:11 AM with Physician A, she stated, This of course was an oversite, that's fine, I don't think the patient was harmed, I think this happens all the time. She further stated it was not a huge deal. She said she was aware the resident had staples because she had written it in her notes, stating she documented to remove the staples in 10-12 days, but forgot to write the order and that the Ball was dropped. She stated the facility was under a lot of pressure stating, It was both of us, we could have put an order in on admission. She said she was notified by the facility yesterday 07/08/19 that the staples were still in the resident's scalp and she gave orders at that time for removal. Interview on 07/09/19 at 1:24 PM with the Treatment nurse, she stated she was not aware the resident had staples because she was not the admitting nurse and there was no documentation of staples on the admission assessment. She stated the nurse should have informed the physician there were staples in the residents' scalp to obtain orders for removal. She further stated staples were normally kept in a resident's skin for about two weeks. When asked if she entered notes on the weekly skin assessments dated 6/24/19, 7/01/19 and 07/08/19 today because there was no documentation of staples when the skin assessments were reviewed earlier today, she stated she was told by the DON she needed to edit/enter a note stating the resident had staples and was trying to take them out. Record review of Resident #4's weekly skin assessments dated 06/24/2019, 07/01/2019, and 07/08/2019 in the electronic medical record revealed the notes were edited on 7/9/19 and included that Resident #4 had staples in her scalp. Interview on 07/09/19 at 2:38 PM with LVN C, she stated staples usually were left in the resident's skin for 3-5 days or whenever the physician orders the staples to be removed. She stated she was the resident's admitting nurse, but she did not assess or document the staples because she was trying to give the resident a shower and the resident was fighting. She further stated she was grateful the resident's family member was present because she assisted her with the shower. LVN C could not state why a skin assessment was not entered after the shower was completed. She said whoever did the admission assessment and the weekly skin assessments should document the presence of staples and follow up with the physician if there were no orders, or if they were not removed. When asked why there was no documentation of staples in the resident's scalp on the weekly skin assessment or any follow up with the physician to obtain orders for removal, LVN C stated, I can't answer that. Resident #3 Record review of the medical record face sheet revealed Resident #3 was [AGE] years old and admitted on [DATE] with Full Code Status. [DIAGNOSES REDACTED]. Record review of the Wound Care Physician's skin assessment Progress note dated 6/20/19 for Resident #3 revealed in part: *initial consult 6/20/19, Integumentary: wound #1 Left Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Measurements are 7.4cm length X 12.1cm width with no measurable depth there is no amount of drainage noted. Wound #2 Sacrum is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer Measurements are 6.9cm length 7.7cm width X 0.1cm depth. There is a moderate amount of drainage noted which has no odor. *Wound orders: Wound #1 Left heel wound cleansing & dressings: Cleanse/Irrigate wound with NS/water - skin prep every day, Wound #2 Sacrum Wound Cleansing & Dressings: Cleanse/Irrigate wound with NS/water, apply Santyl ointment, apply Calcium Alginate, Cover with dry dressing, change dressing every day and as needed. Additional Orders: Implement pressure relieving measures and offloading as tolerated. Record review of the Wound Care Physician's skin assessment Progress note dated 6/27/19 for Resident #3 revealed in part: * Integumentary: wound #1 Left Heel is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Measurements are 5.2cm length X 10.8cm width with no measurable depth there is a none amount of drainage noted which has no odor. Wound #2 Sacrum is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer Measurements are 7.1cm length 8.3cm width X 0.4cm depth. There is a moderate amount of drainage noted which has no odor. Procedures: Wound #2 surgical debridement Subcutaneous was removed along with devitalized tissue:necrotic/eschar and slough. Post Debridment Measurements: 7.1cm length X 8.3cm width X 0.5cm depth. *Wound orders: Wound #1 Left heel wound cleansing & dressings: Cleanse/Irrigate wound with NS/water - skin prep every day, Wound #2 Sacrum Wound Cleansing & Dressings: Cleanse/Irrigate wound with NS/water, apply Santyl ointment, apply Calcium Alginate, Cover with dry dressing, change dressing every day and as needed. Addition

Based on observation, interview and record review, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 7 residents reviewed for Administration (Resident#1, Resident #3, Resident #4, and CR#2). The Administrator failed to: -Monitor the DON to ensure that nursing staff were assessing residents accurately and timely and that nursing staff were following policy and procedures regarding wound prevention, skin assessments and notifying physician of new or worsening wounds. - Develop a policy and procedure to prevent skin breakdown. The DON failed to: -Supervise trained nursing staff to ensure they were performing accurate and timely skin assessments, documenting assessment findings, and notifying the wound care and/or admitting physician of new or worsening wounds. -Monitor nurses and CNA's to ensure they were repositioning residents frequently. -Provide effective training to ensure staff were competent to assess and perform accurate and timely skin assessments. -Monitor the wound management and prevention program to ensure residents do not develop pressure ulcers or have pressure ulcers worsen. These failures resulted in an immediate jeopardy on 7/11/19. While the IJ was removed on 7/13/19 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 4 residents, requiring 1 resident to be hospitalized , and placed them at risk of not being provided with appropriate and timely medical intervention and prevention of pressure wounds resulting in decline in their quality of care, quality of life, hospitalization and possible death. Findings include: Interview on 07/10/19 at 12:16 PM with the DON, when asked what system was in place for pressure ulcer prevention/skin management, she stated weekly skin assessments were completed by the treatment nurse or DON, stating each hall was assigned a day of the week. She said if a new pressure ulcer was identified, she was notified immediately and if the treatment nurse is at the facility, the nurse would assess and treat. She said anytime a wound was identified or there were skin changes, interventions were put into place by the nurse until the treatment nurse can assess the resident. She further stated if the treatment nurse was not at the facility, the responsible nurse would measure the wound and start a treatment based on the assessment and if the treatment nurse did not agree, she could change the treatment. She said the wound care physician saw residents on Thursdays around 10:00 AM unless he rescheduled, stating she was with the wound care physician during his weekly rounds. She stated the facility had weekly S[NAME] meetings on Thursdays at 11:00 AM so she may not be able to round with the wound care physician if the meeting runs over. She stated the Administrator, Medical director, DON, ADON, SW, AD, Dietary manager, and Therapy attend the weekly S[NAME] meetings to discuss residents' wounds and treatments. In an interview on 7/10/19 at 2:00pm with the DON, she stated that she was not the person who managed the wound system. She said the Medical Director was managing the wound system. DON stated she just managed and monitored the treatment nurse to make sure the wound and treatments were completed. She said she just gathered the information and reviewed it with the Medical Director on Thursdays. DON said on Thursdays they discuss progression, healing and reviewed the wound care doctors notes and what was discussed on wound rounds. When asked why Resident #3's treatment did not match the wound care physician's orders [REDACTED]. Interview on 07/12/19 at 1:54 PM with the Administrator, when asked why she thought the IJ occurred, she stated she was in the hospital when CR #2 was admitted , stating he was only at the facility for a week, so she was not aware of what occurred with the resident. She stated she normally reviewed a lot of what was done at the facility such as the skin assessments, further stating, I drive a lot of what's done. She was unable to state where the system failed for Resident #1 and stated she remembered calling in an incident with Resident #4, but no one notified her the resident was readmitted with staples. She said staff were supposed to notify her for everything, a bruise, fall, injury of unknown origin. She said the staff were aware of the skin management system and they were trained, stating they had frequent in-services, there were clinical meetings, 1:1 in-services through their computer-based training system. She said, I will be honest, I have had several people with multiple training because they were not reporting in a timely manner. She further stated the DON took on a lot of work and when a treatment nurse was trained and gets acclimated the nurse ends up leaving. Interview on 07/12/19 at 3:42 PM with the DON, she stated the skin management system in place involved the nurses completing a skin assessment on admission and verifying medications. She stated if there was a wound identified, the nurse must do treatment immediately and when the treatment nurse assesses the resident the following day, she will contact the attending physician if he/she is not in agreement with the treatment the admitting nurse started. She further stated the wound care physician only saw residents with worsening wounds, residents admitted with a St III or IV, or wounds that the facility could not heal. She stated if a resident had a St I or II, we can use skin prep, calcium alginate and if it deteriorates, the wound care physician will be contacted. She stated the facility follows the AMT guidelines for wound care. Further interview with the DON on 7/12/19 at 3:42 PM, when asked why she felt the IJ occurred, she stated she thought the nurses failed to assess the resident's skin, document and carry forward the assessments. She said the physician thought the staples were removed for Resident #4, but the nurses were not documenting every single time they assessed her. She stated the treatment nurse for Resident #1 should have followed the skin management policy, but her family member got sick and she did not return to the facility, further stating by the time she found out about the wound, it had worsened. She stated the staff knew what to do, stating when a resident was admitted they each have a sheet that each nurse signs when they complete the task and if a task was not completed, the next shift will complete it and sign off on the sheet. Interview on 06/13/19 at 12:18 PM with the DON, she stated it is the facility's policy to treat wound(s) if it was a St II or less with a topical barrier cream/zinc oxide and if the wound worsened and/or did not improve in two weeks, then she would notify the wound care physician, so the wound could be treated. She stated the wound care physician would be contacted for treatment only if a resident was admitted to the facility with a St III or IV, or with wounds that were not healing. She further stated the facility must show that the wound was not healing, and the treatment was not working before calling the wound care physician. interview on 07/10/19 at 11:14 AM , the Treatment Nurse said it was facility policy not to date or initial the dressing. She further stated she did not agree with the policy because she was always taught to label the dressing so other nurses would know when the dressing was changed. She stated she was recently told by the DON and corporate office staff to stop putting the date and her initials on the dressing. The resident was positioned supine after treatment. Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female originally admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Resident #1 required total assistance for activities of daily living and was non-verbal. She was at high risk for pressure ulcers. Her care plan indicated she needed to be repositioned every 2 hours and to assess the skin weekly. Resident #1 had a skin assessment on 12/6/18 that noted a new left buttock stage II wound. There was no further documentation of the wound on the left buttock until 6/6/19. By 6/6/19, the left buttock wound was larger in size. By 6/27/19 it was a stage VI pressure wound measuring 4.2 cm x4.8 cm, depth unable to determine. Resident #1 had a skin assessment on 12/13/18 that noted a new sacral pressure wound that was not staged or measured. A skin assessment dated [DATE] noted the sacral wound was getting larger. By 6/13/19, the wound had increased in size measuring 8.2cm x 10.7cm x 3.3cm. Resident #1 had a skin assessment on 1/2/19 that noted a new coccyx unstageable wound. By 1/9/19 the wound was a Stage VI. There was no documentation for the St IV coccyx pressure ulcer from 1/9/19 to 06/26/19. On 6/27/19 the wound measured 5.5 cm x 10.6 cm x 3.2 cm. Wound care physician's notes dated 1/9/19 noted the modifying factors for the patient's wound was failure to offload. Record review of the wound care physicians' notes dated 06/06/19, the wound care Objective notes read in part, . the wound is deteriorating. The Patient Assessment notes read in part, Re-Debridement Rationale: . General notes: Rec facility adhere to recommended treatment; also advised family and DON to review VAC technique w/staff. New wound to L buttock may combine w/sacral wound. Observations of Resident #1 on 07/10/19 at 12:54 PM, 1:35 PM and 2:57 PM revealed the resident was not repositioned during the observed times and remained lying supine from 12:54 PM until 4:34 PM. Further observation of Resident #1 at 4:34 PM revealed she was awake and repositioned to her right side with pillow support to her back and between her knees. The HOB was elevated approximately 30 degrees, Tube feeding was infusing. Resident was non-verbal and unable to be interviewed. Interview on 07/10/19 at 11:14 AM with the Treatment nurse, when asked if she knew why the residents' wound had increased in size over a matter of a week, the wound care nurse stated the wound was getting worse for a couple of weeks. She said she informed the DON that the wound was not improving about five weeks ago when there was no treatment nurse at the time, but no one did anything. She stated they did not turn the resident every two hours like they were supposed to, further stating they did not change the dressing and they did not bathe or dress the resident. She said she would come into the residents' room and she would be in the same position she was in when she left her. She stated she had been completing the wound care treatments for Resident #1 for a little under a month. She stated all the residents who had pressure ulcers were facility acquired. Interview on 07/10/19 at 12:16 PM with the DON, when asked how Resident #1's wound worsened and if she was notified, the DON reported the resident's wound worsened because the previous treatment nurse did not notify her of the changes and deterioration. She further stated she did not find out about the wound worsening until she was doing weekly rounds with the wound care physician the following week. When asked if it was a facility policy not to date or initial dressings once treatment was completed, she stated, yes, it has always been a policy. CR #2 Record review of CR#2's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED].'' Record review of hospital discharge physician orders [REDACTED].#2 had bilateral buttocks St II pressure ulcers. Record review of CR #2's weekly wound assessment dated [DATE] revealed documentation of a St II pressure ulcer to the buttocks with moderate, bloody, clear exudate. Wound bed red with rolled under margins, surrounding skin macerated. No wound measurements were documented. Interventions listed as skin protectant daily. There was no documentation that the physician was notified of the residents wound. Record review of nursing progress notes revealed the following, from admission on 05/19/19 until discharge on [DATE], there was no documentation on residents St II pressure wounds or any treatment. Record review of CR #2's hospital admission wound properties dated 05/28/2019 revealed a right and left buttock deep tissue injury St 3 present on admission. Further record review of hospital admission wound properties revealed a left heel stage 1 and a right heel non blanchable pressure ulcer suspected deep tissue injury with a purple wound base present on admission. Interview on 06/13/19 at 10:34 AM with the Treatment nurse, she stated the treatment nurse quit a couple of weeks ago and that she was now doing the wound care. She said before, she was only working on the weekends. She stated CR #2 was not receiving any wound care and the resident was not being repositioned every two hours. She said when she would enter his room, his feet would be touching the foot board. She further stated that someone may have dropped the ball because the resident came to the facility with wounds, but they were not being treated while at the facility. Interview on 06/13/19 at 11:22 AM with the Treatment nurse, she stated she was not CR #2's admission nurse, so she did not complete an initial skin assessment. She said the nurse who admitted the resident should have completed a skin assessment which would have then been followed up the DON. She further stated the resident's skin looked as if someone took a cheese grater and rubbed it across his bottom. She stated there were no orders for wound care and the CNA's were only applying a barrier cream to the affected area. She said the DON was aware of the residents' wounds and there should have been orders for wound care. Interview on 06/13/19 at 12:04 PM with CNA A, she stated (CR #2) had something on his buttocks, and there was some bleeding on the right side. She stated all nurses were aware and that she was applying a barrier cream to his buttock when he was changed because it was the facility's policy. Interview on 06/13/19 at 12:07 PM with LVN B, she stated she thinks she was CR #2's admitting nurse, further stating she did not do an initial skin assessment because he came in late. She said the facility had a treatment nurse at the time and the treatment nurse usually did the assessment. Interview on 06/13/19 at 12:18 PM with the DON, she stated CR #2 had macerated skin when she assessed him. She stated she completed the initial admission skin assessment, stating the resident had unna boots to his BLE and they were put on by the hospital. When asked if she notified the resident's admitting physician about the St II pressure ulcer to the residents' buttocks, she said the resident was only at the facility for a week, so the physician was not contacted. Further interview with the DON on 06/13/19 at 12:18, she stated CR #2 had bleeding when his buttock was wiped, or anytime the skin was manipulated it would bleed, further stating which is good, it shows the skin is viable. She said she only saw the resident on that Saturday, Sunday and Monday stating the treatment nurse should have assessed the resident. Interview on 06/14/19 at 11:15 AM with Physician A, CR #2's PCP at the facility, she stated she was never notified the resident had a St II pressure ulcer. She said she saw the resident before he left but did not do a skin assessment, so she was not aware of any wounds. She further stated typically she would not turn the resident and assess the skin unless the nurses at the facility notified her there were wounds. She said she thinks if a resident has a St II with or without bleeding, they should contact the physician for wound care orders. She stated the facility has a wound care physician and he could have been contacted. Resident #3 Record review of the medical record face sheet revealed Resident #3 was [AGE] years old and admitted on [DATE] with Full Code Status. [DIAGNOSES REDACTED]. Record Review of Resident #3's undated care plan revealed no Care plan for Skin Breakdown, Prevention or risks. The review was conducted on 7/4/19. Record review of facility weekly wound logs dated 6/20/19, 6/27/19 and 7/5/19 revealed in part; Resident #3's wounds: *left heel was unstageable-deep tissue injury, facility acquired 6/18/19 *sacrum was Unstageable-slough and/or eschar, facility acquired 6/18/19 In an observation on 7/4/19 at 10:00am with Treatment Nurse 2, on Resident #3's sacral area was a non-dated foam dressing centered on necrotic tissue, that was not covering approximately a 2-inch border of the necrotic wound. Treatment Nurse 2 stated this is not the type of dressing that should be on here, it's not even covering the whole wound she further stated that feces could get in the wound and cause infection. Treatment Nurse 2 described wounds as follows: #1 half-dollar size, necrotic, leathery, macerated white edges 0.5cm; #2 Intergluteal cleft area, nickel size, brown black necrotic, drainage, hard to touch with macerated edges; #3 right buttock, dime size, black necrotic, draining, hard to touch with macerated edges; #4 Lower right buttock area, hard, slime drainage, quarter size, slough, brown and yellow color; Treatment Nurse 2 stated the wound smells bad, looks bad and possibly infected because there is about 3-4 inch border around the whole wound that is red and warm to touch. In a phone interview on 7/4/19 at 1:50pm with the PCP for Resident #3 revealed she was not aware of Resident #3 wounds and did not know he had that many. She stated that she knew there was a wound care doctor that visited the facility weekly and she did not know what he was doing and was not confident in his abilities. She stated that it sounded like the wound on the sacral area was infected and would get the facility to take a picture of it and send it to her so that she could give orders and go from there. Observations on 7/10/19 of Resident #3 while in bed revealed resident had no top sheet, he had bilateral heel protectors and was laying on an air mattress. Between 8:am to 10:48am he had not been repositioned, laying on back, slightly to left side. No direct care staff has entered room. Surveyors in room across from Resident #3's room, able to have full visual and hearing of resident #3's room. At 11:53am, 12:20pm and 1:30pm he was in the same position. At 2:00pm, he was in the same position and wound treatment being provided. After treatment, he was repositioned to his back at 2:45pm, head of bed high at approximately 70-80 degree angle. At 4:03pm and 6:00pm, he remained on his back, head of bed high, 70-80 degree angle. In an interview on 7/10/19 at 12:18 pm with the DON revealed Resident #3's wounds started with redness on a Friday and when they came back on the Monday or Tuesday it was a stage 2 or 3. DON looked in the computer system and stated a skin assessment was done on 6/21/19 and it just said yes for wounds and referred it to the Treatment Nurse. She said on Monday 6/24/19 Treatment Nurse documented skin/wound assessment for left heel stage 2 and sacral pressure ulcer with measurements, red and a little black in color, no odor and no pain. DON said that she found out about the pressure ulcer on 6/24/19. She revealed she was the one who did the wound treatments M-F, but she was helping out until she could hire someone fulltime. DON stated sacral wound orders started 6/21/19. Then after looking at computer stated it looked like the 1st wound was on 6/19/19 and it was treated with normal saline and skin prep OTA. She said the sacral wound did not have an assessment but did have a Nurses note dated 6/16/19 with measurements and documentation that it was necrotic. DON further stated Resident #3 had no wounds prior to 6/16/19. DON stated that they got a wound care consult on 6/22/19, and 6/27/19 was the first visit. Resident #4 Record review of Resident #4's face sheet revealed she was [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. Record review of hospital wound notes dated 06/11/2019 revealed Resident #4 had a posterior laceration to her head in three directions with a total of 14 staples placed. Record review of Resident #4's Admit/Readmit Screener dated 06/14/2019 revealed no documentation of staples to resident's scalp. Further record review of the resident's weekly skin assessments dated 06/17/19, 06/24/2019, 07/01/2019, and 07/08/2019 revealed no documentation of staples to residents' scalp. Further record review of nursing progress notes dated 07/8/2019 at 13:06 read in part, SW met briefly with resident's (family member) who wanted to know why staples were still in the resident's head. Also noted daughter stated those should have been out long-time ago. SW informed (family member) that she would inform DON. SW informed DON who would resolve issue of concern . Interview on 07/09/2019 at 10:50 AM with the DON, she stated the staples were not removed from the resident's scalp because the physician thought the NP had removed them, further stating the physician thought she had put in orders for the staple removal. When asked how long should staples remain in skin, she stated normally they are left in for 10-14 days. She said if there was dehiscence (wound separation) then the staples would remain in place. When asked what should have happened to prevent the staples from being left in the resident's scalp, she stated the nurse should have assessed the resident' skin per policy and informed the physician there were no orders for removal. Interview on 07/09/19 at 11:11 AM with Physician A, she stated, This of course was an oversite, that's fine, I don't think the patient was harmed, I think this happens all the time. She further stated it was not a huge deal. She said she was aware the resident had staples because she had written it in her notes, stating she documented to remove the staples in 10-12 days, but forgot to write the order and that the Ball was dropped. She stated the facility was under a lot of pressure stating, It was both of us, we could have put an order in on admission. She said she was notified by the facility yesterday 07/08/19 that the staples were still in the resident's scalp and she gave orders at that time for removal. Interview on 07/09/19 at 1:24 PM with the Treatment nurse, she stated she was not aware the resident had staples because she was not the admitting nurse and there was no documentation of staples on the admission assessment. She stated the nurse should have informed the physician there were staples in the residents' scalp to obtain orders for removal. She further stated staples were normally kept in a resident's skin for about two weeks. When asked if she entered notes on the weekly skin assessments dated 6/24/19, 7/01/19 and 07/08/19 today because they was no documentation of staples when the skin assessments were reviewed earlier today, she stated she was told by the DON she needed to edit/enter a note stating the resident had staples and was trying to take them out. Interview on 07/09/19 at 2:38 PM with LVN C, she stated staples usually were left in the resident's skin for 3-5 days or whenever the physician orders [REDACTED]. She stated she was the resident's admitting nurse, but she did not assess or document the staples because she was trying to give the resident a shower and the resident was fighting. She further stated she was grateful the resident's family member was present because she assisted her with the shower. LVN C could not state why a skin assessment was not entered after the shower was completed. She said whoever did the admission assessment and the weekly skin assessments should document the presence of staples and follow up with the physician if there were no orders, or if they were not removed. When asked why there was no documentation of staples in the resident's scalp on the weekly skin assessment or any follow up with the physician to obtain orders for removal, the LVN stated, I can't answer that. Refer to F600 and F686 for more detailed information. Record review of Facility copied AMT copyright dated (YEAR) educational information titled Pressure Ulcer Staging and Recommended Products read in part: Stage 1 Nonblanchable [DIAGNOSES REDACTED]-Topical agents Barrier products per facility protocol . Suspected DTI Depth Unknown- may protect with non-adhesive dry dressing, eliminate pressure as much as possible, off-load heels, monitor diligently and document tissue characteristics daily as DTI can change rapidly . Category/Stage II Partial thickness skin Loss Recommended Guidelines Clean per facility protocol prior to applying new dressings. Dry to Minimum Drainage: Apply Hydrogel (sheet, gauze, or filler) or [MEDICATION NAME]. Moderate to Heavy Drainage: Apply [MEDICATION NAME] Gauze or [MEDICATION NAME]. Cover with a dry secondary dressing (as needed). Record review of Facility Skin Management System undated policy and procedure revealed in part: 1A. Pressure Ulcer, Venous Ulcers and arterial Ulcers and surgical sites will be documented on the weekly wound observation . Daily treatments are documented on the TAR. 1B. Bruises, rashes, and other non-pressure areas are to be documented on the Weekly skin Integrity Form. 2.If a new pressure sore is noted, a weekly wound observation form will be started. 7. Refer to AMT wound Algorithms for suggested protocols. 8. Follow the specialty bed algorithm should a specialty mattress be needed. 10. Keep open lines of communication with physicians, families and residents regarding status of wounds. 12. All dressings are to be dated and initiated upon completion. Record review of the facility's Skin Management System read in part, 1. A head to toe body assessment will be completed on every resident upon admission or readmission. 2. Routine weekly checks will be completed on the Skin Observation Tool on every resident if skin is intact it will be noted as such. If a new pressure sore is noted, a Weekly Wound Observation Form will be started .7. Refer to AMT wound algorithms for suggested protocols .10. Keep open lines of communication with physicians, families, and resident regarding status of wounds .12. All dressings are to be dated and initialed upon completion. The facility Administrator and the DON were notified on 7/11/19 at 5:36pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 7/12/19. After several revisions, the final Plan of Removal was accepted on 7/12/19 at 4:55pm. The plan of removal included the following: Plan of IJ Removal for Focused care at Allenbrook 7/11/19 Abuse and Neglect and Quality of care Plan of action o In-service all Nursing staff (Charge Nurses and CNAs) on ANE prohibition regarding skin management on 7/12/19. o Head to toe skin assessment was completed on all current residents on 7/12/19. o Licensed Nurses (this includes weekend Nurses) will be provided with In-services on 7/12/19, all Licensed Nurses will be educated before start of work assignment. Weekend Nurses will be provided with these in-services by the DON on 7/13/19 The in-services include: 1. Proper skin assessments on admissions, weekly, and with a change in condition. 2. Identifying a change in condition of the wound, and reporting it to attending physician 3. Daily wound monitoring, weekly assessment per schedule, and document the assessment on PCC 4. Turning, and repositioning every 2 hours to prevent pressure injury 5. Receiving orders on wounds from attending physician, and ensure orders were carried out timely. 6. Certified Nursing aide will be trained on turning, and repositioning of high risk residents, and to report changes to skin condition to charge Nurses. o Resident #3 was provided with Air mattress and heel protector to improve wound healing on 7/8/19, the wounds were re-assessed to ensure proper staging on 7/12/19. The MD/RP were updated on wounds, and care plan was updated on 7/12/19. Turning and repositioning process was put in place on 7/12/19. o Resident #4 staples were removed on 7/8/19. o Resident #1 wound was re-assessed, MD/RP were updated on wound, turning and repositioning process was put in place on 7/12/19. o DON/ADON will be educated on monitoring of skin assessment, wound assessment, MD notification, and wound documentation by the regional Nurse by 7/12/19. Responsible staff DON/Designee Validation/Monitoring tool - Skilled check/posttest will be conducted post in-service to ensure understanding of the process is established. - 24- Hour report will be reviewed daily by the DON/Designee to identify new admit, and verify skin assessment was completed on admission, and wounds identified were assessed and treatment obtained for the identified wound. - UDA tool will be used to audit daily skin assessment for schedule, and completion by DON/designee. The surveyors confirmed the Plan to lower the Immediate Jeopardy had been implemented sufficiently by: Interviews with different staff including nursing staff from multiple shifts on 07/12/19 and 07/13/19 revealed they had been in-serviced on A/N/E, skin assessments, weekly reviews, notifying the physician, Administrator and DON of any skin changes and turning residents every two hours. Observations on 07/13/19 revealed CNA's were observed turning high risk residents every two hours. Observations on 07/13/19 revealed nurses performing complete skin assessments appropriately on residents. Record review of in-services conducted included, proper skin assessments upon admission, weekly and with a change of condition and notifying the physician in a timely manner, wound monitoring daily and documentation, turning every two hours for wound prevention, entering orders in a timely manner once received by the physician, and abuse and neglect prohibition. Record review of the facility Assessment History Report dated 07/12/19 revealed all current residents received head-to-toe skin assessments. Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 07/13/19 most of the staff had been in-serviced. During the monitoring phase between 7/11/19-7/13/19, interviews were conducted by the surveyor on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on wound monitoring, weekly skin assessments, stop and watch c

Based on interview and record review, the facility failed to residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record receive gradual dose reductions and behavioral interventions in an effort to discontinue these drugs for one resident (Resident #1) reviewed for unnecessary medications in that; -The facility failed to ensure that Resident #1 had appropriate indications for the concomitant use of 5 different [MEDICAL CONDITION] medications and did not document a clinical rationale for using multiple medications in the same pharmacological class. - The facility failed to effectively monitor side effects of Resident #1's [MEDICAL CONDITION] medication use, resulting in 12 falls in three months. The last fall the resident sustained [REDACTED]. This failure affected 1 resident and placed him at risk of potential adverse events and hospitalization from concomitant use of [MEDICAL CONDITION] medications. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old-male originally admitted to the facility on [DATE] and re-admitted on [DATE] after being admitted to a behavioral health hospital, with [DIAGNOSES REDACTED]. Record review of Resident #1's Medication Administration Record [REDACTED]. Record review of Resident #1's MAR for the month of January, 2019 revealed the resident was administered [MEDICATION NAME] 5 mg PO daily and 10 mg PO at bedtime started on 1/8/19; [MEDICATION NAME] 75 mg PO BID and 100 mg PO at bedtime, started on 1/08/19; [MEDICATION NAME] 5 mg PO daily, started on 1/10/19; [MEDICATION NAME] tablet delayed release 250 mg 1 tablet PO three times daily, started on 1/08/19 and [MEDICATION NAME] 0.5 mg PO every 6 hours PRN, started on 1/8/19 for 14 days. [DIAGNOSES REDACTED]. Record review of the facility's Behavior Management - Psychoactive Medication Therapy Consent forms dated 01/08/19 revealed [MEDICATION NAME] and [MEDICATION NAME] were ordered for the specific treatment of [REDACTED]. The proposed course of the medication was checked for 1 month. Further review of Resident #1's Consent forms revealed there was no consent for the [MEDICATION NAME] medication in (MONTH) 2019. Record review of pharmacy MRR dated 01/09/2019 read in part, Resident on multiple antipsychotic medications with [DIAGNOSES REDACTED]. Please ensure proper documentation to support diagnosis. A written note off to the side read in part, Referral sent to psych 1-11-19. Record review of Resident #1's Behavioral medicine/Progress note dated 1/14/19 read in part, Patient is new to (behavioral health company). This is my first time assessing the patient. Follow up on medication management and behavioral s/x related to: dementia, [MEDICAL CONDITION]. Further review of the progress note read in part, Current Psych Meds: Pt receiving [MEDICATION NAME] 0.25 mg POq6h PRN anxiety .started by FNP 1/8/19. [MEDICATION NAME] 5 mg, PO qday & 10 mg qhs [MEDICAL CONDITION] .started by FNP 1/8/19, [MEDICATION NAME] 75 mg, PO bid, & 100 mg, qhs .started 1/8/19, [MEDICATION NAME] 10 mg, qhs .started 1/08/19, [MEDICATION NAME] 5 mg, PO qday .started 1/10/19. Record review of nursing progress notes revealed a total of two episodes of Resident #1 wandering/elopement dated on 1/9/2019 and 1/29/2019. Record review of Resident #1's Behavioral medicine/Progress note dated 1/21/19 read in part, Clinical status and Impressions: D/C [MEDICATION NAME], (pt was placed on three anti-psychotics, no dx to support either). Will f/u in one week. Record review of Resident #1's care plan dated 1/21/19 revealed the resident had actual falls with no injuries on 1/19/19, 1/20/19, 2/2/19, 2/10/19 and twice on 2/11/19. Interventions included diagnostic tests, check for range of motion, non-slid shoes, monitor for sleepiness/agitation, and pharmacy consult to evaluate medications. Record review of Resident #1's care plan dated 1/23/19 revealed he was at risk of adverse consequences related to [MEDICAL CONDITION] medication use. as evidence by: Behavior management .potential for injury to self or others . Interventions included, Administer [MEDICAL CONDITION] medications as ordered by the physician. Monitor for side effects and effectiveness .consult with pharmacy, MD to consider dosage reduction .Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy . Further review of the care plan dated 1/23/19 revealed Resident #1 had the potential to be physically aggressive and fighting with roommate, residents and staff. Examples given were, Taking personal belongings from others (sic) resident room .Removing mattress off of bed frame . For interventions, it was noted the trigger physical aggression was personal space. Interventions included, Administer medications as ordered .Analyze times of day, places, circumstances, triggers . psychiatric .consults as indicated .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress . Record review of facility nursing progress notes revealed Resident #1 had two episodes of aggressive behaviors. The first episode was documented on 01/27/19, the progress note read in part, CNA approached nurse told me had walked into another room to redirect resident and witnessed resident banging his hand into glass picture frame bleeding .nurse noted laceration to 5th finger right hand cleaned laceration with soap and water. The second behavior was documented on 2/22/2019 which read in part, Awake, alert, awake all night, attempted to get urine for ua c&s explained procedure started hitting writer in stomach and said wanted to slap this writer. Unable to get urine, unable to redirect. Record review of Resident #1's MAR for the month of February, 2019 revealed the resident was administered [MEDICATION NAME] 5 mg PO daily and 10 mg PO at bedtime; [MEDICATION NAME] 75 mg PO BID and 100 mg at bedtime, [MEDICATION NAME] tablet 250 mg delayed release 1 tablet three times daily and [MEDICATION NAME] 0.5 mg PO every 6 hours PRN started on 02/18/19 for 14 days. [DIAGNOSES REDACTED]. Resident #1 received [MEDICATION NAME] 0.5mg on the following dates: 2/19/19, 2/22/19, 2/26/19 and 2/27/19. Record review of Resident #1's nursing progress notes dated 2/12/2019 read in part, . (family member) here, saw resident sleeping in chair told her we can put him to bed. Cna in room with writer. Attempting to put resident in bed told us no don't put him to bed better he goes in room d/r so he can be watched. Asked why he was sleepy to writer, told gave her pain medication this am, resident arouses easily. Assisted to d/r awake and alert; asked wanted to stay in w/c stated: 'Yes' has periods of confusion (family member) had questions regarding medications spoke with (ADON) . Further record review of facility nursing progress notes dated 2/13/2019 read in part, Resident is S/P fall day day 2/3. Resident had been sitting and sleeping in his wheelchair. Resident states he wants to go to his house. NOD suggested resident relax and speak with his (family member) about visiting his home. Resident's (family members) came to visit resident today . Further record review of facility nursing progress notes dated 02/14/2019 read in part, Resident is s/p fall day day 3/3. Resident has been sitting and sleeping in his wheelchair. Resident continues trying to get out of his wheelchair. Resident's balance is not good .Resident continues to state he wants to go to his house . Record review of Resident #1's MAR from (MONTH) 1,2019 thru (MONTH) 13, 2019 revealed the resident was administered [MEDICATION NAME] 100 mg daily at bedtime, started 3/01/19 and discontinued on 03/10/19, [MEDICATION NAME] 150 mg PO daily at bedtime, started 3/10/19, [MEDICATION NAME] 75 mg BID discontinue date of 03/11/19, [MEDICATION NAME] 10 mg PO BID with a discontinue date of 03/11/19, [MEDICATION NAME] 5 mg PO daily start date 03/19/19 and [MEDICATION NAME] Sprinkles delayed release 125 mg, give 250 mg (2 capsules) three times daily, start date 03/11/19. [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. [MEDICATION NAME] tablet 50 mg give 3 tablet by mouth at bedtime for [MEDICAL CONDITION] related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. [MEDICATION NAME] tablet 5 mg give 5 mg by mouth one time a day related to unspecified dementia with behavioral disturbance for seven days. Record review of Resident #1's care plan dated 3/8/19 revealed the resident was physically aggressive and on 3/7/19, he punched a CNA in the face. Interventions included, Analyze times of day, places, circumstances, triggers and what de-escalates behavior and document .when the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress . Record review of Psychiatric Subsequent assessment dated [DATE] revealed Resident #1 was referred to psychiatric services for [MEDICAL CONDITION], anxiety/worrying, confusion, memory loss and dementia. The NP's history of present illness read in part, Patient is a [AGE] year old Hispanic Male admitted to the facility on [DATE] for Long Term Care. Patient has a history of [MEDICAL CONDITION]; Dementia with Behaviors. Patient seen per staff request after having punched a staff member. Patient exhibits aggressive and restless behaviors. At this time of visit, patient sitting up in wheelchair, awake and alert. Reports that he is doing good. Restlessness noted. Patient unable to provide historical data. Progress notes review, no suicidal or homicidal ideations. Patient with recent fall with injury. UA collected-negative. Intake adequate. No issues with sleep reported. Medical records reviewed, primary care recently increase [MEDICATION NAME] to 150mg at bedtime, and [MEDICATION NAME] was increased to 10mg twice a day. NP's review of history revealed psychiatric history of [MEDICAL CONDITION]; dementia with behaviors. Further review of the NP's psychiatric assessment notes revealed the assessment/plan which read in part, 1. [MEDICAL CONDITION]ly to GMC. Uncontrolled. Case discussed with supervision psychiatrist. Decrease [MEDICATION NAME] to 5 mg twice a day x 7 days then discontinue. Increase [MEDICATION NAME] to 50 mg twice a day and keep bedtime dosage at 150mg. Change [MEDICATION NAME] to Sprinkles which is more effective in treating [MEDICAL CONDITION] symptoms because of immediate release. Medications to target disorganized thoughts, delusions, hallucinations, and aggressive behaviors. Goal to maintain patient on minimum medications necessary to treat conditions and avoid multiple antipsychotics. Record review of physician's orders [REDACTED].#1 was sent out to the hospital via 911 for CT scan of the head and evaluation for s/p fall with laceration to the left eyebrow and top of nose. Record review of the facility's Therapy Screening Forms revealed Resident #1 was evaluated for physical therapy on 02/04/19 due to his fall risk and feet shuffling. Physical therapy was not started due to pending approval from the residents' insurance and he remained on the restorative nursing program (RNP). Further review of the rehabilitation notes revealed the resident had a total of 12 falls starting on 01/18/19 through 3/13/19. The most recent fall was documented on 03/13/19, which resulted in the resident being discharged from the facility and admitted to the hospital due to a left eyebrow and nose laceration. Interview on 04/17/19 at 12:25 PM with CNA A, she stated she did not work with Resident #1. When asked how were residents with dementia or cognitive impairment who have behaviors managed, she stated they are redirected. Interview on 04/17/19 at 12:40 PM with LVN B, she reported she was a new employee and had not worked with Resident #1. When asked how are residents cared for who have dementia or cognitive impairment with behaviors, she reported she would try to find out what is wrong, or bothering the resident and then redirect the resident and document what was done in the residents' record. Interview with the Administrator on 04/18/19 at 2:25 PM, she stated Resident #1 was approved to take the antipsychotic medications because of his behaviors and said the medications could not be stopped abruptly. When the surveyor asked about the multiple [MEDICAL CONDITION] medications and frequent falls around the time the medications were started, the Administrator stated a surveyor cited this before on another resident and she requested an IDR and won further stating she will IDR the citation again if written. Record review of Medscape (2016) Black Box Warning for antipsychotic medications [MEDICATION NAME] and [MEDICATION NAME] read in part, Patients with dementia-related [MEDICAL CONDITION] who are treated with antipsychotic drugs are at an increased risk for death, as shown in short-term controlled trials; deaths in trials appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature. Not approved for treatment of [REDACTED]. Further review of Medscape (2016) Post marketing Report Warnings revealed, Falls, Rhabdomyolysis and Hypersensitivity when taking antipsychotic medications.

Based on observation, interview and record review, the facility failed to ensure 3 of 10 residents (Residents #12, #9, and #16) reviewed for abuse and neglect was free from abuse and neglect. -The facility staff failed to protect Resident #12 from multiple acts of mental abuse from facility Medical Director and Facility Social Worker. The facility failed to assess Resident #12 and provide relief when she complained of pain. Resident #12 was not assessed or given as needed medication when he scheduled pain medication did not cover her pain. -The facility failed to ensure Resident # 9 received adequate pain control following a fall and fractured right femur. -The facility failed to ensure Resident #16's was assessed and received pain management when the scheduled pain medication was not effective. An Immediate Jeopardy (IJ) was identified on 8/10/17. While the IJ was lowered on 8/16/17, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 3 residents and placed 66 residents whom received services from the facility's Social Worker, Director of Nurses (DON), Medical Director, and Administrator at risk for abuse and/or neglect. Intake # 3 Findings Include: Resident #12 Record review of Resident #12's face sheet revealed an admission date of [DATE] and a readmission date of [DATE]. Her Diagnoses: [REDACTED]. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #12 required supervision with set up only for bed mobility, transfer, ambulation, dressing, eating, toilet use, personal hygiene and bathing. Resident #12 used a walker and a wheelchair for mobility and had received pain medication and non-medication interventions for pain. The section for pain revealed the pain frequency was documented as frequently. The review also revealed pain was rated at a 6 out of 10 but the intensity of pain was not documented and was left blank. Record review of Resident #12's care plans dated 12/01/2016 revealed the following: Pain related to residents pain score on admission of 6 out of 10. The approaches included: Assess and document the location, frequency, duration and intensity of her pain. Report increased pain trend to the physician, administer pain medications as ordered and requested and document effectiveness. Attempt non-pharmacological pain relief measures such as, repositioning, back rubs, periodic rest, breathing techniques, music and active range of motion. Provide diversional activities if appropriate. Keep call light within reach at all times. Encourage resident to report pain at onset. Assess for breakthrough pain as needed when on routine medications. Refer resident to therapy services. Display of socially inappropriate/disruptive behavior of repeatedly asking for pain medication when it was not due. The approaches included: Activities staff to visit with and provide diversional activities, monitor and document behaviors, do not argue . Elicit my family input for best approaches. Discuss options for appropriate channeling of anger . Praise for demonstrating desired behavior. Administer behavior medications as ordered by the physician. Talk in a calm voice when behavior is disruptive and unacceptable. Encourage family/responsible party to visit. Social Services to evaluate and visit at least weekly. Record review of Resident #12's Medication Administration Record [REDACTED]. Record review revealed that Tylenol 325 mg (2 tablets) had been administered and documented on 08/10/2017 following surveyor intervention. All other dates were blank. [MEDICATION NAME] 50 mg- administer one tablet by mouth every eight hours at 6:00 am, 2:00 p.m. and 10:00 p.m . Further review revealed Resident #12 was not medicated with [MEDICATION NAME] 50 mg as ordered by the physician orders [REDACTED]. Tylenol 325 mg- one tablet four times a day at 9:00 am, 1:00 p.m., 5:00 p.m. and 9:00 p.m . Review revealed Resident #12 was not medicated with Tylenol 325 mg at 1:00 p.m. per physician orders [REDACTED]. Record review of Resident #12's physician encounters and procedures dated 04/06/2017 revealed the following: Record review of the clinical chart revealed Resident #12 had a history of [REDACTED]. Resident #12 was sent to the psychiatric hospital in March 2017 following an incident of a suicide attempt. Resident #12 attempted to stab herself with a butter knife in an attempt to be transferred to a hospital for pain management. Resident #12 had a procedure for removal of a gallstone but continued to experience pain. Upon return to the facility from the hospital, all pain medications were discontinued. The resident continued to demand pain medications and was described as harassing staff for pain medications. The facility then elicited the assistance of the local Ombudsman. The resident was provided the option of going to a detox program but she declined. Observation and interview on 08/10/2017 at 9:50 am of Resident #12 revealed her ambulating slowly near the nurses' station, her face was red and she was not smiling. Resident #12 complained of pain to the left side of her face, right lower leg, right lower back and right lower abdominal area. Resident was asked if she had reported pain to nursing staff and she said she had and was told she already had been medicated earlier and she could not have anything for pain until 1:00 p.m. or 2:00 p.m. when the next dose was due. Interview on 08/10/2017 at 10:00 am with Resident #12 revealed her problems with pain began in 2005 following toxic environmental exposure, weight loss, a fracture of her left hip and hemiathroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) which became infected. She stated she had a new hip but continued to have pain in the left hip. Resident #12 stated she limped when walking and could walk with a walker but then the pain is too much. Observation and interview on 08/10/2017 at 10:01 am revealed Resident #12 sitting on the edge of her bed rocking back and forth, facial flushing and grimacing. In an interview at same time on 08/10/2017 with Resident #12, she said she had pain to her right lower abdominal area, right lower back area, and said she hurts all over. Resident #12 rated her pain at a 9/10. Resident #12 said she had a history of [REDACTED]. Resident #12 showed her legs were she had multiple golf ball sized indentions from previous surgeries. Resident #12 then showed her left hip which had a surgical scar that ran from the top of her hip to below mid-thigh region. Resident #12 said she had hip replacement and it became infected and due to the infection the hardware had to be removed and they performed the surgery again. Resident #12 said she did not want to cause any problems or complain about pain because she did not want to be discharged to the psych hospital. When asked what she meant by that statement, Resident #12 said the Medical Director and the Social Worker had told her if she continued to complain of pain she would be discharged from the facility to a psych hospital. Interview on 08/10/2017 at 10:20 am Licensed Vocational Nurse (LVN) C said she was not aware that Resident #12 had pain but Resident #12 would be assessed. Social Worker intervened in the interview and said Resident #12 had a history of [REDACTED]. In an interview with the DON on 08/10/2017 at 10:29 am, she said she would assess Resident #12 for pain and notify the physician. Record review of Resident #12's nurse note dated 08/10/2017 at 11:52 am read in part . Resident lying in bed, respirations even, unlabored, skin warm and dry, no shortness of breath at rest, and no [MEDICAL CONDITION] noted to extremities. Resident explained her pain history to nurse, having some ear pain and states the doctor knows, she had ear wax come out that had built up some time back but it had hurt for about a year if she had to guess. Complains of pain to her abdomen and said she had gallstones but her gallbladder was removed. She complained of hurting all over and this had been about 3 years because she had [MEDICAL CONDITION] arthritis. Resident #12 denied any changes in her pain in regards to location, severity, intensity, or duration. Resident #12 was ambulating up and down hallway multiple times today with assist. Asked the patient if she told the nurse she was having issues and she said no, I told the state lady. Patient had been seen by primary care physician multiple times. No signs of acute illness or change in condition in this patient at this time. Physician and family will be contacted, however, to see what has been evaluated for Resident #12 and what if anything can still be done for her conditions. Record review of Resident #12's Social Worker notes dated 08/11/2017 at 8:54 am read in part . per surveyor that Resident #12 had informed her that she was in pain and her body ached and the staff ignored her and threatened to send her to Psychiatric hospital . Resident #12 was sent to Psychiatric Center due to resident hitting window with hand and breaking glass, threatening to hurt herself due to stating she was in so much pain. Resident #12 . was placed on medication management by primary care physician and was doing well, however, she did have drug dependence history of opioid abuse and other pain killers. Surveyor informed that resident was well documented of consistent report of pain, regular visit with primary care physician at facility and other [DIAGNOSES REDACTED]. Resident was sent to emergency room after resident was assessed, however, resident had no specific area of pain . Resident #12 was sent to emergency room and later sent back with no new orders. Observation and interview on 08/10/2017 at 4:20 p.m. the facility's Social Worker escorted the Medical Director, the Administrator, Clinical Corporate Nurse, DON and other staff into the conference room. The Medical Director stood up over Surveyors and refused to have a seat. The Medical Director was gripping his umbrella and ringing his hand around neck of umbrella while speaking loudly to surveyors. The Medical Director said he was not happy with the survey team and Resident #12 was a Pain Seeker. The Medical Director said Resident #12 was competent and was borderline psychotic and continued to seek pain medications. The Medical Director said that he had told Resident #12 that if she continued to complain of pain and ask for pain medications he would discharge her from the facility. When asked if he told her she would be sent to a psych facility for complaining of pain, the Medical Director did not answer but did say he had told her she would be discharged from the facility. The Medical Director said Resident #12 had been sent to the emergency room for evaluation of pain but the hospital probably would not do anything as they were aware of her drug seeking. He said that upon her return from the hospital he would give her a 30 day notice and discharge her and would only treat her if she had an emergency situation until her discharge from the facility, but would no longer provide any other services. The Medial Director said he had reduced Resident #12's pain medications because she had a history of [REDACTED]. He said she complained of pain and perceived it as pain but she had played y'all. The Medical Director said Resident #12 was an addict and she seeks drugs. He said Resident #12 complained of pain all the time, was consistent with her requests for pain medications, she was not able to pin point her pain and ambulates about the building and was outside smoking a lot of the times and that was not what people in pain do. When asked if people walked around all the time in pain and worked 40 hour work weeks while in pain and he said yes but said Resident #12 was a drug seeker. The Medical Director said that since Resident #12 had a history of [REDACTED]. He went on to say he and Resident #12 had a contract that if she complained of pain she would be discharged from the facility. The Medical Director was asked if Resident #12 had the right to be assessed for pain when she complained of pain and he said yes. When asked if Resident #12 had been referred to a pain specialist for evaluation the Medical Director replied No and stated her insurance probably would not cover it and Resident #12 probably could not afford it. In an interview on 08/10/2017 at 4:50 p.m. with the DON, she said Resident #12 was sent to the emergency room for evaluation of her pain. Record review of hospital medical records for Resident #12 dated 08/10/2017 revealed she was admitted to the hospital emergency roiagnom on [DATE] at 2:13 p.m. for generalized pain. Record review of Resident #12's CT Scans dated 08/10/2017 revealed the following: Abdomen and Pelvis without contrast Impression- No CT evidence for acute abdomen-pelvic process on this non-contrast examination. CT scan of head: Impression- No acute intracranial abnormality identified. Frothy secretions in the right sphenoid sinus were nonspecific but could represent acute sinusitis. Record review of Resident #12's X-ray of left hip dated 08/10/2017 revealed: Impression- status [REDACTED]. There was a healed distal femoral fracture. Record review further revealed Resident #12 was diagnosed with [REDACTED]. Abdominal pain, unspecified location. Acute non-intractable headache, unspecified headache type. Record review of hospital discharge form dated 08/10/2017 revealed Resident #12 should follow up with her primary care physician and an orthopedic surgeon. In an interview on 08/11/2017 at 7:50 am with the DON, an assessment and SBAR for Resident #12 was requested. The DON said the SBAR was completed on a plain sheet of copy paper and the nurse note had not been put into the computer yet. A copy of the SBAR written on plain copy paper was received from the DON. Record review of the SBAR for Resident #12, hand written on plain copy paper dated 08/10/2017 at 10:45 am, read in part .Abdominal pain, left hip pain rated as a 9 out of 10, whole body hurts .[MEDICAL CONDITION] arthritis. Back of neck and pain of left ear and left side of head rated as a 4 out of 10 and it had been hurting for over 1 year. Pain with abdominal palpation. Patient states, just call the doctor and tell him I want [MEDICATION NAME]. Do you want her sent to ER? No not necessarily. (It was not specified who was asked this question.) Interview with the DON on 08/11/2017 at 7:45 am, she said that Resident #12's pain medications had been completely stopped at one point. She said the Medical Director just stopped Resident #12's pain medication because she was on a lot of pain medications. The DON said that the Medical Director put Resident #12 on [MEDICATION NAME] 50 mg three times a day along with [MEDICATION NAME] and Tylenol. The DON said the facility had a care plan meeting with Resident #12 and her daughter and the Medical Director set up boundaries and behavior modifications, like a contract. The DON said the Medical Director informed staff that Resident #12 knew what she was doing and every time he walked into the building she was hurting. The DON said they were told to only give Resident #12 Tylenol as needed for her complaints of pain. She further said that the Medical Director said he was not prescribing anymore narcotics for her pain and no further instructions were given in regards to her pain. When asked what should be done if Resident #12 kept complaining of pain, the DON said I guess I would call him, but I never have. The DON said the Medical Director had said to get Resident #12 involved in activities. The DON said she could not remember if the Medical Director had suggested any other interventions regarding Resident #12's pain but did say the Medical Director said that Resident #12 was aware of what she was doing, she doesn't mean it and it is just part of her personality. The DON went on to say that Resident #12's daughter did not want her on a lot of medications. Interview on 08/11/2017 at 11:15 am LVN C said the Medical Director had told her and other nurses at the facility that if Resident #12 complained of pain that staff should re-direct her if her pain medication was not due. LVN C was asked what was done if Resident #12 continued to complain of pain following redirection and she said that she would call the Medical Director but he would just say to re-direct Resident #12. LVN C said the Medical Director said he would not prescribe anything else for her pain as Resident #12 was pain seeking. Interview with Resident #12 on 08/11/2017 at 1:12 p.m. revealed her doctor, the Medical Director, told her if she did not stop complaining of pain and harassing the nurses, he was going to send her out of the facility. Resident #12 further said the Social Worker was the main one who said she needed attention. Resident #12 said the social worker and physician would usually come to her room together when they visited her. Resident #12 said if she needed anything that staff waited to the very last to assist her with anything. Resident #12 asked what to tell the staff when they ask her what she told the surveyor. Resident #12 was informed she did not need to give an explanation to any staff member of the facility for speaking to a surveyor and DADS hot line number was given. Resident #12 was very thankful but concerned about retaliation from the facility for speaking to the surveyor. In an interview with Resident #12 on 08/12/2017 at 11:12 am she said the facility staff asked her if everything was alright following previous interview with surveyor. Resident #12 said she told the staff that everything was ok, because I don't want any problems or them to kick me out. Interview on 08/12/2017 at 11:46 am with Social Worker, when she was asked what interventions have been provided for Resident #12 regarding her pain, she said that every time Resident #12 was medicated she wanted more. Social Worker said the facility may need to find a place that can help her. Social Worker said she knew everything was being done for Resident #12 to keep her alive. Social Worker said Resident #12 was doing well until about 2 weeks ago following surveyor intervention. Record review of Pain Monitoring Record for the month of June 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of June 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of July 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of July 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of August 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift on the following dates: 08/01/2017-08/08/2017 a zero was documented for the pain level which indicated no pain. For the date of 08/09/2017 pain levels were not recorded for any shifts. In an interview with LVN K on 08/12/2017 at 12:03 p.m., she said she worked with Resident #12 every weekend. LVN K said Resident #12 usually complained of pain and rated it at an 8 out of 10 and she usually complained of pain about 2 hours before her next pain medication was scheduled. LVN K said that she would tell Resident #12 to wait it out until the next dose of pain medication was due. LVN K was asked if she had ever called the physician regarding Resident #12 and her pain and LVN K said that she had not. In an interview with LVN C on 08/12/2017 at 1:00 p.m., when asked if Resident #12 had complaints of pain and LVN C confirmed Resident #12 complained of pain all the time. LVN C was asked why there was no documentation of pain on the Pain Monitoring Record if Resident #12 always complained of pain and LVN C said I'm not going to lie, I don't know why they are all zeros. In an interview with the DON on 08/12/2017 at 1:11 p.m., she said if Resident #12 complained of pain that the staff was to offer distractions and redirection. The DON said that smoking was a distraction for Resident #12 and participating in activities. The DON said Truthfully, I wouldn't want to walk around living here, I'm sure she wants to be home. The DON said that Resident #12 complained often of pain and that she complained a lot when the physician (Medical Director) was in the building. The DON said Resident #12 had [MEDICATION NAME] and Tylenol for pain. The DON was shown the copies of the Pain Monitoring Record for the Months of June 2017, July 2017 and August 2017 and she replied Interesting. When asked about the pain being assessed as a zero (which indicated no pain) the DON said I don't know what to say, I just don't know why that is. In an interview with the Clinical Corporate Nurse on 08/12/2017 at 1:43 p.m., she said Resident #12 had days where she did not complain of pain but most days she did complain of pain. The Clinical Nurse further said sometimes when someone continues to complain of pain it becomes a behavior. Record review of Pain Review conducted by LVN C on 08/13/2017 at 4:45 p.m. for Resident #12 revealed she had existing pain, rated it as severe pain and was noted to be moaning and grimacing. The review revealed Resident #12 said the pain was almost constant and listed the following locations of the pain: Hip or knee joint, shoulder/arm/hand/joint, abdomen and a headache. Pain was documented as bilateral sharp and aching. Pain was exacerbated by movement and lying down; and rest helped to alleviate the pain. Pain affected sleep, energy and day to day activities. Record review of Pain Review further revealed Resident #12 was currently on scheduled pain medication that was not effective, was receiving PRN (as needed) pain medication that was not effective and that Resident #12 was not satisfied with pain control. Interview with Clinical Corporate Nurse on 08/14/2017 at 1:26 p.m., revealed Resident #12's new physician had ordered an evaluation by a pain specialist with an appointment scheduled for 08/16/2017. Record review of physician order [REDACTED]. Interview with LVN C on 08/16/2017 at 1:35 p.m., revealed Resident #12 had been referred to a pain specialist and she was currently at her appointment for evaluation. Record review of Statement of Resident Rights provided by the facility, not dated, read: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. A document/list of resident who were receiving primary physician services from the Medical Director was provided to the Survey team on 8/12/17 by the facility's Social Worker. The review of the document revealed 43 residents had been receiving primary physician services from the Medical Director. Resident #9 Record review of the clinical chart for Resident #9 revealed the [AGE] year-old resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The review revealed Resident # 9 has the following Diagnoses: [REDACTED]. Record review of Resident #9's Admission MDS revealed a BIMS could not be conducted due to the severity of the resident's cognition level. Record review of the documentation in the body of the intake dated 07/21/17 revealed Resident #9 was in the day area and as she was reaching for a tray from another resident, she fell to the floor on her right side. Record review of the document entitled, Provider Investigation Report for this incident dated 07/21/17. Review of the section entitled Investigation Summary (attach additional sheets as necessary), read, The resident did have a witnessed fall resulting in injury. The section entitled Provider Action Taken Post Investigation, read, 1. will begin sending staff to trainings for dementia patients. Record review of attached statements from staff and family members. Review of statement from Family Member dated 7/20/17 revealed that on 7/20/17, Resident #9 was sitting on the couch in the back of Hall A. She pushed herself up in a standing position. She reached for the eating tray. The tray moved because she was trying to get a grip on it. She fell and landed on her right side, and on the way down she hit her hip and then, (illegible), over and started to cry. Several of the other residents were back there. There was no one, (words underlined twice) staff with the residents when .Resident #9, fell . The review revealed that this family member actually took the resident to sit down prior to the fall. The document further read, .I immediately screamed for the staff . and revealed 2 staff came to the scene of the incident at 1:55 PM. Attached statement from CNA O read in part, .Fall July 21, 2017 .I was doing my last ADL rounds when I heard a family member yelling out .I ran out of a resident's room and went to the back room with the nurse. Statements from 2 other staff were attached. Record review of a statement from Assistant Activity Director revealed that she had seen the resident on a couch and had left the room to take dishes from resident rooms to the main dining room. Review of a statement from CNA Z revealed she was assisting a resident with toileting at the time of the accident. Record review of Resident #9's nurse's notes dated 7/21/17 read, 2:53 PM Resident was in the back sitting area, Visitor reported that resident stood up, lost balance and fell to the floor hitting right hip and leg. This nurse assessed resident from head to toe noted that resident was complaining of right leg pain upon moving. Called MD and received orders for Tylenol 650 now and Q 6 hours prn pain and x-ray to right hip, pelvis and entire right leg . Record review of Resident #9's social service noted dated 7/21/17 3:02 PM read, in part, .Resident grimaced and moaned as nurse assessed and touched resident's right leg .' Record review of Resident #9's Nurse's Notes dated 7/21/17 5:30 PM revealed that the resident's son requested to know the time the x-ray was to be conducted because his mother was in pain. The notes read in part, .SN assessed the res and areas of concern when touching the res was the greater trochanter area, the lateral patella and approx. three inches below the anterior patella. Res verbalized she was in pain at the time of the assessment and it was documented that the order given was for Tylenol 325 mg (2) tabs PO q 6 hrs PRN. Res had the medication documented by previous shift and SN explained to son that I was not able to administer anymore another 2-2 1/2 hours before the tech would be arriving. The review revealed no documentation of the effectiveness of the pain medication after it was administered and if the physician was contacted regarding Resident #9's pain management. Record review of Resident #9's nurse's notes for 7/21/17 revealed the next documented entry for 7/21/17 was at 9:59 PM and read, .Resident resting in bed at this time. Resident displaying nonverbal signs of pain (Facial grimacing) this nurse administered Tylenol 325 mg 2 tabs . The review revealed no documentation that the physician had been contacted to inform him the medication ordered had been ineffective. Review of the next documented entry read, 10:06 PM X ray results received and phoned in to MD. The physician then ordered the resident transferred to the hospital for further evaluation and treatment. The review revealed the RP was contacted and the contract ambulance service was contacted at 10:15 PM and informed the staff there would be an estimated time of arrival in 15 minutes. Record review of Resident #9's Social Services Notes dated 7/23/17 at 10:25 AM read, Late entry; SW received a call .that resident has a broken right femur .SW noted upon investigation of this fall this writer spoke with another resident family member who informed this writer that resident was redirected by her several times to sit down, however the last time resident stood up and fell Record review of Resident #9's Social Service notes dated 7/27/17 revealed the Responsible Party, the resident's son informed the facility's social worker that the resident had hip surgery-rod and screws placed in hip to correct the injured right leg . Interview on 8/10/17 at 3:00 PM with the Administrator revealed he would ensure that future incidents are thoroughly investigated. A review of facility abuse and neglect written policy was received by the Survey team on 8/14/17. The document read in part, .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator will appoint a member of management to investigate the alleged incident . Interview staff members (on all shifts) who have had contact with the resident during the peri(TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect for 3 of 26 residents (Resident #12, Resident #9 and Resident #16) reviewed for abuse and neglect. The facility failed to protect Resident #12 from multiple acts of verbal/mental abuse from the facility's Medical Director. The facility failed to protect Resident #12 from multiple acts of verbal/mental abuse from the facility's Social Worker The facility failed to assess Resident #12 for pain and provide effective pain relief when she complained of pain. The facility failed to address Resident #16's pain after numerous complaints of pain. The facility failed to address Resident #9's pain after the pain medication administered was found to be ineffective. The facility failed to provide adequate treatment in a timely manner for Resident #9 following a fall with a [MEDICAL CONDITION]. An Immediate Jeopardy (IJ) was identified on 8/10/17. While the IJ was lowered on 8/16/17, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected three residents and placed an additional 66 residents who received services from the facility's Social Worker, Director of Nurses (DON), Medical Director, and Administrator at risk for abuse and/or neglect. Intake # 3 Findings Include: Resident #12 Record review of Resident #12's face sheet revealed an admission date of [DATE] and a readmission date of [DATE]. Her Diagnoses: [REDACTED]. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #12 required supervision with set up only for bed mobility, transfer, ambulation, dressing, eating, toilet use, personal hygiene and bathing. Resident #12 used a walker and a wheelchair for mobility and had received pain medication and non-medication interventions for pain. The section for pain revealed the pain frequency was documented as frequently. The review also revealed pain was rated at a 6 out of 10 but the intensity of pain was not documented and was left blank. Record review of Resident #12's care plans dated 12/01/2016 revealed the following: Pain related to residents pain score on admission of 6 out of 10. The approaches included: Assess and document the location, frequency, duration and intensity of her pain. Report increased pain trend to the physician, administer pain medications as ordered and requested and document effectiveness. Attempt non-pharmacological pain relief measures such as, repositioning, back rubs, periodic rest, breathing techniques, music and active range of motion. Provide diversional activities if appropriate. Keep call light within reach at all times. Encourage resident to report pain at onset. Assess for breakthrough pain as needed when on routine medications. Refer resident to therapy services. Display of socially inappropriate/disruptive behavior of repeatedly asking for pain medication when it was not due. The approaches included: Activities staff to visit with and provide diversional activities, monitor and document behaviors, do not argue . Elicit my family input for best approaches. Discuss options for appropriate channeling of anger . Praise for demonstrating desired behavior. Administer behavior medications as ordered by the physician. Talk in a calm voice when behavior is disruptive and unacceptable. Encourage family/responsible party to visit. Social Services to evaluate and visit at least weekly. Record review of Resident #12's Medication Administration Record [REDACTED]. Record review revealed that Tylenol 325 mg (2 tablets) had been administered and documented on 08/10/2017 following surveyor intervention. All other dates were blank. [MEDICATION NAME] 50 mg- administer one tablet by mouth every eight hours at 6:00 am, 2:00 p.m. and 10:00 p.m . Further review revealed Resident #12 was not medicated with [MEDICATION NAME] 50 mg as ordered by the physician orders [REDACTED]. Tylenol 325 mg- one tablet four times a day at 9:00 am, 1:00 p.m., 5:00 p.m. and 9:00 p.m . Review revealed Resident #12 was not medicated with Tylenol 325 mg at 1:00 p.m. per physician orders [REDACTED]. Record review of Resident #12's physician encounters and procedures dated 04/06/2017 revealed the following: Record review of the clinical chart revealed Resident #12 had a history of [REDACTED]. Resident #12 was sent to the psychiatric hospital in March 2017 following an incident of a suicide attempt. Resident #12 attempted to stab herself with a butter knife in an attempt to be transferred to a hospital for pain management. Resident #12 had a procedure for removal of a gallstone but continued to experience pain. Upon return to the facility from the hospital, all pain medications were discontinued. The resident continued to demand pain medications and was described as harassing staff for pain medications. The facility then elicited the assistance of the local Ombudsman. The resident was provided the option of going to a detox program but she declined. Observation and interview on 08/10/2017 at 9:50 am of Resident #12 revealed her ambulating slowly near the nurses' station, her face was red and she was not smiling. Resident #12 complained of pain to the left side of her face, right lower leg, right lower back and right lower abdominal area. Resident was asked if she had reported pain to nursing staff and she said she had and was told she already had been medicated earlier and she could not have anything for pain until 1:00 p.m. or 2:00 p.m. when the next dose was due. Interview on 08/10/2017 at 10:00 am with Resident #12 revealed her problems with pain began in 2005 following toxic environmental exposure, weight loss, a fracture of her left hip and hemiathroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) which became infected. She stated she had a new hip but continued to have pain in the left hip. Resident #12 stated she limped when walking and could walk with a walker but then the pain is too much. Observation and interview on 08/10/2017 at 10:01 am revealed Resident #12 sitting on the edge of her bed rocking back and forth, facial flushing and grimacing. In an interview at same time on 08/10/2017 with Resident #12, she said she had pain to her right lower abdominal area, right lower back area, and said she hurts all over. Resident #12 rated her pain at a 9/10. Resident #12 said she had a history of [REDACTED]. Resident #12 showed her legs were she had multiple golf ball sized indentions from previous surgeries. Resident #12 then showed her left hip which had a surgical scar that ran from the top of her hip to below mid-thigh region. Resident #12 said she had hip replacement and it became infected and due to the infection the hardware had to be removed and they performed the surgery again. Resident #12 said she did not want to cause any problems or complain about pain because she did not want to be discharged to the psych hospital. When asked what she meant by that statement, Resident #12 said the Medical Director and the Social Worker had told her if she continued to complain of pain she would be discharged from the facility to a psych hospital. Interview on 08/10/2017 at 10:20 am Licensed Vocational Nurse (LVN) C said she was not aware that Resident #12 had pain but Resident #12 would be assessed. Social Worker intervened in the interview and said Resident #12 had a history of [REDACTED]. In an interview with the DON on 08/10/2017 at 10:29 am, she said she would assess Resident #12 for pain and notify the physician. Record review of Resident #12's nurse note dated 08/10/2017 at 11:52 am read in part . Resident lying in bed, respirations even, unlabored, skin warm and dry, no shortness of breath at rest, and no [MEDICAL CONDITION] noted to extremities. Resident explained her pain history to nurse, having some ear pain and states the doctor knows, she had ear wax come out that had built up some time back but it had hurt for about a year if she had to guess. Complains of pain to her abdomen and said she had gallstones but her gallbladder was removed. She complained of hurting all over and this had been about 3 years because she had [MEDICAL CONDITION] arthritis. Resident #12 denied any changes in her pain in regards to location, severity, intensity, or duration. Resident #12 was ambulating up and down hallway multiple times today with assist. Asked the patient if she told the nurse she was having issues and she said no, I told the state lady. Patient had been seen by primary care physician multiple times. No signs of acute illness or change in condition in this patient at this time. Physician and family will be contacted, however, to see what has been evaluated for Resident #12 and what if anything can still be done for her conditions. Record review of Resident #12's Social Worker notes dated 08/11/2017 at 8:54 am read in part . per surveyor that Resident #12 had informed her that she was in pain and her body ached and the staff ignored her and threatened to send her to Psychiatric hospital . Resident #12 was sent to Psychiatric Center due to resident hitting window with hand and breaking glass, threatening to hurt herself due to stating she was in so much pain. Resident #12 . was placed on medication management by primary care physician and was doing well, however, she did have drug dependence history of opioid abuse and other pain killers. Surveyor informed that resident was well documented of consistent report of pain, regular visit with primary care physician at facility and other [DIAGNOSES REDACTED]. Resident was sent to emergency room after resident was assessed, however, resident had no specific area of pain . Resident #12 was sent to emergency room and later sent back with no new orders. Observation and interview on 08/10/2017 at 4:20 p.m. the facility's Social Worker escorted the Medical Director, the Administrator, Clinical Corporate Nurse, DON and other staff into the conference room. The Medical Director stood up over Surveyors and refused to have a seat. The Medical Director was gripping his umbrella and ringing his hand around neck of umbrella while speaking loudly to surveyors. The Medical Director said he was not happy with the survey team and Resident #12 was a Pain Seeker. The Medical Director said Resident #12 was competent and was borderline psychotic and continued to seek pain medications. The Medical Director said that he had told Resident #12 that if she continued to complain of pain and ask for pain medications he would discharge her from the facility. When asked if he told her she would be sent to a psych facility for complaining of pain, the Medical Director did not answer but did say he had told her she would be discharged from the facility. The Medical Director said Resident #12 had been sent to the emergency room for evaluation of pain but the hospital probably would not do anything as they were aware of her drug seeking. He said that upon her return from the hospital he would give her a 30 day notice and discharge her and would only treat her if she had an emergency situation until her discharge from the facility, but would no longer provide any other services. The Medial Director said he had reduced Resident #12's pain medications because she had a history of [REDACTED]. He said she complained of pain and perceived it as pain but she had played y'all. The Medical Director said Resident #12 was an addict and she seeks drugs. He said Resident #12 complained of pain all the time, was consistent with her requests for pain medications, she was not able to pin point her pain and ambulates about the building and was outside smoking a lot of the times and that was not what people in pain do. When asked if people walked around all the time in pain and worked 40 hour work weeks while in pain and he said yes but said Resident #12 was a drug seeker. The Medical Director said that since Resident #12 had a history of [REDACTED]. He went on to say he and Resident #12 had a contract that if she complained of pain she would be discharged from the facility. The Medical Director was asked if Resident #12 had the right to be assessed for pain when she complained of pain and he said yes. When asked if Resident #12 had been referred to a pain specialist for evaluation the Medical Director replied No and stated her insurance probably would not cover it and Resident #12 probably could not afford it. In an interview on 08/10/2017 at 4:50 p.m. with the DON, she said Resident #12 was sent to the emergency room for evaluation of her pain. Record review of hospital medical records for Resident #12 dated 08/10/2017 revealed she was admitted to the hospital emergency roiagnom on [DATE] at 2:13 p.m. for generalized pain. Record review of Resident #12's CT Scans dated 08/10/2017 revealed the following: Abdomen and Pelvis without contrast Impression- No CT evidence for acute abdomen-pelvic process on this non-contrast examination. CT scan of head: Impression- No acute intracranial abnormality identified. Frothy secretions in the right sphenoid sinus were nonspecific but could represent acute sinusitis. Record review of Resident #12's X-ray of left hip dated 08/10/2017 revealed: Impression- status [REDACTED]. There was a healed distal femoral fracture. Record review further revealed Resident #12 was diagnosed with [REDACTED]. Abdominal pain, unspecified location. Acute non-intractable headache, unspecified headache type. Record review of hospital discharge form dated 08/10/2017 revealed Resident #12 should follow up with her primary care physician and an orthopedic surgeon. In an interview on 08/11/2017 at 7:50 am with the DON, an assessment and SBAR for Resident #12 was requested. The DON said the SBAR was completed on a plain sheet of copy paper and the nurse note had not been put into the computer yet. A copy of the SBAR written on plain copy paper was received from the DON. Record review of the SBAR for Resident #12, hand written on plain copy paper dated 08/10/2017 at 10:45 am, read in part .Abdominal pain, left hip pain rated as a 9 out of 10, whole body hurts .[MEDICAL CONDITION] arthritis. Back of neck and pain of left ear and left side of head rated as a 4 out of 10 and it had been hurting for over 1 year. Pain with abdominal palpation. Patient states, just call the doctor and tell him I want [MEDICATION NAME]. Do you want her sent to ER? No not necessarily. (It was not specified who was asked this question.) Interview with the DON on 08/11/2017 at 7:45 am, she said that Resident #12's pain medications had been completely stopped at one point. She said the Medical Director just stopped Resident #12's pain medication because she was on a lot of pain medications. The DON said that the Medical Director put Resident #12 on [MEDICATION NAME] 50 mg three times a day along with [MEDICATION NAME] and Tylenol. The DON said the facility had a care plan meeting with Resident #12 and her daughter and the Medical Director set up boundaries and behavior modifications, like a contract. The DON said the Medical Director informed staff that Resident #12 knew what she was doing and every time he walked into the building she was hurting. The DON said they were told to only give Resident #12 Tylenol as needed for her complaints of pain. She further said that the Medical Director said he was not prescribing anymore narcotics for her pain and no further instructions were given in regards to her pain. When asked what should be done if Resident #12 kept complaining of pain, the DON said I guess I would call him, but I never have. The DON said the Medical Director had said to get Resident #12 involved in activities. The DON said she could not remember if the Medical Director had suggested any other interventions regarding Resident #12's pain but did say the Medical Director said that Resident #12 was aware of what she was doing, she doesn't mean it and it is just part of her personality. The DON went on to say that Resident #12's daughter did not want her on a lot of medications. Interview on 08/11/2017 at 11:15 am LVN C said the Medical Director had told her and other nurses at the facility that if Resident #12 complained of pain that staff should re-direct her if her pain medication was not due. LVN C was asked what was done if Resident #12 continued to complain of pain following redirection and she said that she would call the Medical Director but he would just say to re-direct Resident #12. LVN C said the Medical Director said he would not prescribe anything else for her pain as Resident #12 was pain seeking. Interview with Resident #12 on 08/11/2017 at 1:12 p.m. revealed her doctor, the Medical Director, told her if she did not stop complaining of pain and harassing the nurses, he was going to send her out of the facility. Resident #12 further said the Social Worker was the main one who said she needed attention. Resident #12 said the social worker and physician would usually come to her room together when they visited her. Resident #12 said if she needed anything that staff waited to the very last to assist her with anything. Resident #12 asked what to tell the staff when they ask her what she told the surveyor. Resident #12 was informed she did not need to give an explanation to any staff member of the facility for speaking to a surveyor and DADS hot line number was given. Resident #12 was very thankful but concerned about retaliation from the facility for speaking to the surveyor. In an interview with Resident #12 on 08/12/2017 at 11:12 am she said the facility staff asked her if everything was alright following previous interview with surveyor. Resident #12 said she told the staff that everything was ok, because I don't want any problems or them to kick me out. Interview on 08/12/2017 at 11:46 am with Social Worker, when she was asked what interventions have been provided for Resident #12 regarding her pain, she said that every time Resident #12 was medicated she wanted more. Social Worker said the facility may need to find a place that can help her. Social Worker said she knew everything was being done for Resident #12 to keep her alive. Social Worker said Resident #12 was doing well until about 2 weeks ago following surveyor intervention. Record review of Pain Monitoring Record for the month of June 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of June 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of July 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of July 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of August 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift on the following dates: 08/01/2017-08/08/2017 a zero was documented for the pain level which indicated no pain. For the date of 08/09/2017 pain levels were not recorded for any shifts. In an interview with LVN K on 08/12/2017 at 12:03 p.m., she said she worked with Resident #12 every weekend. LVN K said Resident #12 usually complained of pain and rated it at an 8 out of 10 and she usually complained of pain about 2 hours before her next pain medication was scheduled. LVN K said that she would tell Resident #12 to wait it out until the next dose of pain medication was due. LVN K was asked if she had ever called the physician regarding Resident #12 and her pain and LVN K said that she had not. In an interview with LVN C on 08/12/2017 at 1:00 p.m., when asked if Resident #12 had complaints of pain and LVN C confirmed Resident #12 complained of pain all the time. LVN C was asked why there was no documentation of pain on the Pain Monitoring Record if Resident #12 always complained of pain and LVN C said I'm not going to lie, I don't know why they are all zeros. In an interview with the DON on 08/12/2017 at 1:11 p.m., she said if Resident #12 complained of pain that the staff was to offer distractions and redirection. The DON said that smoking was a distraction for Resident #12 and participating in activities. The DON said Truthfully, I wouldn't want to walk around living here, I'm sure she wants to be home. The DON said that Resident #12 complained often of pain and that she complained a lot when the physician (Medical Director) was in the building. The DON said Resident #12 had [MEDICATION NAME] and Tylenol for pain. The DON was shown the copies of the Pain Monitoring Record for the Months of June 2017, July 2017 and August 2017 and she replied Interesting. When asked about the pain being assessed as a zero (which indicated no pain) the DON said I don't know what to say, I just don't know why that is. In an interview with the Clinical Corporate Nurse on 08/12/2017 at 1:43 p.m., she said Resident #12 had days where she did not complain of pain but most days she did complain of pain. The Clinical Nurse further said sometimes when someone continues to complain of pain it becomes a behavior. Record review of Pain Review conducted by LVN C on 08/13/2017 at 4:45 p.m. for Resident #12 revealed she had existing pain, rated it as severe pain and was noted to be moaning and grimacing. The review revealed Resident #12 said the pain was almost constant and listed the following locations of the pain: Hip or knee joint, shoulder/arm/hand/joint, abdomen and a headache. Pain was documented as bilateral sharp and aching. Pain was exacerbated by movement and lying down; and rest helped to alleviate the pain. Pain affected sleep, energy and day to day activities. Record review of Pain Review further revealed Resident #12 was currently on scheduled pain medication that was not effective, was receiving PRN (as needed) pain medication that was not effective and that Resident #12 was not satisfied with pain control. Interview with Clinical Corporate Nurse on 08/14/2017 at 1:26 p.m., revealed Resident #12's new physician had ordered an evaluation by a pain specialist with an appointment scheduled for 08/16/2017. Record review of physician order [REDACTED]. Interview with LVN C on 08/16/2017 at 1:35 p.m., revealed Resident #12 had been referred to a pain specialist and she was currently at her appointment for evaluation. Record review of Statement of Resident Rights provided by the facility, not dated, read: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. A document/list of resident who were receiving primary physician services from the Medical Director was provided to the Survey team on 8/12/17 by the facility's Social Worker. The review of the document revealed 43 residents had been receiving primary physician services from the Medical Director. Resident #9 Record review of the clinical chart for Resident #9 revealed the [AGE] year-old resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The review revealed Resident # 9 has the following Diagnoses: [REDACTED]. Record review of Resident #9's Admission MDS revealed a BIMS could not be conducted due to the severity of the resident's cognition level. Record review of the documentation in the body of the intake dated 07/21/17 revealed Resident #9 was in the day area and as she was reaching for a tray from another resident, she fell to the floor on her right side. Record review of the document entitled, Provider Investigation Report for this incident dated 07/21/17. Review of the section entitled Investigation Summary (attach additional sheets as necessary), read, The resident did have a witnessed fall resulting in injury. The section entitled Provider Action Taken Post Investigation, read, 1. will begin sending staff to trainings for dementia patients. Record review of attached statements from staff and family members. Review of statement from Family Member dated 7/20/17 revealed that on 7/20/17, Resident #9 was sitting on the couch in the back of Hall A. She pushed herself up in a standing position. She reached for the eating tray. The tray moved because she was trying to get a grip on it. She fell and landed on her right side, and on the way down she hit her hip and then, (illegible), over and started to cry. Several of the other residents were back there. There was no one, (words underlined twice) staff with the residents when .Resident #9, fell . The review revealed that this family member actually took the resident to sit down prior to the fall. The document further read, .I immediately screamed for the staff . and revealed 2 staff came to the scene of the incident at 1:55 PM. Attached statement from CNA O read in part, .Fall July 21, 2017 .I was doing my last ADL rounds when I heard a family member yelling out .I ran out of a resident's room and went to the back room with the nurse. Statements from 2 other staff were attached. Record review of a statement from Assistant Activity Director revealed that she had seen the resident on a couch and had left the room to take dishes from resident rooms to the main dining room. Review of a statement from CNA Z revealed she was assisting a resident with toileting at the time of the accident. Record review of Resident #9's nurse's notes dated 7/21/17 read, 2:53 PM Resident was in the back sitting area, Visitor reported that resident stood up, lost balance and fell to the floor hitting right hip and leg. This nurse assessed resident from head to toe noted that resident was complaining of right leg pain upon moving. Called MD and received orders for Tylenol 650 now and Q 6 hours prn pain and x-ray to right hip, pelvis and entire right leg . Record review of Resident #9's social service noted dated 7/21/17 3:02 PM read, in part, .Resident grimaced and moaned as nurse assessed and touched resident's right leg .' Record review of Resident #9's Nurse's Notes dated 7/21/17 5:30 PM revealed that the resident's son requested to know the time the x-ray was to be conducted because his mother was in pain. The notes read in part, .SN assessed the res and areas of concern when touching the res was the greater trochanter area, the lateral patella and approx. three inches below the anterior patella. Res verbalized she was in pain at the time of the assessment and it was documented that the order given was for Tylenol 325 mg (2) tabs PO q 6 hrs PRN. Res had the medication documented by previous shift and SN explained to son that I was not able to administer anymore another 2-2 1/2 hours before the tech would be arriving. The review revealed no documentation of the effectiveness of the pain medication after it was administered and if the physician was contacted regarding Resident #9's pain management. Record review of Resident #9's nurse's notes for 7/21/17 revealed the next documented entry for 7/21/17 was at 9:59 PM and read, .Resident resting in bed at this time. Resident displaying nonverbal signs of pain (Facial grimacing) this nurse administered Tylenol 325 mg 2 tabs . The review revealed no documentation that the physician had been contacted to inform him the medication ordered had been ineffective. Review of the next documented entry read, 10:06 PM X ray results received and phoned in to MD. The physician then ordered the resident transferred to the hospital for further evaluation and treatment. The review revealed the RP was contacted and the contract ambulance service was contacted at 10:15 PM and informed the staff there would be an estimated time of arrival in 15 minutes. Record review of Resident #9's Social Services Notes dated 7/23/17 at 10:25 AM read, Late entry; SW received a call .that resident has a broken right femur .SW noted upon investigation of this fall this writer spoke with another resident family member who informed this writer that resident was redirected by her several times to sit down, however the last time resident stood up and fell Record review of Resident #9's Social Service notes dated 7/27/17 revealed the Responsible Party, the resident's son informed the facility's social worker that the resident had hip surgery-rod and screws placed in hip to correct the injured right leg . Interview on 8/10/17 at 3:00 PM with the Administrator revealed he would ensure that future incidents are thoroughly investigated. A review of facility abuse and neglect written policy was received by the Survey team on 8/14/17. The document read in part, .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator will appoint a member (TRUNCATED)

Based on interview and record review, the facility failed to administer the facility in manor that enabled it to use its resources effectively and efficently to attain or maintain the highest practicalble physical, mental and psychosocial wellbeing of three of 26 residents (Resident #9, #12 and #16) who were reviewed for effective administration to manage their pain and psychosocial wellbeing in that: The Administrator failed to implement the facility's abuse and neglect policies and procedures. The Administrator failed to monitor the DON to ensure staff were trained to identify and care for residents experiencing changes in condition, and pain control/ineffective pain control. The Administrator failed to monitor the Medical Director to ensure residents seeking pain relief had their needs addressed without being labled as being drug seeking or without fear of reprisal. The Administrator failed to ensure the DON trained staff to contact physicians when pain interventions were ineffective, to assess residents who were voicing pain issues. The Administrator failed to the staff to report any failures to address issues of pain which could constitute abuse or neglect. The Administrator failed to monitor the DON to ensure the staff were trained on residents rights and the right to be free from retaliation. The Administrator failed to monitor the Social Worker to ensure that residents complaints of pain did not result in residents being labeled as drug seeking and to ensure there was no retaliation against residents who made requests for care. An Immediate Jeopardy (IJ) was identified on 8/10/17. While the IJ was lowered on 8/16/17, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected three residents and placed 66 additional residents at risk of harm/decline due to physical, emotional, psychological impact of abuse and neglect from not having their needs met. Findings include: Resident #12 Record review of the clinical chart for Resident #12 revealed the resident was originally admitted to the facility on [DATE] and re-admitted on [DATE]. The review revealed [DIAGNOSES REDACTED]. The review revealed the resident had also received a hip replacement and had a history of [REDACTED].#12 revealed the resident was cognitively alert and oriented. Record review of physician's orders [REDACTED].#12 had an order for [REDACTED]. The review also revealed the resident had an order for [REDACTED].#12 had orders for Tylenol 325mg scheduled for 4 times per day including an administration time of 1:00 PM yet was not administered her 1:00 PM dose prior to being sent to the hospital for uncontrolled pain on 8/10/2017. Record reviews of Resident #12's Pain Monitoring Assessments June, July and August 2017, every shift on every day of all the 3 months revealed a 0 indicating the resident had no pain. Observations of Resident #12 on 8/10/17 at 9:50 AM and on 8/10/17 at 10:01 revealed her face was red, she was not smiling she was grimacing and rocking back and forth. Interview on 8/10/17 at 9:50 AM and 10:01 AM revealed the resident had informed the staff she was in pain but was told she could not have anything for pain until her next scheduled dose. She stated she did not want to cause any problems or complain about pain because the Social Worker informed her if she continued to complain about pain she would be discharged to a psychiatric hospital. Interview on /10/17 at 1:00 PM with the DON revealed she herself had assessed the resident for pain and would provide the pain assessment. However the pain assessment was not provided. Interview on 8/11/17 at 11:15 AM with LVN C revealed the Medical Director had informed her and other nurses at the facility if Resident #12 complained of pain she should be re-directed if her pain medication was not due. She stated if the resident continued to complain of pain after re-direction and she contacted the Medical Director he would just say to continue to re-direct as she was pain seeking and would not prescribe anything for her pain. The Medical Director was brought to the conference room by the Administration of the facility on 8/10/17 at 4:20 PM to address the State Survey Team and Federal Surveyors. Other facility staff including the Administrator, DON, Clinical/Corporate Nurse and the Social Worker remained in the room during the Medical Director's presentation. The Medical Director stated he was not happy with the Survey team and that Resident #12 was drug seeking. He stated he had informed the resident he would discharge her from the facility if she continued to request pain medications. When asked if he had informed Resident #12 she would be transferred to a Psychiatric facility he failed to answer. He stated she was able to walk around and go smoke and consequently could not be in pain. When questioned if she had been referred to a pain management specialist he stated no as her insurance would probably not cover it and she cannot afford it. During the Medical Director's verbal presentation to the the surveyors, there were no comments or questions from the facility staff in attendance at the meeting. Interview on 8/11/17 at 1:12 PM with Resident #12 revealed she was concerned about retaliation and asked what she should tell staff about her comments to the surveyor. She stated the Medical Director told her she would be sent out of the facility if she did not stop complaining of pain and harassing the nurses. She stated it was mainly the Social Worker who who said I need attention and that usually the Medical Director and Social Worker would come together when they visited her. Interview on 8/12/17 at 1:12 PM with Resident #12 revealed she was questioned by staff as to what her concerns were when she spoke to surveyor and she informed them she did not have any concerns because she did not want to be kicked out of the facility. Interview on 8/12/17 at 11:46 PM with the facility's Social Worker revealed Resident #12 when medicated always wants more medication and the facility might have to find her a place that could help her and she knew everything was being done for the resident to keep her alive. She state that the resident had been doing well until surveyor intervention. Resident #9 Record review of the clinical chart for Resident #9 revealed the [AGE] year-old resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The review revealed multiple [DIAGNOSES REDACTED]. Review of the nurses notes and statements from the Provider Incident Report for Intake # 3 revealed Resident #9 experienced a fall on 7/21/17 at approximately 2:00 PM. The review revealed the nurse contacted the Medical Director and received orders for Tylenol 650 now and Q 6 hours prn and x-ray. Record review of Resident #9's Nurses notes on 6/21/17 at 5:30 PM revealed the resident was grimacing and moaning in pain but the nurse informed the family member no additional medication could be administered. The review also revealed no documentation regarding the physician being notified to inform him the medication had been ineffective. The review revealed that nurses notes for 9:59 PM on 7/21/17 read that Resident displaying non verbal signs of pain (facial grimacing) The review further revealed the resident was not sent to the hospital until approximately 8 hours later at 10:15 PM after receiving x-ray results indicating a [MEDICAL CONDITION]. Interview on 8/12/17 at 10:00 AM with the DON revealed she had no idea why the Resident had remained in pain for such a length of time. Resident #16 Review of the clinical chart for Resident #16 revealed the [AGE] year-old resident was admitted on [DATE]. The review revealed multiple [DIAGNOSES REDACTED]. The review revealed he was receiving [MEDICATION NAME] and Klonopin. Interview with and observation of Resident #16 on 8/10/17 revealed he was in his room getting ready to lie down . He stated he had to lie on his bed with his feet elevated for relief of his back pain and that he was in pain all the time. He stated his doctor told him he could not have a prescription for any other pain medications because of the psych medications he was receiving. When questioned as to who his physician was, he stated his doctor was the Medical Director. Interview on 8/13/17 at 12:15 PM, Resident #16 informed Surveyor his pain was now manageable as he had selected a new doctor and received x-rays of his knees last night. In an interview with the Administrator on 8/14/17 at 12:40 PM he was asked: 1. What type of procedure is there to make sure the nursing needs of residents are being met? Administrator's Response, Resident's rights--Residents have the right to be free from intimidation, abuse, neglect. If they experience it they should report it to me Staff in-services Abuse/Neglect Policy-- Regional Nurse Consultant--Regional Administrator. 2. How do you monitor staff (i.e. DON) to ensure the systems they monitor are being done sufficiently? Ensure competency of staff? Evaluate P & P? Ensure effectiveness of facility processes? Administrator's response, Stand-up meeting-We outline how. Do some rounding and how it went. Go over census. Clinical meetings 24 hour report --DON follows up Discuss admission/care plans. 3. How do you think this incident (I.J. SQC came about? Were you aware of the situation? If so, did you investigate or implement corrective measures? Administrator's response, Not aware of an issue Turn over of staff (major issue) No ADON We had to let 2 of the nurses go. He did not have a reason for the IJ other than issues with the Medical Director. 4. What resources are available to you and your staff? (P & P, consultants, sister facilities, Medical Director)? Administrator's Response, Regional consultant, Policy and Procedures Use of sister facilities and Human Resources. In an interview on 8/14/17 at 1:00 PM with the DON was asked: 1. What training did you ensure the nurses's had in order to care for a resident with pain? DON'S response, In-service with nurses, pain evaluation, AHT, (new online training system) online documentation, In-services on assessments abuse and neglect. 2. How did you ensure the nurses were competent in caring for a resident with pain? . DON'S response, In services on pain and assessment Stop and watch tool 3. What type of plan was in place for abuse/neglect? . DON's response, Abuse coordinator-Administrator Original Abuse/Neglect--Use one page Abuse neglect Policy. We use DAD'S ANE. 4. Has there been any types of in-services on pain-assessments since admitting resident (s) with pain? DON'S response, Re-in-servicing all staff. 5. How do you think this incident (IJ, SQC, etc,) came about? DON'S response, two things-I believe it was called because, the Medical Director, came in there and said everything he said. I feel, Resident #12, was not being addressed and we had to make sure others were safe. 5. What resources are available to you and your staff? (P & P, consultants, sister facilities, Medical director? DON'S response, P & P, Regional Consultant, Google things I don't know The Administrator was notified on 8/10/17 at 10:00 am of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 8/16/17 at 3:30 p.m. The PoR included in part: PAIN PLAN OF REMOVAL Every resident at the facility will be evaluated for pain and any issues addressed immediately. If any resident does not have pain medication and complains of pain, the Physician will be notified and pain medication order obtained. The assessments will be completed by the DON, Charge Nurses's, (sic), and Treatment Nurse. This was started on 8/11/17 and completed on 8/14/17. No other residents were identified with uncontrolled pain. Four residents indicated they had pain; however they stated their pain medication was sufficient. Completed 8/14/17. Care plans were modified. Completed 8/14/17. Resident, (#12), was assessed and sent to the ER for evaluation of her pain. The review of the document further revealed that if Resident #12 should present with pain that cannot be controlled by Tylenol, the Charge Nurse will assess and contact Resident #12's new physician. The review revealed Resident 312 had been referred to a Pain Management Physician. The review further revealed the present Medical Director for the facility had been removed and replaced by another physician that was named on the document. Review of the document further read, If any resident complains of pain with no pain medication, the Licensed Nurse will evaluates, (sic), the resident using the PRN pain flow sheet and the physician will be notified for new orders. The review revealed if the physician was not available or in the event the physician were to not address the issue, the new Medical Director would be contacted. Review of the document further read, An in-service will be given by the Director of Nursing and MDS Coordinator to the Licensed Staff on how to complete the pain review, The in-service will include the residents diagnosis, current pain/existing pain, frequency, pain location, character of the pain, what elevates the pain, if the resident has scheduled or prn treatment for [REDACTED]. These evaluations will be completed upon admission, quarterly, and with change of condition. Began 8/11/17 and completed 8/14/17. Resident on pain management will be evaluated like any other resident with pain each time they require prn pain medication or complain of pain there will be a pain evaluation completed using the PRN pain management flow sheet. Residents receiving routine medication are asked if their routine medication was effective but residents that require prn pain medication are evaluated using the PRN Management Flow Sheet. After any pain medication the Charge Nurse will ask the resident if the medication was effective. The Caregivers and other staff will be in-serviced by the DON or MDS Coordinator on Stop and Watch Sheets. Aides or other staff have been trained to ask the residents if the the resident is in pain or if the resident is grimacing, crying, rubbing a certain spot, holding a place on their body or in any other way appears to be in pain, and if the resident is in pain to fill out the Stop and watch form and give it to the nurse for follow-up. Started 8/11/17 and completed 8/14/127. Any staff member not available for the in-service on the dates above will be in-serviced before being allowed to return to work. The in-service will be done by the Director of Nurses. If any resident continues to complain of pain after receiving their pain medication, the Licensed Nurse will evaluate the resident and notify the physician. The Licensed Nurse will use the face pain scale to identify pain when a resident cannot communicate his/her pain intensity. Licensed nurses and direct care staff will be in-serviced by the Director of Nursing or MDS Coordinator on interpreting pain in residents that aphasic or cannot otherwise tell the nurses when they are in pain. This was started on 8/11/17 and completed 8/14/17. Any staff member not available for for the in-service on the dates above will be in-serviced before being allowed to return to work. The in-service will be done by the DON. The weekend staff and 10-6 staff were in-serviced by the MDS Coordinator on 8/11/17 and completed on 8/14/17. The Plans of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in the Stop & Watch process. They were taught or re-taught how to recognize indicators of pain; reminded to ask residents about pain, report to nurses when residents responded verbally or non-verbally in ways indicating that they were in pain; and reminded to complete Stop & Watch forms. This training was completed on 8/12/17. -All medication aides and nurses received in-service training by the DON about the medications not to be crushed. This training was completed on 8/10/17. -All housekeeping staff and CNAs received in-service training on the policies on isolation room cleaning, general cleaning of rooms. -All staff received in-service training on Resident rights, Abuse, Neglect. -All nursing staff received in-service training on pain awareness, and how to recognize changes in residents' condition. This training was completed on 8/6/17. -All housekeeping staff and CNAs received in-service training on the policies on isolation room cleaning, general cleaning of rooms. -All housekeeping staff and CNAs received in-service training on linen handling in isolation rooms. This training was completed on 8/15/17. -All CNAs received in-service training on incontinent care, wearing gloves, and the incontinent care policy. This training was completed on 8/15/17. -All nursing staff received in-service training on Infection control, wearing gloves. This training was completed on 8/15/17. -All nursing staff received in-service training on isolation. This training was completed on 8/15/17. Random interviews were conducted during the monitoring. Staff indicated that they attended these training sessions. They were able to describe the training they received and that training reflected correct techniques. Observations were conducted during the monitoring. No additional concerns were identified between the acceptance of the PoR and the lowering of the IJ. The Administrator was informed on 8/16/17 at 5:10 p.m. that the IJ was lowered; however the facility remained out of compliance at a level of wide spread and a severity of potential for more than minimal harm that was not immediate jeopardy due to the facility needing more time to ensure that the plan of removal was effective. According to the CMS 672, the census was 69.

Based on observation, interview and record review; it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the plan of care for 5 of 16 residents reviewed for quality of care (Resident #12, #16, #11, #21 and #9). Resident #12 did not receive pain assessments or effective pain management when she complained of pain. Resident #12 was told by the Medical Director and facility Social Worker that if she continued to complain of pain or request pain medication outside of the scheduled times she would be discharged from the facility to pyschiatric hospital, this led to ineffective pain management. -The facility failed to ensure Resident # 9 received adequate pain control following a fall and fractured right femur. Resident #9 did not receive effective care and treatment for [REDACTED]. -The facility failed to ensure Resident #16's was assessed and received pain management when the scheduled pain medication was not effective. The facility failed to ensure Resident #11 received her Dialyite 800 mg with Ultra D multivitamin one daily as prescribed by her physician. The facility failed to ensure Resident #11's blood pressure medication was held five different days in August 2017 when her blood pressure was below the parameters the physician had ordered when the medication was to be held. The facility failed to ensure Resident #11 was provided the ted (compression) hose to wear as ordered by the physician. Resident # 21's weight loss and recommendations were not followed up on. An Immediate Jeopardy (IJ) was identified on 8/10/17. While the IJ was lowered on 8/16/17, the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected five residents and placed 64 residents at risk of ineffective nursing care, poor quality of life, severe untreated pain, infections and compromised health conditions along with feelings of low self-esteem, fear of loosing their home and fear of not receiving care. Intake # 3 Findings include: Resident #12 Record review of Resident #12's face sheet revealed an admission date of [DATE] and a readmission date of [DATE]. Her Diagnoses: [REDACTED]. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #12 required supervision with set up only for bed mobility, transfer, ambulation, dressing, eating, toilet use, personal hygiene and bathing. Resident #12 used a walker and a wheelchair for mobility and had received pain medication and non-medication interventions for pain. The section for pain revealed the pain frequency was documented as frequently. The review also revealed pain was rated at a 6 out of 10 but the intensity of pain was not documented and was left blank. Record review of Resident #12's care plans dated 12/01/2016 revealed the following: Pain related to residents pain score on admission of 6 out of 10. The approaches included: Assess and document the location, frequency, duration and intensity of her pain. Report increased pain trend to the physician, administer pain medications as ordered and requested and document effectiveness. Attempt non-pharmacological pain relief measures such as, repositioning, back rubs, periodic rest, breathing techniques, music and active range of motion. Provide diversional activities if appropriate. Keep call light within reach at all times. Encourage resident to report pain at onset. Assess for breakthrough pain as needed when on routine medications. Refer resident to therapy services. Display of socially inappropriate/disruptive behavior of repeatedly asking for pain medication when it was not due. The approaches included: Activities staff to visit with and provide diversional activities, monitor and document behaviors, do not argue . Elicit my family input for best approaches. Discuss options for appropriate channeling of anger . Praise for demonstrating desired behavior. Administer behavior medications as ordered by the physician. Talk in a calm voice when behavior is disruptive and unacceptable. Encourage family/responsible party to visit. Social Services to evaluate and visit at least weekly. Record review of Resident #12's Medication Administration Record [REDACTED]. Record review revealed that Tylenol 325 mg (2 tablets) had been administered and documented on 08/10/2017 following surveyor intervention. All other dates were blank. [MEDICATION NAME] 50 mg- administer one tablet by mouth every eight hours at 6:00 am, 2:00 p.m. and 10:00 p.m . Further review revealed Resident #12 was not medicated with [MEDICATION NAME] 50 mg as ordered by the physician orders [REDACTED]. Tylenol 325 mg- one tablet four times a day at 9:00 am, 1:00 p.m., 5:00 p.m. and 9:00 p.m . Review revealed Resident #12 was not medicated with Tylenol 325 mg at 1:00 p.m. per physician orders [REDACTED]. Record review of Resident #12's physician encounters and procedures dated 04/06/2017 revealed the following: Record review of the clinical chart revealed Resident #12 had a history of [REDACTED]. Resident #12 was sent to the psychiatric hospital in March 2017 following an incident of a suicide attempt. Resident #12 attempted to stab herself with a butter knife in an attempt to be transferred to a hospital for pain management. Resident #12 had a procedure for removal of a gallstone but continued to experience pain. Upon return to the facility from the hospital, all pain medications were discontinued. The resident continued to demand pain medications and was described as harassing staff for pain medications. The facility then elicited the assistance of the local Ombudsman. The resident was provided the option of going to a detox program but she declined. Observation and interview on 08/10/2017 at 9:50 am of Resident #12 revealed her ambulating slowly near the nurses' station, her face was red and she was not smiling. Resident #12 complained of pain to the left side of her face, right lower leg, right lower back and right lower abdominal area. Resident was asked if she had reported pain to nursing staff and she said she had and was told she already had been medicated earlier and she could not have anything for pain until 1:00 p.m. or 2:00 p.m. when the next dose was due. Interview on 08/10/2017 at 10:00 am with Resident #12 revealed her problems with pain began in 2005 following toxic environmental exposure, weight loss, a fracture of her left hip and hemiathroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) which became infected. She stated she had a new hip but continued to have pain in the left hip. Resident #12 stated she limped when walking and could walk with a walker but then the pain is too much. Observation and interview on 08/10/2017 at 10:01 am revealed Resident #12 sitting on the edge of her bed rocking back and forth, facial flushing and grimacing. In an interview at same time on 08/10/2017 with Resident #12, she said she had pain to her right lower abdominal area, right lower back area, and said she hurts all over. Resident #12 rated her pain at a 9/10. Resident #12 said she had a history of [REDACTED]. Resident #12 showed her legs were she had multiple golf ball sized indentions from previous surgeries. Resident #12 then showed her left hip which had a surgical scar that ran from the top of her hip to below mid-thigh region. Resident #12 said she had hip replacement and it became infected and due to the infection the hardware had to be removed and they performed the surgery again. Resident #12 said she did not want to cause any problems or complain about pain because she did not want to be discharged to the psych hospital. When asked what she meant by that statement, Resident #12 said the Medical Director and the Social Worker had told her if she continued to complain of pain she would be discharged from the facility to a psych hospital. Interview on 08/10/2017 at 10:20 am Licensed Vocational Nurse (LVN) C said she was not aware that Resident #12 had pain but Resident #12 would be assessed. Social Worker intervened in the interview and said Resident #12 had a history of [REDACTED]. In an interview with the DON on 08/10/2017 at 10:29 am, she said she would assess Resident #12 for pain and notify the physician. Record review of Resident #12's nurse note dated 08/10/2017 at 11:52 am read in part . Resident lying in bed, respirations even, unlabored, skin warm and dry, no shortness of breath at rest, and no [MEDICAL CONDITION] noted to extremities. Resident explained her pain history to nurse, having some ear pain and states the doctor knows, she had ear wax come out that had built up some time back but it had hurt for about a year if she had to guess. Complains of pain to her abdomen and said she had gallstones but her gallbladder was removed. She complained of hurting all over and this had been about 3 years because she had [MEDICAL CONDITION] arthritis. Resident #12 denied any changes in her pain in regards to location, severity, intensity, or duration. Resident #12 was ambulating up and down hallway multiple times today with assist. Asked the patient if she told the nurse she was having issues and she said no, I told the state lady. Patient had been seen by primary care physician multiple times. No signs of acute illness or change in condition in this patient at this time. Physician and family will be contacted, however, to see what has been evaluated for Resident #12 and what if anything can still be done for her conditions. Record review of Resident #12's Social Worker notes dated 08/11/2017 at 8:54 am read in part . per surveyor that Resident #12 had informed her that she was in pain and her body ached and the staff ignored her and threatened to send her to Psychiatric hospital . Resident #12 was sent to Psychiatric Center due to resident hitting window with hand and breaking glass, threatening to hurt herself due to stating she was in so much pain. Resident #12 . was placed on medication management by primary care physician and was doing well, however, she did have drug dependence history of opioid abuse and other pain killers. Surveyor informed that resident was well documented of consistent report of pain, regular visit with primary care physician at facility and other [DIAGNOSES REDACTED]. Resident was sent to emergency room after resident was assessed, however, resident had no specific area of pain . Resident #12 was sent to emergency room and later sent back with no new orders. Observation and interview on 08/10/2017 at 4:20 p.m. the facility's Social Worker escorted the Medical Director, the Administrator, Clinical Corporate Nurse, DON and other staff into the conference room. The Medical Director stood up over Surveyors and refused to have a seat. The Medical Director was gripping his umbrella and ringing his hand around neck of umbrella while speaking loudly to surveyors. The Medical Director said he was not happy with the survey team and Resident #12 was a Pain Seeker. The Medical Director said Resident #12 was competent and was borderline psychotic and continued to seek pain medications. The Medical Director said that he had told Resident #12 that if she continued to complain of pain and ask for pain medications he would discharge her from the facility. When asked if he told her she would be sent to a psych facility for complaining of pain, the Medical Director did not answer but did say he had told her she would be discharged from the facility. The Medical Director said Resident #12 had been sent to the emergency room for evaluation of pain but the hospital probably would not do anything as they were aware of her drug seeking. He said that upon her return from the hospital he would give her a 30 day notice and discharge her and would only treat her if she had an emergency situation until her discharge from the facility, but would no longer provide any other services. The Medial Director said he had reduced Resident #12's pain medications because she had a history of [REDACTED]. He said she complained of pain and perceived it as pain but she had played y'all. The Medical Director said Resident #12 was an addict and she seeks drugs. He said Resident #12 complained of pain all the time, was consistent with her requests for pain medications, she was not able to pin point her pain and ambulates about the building and was outside smoking a lot of the times and that was not what people in pain do. When asked if people walked around all the time in pain and worked 40 hour work weeks while in pain and he said yes but said Resident #12 was a drug seeker. The Medical Director said that since Resident #12 had a history of [REDACTED]. He went on to say he and Resident #12 had a contract that if she complained of pain she would be discharged from the facility. The Medical Director was asked if Resident #12 had the right to be assessed for pain when she complained of pain and he said yes. When asked if Resident #12 had been referred to a pain specialist for evaluation the Medical Director replied No and stated her insurance probably would not cover it and Resident #12 probably could not afford it. In an interview on 08/10/2017 at 4:50 p.m. with the DON, she said Resident #12 was sent to the emergency room for evaluation of her pain. Record review of hospital medical records for Resident #12 dated 08/10/2017 revealed she was admitted to the hospital emergency roiagnom on [DATE] at 2:13 p.m. for generalized pain. Record review of Resident #12's CT Scans dated 08/10/2017 revealed the following: Abdomen and Pelvis without contrast Impression- No CT evidence for acute abdomen-pelvic process on this non-contrast examination. CT scan of head: Impression- No acute intracranial abnormality identified. Frothy secretions in the right sphenoid sinus were nonspecific but could represent acute sinusitis. Record review of Resident #12's X-ray of left hip dated 08/10/2017 revealed: Impression- status [REDACTED]. There was a healed distal femoral fracture. Record review further revealed Resident #12 was diagnosed with [REDACTED]. Abdominal pain, unspecified location. Acute non-intractable headache, unspecified headache type. Record review of hospital discharge form dated 08/10/2017 revealed Resident #12 should follow up with her primary care physician and an orthopedic surgeon. In an interview on 08/11/2017 at 7:50 am with the DON, an assessment and SBAR for Resident #12 was requested. The DON said the SBAR was completed on a plain sheet of copy paper and the nurse note had not been put into the computer yet. A copy of the SBAR written on plain copy paper was received from the DON. Record review of the SBAR, hand written on plain copy paper dated 08/10/2017 at 10:45 am, read in part .Abdominal pain, left hip pain rated as a 9 out of 10, whole body hurts .[MEDICAL CONDITION] arthritis. Back of neck and pain of left ear and left side of head rated as a 4 out of 10 and it had been hurting for over 1 year. Pain with abdominal palpation. Patient states, just call the doctor and tell him I want [MEDICATION NAME]. Do you want her sent to ER? No not necessarily. (It was not specified who was asked this question.) Interview with the DON on 08/11/2017 at 7:45 am, she said that Resident #12's pain medications had been completely stopped at one point. She said the Medical Director just stopped Resident #12's pain medication because she was on a lot of pain medications. The DON said that the Medical Director put Resident #12 on [MEDICATION NAME] 50 mg three times a day along with [MEDICATION NAME] and Tylenol. The DON said the facility had a care plan meeting with Resident #12 and her daughter and the Medical Director set up boundaries and behavior modifications, like a contract. The DON said the Medical Director informed staff that Resident #12 knew what she was doing and every time he walked into the building she was hurting. The DON said they were told to only give Resident #12 Tylenol as needed for her complaints of pain. She further said that the Medical Director said he was not prescribing anymore narcotics for her pain and no further instructions were given in regards to her pain. When asked what should be done if Resident #12 kept complaining of pain, the DON said I guess I would call him, but I never have. The DON said the Medical Director had said to get Resident #12 involved in activities. The DON said she could not remember if the Medical Director had suggested any other interventions regarding Resident #12's pain but did say the Medical Director said that Resident #12 was aware of what she was doing, she doesn't mean it and it is just part of her personality. The DON went on to say that Resident #12's daughter did not want her on a lot of medications. Interview on 08/11/2017 at 11:15 am LVN C said the Medical Director had told her and other nurses at the facility that if Resident #12 complained of pain that staff should re-direct her if her pain medication was not due. LVN C was asked what was done if Resident #12 continued to complain of pain following redirection and she said that she would call the Medical Director but he would just say to re-direct Resident #12. LVN C said the Medical Director said he would not prescribe anything else for her pain as Resident #12 was pain seeking. Interview with Resident #12 on 08/11/2017 at 1:12 p.m. revealed her doctor, the Medical Director, told her if she did not stop complaining of pain and harassing the nurses, he was going to send her out of the facility. Resident #12 further said the Social Worker was the main one who said she needed attention. Resident #12 said the social worker and physician would usually come to her room together when they visited her. Resident #12 said if she needed anything that staff waited to the very last to assist her with anything. Resident #12 asked what to tell the staff when they ask her what she told the surveyor. Resident #12 was informed she did not need to give an explanation to any staff member of the facility for speaking to a surveyor and DADS hot line number was given. Resident #12 was very thankful but concerned about retaliation from the facility for speaking to the surveyor. In an interview with Resident #12 on 08/12/2017 at 11:12 am she said the facility staff asked her if everything was alright following previous interview with surveyor. Resident #12 said she told the staff that everything was ok, because I don't want any problems or them to kick me out. Interview on 08/12/2017 at 11:46 am with Social Worker, when she was asked what interventions have been provided for Resident #12 regarding her pain, she said that every time Resident #12 was medicated she wanted more. Social Worker said the facility may need to find a place that can help her. Social Worker said she knew everything was being done for Resident #12 to keep her alive. Social Worker said Resident #12 was doing well until about 2 weeks ago following surveyor intervention. Record review of Pain Monitoring Record for the month of June 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of June 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of July 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of July 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of August 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift on the following dates: 08/01/2017-08/08/2017 a zero was documented for the pain level which indicated no pain. For the date of 08/09/2017 pain levels were not recorded for any shifts. In an interview with LVN K on 08/12/2017 at 12:03 p.m., she said she worked with Resident #12 every weekend. LVN K said Resident #12 usually complained of pain and rated it at an 8 out of 10 and she usually complained of pain about 2 hours before her next pain medication was scheduled. LVN K said that she would tell Resident #12 to wait it out until the next dose of pain medication was due. LVN K was asked if she had ever called the physician regarding Resident #12 and her pain and LVN K said that she had not. In an interview with LVN C on 08/12/2017 at 1:00 p.m., when asked if Resident #12 had complaints of pain and LVN C confirmed Resident #12 complained of pain all the time. LVN C was asked why there was no documentation of pain on the Pain Monitoring Record if Resident #12 always complained of pain and LVN C said I'm not going to lie, I don't know why they are all zeros. In an interview with the DON on 08/12/2017 at 1:11 p.m., she said if Resident #12 complained of pain that the staff was to offer distractions and redirection. The DON said that smoking was a distraction for Resident #12 and participating in activities. The DON said Truthfully, I wouldn't want to walk around living here, I'm sure she wants to be home. The DON said that Resident #12 complained often of pain and that she complained a lot when the physician (Medical Director) was in the building. The DON said Resident #12 had [MEDICATION NAME] and Tylenol for pain. The DON was shown the copies of the Pain Monitoring Record for the Months of June 2017, July 2017 and August 2017 and she replied Interesting. When asked about the pain being assessed as a zero (which indicated no pain) the DON said I don't know what to say, I just don't know why that is. In an interview with the Clinical Corporate Nurse on 08/12/2017 at 1:43 p.m., she said Resident #12 had days where she did not complain of pain but most days she did complain of pain. The Clinical Nurse further said sometimes when someone continues to complain of pain it becomes a behavior. Record review of Pain Review conducted by LVN C on 08/13/2017 at 4:45 p.m. for Resident #12 revealed she had existing pain, rated it as severe pain and was noted to be moaning and grimacing. The review revealed Resident #12 said the pain was almost constant and listed the following locations of the pain: Hip or knee joint, shoulder/arm/hand/joint, abdomen and a headache. Pain was documented as bilateral sharp and aching. Pain was exacerbated by movement and lying down; and rest helped to alleviate the pain. Pain affected sleep, energy and day to day activities. Record review of Pain Review further revealed Resident #12 was currently on scheduled pain medication that was not effective, was receiving PRN (as needed) pain medication that was not effective and that Resident #12 was not satisfied with pain control. Interview with Clinical Corporate Nurse on 08/14/2017 at 1:26 p.m., revealed Resident #12's new physician had ordered an evaluation by a pain specialist with an appointment scheduled for 08/16/2017. Record review of physician order [REDACTED]. Interview with LVN C on 08/16/2017 at 1:35 p.m., revealed Resident #12 had been referred to a pain specialist and she was currently at her appointment for evaluation. Record review of Statement of Resident Rights provided by the facility, not dated read: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. A document/list of resident who were receiving primary physician services from the Medical Director was provided to the Survey team on 8/12/17 by the facility's Social Worker. The review of the document revealed 43 residents had been receiving primary physician services from the Medical Director. Resident # 16 Record review of the face sheet for Resident # 16 revealed a [AGE] year old male with admission date of [DATE]. [DIAGNOSES REDACTED]. Record review of Resident # 16's care plan dated 3/17/17 revealed a problem of frequent pain in legs and back, with interventions including evaluate pain daily, assist with diversional activities, monitor for worsening pain, administer pain medication as ordered, with a Pain goal of 4. Record review of Resident # 16's Admission MDS dated [DATE] and Quarterly MDS dated [DATE] revealed Resident # 16 was independent of cognitive skills for daily decision making. He required supervision/set-up for ADL's, and had no limitations in range of motion. He reported frequent pain at a level of 6 in the last 5 days before assessment. Pain management included scheduled pain medication, PRN pain medication, and non-medical intervention for pain. MDS indicated the staff assessment of pain should not be conducted. Pain was a triggered care area, but there was no care planning decision. Record review of Resident # 16's Quarterly MDS dated [DATE] revealed no pain presence had been reported in the 5 days before assessment, and he had been receiving scheduled pain medication and non-medication intervention for pain. Record review of Resident # 16's Pain Monitoring documentation for July, 2017 revealed pain was assessed on each shift for the entire month of July, with documentation of 0 - no pain on each shift. The documentation sheet for PRN pain medication dosage for July, 2017 was blank. In an interview with LVN C on 8/12/17 at 2:30 p.m., she stated Resident # 16 did complain of pain, and she did not know why the pain monitoring sheet had all zeros. She further stated maybe he was assessed after he took his pain medications. Observation of Resident # 16 on 8/8/17 at 9:00 am revealed he was sitting outside in the smoking area, petting the facility cat. Interview at that time revealed he liked to sit with the cat in his lap and pet the cat because it helped take his mind off his pain. He was ambulatory with a cane, and walked slowly with his shoulders and back stiff. Observation/interview with Resident # 16 on 8/10/17 at 8:10 am revealed he was in his room, getting ready to lie on his bed. He stated he had to lie on his bed with his feet elevated for relief of his back pain, and he was in pain all the time. He stated his Doctor told him he could not give him anything else for his pain because of the psych medications he was taking. When asked who his Doctor was, he stated the Medical Director. Observation and interview with Resident # 16 on 8/10/17 at 1:35 p.m. revealed he was walking into the facility after smoke break. Interview at that time revealed he said he would be willing to talk to a different Dr. to see if he or she could do something more about his pain, because he was constantly in pain. Record review of Resident # 16's consolidated physician's orders [REDACTED]. [MEDICATION NAME] 100 mg every day was prescribed for [MEDICAL CONDITION] disorder, [MEDICATION NAME] 20 mg every day for major [MEDICAL CONDITION], and Klonopin 1 mg TID for anxiety disorder. Record review of Resident # 16's nurses note dated 8/12/17 revealed SW spoke to resident and/or family member to inform that Medical Director would no longer be providing medical care services at this facility and they had a choice to choose from 3 other physicians who would provide care at the facility .resident was given right to choose Doctor and ask any questions, including a brief Life Satisfaction Survey .resident and/or family chose a new Doctor. Record review of Resident # 16's nurse's note dated 8/12/17 revealed resident had complained of pain to bilateral knees. Record review of Resident #16's physician's orders [REDACTED]. Orders were signed by Resident # 16's new Doctor. Record review of Resident #16's physician's orders [REDACTED].=150 mg TID at 8 a.m., 4 p.m., 12 a.m Orders were signed by Resident # 16's new Doctor. Observation and interview with Resident # 16 on 8/13/17 at 12:15 p.m. revealed he was walking slowly with his cane for support, going into the dining room for lunch. Interview at that time revealed his pain was manageable now. He stated he had a new Doctor, and had x-rays of his knees last night. He said he was pleased with his new Doctor. Resident #11 Observation and interview on 08/08/17 at 11:00 am revealed Resident #11 was in bed. She was alert and oriented. During an interview Resident # 11 said she went to [MEDICAL TREATMENT] three times a week on Mondays Wednesday and Fridays. Records review of Resident #11's clinical records Face sheet revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #11's physician's orders [REDACTED]. Daily Weight 6-2 p.m. Vital signs pre and post [MEDICAL TREATMENT] Mondays, Wednesday and Fridays. Daily Weights, Measure Abdominal Girth every morning, Ted Hose from 7 a(TRUNCATED)

Based on observations, interviews and record reviews, the facility failed to follow an implement an appropriate abuse and neglect prohibition policy and implement all appropriate abuse and neglect policy and procedures for reporting, protection and investigation of abuse and neglect for 3 of 26 residents, (Resident #12, Resident #9 and Resident #16), reviewed for neglect in that: -The facility staff failed to protect Resident #12 from multiple acts of mental abuse from facility Medical Director and Facility Social Worker. The facility failed to assess Resident #12 and provide relief when she complained of pain. Resident #12 was not assessed or given as needed medication when he scheduled pain medication did not cover her pain. -The facility failed to thoroughly investigate the fall and injuries sustained by Resident #9 and document their findings for an incident of alleged neglect of this resident.The facility failed to ensure Resident # 9 received effective pain control following a fall and fractured right femur. -The facility failed to ensure Resident #16's was assessed and received effective pain management when the scheduled pain medication did not control his pain. An Immediate Jeopardy (IJ) was identified on 8/10/17. While the IJ was lowered on 8/16/17, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected 3 residents and placed 65 additional residents at risk for abuse and/or neglect, harm or a violation of their rights from not adequately and completely investigating circumstances leading to potential incidents. Findings include: Record review of the facility's abuse and neglect prevention policy revised August 2014, read in part, All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly and properly investigated by facility management . Record review of facility abuse and neglect written policy read in part, .Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator will appoint a member of management to investigate the alleged incident Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Review all events leading up to the alleged incident Resident #12 Record review of Resident #12's face sheet revealed an admission date of [DATE] and a readmission date of [DATE]. Her Diagnoses: [REDACTED]. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #12 required supervision with set up only for bed mobility, transfer, ambulation, dressing, eating, toilet use, personal hygiene and bathing. Resident #12 used a walker and a wheelchair for mobility and had received pain medication and non-medication interventions for pain. The section for pain revealed the pain frequency was documented as frequently. The review also revealed pain was rated at a 6 out of 10 but the intensity of pain was not documented and was left blank. Record review of Resident #12's care plans dated 12/01/2016 revealed the following: Pain related to residents pain score on admission of 6 out of 10. The approaches included: Assess and document the location, frequency, duration and intensity of her pain. Report increased pain trend to the physician, administer pain medications as ordered and requested and document effectiveness. Attempt non-pharmacological pain relief measures such as, repositioning, back rubs, periodic rest, breathing techniques, music and active range of motion. Provide diversional activities if appropriate. Keep call light within reach at all times. Encourage resident to report pain at onset. Assess for breakthrough pain as needed when on routine medications. Refer resident to therapy services. Display of socially inappropriate/disruptive behavior of repeatedly asking for pain medication when it was not due. The approaches included: Activities staff to visit with and provide diversional activities, monitor and document behaviors, do not argue . Elicit my family input for best approaches. Discuss options for appropriate channeling of anger . Praise for demonstrating desired behavior. Administer behavior medications as ordered by the physician. Talk in a calm voice when behavior is disruptive and unacceptable. Encourage family/responsible party to visit. Social Services to evaluate and visit at least weekly. Record review of Resident #12's Medication Administration Record [REDACTED]. Record review revealed that Tylenol 325 mg (2 tablets) had been administered and documented on 08/10/2017 following surveyor intervention. All other dates were blank. [MEDICATION NAME] 50 mg- administer one tablet by mouth every eight hours at 6:00 am, 2:00 p.m. and 10:00 p.m . Further review revealed Resident #12 was not medicated with [MEDICATION NAME] 50 mg as ordered by the physician orders [REDACTED]. Tylenol 325 mg- one tablet four times a day at 9:00 am, 1:00 p.m., 5:00 p.m. and 9:00 p.m . Review revealed Resident #12 was not medicated with Tylenol 325 mg at 1:00 p.m. per physician orders [REDACTED]. Record review of Resident #12's physician encounters and procedures dated 04/06/2017 revealed the following: Record review of the clinical chart revealed Resident #12 had a history of [REDACTED]. Resident #12 was sent to the psychiatric hospital in March 2017 following an incident of a suicide attempt. Resident #12 attempted to stab herself with a butter knife in an attempt to be transferred to a hospital for pain management. Resident #12 had a procedure for removal of a gallstone but continued to experience pain. Upon return to the facility from the hospital, all pain medications were discontinued. The resident continued to demand pain medications and was described as harassing staff for pain medications. The facility then elicited the assistance of the local Ombudsman. The resident was provided the option of going to a detox program but she declined. Observation and interview on 08/10/2017 at 9:50 am of Resident #12 revealed her ambulating slowly near the nurses' station, her face was red and she was not smiling. Resident #12 complained of pain to the left side of her face, right lower leg, right lower back and right lower abdominal area. Resident was asked if she had reported pain to nursing staff and she said she had and was told she already had been medicated earlier and she could not have anything for pain until 1:00 p.m. or 2:00 p.m. when the next dose was due. Interview on 08/10/2017 at 10:00 am with Resident #12 revealed her problems with pain began in 2005 following toxic environmental exposure, weight loss, a fracture of her left hip and hemiathroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) which became infected. She stated she had a new hip but continued to have pain in the left hip. Resident #12 stated she limped when walking and could walk with a walker but then the pain is too much. Observation and interview on 08/10/2017 at 10:01 am revealed Resident #12 sitting on the edge of her bed rocking back and forth, facial flushing and grimacing. In an interview at same time on 08/10/2017 with Resident #12, she said she had pain to her right lower abdominal area, right lower back area, and said she hurts all over. Resident #12 rated her pain at a 9/10. Resident #12 said she had a history of [REDACTED]. Resident #12 showed her legs were she had multiple golf ball sized indentions from previous surgeries. Resident #12 then showed her left hip which had a surgical scar that ran from the top of her hip to below mid-thigh region. Resident #12 said she had hip replacement and it became infected and due to the infection the hardware had to be removed and they performed the surgery again. Resident #12 said she did not want to cause any problems or complain about pain because she did not want to be discharged to the psych hospital. When asked what she meant by that statement, Resident #12 said the Medical Director and the Social Worker had told her if she continued to complain of pain she would be discharged from the facility to a psych hospital. Interview on 08/10/2017 at 10:20 am Licensed Vocational Nurse (LVN) C said she was not aware that Resident #12 had pain but Resident #12 would be assessed. Social Worker intervened in the interview and said Resident #12 had a history of [REDACTED]. In an interview with the DON on 08/10/2017 at 10:29 am, she said she would assess Resident #12 for pain and notify the physician. Record review of Resident #12's nurse note dated 08/10/2017 at 11:52 am read in part . Resident lying in bed, respirations even, unlabored, skin warm and dry, no shortness of breath at rest, and no [MEDICAL CONDITION] noted to extremities. Resident explained her pain history to nurse, having some ear pain and states the doctor knows, she had ear wax come out that had built up some time back but it had hurt for about a year if she had to guess. Complains of pain to her abdomen and said she had gallstones but her gallbladder was removed. She complained of hurting all over and this had been about 3 years because she had [MEDICAL CONDITION] arthritis. Resident #12 denied any changes in her pain in regards to location, severity, intensity, or duration. Resident #12 was ambulating up and down hallway multiple times today with assist. Asked the patient if she told the nurse she was having issues and she said no, I told the state lady. Patient had been seen by primary care physician multiple times. No signs of acute illness or change in condition in this patient at this time. Physician and family will be contacted, however, to see what has been evaluated for Resident #12 and what if anything can still be done for her conditions. Record review of Resident #12's Social Worker notes dated 08/11/2017 at 8:54 am read in part . per surveyor that Resident #12 had informed her that she was in pain and her body ached and the staff ignored her and threatened to send her to Psychiatric hospital . Resident #12 was sent to Psychiatric Center due to resident hitting window with hand and breaking glass, threatening to hurt herself due to stating she was in so much pain. Resident #12 . was placed on medication management by primary care physician and was doing well, however, she did have drug dependence history of opioid abuse and other pain killers. Surveyor informed that resident was well documented of consistent report of pain, regular visit with primary care physician at facility and other [DIAGNOSES REDACTED]. Resident was sent to emergency room after resident was assessed, however, resident had no specific area of pain . Resident #12 was sent to emergency room and later sent back with no new orders. Observation and interview on 08/10/2017 at 4:20 p.m. the facility's Social Worker escorted the Medical Director, the Administrator, Clinical Corporate Nurse, DON and other staff into the conference room. The Medical Director stood up over Surveyors and refused to have a seat. The Medical Director was gripping his umbrella and ringing his hand around neck of umbrella while speaking loudly to surveyors. The Medical Director said he was not happy with the survey team and Resident #12 was a Pain Seeker. The Medical Director said Resident #12 was competent and was borderline psychotic and continued to seek pain medications. The Medical Director said that he had told Resident #12 that if she continued to complain of pain and ask for pain medications he would discharge her from the facility. When asked if he told her she would be sent to a psych facility for complaining of pain, the Medical Director did not answer but did say he had told her she would be discharged from the facility. The Medical Director said Resident #12 had been sent to the emergency room for evaluation of pain but the hospital probably would not do anything as they were aware of her drug seeking. He said that upon her return from the hospital he would give her a 30 day notice and discharge her and would only treat her if she had an emergency situation until her discharge from the facility, but would no longer provide any other services. The Medial Director said he had reduced Resident #12's pain medications because she had a history of [REDACTED]. He said she complained of pain and perceived it as pain but she had played y'all. The Medical Director said Resident #12 was an addict and she seeks drugs. He said Resident #12 complained of pain all the time, was consistent with her requests for pain medications, she was not able to pin point her pain and ambulates about the building and was outside smoking a lot of the times and that was not what people in pain do. When asked if people walked around all the time in pain and worked 40 hour work weeks while in pain and he said yes but said Resident #12 was a drug seeker. The Medical Director said that since Resident #12 had a history of [REDACTED]. He went on to say he and Resident #12 had a contract that if she complained of pain she would be discharged from the facility. The Medical Director was asked if Resident #12 had the right to be assessed for pain when she complained of pain and he said yes. When asked if Resident #12 had been referred to a pain specialist for evaluation the Medical Director replied No and stated her insurance probably would not cover it and Resident #12 probably could not afford it. In an interview on 08/10/2017 at 4:50 p.m. with the DON, she said Resident #12 was sent to the emergency room for evaluation of her pain. Record review of hospital medical records for Resident #12 dated 08/10/2017 revealed she was admitted to the hospital emergency roiagnom on [DATE] at 2:13 p.m. for generalized pain. Record review of Resident #12's CT Scans dated 08/10/2017 revealed the following: Abdomen and Pelvis without contrast Impression- No CT evidence for acute abdomen-pelvic process on this non-contrast examination. CT scan of head: Impression- No acute intracranial abnormality identified. Frothy secretions in the right sphenoid sinus were nonspecific but could represent acute sinusitis. Record review of Resident #12's X-ray of left hip dated 08/10/2017 revealed: Impression- status [REDACTED]. There was a healed distal femoral fracture. Record review further revealed Resident #12 was diagnosed with [REDACTED]. Abdominal pain, unspecified location. Acute non-intractable headache, unspecified headache type. Record review of hospital discharge form dated 08/10/2017 revealed Resident #12 should follow up with her primary care physician and an orthopedic surgeon. In an interview on 08/11/2017 at 7:50 am with the DON, an assessment and SBAR for Resident #12 was requested. The DON said the SBAR was completed on a plain sheet of copy paper and the nurse note had not been put into the computer yet. A copy of the SBAR written on plain copy paper was received from the DON. Record review of the SBAR, hand written on plain copy paper dated 08/10/2017 at 10:45 am, read in part .Abdominal pain, left hip pain rated as a 9 out of 10, whole body hurts .[MEDICAL CONDITION] arthritis. Back of neck and pain of left ear and left side of head rated as a 4 out of 10 and it had been hurting for over 1 year. Pain with abdominal palpation. Patient states, just call the doctor and tell him I want [MEDICATION NAME]. Do you want her sent to ER? No not necessarily. (It was not specified who was asked this question.) Interview with the DON on 08/11/2017 at 7:45 am, she said that Resident #12's pain medications had been completely stopped at one point. She said the Medical Director just stopped Resident #12's pain medication because she was on a lot of pain medications. The DON said that the Medical Director put Resident #12 on [MEDICATION NAME] 50 mg three times a day along with [MEDICATION NAME] and Tylenol. The DON said the facility had a care plan meeting with Resident #12 and her daughter and the Medical Director set up boundaries and behavior modifications, like a contract. The DON said the Medical Director informed staff that Resident #12 knew what she was doing and every time he walked into the building she was hurting. The DON said they were told to only give Resident #12 Tylenol as needed for her complaints of pain. She further said that the Medical Director said he was not prescribing anymore narcotics for her pain and no further instructions were given in regards to her pain. When asked what should be done if Resident #12 kept complaining of pain, the DON said I guess I would call him, but I never have. The DON said the Medical Director had said to get Resident #12 involved in activities. The DON said she could not remember if the Medical Director had suggested any other interventions regarding Resident #12's pain but did say the Medical Director said that Resident #12 was aware of what she was doing, she doesn't mean it and it is just part of her personality. The DON went on to say that Resident #12's daughter did not want her on a lot of medications. Interview on 08/11/2017 at 11:15 am LVN C said the Medical Director had told her and other nurses at the facility that if Resident #12 complained of pain that staff should re-direct her if her pain medication was not due. LVN C was asked what was done if Resident #12 continued to complain of pain following redirection and she said that she would call the Medical Director but he would just say to re-direct Resident #12. LVN C said the Medical Director said he would not prescribe anything else for her pain as Resident #12 was pain seeking. Interview with Resident #12 on 08/11/2017 at 1:12 p.m. revealed her doctor, the Medical Director, told her if she did not stop complaining of pain and harassing the nurses, he was going to send her out of the facility. Resident #12 further said the Social Worker was the main one who said she needed attention. Resident #12 said the social worker and physician would usually come to her room together when they visited her. Resident #12 said if she needed anything that staff waited to the very last to assist her with anything. Resident #12 asked what to tell the staff when they ask her what she told the surveyor. Resident #12 was informed she did not need to give an explanation to any staff member of the facility for speaking to a surveyor and DADS hot line number was given. Resident #12 was very thankful but concerned about retaliation from the facility for speaking to the surveyor. In an interview with Resident #12 on 08/12/2017 at 11:12 am she said the facility staff asked her if everything was alright following previous interview with surveyor. Resident #12 said she told the staff that everything was ok, because I don't want any problems or them to kick me out. Interview on 08/12/2017 at 11:46 am with Social Worker, when she was asked what interventions have been provided for Resident #12 regarding her pain, she said that every time Resident #12 was medicated she wanted more. Social Worker said the facility may need to find a place that can help her. Social Worker said she knew everything was being done for Resident #12 to keep her alive. Social Worker said Resident #12 was doing well until about 2 weeks ago following surveyor intervention. Record review of Pain Monitoring Record for the month of June 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of June 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of July 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of July 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of August 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift on the following dates: 08/01/2017-08/08/2017 a zero was documented for the pain level which indicated no pain. For the date of 08/09/2017 pain levels were not recorded for any shifts. In an interview with LVN K on 08/12/2017 at 12:03 p.m., she said she worked with Resident #12 every weekend. LVN K said Resident #12 usually complained of pain and rated it at an 8 out of 10 and she usually complained of pain about 2 hours before her next pain medication was scheduled. LVN K said that she would tell Resident #12 to wait it out until the next dose of pain medication was due. LVN K was asked if she had ever called the physician regarding Resident #12 and her pain and LVN K said that she had not. In an interview with LVN C on 08/12/2017 at 1:00 p.m., when asked if Resident #12 had complaints of pain and LVN C confirmed Resident #12 complained of pain all the time. LVN C was asked why there was no documentation of pain on the Pain Monitoring Record if Resident #12 always complained of pain and LVN C said I'm not going to lie, I don't know why they are all zeros. In an interview with the DON on 08/12/2017 at 1:11 p.m., she said if Resident #12 complained of pain that the staff was to offer distractions and redirection. The DON said that smoking was a distraction for Resident #12 and participating in activities. The DON said Truthfully, I wouldn't want to walk around living here, I'm sure she wants to be home. The DON said that Resident #12 complained often of pain and that she complained a lot when the physician (Medical Director) was in the building. The DON said Resident #12 had [MEDICATION NAME] and Tylenol for pain. The DON was shown the copies of the Pain Monitoring Record for the Months of June 2017, July 2017 and August 2017 and she replied Interesting. When asked about the pain being assessed as a zero (which indicated no pain) the DON said I don't know what to say, I just don't know why that is. In an interview with the Clinical Corporate Nurse on 08/12/2017 at 1:43 p.m., she said Resident #12 had days where she did not complain of pain but most days she did complain of pain. The Clinical Nurse further said sometimes when someone continues to complain of pain it becomes a behavior. Record review of Pain Review conducted by LVN C on 08/13/2017 at 4:45 p.m. for Resident #12 revealed she had existing pain, rated it as severe pain and was noted to be moaning and grimacing. The review revealed Resident #12 said the pain was almost constant and listed the following locations of the pain: Hip or knee joint, shoulder/arm/hand/joint, abdomen and a headache. Pain was documented as bilateral sharp and aching. Pain was exacerbated by movement and lying down; and rest helped to alleviate the pain. Pain affected sleep, energy and day to day activities. Record review of Pain Review further revealed Resident #12 was currently on scheduled pain medication that was not effective, was receiving PRN (as needed) pain medication that was not effective and that Resident #12 was not satisfied with pain control. Interview with Clinical Corporate Nurse on 08/14/2017 at 1:26 p.m., revealed Resident #12's new physician had ordered an evaluation by a pain specialist with an appointment scheduled for 08/16/2017. Record review of physician order [REDACTED]. Interview with LVN C on 08/16/2017 at 1:35 p.m., revealed Resident #12 had been referred to a pain specialist and she was currently at her appointment for evaluation. Record review of Statement of Resident Rights provided by the facility, not dated read: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. A document/list of resident who were receiving primary physician services from the Medical Director was provided to the Survey team on 8/12/17 by the facility's Social Worker. The review of the document revealed 43 residents had been receiving primary physician services from the Medical Director. Resident #9 Record review of the clinical chart for Resident #9 revealed the [AGE] year-old resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The review revealed Resident # 9 has the following Diagnoses: [REDACTED]. Record review of Resident #9's Admission MDS revealed a BIMS could not be conducted due to the severity of the resident's cognition level. Record review of the documentation in the body of the intake dated 07/21/17 revealed Resident #9 was in the day area and as she was reaching for a tray from another resident, she fell to the floor on her right side. Record review of the document entitled, Provider Investigation Report for this incident dated 07/21/17. Review of the section entitled Investigation Summary (attach additional sheets as necessary), read, The resident did have a witnessed fall resulting in injury. The section entitled Provider Action Taken Post Investigation, read, 1. will begin sending staff to trainings for dementia patients. Record review of attached statements from staff and family members. Review of statement from Family Member dated 7/20/17 revealed that on 7/20/17, Resident #9 was sitting on the couch in the back of Hall A. She pushed herself up in a standing position. She reached for the eating tray. The tray moved because she was trying to get a grip on it. She fell and landed on her right side, and on the way down she hit her hip and then, (illegible), over and started to cry. Several of the other residents were back there. There was no one, (words underlined twice) staff with the residents when .Resident #9, fell . The review revealed that this family member actually took the resident to sit down prior to the fall. The document further read, .I immediately screamed for the staff . and revealed 2 staff came to the scene of the incident at 1:55 PM. Attached statement from CNA O read in part, .Fall July 21, 2017 .I was doing my last ADL rounds when I heard a family member yelling out .I ran out of a resident's room and went to the back room with the nurse. Statements from 2 other staff were attached. Record review of a statement from Assistant Activity Director revealed that she had seen the resident on a couch and had left the room to take dishes from resident rooms to the main dining room. Review of a statement from CNA Z revealed she was assisting a resident with toileting at the time of the accident. Record review of Resident #9's nurse's notes dated 7/21/17 read, 2:53 PM Resident was in the back sitting area, Visitor reported that resident stood up, lost balance and fell to the floor hitting right hip and leg. This nurse assessed resident from head to toe noted that resident was complaining of right leg pain upon moving. Called MD and received orders for Tylenol 650 now and Q 6 hours prn pain and x-ray to right hip, pelvis and entire right leg . Record review of Resident #9's social service noted dated 7/21/17 3:02 PM read, in part, .Resident grimaced and moaned as nurse assessed and touched resident's right leg .' Record review of Resident #9's Nurse's Notes dated 7/21/17 5:30 PM revealed that the resident's son requested to know the time the x-ray was to be conducted because his mother was in pain. The notes read in part, .SN assessed the res and areas of concern when touching the res was the greater trochanter area, the lateral patella and approx. three inches below the anterior patella. Res verbalized she was in pain at the time of the assessment and it was documented that the order given was for Tylenol 325 mg (2) tabs PO q 6 hrs PRN. Res had the medication documented by previous shift and SN explained to son that I was not able to administer anymore another 2-2 1/2 hours before the tech would be arriving. The review revealed no documentation of the effectiveness of the pain medication after it was administered and if the physician was contacted regarding Resident #9's pain management. Record review of Resident #9's nurse's notes for 7/21/17 revealed the next documented entry for 7/21/17 was at 9:59 PM and read, .Resident resting in bed at this time. Resident displaying nonverbal signs of pain (Facial grimacing) this nurse administered Tylenol 325 mg 2 tabs . The review revealed no documentation that the physician had been contacted to inform him the medication ordered had been ineffective. Review of the next documented entry read, 10:06 PM X ray results received and phoned in to MD. The physician then ordered the resident transferred to the hospital for further evaluation and treatment. The review revealed the RP was contacted and the contract ambulance service was contacted at 10:15 PM and informed the staff there would be an estimated time of arrival in 15 minutes. Record review of Resident #9's Social Services Notes dated 7/23/17 at 10:25 AM read, Late entry; SW received a call .that resident has a broken ri(TRUNCATED)

Based on observations, interviews and record reviews the facility failed to ensure that 1 of 26 residents (Resident #12) reviewed for resident rights could exercise her rights without interference, coercion, discrimination or reprisal in that: The facility's Medical Director informed Resident #12 she would be discharged if she continued to complain of pain and request pain medications. The facility's Social Worker informed Resident #12 she would be discharged from the facility if she continued to complain of pain and request pain medications. An Immediate Jeopardy (IJ) was identified on 08/10/2017. While the IJ was lowered on 8/14/17, the facility remained out of compliance at a scope of isolated and a severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure affected one resident and placed 68 residents at risk of not being able to exercise their rights, psycho-social harm, untreated pain and an over-all decline in Quality of Life and Findings include: Resident #12 Record review of Resident #12's face sheet revealed an admission date of [DATE] and a readmission date of [DATE]. Her Diagnoses: [REDACTED]. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #12 required supervision with set up only for bed mobility, transfer, ambulation, dressing, eating, toilet use, personal hygiene and bathing. Resident #12 used a walker and a wheelchair for mobility and had received pain medication and non-medication interventions for pain. The section for pain revealed the pain frequency was documented as frequently. The review also revealed pain was rated at a 6 out of 10 but the intensity of pain was not documented and was left blank. Record review of Resident #12's care plans dated 12/01/2016 revealed the following: Pain related to residents pain score on admission of 6 out of 10. The approaches included: Assess and document the location, frequency, duration and intensity of her pain. Report increased pain trend to the physician, administer pain medications as ordered and requested and document effectiveness. Attempt non-pharmacological pain relief measures such as, repositioning, back rubs, periodic rest, breathing techniques, music and active range of motion. Provide diversional activities if appropriate. Keep call light within reach at all times. Encourage resident to report pain at onset. Assess for breakthrough pain as needed when on routine medications. Refer resident to therapy services. Display of socially inappropriate/disruptive behavior of repeatedly asking for pain medication when it was not due. The approaches included: Activities staff to visit with and provide diversional activities, monitor and document behaviors, do not argue . Elicit my family input for best approaches. Discuss options for appropriate channeling of anger . Praise for demonstrating desired behavior. Administer behavior medications as ordered by the physician. Talk in a calm voice when behavior is disruptive and unacceptable. Encourage family/responsible party to visit. Social Services to evaluate and visit at least weekly. Record review of Resident #12's Medication Administration Record [REDACTED]. Record review revealed that Tylenol 325 mg (2 tablets) had been administered and documented on 08/10/2017 following surveyor intervention. All other dates were blank. [MEDICATION NAME] 50 mg- administer one tablet by mouth every eight hours at 6:00 am, 2:00 p.m. and 10:00 p.m . Further review revealed Resident #12 was not medicated with [MEDICATION NAME] 50 mg as ordered by the physician orders [REDACTED]. Tylenol 325 mg- one tablet four times a day at 9:00 am, 1:00 p.m., 5:00 p.m. and 9:00 p.m . Review revealed Resident #12 was not medicated with Tylenol 325 mg at 1:00 p.m. per physician orders [REDACTED]. Record review of Resident #12's physician encounters and procedures dated 04/06/2017 revealed the following: Record review of the clinical chart revealed Resident #12 had a history of [REDACTED]. Resident #12 was sent to the psychiatric hospital in March 2017 following an incident of a suicide attempt. Resident #12 attempted to stab herself with a butter knife in an attempt to be transferred to a hospital for pain management. Resident #12 had a procedure for removal of a gallstone but continued to experience pain. Upon return to the facility from the hospital, all pain medications were discontinued. The resident continued to demand pain medications and was described as harassing staff for pain medications. The facility then elicited the assistance of the local Ombudsman. The resident was provided the option of going to a detox program but she declined. Observation and interview on 08/10/2017 at 9:50 am of Resident #12 revealed her ambulating slowly near the nurses' station, her face was red and she was not smiling. Resident #12 complained of pain to the left side of her face, right lower leg, right lower back and right lower abdominal area. Resident was asked if she had reported pain to nursing staff and she said she had and was told she already had been medicated earlier and she could not have anything for pain until 1:00 p.m. or 2:00 p.m. when the next dose was due. Interview on 08/10/2017 at 10:00 am with Resident #12 revealed her problems with pain began in 2005 following toxic environmental exposure, weight loss, a fracture of her left hip and hemiathroplasty (a surgical procedure that replaces one half of the hip joint with a prosthetic, while leaving the other half intact) which became infected. She stated she had a new hip but continued to have pain in the left hip. Resident #12 stated she limped when walking and could walk with a walker but then the pain is too much. Observation and interview on 08/10/2017 at 10:01 am revealed Resident #12 sitting on the edge of her bed rocking back and forth, facial flushing and grimacing. In an interview at same time on 08/10/2017 with Resident #12, she said she had pain to her right lower abdominal area, right lower back area, and said she hurts all over. Resident #12 rated her pain at a 9/10. Resident #12 said she had a history of [REDACTED]. Resident #12 showed her legs were she had multiple golf ball sized indentions from previous surgeries. Resident #12 then showed her left hip which had a surgical scar that ran from the top of her hip to below mid-thigh region. Resident #12 said she had hip replacement and it became infected and due to the infection the hardware had to be removed and they performed the surgery again. Resident #12 said she did not want to cause any problems or complain about pain because she did not want to be discharged to the psych hospital. When asked what she meant by that statement, Resident #12 said the Medical Director and the Social Worker had told her if she continued to complain of pain she would be discharged from the facility to a psych hospital. Interview on 08/10/2017 at 10:20 am Licensed Vocational Nurse (LVN) C said she was not aware that Resident #12 had pain but Resident #12 would be assessed. Social Worker intervened in the interview and said Resident #12 had a history of [REDACTED]. In an interview with the DON on 08/10/2017 at 10:29 am, she said she would assess Resident #12 for pain and notify the physician. Record review of Resident #12's nurse note dated 08/10/2017 at 11:52 am read in part . Resident lying in bed, respirations even, unlabored, skin warm and dry, no shortness of breath at rest, and no [MEDICAL CONDITION] noted to extremities. Resident explained her pain history to nurse, having some ear pain and states the doctor knows, she had ear wax come out that had built up some time back but it had hurt for about a year if she had to guess. Complains of pain to her abdomen and said she had gallstones but her gallbladder was removed. She complained of hurting all over and this had been about 3 years because she had [MEDICAL CONDITION] arthritis. Resident #12 denied any changes in her pain in regards to location, severity, intensity, or duration. Resident #12 was ambulating up and down hallway multiple times today with assist. Asked the patient if she told the nurse she was having issues and she said no, I told the state lady. Patient had been seen by primary care physician multiple times. No signs of acute illness or change in condition in this patient at this time. Physician and family will be contacted, however, to see what has been evaluated for Resident #12 and what if anything can still be done for her conditions. Record review of Resident #12's Social Worker notes dated 08/11/2017 at 8:54 am read in part . per surveyor that Resident #12 had informed her that she was in pain and her body ached and the staff ignored her and threatened to send her to Psychiatric hospital . Resident #12 was sent to Psychiatric Center due to resident hitting window with hand and breaking glass, threatening to hurt herself due to stating she was in so much pain. Resident #12 . was placed on medication management by primary care physician and was doing well, however, she did have drug dependence history of opioid abuse and other pain killers. Surveyor informed that resident was well documented of consistent report of pain, regular visit with primary care physician at facility and other [DIAGNOSES REDACTED]. Resident was sent to emergency room after resident was assessed, however, resident had no specific area of pain . Resident #12 was sent to emergency room and later sent back with no new orders. Observation and interview on 08/10/2017 at 4:20 p.m. the facility's Social Worker escorted the Medical Director, the Administrator, Clinical Corporate Nurse, DON and other staff into the conference room. The Medical Director stood up over Surveyors and refused to have a seat. The Medical Director was gripping his umbrella and ringing his hand around neck of umbrella while speaking loudly to surveyors. The Medical Director said he was not happy with the survey team and Resident #12 was a Pain Seeker. The Medical Director said Resident #12 was competent and was borderline psychotic and continued to seek pain medications. The Medical Director said that he had told Resident #12 that if she continued to complain of pain and ask for pain medications he would discharge her from the facility. When asked if he told her she would be sent to a psych facility for complaining of pain, the Medical Director did not answer but did say he had told her she would be discharged from the facility. The Medical Director said Resident #12 had been sent to the emergency room for evaluation of pain but the hospital probably would not do anything as they were aware of her drug seeking. He said that upon her return from the hospital he would give her a 30 day notice and discharge her and would only treat her if she had an emergency situation until her discharge from the facility, but would no longer provide any other services. The Medial Director said he had reduced Resident #12's pain medications because she had a history of [REDACTED]. He said she complained of pain and perceived it as pain but she had played y'all. The Medical Director said Resident #12 was an addict and she seeks drugs. He said Resident #12 complained of pain all the time, was consistent with her requests for pain medications, she was not able to pin point her pain and ambulates about the building and was outside smoking a lot of the times and that was not what people in pain do. When asked if people walked around all the time in pain and worked 40 hour work weeks while in pain and he said yes but said Resident #12 was a drug seeker. The Medical Director said that since Resident #12 had a history of [REDACTED]. He went on to say he and Resident #12 had a contract that if she complained of pain she would be discharged from the facility. The Medical Director was asked if Resident #12 had the right to be assessed for pain when she complained of pain and he said yes. When asked if Resident #12 had been referred to a pain specialist for evaluation the Medical Director replied No and stated her insurance probably would not cover it and Resident #12 probably could not afford it. In an interview on 08/10/2017 at 4:50 p.m. with the DON, she said Resident #12 was sent to the emergency room for evaluation of her pain. Record review of hospital medical records for Resident #12 dated 08/10/2017 revealed she was admitted to the hospital emergency roiagnom on [DATE] at 2:13 p.m. for generalized pain. Record review of Resident #12's CT Scans dated 08/10/2017 revealed the following: Abdomen and Pelvis without contrast Impression- No CT evidence for acute abdomen-pelvic process on this non-contrast examination. CT scan of head: Impression- No acute intracranial abnormality identified. Frothy secretions in the right sphenoid sinus were nonspecific but could represent acute sinusitis. Record review of Resident #12's X-ray of left hip dated 08/10/2017 revealed: Impression- status [REDACTED]. There was a healed distal femoral fracture. Record review further revealed Resident #12 was diagnosed with [REDACTED]. Abdominal pain, unspecified location. Acute non-intractable headache, unspecified headache type. Record review of hospital discharge form dated 08/10/2017 revealed Resident #12 should follow up with her primary care physician and an orthopedic surgeon. In an interview on 08/11/2017 at 7:50 am with the DON, an assessment and SBAR for Resident #12 was requested. The DON said the SBAR was completed on a plain sheet of copy paper and the nurse note had not been put into the computer yet. A copy of the SBAR written on plain copy paper was received from the DON. Record review of the SBAR, hand written on plain copy paper dated 08/10/2017 at 10:45 am, read in part .Abdominal pain, left hip pain rated as a 9 out of 10, whole body hurts .[MEDICAL CONDITION] arthritis. Back of neck and pain of left ear and left side of head rated as a 4 out of 10 and it had been hurting for over 1 year. Pain with abdominal palpation. Patient states, just call the doctor and tell him I want [MEDICATION NAME]. Do you want her sent to ER? No not necessarily. (It was not specified who was asked this question.) Interview with the DON on 08/11/2017 at 7:45 am, she said that Resident #12's pain medications had been completely stopped at one point. She said the Medical Director just stopped Resident #12's pain medication because she was on a lot of pain medications. The DON said that the Medical Director put Resident #12 on [MEDICATION NAME] 50 mg three times a day along with [MEDICATION NAME] and Tylenol. The DON said the facility had a care plan meeting with Resident #12 and her daughter and the Medical Director set up boundaries and behavior modifications, like a contract. The DON said the Medical Director informed staff that Resident #12 knew what she was doing and every time he walked into the building she was hurting. The DON said they were told to only give Resident #12 Tylenol as needed for her complaints of pain. She further said that the Medical Director said he was not prescribing anymore narcotics for her pain and no further instructions were given in regards to her pain. When asked what should be done if Resident #12 kept complaining of pain, the DON said I guess I would call him, but I never have. The DON said the Medical Director had said to get Resident #12 involved in activities. The DON said she could not remember if the Medical Director had suggested any other interventions regarding Resident #12's pain but did say the Medical Director said that Resident #12 was aware of what she was doing, she doesn't mean it and it is just part of her personality. The DON went on to say that Resident #12's daughter did not want her on a lot of medications. Interview on 08/11/2017 at 11:15 am LVN C said the Medical Director had told her and other nurses at the facility that if Resident #12 complained of pain that staff should re-direct her if her pain medication was not due. LVN C was asked what was done if Resident #12 continued to complain of pain following redirection and she said that she would call the Medical Director but he would just say to re-direct Resident #12. LVN C said the Medical Director said he would not prescribe anything else for her pain as Resident #12 was pain seeking. Interview with Resident #12 on 08/11/2017 at 1:12 p.m. revealed her doctor, the Medical Director, told her if she did not stop complaining of pain and harassing the nurses, he was going to send her out of the facility. Resident #12 further said the Social Worker was the main one who said she needed attention. Resident #12 said the social worker and physician would usually come to her room together when they visited her. Resident #12 said if she needed anything that staff waited to the very last to assist her with anything. Resident #12 asked what to tell the staff when they ask her what she told the surveyor. Resident #12 was informed she did not need to give an explanation to any staff member of the facility for speaking to a surveyor and DADS hot line number was given. Resident #12 was very thankful but concerned about retaliation from the facility for speaking to the surveyor. In an interview with Resident #12 on 08/12/2017 at 11:12 am she said the facility staff asked her if everything was alright following previous interview with surveyor. Resident #12 said she told the staff that everything was ok, because I don't want any problems or them to kick me out. Interview on 08/12/2017 at 11:46 am with Social Worker, when she was asked what interventions have been provided for Resident #12 regarding her pain, she said that every time Resident #12 was medicated she wanted more. Social Worker said the facility may need to find a place that can help her. Social Worker said she knew everything was being done for Resident #12 to keep her alive. Social Worker said Resident #12 was doing well until about 2 weeks ago following surveyor intervention. Record review of Pain Monitoring Record for the month of June 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of June 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of July 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift and every day for the month of July 2017 that 0 (zero) was documented as the pain level for Resident #12 which indicated no pain. Record review of Pain Monitoring Record for the month of August 2017 for Resident #12 revealed that pain levels were to be assessed every shift. The shifts were 6:00 am- 2:00 p.m., 2:00 p.m. - 10:00 p.m. and 10:00 p.m. - 6:00 am. The Pain Monitoring Record revealed that for every shift on the following dates: 08/01/2017-08/08/2017 a zero was documented for the pain level which indicated no pain. For the date of 08/09/2017 pain levels were not recorded for any shifts. In an interview with LVN K on 08/12/2017 at 12:03 p.m., she said she worked with Resident #12 every weekend. LVN K said Resident #12 usually complained of pain and rated it at an 8 out of 10 and she usually complained of pain about 2 hours before her next pain medication was scheduled. LVN K said that she would tell Resident #12 to wait it out until the next dose of pain medication was due. LVN K was asked if she had ever called the physician regarding Resident #12 and her pain and LVN K said that she had not. In an interview with LVN C on 08/12/2017 at 1:00 p.m., when asked if Resident #12 had complaints of pain and LVN C confirmed Resident #12 complained of pain all the time. LVN C was asked why there was no documentation of pain on the Pain Monitoring Record if Resident #12 always complained of pain and LVN C said I'm not going to lie, I don't know why they are all zeros. In an interview with the DON on 08/12/2017 at 1:11 p.m., she said if Resident #12 complained of pain that the staff was to offer distractions and redirection. The DON said that smoking was a distraction for Resident #12 and participating in activities. The DON said Truthfully, I wouldn't want to walk around living here, I'm sure she wants to be home. The DON said that Resident #12 complained often of pain and that she complained a lot when the physician (Medical Director) was in the building. The DON said Resident #12 had [MEDICATION NAME] and Tylenol for pain. The DON was shown the copies of the Pain Monitoring Record for the Months of June 2017, July 2017 and August 2017 and she replied Interesting. When asked about the pain being assessed as a zero (which indicated no pain) the DON said I don't know what to say, I just don't know why that is. In an interview with the Clinical Corporate Nurse on 08/12/2017 at 1:43 p.m., she said Resident #12 had days where she did not complain of pain but most days she did complain of pain. The Clinical Nurse further said sometimes when someone continues to complain of pain it becomes a behavior. Record review of Pain Review conducted by LVN C on 08/13/2017 at 4:45 p.m. for Resident #12 revealed she had existing pain, rated it as severe pain and was noted to be moaning and grimacing. The review revealed Resident #12 said the pain was almost constant and listed the following locations of the pain: Hip or knee joint, shoulder/arm/hand/joint, abdomen and a headache. Pain was documented as bilateral sharp and aching. Pain was exacerbated by movement and lying down; and rest helped to alleviate the pain. Pain affected sleep, energy and day to day activities. Record review of Pain Review further revealed Resident #12 was currently on scheduled pain medication that was not effective, was receiving PRN (as needed) pain medication that was not effective and that Resident #12 was not satisfied with pain control. Interview with Clinical Corporate Nurse on 08/14/2017 at 1:26 p.m., revealed Resident #12's new physician had ordered an evaluation by a pain specialist with an appointment scheduled for 08/16/2017. Record review of physician order [REDACTED]. Interview with LVN C on 08/16/2017 at 1:35 p.m., revealed Resident #12 had been referred to a pain specialist and she was currently at her appointment for evaluation. Record review of Statement of Resident Rights provided by the facility, not dated read: You, the resident, do not give up any rights when you enter a nursing facility. The facility must encourage and assist you to fully exercise your rights. Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate or retaliate against you for exercising your rights. If anyone hurts you, threatens to hurt you, neglects your care, takes your property, or violates your dignity, you have the right to file a complaint with the facility administrator or with the Texas Department of Aging and Disability Services by calling [PHONE NUMBER]. A document/list of resident who were receiving primary physician services from the Medical Director was provided to the Survey team on 8/12/17 by the facility's Social Worker. The review of the document revealed 43 residents had been receiving primary physician services from the Medical Director. The Administrator was notified on 8/10/17 at 10:00 am of the IJ due to the above failures and a Plan of Removal (PoR) was requested. A PoR was received and after several revision, a PoR was accepted on 8/16/17 at 3:30 p.m. The PoR included in part: Every resident at the facility will be evaluated for pain and any issues addressed immediately. If any resident does not have pain medication and complains of pain, the Physician will be notified and pain medication order obtained. The assessments will be completed by the DON, Charge Nurses's (sic), and Treatment Nurse. This was started on 8/11/17 and completed on 8/14/17. No other residents were identified with uncontrolled pain. Four residents indicated they had pain; however they stated their pain medication was sufficient. Completed 8/14/17. Care plans were modified. Completed 8/14/17. Resident, (#12), was assessed and sent to the ER for evaluation of her pain. The review of the document further revealed that if Resident #12 should present with pain that cannot be controlled by Tylenol, the Charge Nurse will assess and contact Resident #12's new physician. The review revealed Resident 312 had been referred to a Pain Management Physician. The review further revealed the present Medical Director for the facility had been removed and replaced by another physician that was named on the document. Review of the document further read, If any resident complains of pain with no pain medication, the Licensed Nurse will evaluates, (sic), and the resident using the PRN pain flow sheet and the physician will be notified for new orders. The review revealed if the physician was not available or in the event the physician were to not address the issue, the new Medical Director would be contacted. Review of the document further read, An in-service will be given by the Director of Nursing and MDS Coordinator to the Licensed Staff on how to complete the pain review, The in-service will include the residents diagnosis, current pain/existing pain, frequency, pain location, character of the pain, what elevates the pain, if the resident has scheduled or prn treatment for [REDACTED]. These evaluations will be completed upon admission, quarterly, and with change of condition. Began 8/11/17 and completed 8/14/17. Resident on pain management will be evaluated like any other resident with pain each time they require prn pain medication or complain of pain there will be a pain evaluation completed using the PRN pain management flow sheet. Residents receiving routine medication are asked if their routine medication was effective but residents that require prn pain medication are evaluated using the PRN Management Flow Sheet. After any pain medication the Charge Nurse will ask the resident if the medication was effective. The Caregivers and other staff will be in-serviced by the DON or MDS Coordinator on Stop and Watch Sheets. Aides or other staff have been trained to ask the residents if the resident is in pain or if the resident is grimacing, crying, rubbing a certain spot, holding a place on their body or in any other way appears to be in pain, and if the resident is in pain to fill out the Stop and watch form and give it to the nurse for follow-up. Started 8/11/17 and completed 8/14/127. Any staff member not available for the in-service on the dates above will be in-serviced before being allowed to return to work. The in-service will be done by the Director of Nurses. If any resident continues to complain of pain after receiving their pain medication, the Licensed Nurse will evaluate the resident and notify the physician. The Licensed Nurse will use the face pain scale to identify pain when a resident cannot communicate his/her pain intensity. Licensed nurses and direct care staff will be in-serviced by the Director of Nursing or MDS Coordinator on interpreting pain in residents that aphasic or cannot otherwise tell the nurses when they are in pain. This was started on 8/11/17 and completed 8/14/17. Any staff member not available for for the in-service on the dates above will be in-serviced before being allowed to return to work. The in-service will be done by the DON. The weekend staff and 10-6 staff were in-serviced by the MDS Coordinator on 8/11/17 and completed on 8/14/17. The Plan of Removal was monitored until the IJ was lowered: Record review of the in-service training provided to staff revealed that all staff were trained or retrained in the following: -All CNAs were trained in the Stop & Watch process. They were taught or re-taught how to recognize indicators of pain; reminded to ask residents about pain, report to nurses when residents responded verbally or non-verbally in ways indicating that they were in pain; and reminded to complete Stop & Watch forms. This training was completed on 8/12/17. -All medication aides and nurses received in-service training by the DON about the medications not to be crushed. This training was completed on 8/10/17. -All housekeeping staff and CNAs received in-service training on the policies on isolation room cleaning, general cleaning of rooms. -All staff received in-services revealed an in-service was performed by the facility Administrator for staff on 08/14/2017 regarding Resident Rights, Abuse, Neglect and exploitation. -All nursing staff received in-service training on pain awareness, and how to recognize changes in residents' condition. This training was completed on 8/16/17. Random interviews were conducted during the monitoring. Staff indicated that they attended these training sessions. They were able to describe the training they received and that training reflected correct techniques. Observations were conducted during the monitoring. No additional concerns were identified between the acceptance of the PoR and the lowering of the IJ. The Administrator was informed on 8/16/17 at 5:10 p.m. that the IJ was lowered; however the facility remained out of compliance at a level of isolated and a severity of actual harm that is not immediate jeopardy due to the facility needing more time to ensure that the plan of removal was effective. According to the CMS 672, the census was 69.

Complaint # 6 Based on observation, interview and record review facility failed to provide grooming, incontinent care, mouth and skin care (activities of daily living- ADL) to three of six sampled residents (Resident #4, #5 and #6) who were unable to carry out ADLs. The facility failed to: Resident #4 - provide timely incontinent care, mouth care, dressing and showers Resident #5 - provide timely incontinent care, mouth care dressing and showers Resident #6 - provide timely incontinent care, mouth care dressing and showers This failure affected 3 residents and placed 62 others at risk of not receiving assistance with maintaining personal hygiene. Findings include: Resident #4 Record review of Face sheet revealed Resident #4 was last admitted to the facility on [DATE]. The [AGE] year old had [DIAGNOSES REDACTED]. Record review of Physician orders [REDACTED]. Observation on 08/23/12 at 12:00 PM revealed Resident #4 lying in bed on her back in her hospital gown. A strong smell of urine surrounded her bed. Resident ' s bed pad and sheets were wet. A urine ring stain was visible from under pad and under pillow. A sheet was wadded up and placed over Resident ' s groin and appeared wet. Her lower legs were dry and flakey. Hand and forearm splints were on both hands. Resident ' s fingernails were long and extended 1.5 cm beyond her fingertips. Dark brown and black matter was visible under her fingernails. The splints were removed. The skin in the folds of her palms and at the base of her digits was white macerated. Her hands were malodorus. Residents toenails were long and extended. Black flakey matter was visible in between and under her toes. There were no other skin protectors on resident. Interview on 08/23/12 at 12 PM CNA I revealed she was helping out on that hall. She said restorative aides put on and took off the hand splints. She did not think Resident had received her AM care. She had not had a bath or shower. Observations on 08/24/12 at 9:05 am revealed Resident #4 was in bed lying on her back. An over powering ammonia stench filled the room. When turned to her side the saturated bed pad was visible. Soft stool oozed from her rectum. There was a dark red amber ring across the bed pad and onto the sheets. The urine ring extended up and under the Resident ' s pillow. Resident ' s hands were contractured and there were no splints or hand rolls. Resident #4's nails extended approximately 1 cm beyond her fingertips and were caked with light and dark brown and black matter. Her nails pressed into the skin of her palms. Interview on 08/24/12 at 09:05 AM CNA K said Resident #4 had not been up or cleaned that morning. Observations on 08/28/12 at 8:30 am revealed Resident #4 was lying on her back in bed. There was an over-powering smell of ammonia around Resident's bed. When Resident was turned to her side, she was not able to assist in any movement. Her pad and mattress were wet. And reddish ring stained pad and sheet under Resident. Soft formed stool oozed from her rectum. Resident wore splints on both hands. Her hands were malodorus. Record review of Resident #4's Nursing MAR indicated [REDACTED]. Every blank on every shift had been initialed as completed from August 01, 2012 through August 27, 2012. Record review of Resident #4's ADL sheet recorded: Bed mobility: self performance as totally dependent and support provided 2 helpers and eating/drinking: self and support provided. The ADL sheet was not initialed 48 times during August 2012, all 3 shifts. Transfer assistance was recorded on the ADL sheet as 8 - 'Activity did not occur' from 08/01-27/12 on 2pm-10 and 10pm-6 am shifts. Transfers were not initialed as completed 14 day shifts from August 01, 2012 through August 23, 2012. Range of motion: Not initialed as completed 20 times on all 3 shifts 08/01-23/12. Showers were initialed as completed 4 times from 08/01-23/12. Record review of Resident #4 ' s Quarterly 6/24/12 MDS revealed rarely or never understood; was totally dependent on staff for bed mobility, transfers, dressing, eating, toileting and personal hygiene. There were no mobility devices listed and functional status was impaired both sides upper and lower. She was at risk for pressure ulcers. Resident #5 Record review of Resident #5's 08/28/12 face sheet revealed the [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 08/23/12 at 1:50 PM revealed Resident #5 was lying in bed on her back with her feet crossed. She smelled of urine and body odor. Resident's mouth contained 1 upper denture and no lower teeth. Her denture was caked with plaque and scum. It was discolored yellow and brown. The plaque build-up obscured the definition between each tooth on the denture. Resident had very great pendulous breasts. On skin examination, her breasts were lifted to reveal open wounds under both breasts the full length of the skin fold. The skin was grey and macerated and the wounds were each about 25 cm long. Resident grimaced and complained of pain under her breasts. Resident was not able to assist in repositioning or turning over. She did re-cross her legs when the care was finished. Interview on 08/23/12 at 1:50 pm CNA H said she did not have time to do showers or mouth care or get residents out of bed. She could not do nails. That day she had time to do one shower out of 6 she was supposed to do. She and the other aide had never seen the wounds under her breasts before. But she was off for a couple days and she got moved often. Observation 08/24/12 at 5:45 am Resident #5 was in bed lying on her back with her head elevated 20 degrees. Her feet were crossed. A strong urine ammonia smell permeated her bedroom. Room was still dark. She was wearing her dentures. Observations on 08/24/12 at 6:45 am revealed Resident #5 was in bed lying on her back with her head up 20 degrees. The smell of urine was present around her bed. She did not have hand rolls or splints; and there were no skin protectors on her extremities. Her legs were crossed and heels were not off-loaded. Her mouth smelled. The upper denture was encrusted with brown and yellowish plaque. Observation on 08/24/12 at 9:10 am revealed Resident #5 was lying in bed on her back. There was a strong urine stench in her room. There were no hand rolls, skin protectors or off-loading. Resident ' s legs were crossed and her feet dropped. When her breasts were lifted a strong body odor became apparent. The skin under both breasts, a length of about 25 cm on each side was open stage 2 gray macerated with some skin sloughing. No barrier cream or dressings were visible. The Resident grimaced and moaned from pain. Interview on 08/24/12 at 9:10 am Resident #5 said the pain was from the skin under her breasts. Interview on 08/24/12 at 9:10 am CNA G revealed Resident #5 had not been changed or bathed yet. Interview 08/28/12 at 9:30 am Resident #5's family members revealed they visited 1-2 times weekly. She and other family staggered their visits. She had always seen Resident #5 in that position (on her back). She had never seen her dentures out or washed. Resident never got up to shower. The facility bathed her in the bed. Observation at that time, CNA J was asked to remove the denture and clean it. The Resident was not able to pull it loose from her mouth. It came loose with moderate pulling and loosening from side to side by aide. She was not able to remove the plaque by rubbing it under sink water. She could not find the denture cup and/or toothbrush until she searched through several places in her personal effects. The denture cup with the lower plate, had no liquid in it. The toothbrush was still in an unopened package. Both items were in a ziplock baggie containing jewelry and other personal effects. The upper was a significantly different color than the lower plate. Interview at that time, CNA J revealed Resident #5's denture cup, paste, denture cleaner and brush should not have been in that bag. She also said she never had time to do mouth care. Record review of Resident #5's 08/03/12 Nurses' Summary revealed Skin Conditions: Skin normal, pressure reducing device for bed, turning/repositioning program, application to dressing (with or without topical medications) other than to feet; GI and Bladder: Always incontinent, pad/briefs utilized. Record review of Resident #5's 7/26/12 Skin Risk Analysis revealed Chronic bowel and urinary incontinence, decreased mental status and limited mobility; report any skin issues noted during care; use moisturizers for dry skin; keep skin clean and dry; turning and repositioning; and peri-care. Record review of Resident #5's ADL sheet revealed: No showers were documented as given for the month of August 2012 except on August 02, 2012. Oral/denture care twice daily was initialed A for assisted 2 shifts from 08/01-08/17. Assistance was provided 6 times between 08/17 and 08/23. Record review of 07/23/12 Quarterly MDS revealed Resident #5 did not refuse care, had highly impaired vision; required extensive assistance for bed mobility, transfers, dressing and personal hygiene. Resident was totally dependent on staff for bathing; always incontinent of bladder and bowel. She utilized a wheelchair to transport. She had no skin issues and was on a turning/repositioning program. Resident #6 Record review of Resident #6 ' s 08/18/12 face sheet revealed the [AGE] year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations 08/23/12 at 1:40 PM revealed Resident #6 was lying on her back in bed in hospital gown. She mumbled to herself. There was a strong smell of urine around her bed. There were no splints or skin protectors on resident. Interview at that time CNA J said it was Resident #6 ' s turn to shower but she did not have time. (Her shift almost over.) She said with her assignment there was not enough time to shower the 4 or 5 residents she had. Observation on 08/24/12 at 5:40 AM revealed Resident #6 was lying in bed on her back, talking to herself. A pungent stench of ammonia permeated her room. Her mouth smelled putrid as she spoke. She opened her mouth to reveal brown, yellow and cream colored plaque covering the few remaining teeth. Her lips were dry and flaking. Her tongue was covered with a dry white film and had some surface grooves. Both hands were grossly contractured and without hand splints. Resident was unable to open her right hand without grimacing and crying in pain. Both hands were malodorous. Opaque gray macerated skin was visible in between her fingers of her right hand. Her fingernails were each about 1 cm. long beyond the fingertips. Brown and black matter was visible under her fingernails. There were no skin protectors, heel protectors or padding elsewhere on or around resident. Her legs and feet were not off-loaded. (Off-loading is a term used in wound care to relieve pressure from an area of the body. The process of off-loading heels requires pillow to be placed under the lower leg in such a way that heels are not touching anything.) The skin on her lower legs and feet was flakey. Her toenails were approximately 1 cm long and [DIAGNOSES REDACTED]. Dark brown matter was visible under her toenails. Black and dark gray matter was visible in between and under her toes. A pool of green drainage about 1 cm x 1cm collected below the inner corner of her right eye. Observation on 08/24/12 at 6:20 am of Resident #6 and with ADON revealed Resident #6 was laying on her back. Ammonia smell remained strong in the room. There were 2 soaked, wet bed pads under Resident #6. The sheet under her also appeared wet and a brown ring was visible under her neck. Both her left and right hands remained contractured without splints or rolls. Both hands smelled like feet. Interview at that time, the ADON confirmed the sheet was wet. She did not know why there were 2 bed pads under Resident #6. She said the matter under Resident #6 ' s right eye was not infection. She confirmed there were no hand rolls and legs were not off-loaded. Observation on 08/24/12 at 9:00 am revealed Resident #6 was lying on her back. Resident had strong body odor and smelled of urine. Both her left and right hands remained contractured without splints or rolls. Both hands were malodorus. Interview on 08/24/12 at 9:00 am CNA G revealed Resident #6 had not been cleaned or bathed. It was time to do Resident's ADLs but she had to help another CNA. Record review of 08/12 Physician order [REDACTED]. Record review of 06/09/09 Care plan revealed last review on 03/28/12 required Maximum assist with ADLS related to stroke with left sided weakness. Currently resident unable to participate in care and did not express needs to staff. ROM with ADLS daily, nail care weekly and as needed; nurse to cut nails ...assist with oral care every shift and as needed. Shower 3 times a week per schedule; assist resident with dressing, make sure clothing is clean and seasonally appropriate as she is total care with all ADLs. Interview on 08/23/12 at 4:00 pm the Director of Nurses (DON) said the purpose of the ADL book was to record amount of assistance needed by staff to accomplish ADLs and the amount the residents can do independently. The information was used to do the MDS. The CNAs and restorative aides signed off the care. At the end of the shift the nurses signed the ADL sheet verifying the care was done. She confirmed much of the ADLs were not signed off by the aides on several residents for more than 2 months. She agreed work not documented was not done. She believed the care was done but aides rushed at the end of their shift and forgot to sign the paper. There were 2 ADONs but 1 was out sick. The other made rounds on the halls. The DON rounded all the halls to make sure the care was done. A confidential interview on 08/23/12 at 12:37 pm said sometimes there is only one aide on that hall. The nurse passes all oral and gastrostomy tube medications, does assessments and nursing care for the whole hall. The medications aides were assigned as nursing aides. The facility did not have a full time wound care nurse yet. The full time wound care nurse left. The part-time wound care nurse was filling in. Most times she got it all done but when she did not finish, she put a note in the 24 hour log and the unit nurses finished it. Wound care nurse did all weekly skin assessments.Mostly the aides were the ones really struggling to get all their work done. They just don't have enough help. Interview on 08/23/12 at 4:00 pm the Director of Nurses (DON) said the purpose of the ADL book was to record amount of assistant needed by staff to accomplish ADLs and the amount the residents can do independently. The information was used to do the MDS. The CNAs and restorative aides signed off the care. At the end of the shift the nurses signed the ADL sheet verifying the care was done. She confirms much of the ADLs were not signed off by the aides on several residents for more than 2 months. She agreed work not documented was not done. She believed the care was done but aides rushed at the end of their shift and forgot to sign the paper. There were 2 ADONs but 1 was out sick. The other made rounds on the hall. The DON makes rounds on all the halls to make sure the care was done. During that interview, the DON said staff had complained about the level of work. She said they assessed the resident requirements: some being more work than others. The aides staffing was reduced from 8 on 6-2 and 2-10 shifts to 7 on each of those shifts. When the aides complained, the Administrator agreed to change the aide staffing back to 8 per shift days and evenings. The DON only had 7 aides on 6-2 shift. She put 3 aides on the locked unit. One aide worked on D hall. But that aide was a Medication aide. Nurses passed their own medications. The 3 remaining CNAs covered B and C halls. One CNA was shared between the 2 halls. The facility 670 recorded a census of 88: 65 dependent on staff for bathing, 72 dependent for dressing.

Based on observation, record review and interview the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents experiencing pain. (Resident #4) The facility failed to give Resident #4 her increased dosage of [MEDICATION NAME] as ordered by the doctor. This failure affected one residents with pain and placed 37 residents on pain management at risk for pain. Findings include: Resident #4 Record review of the face sheet for Resident #4 revealed she was admitted on [DATE]. Resident ' s [DIAGNOSES REDACTED]. Observation on 11/9/11 at 1:10 p.m. revealed Resident #4 was lying in bed crying out Dear God, dear God please help me, nurse I know you can do something, please, please, please dear God. In an interview at this time, while outside Resident #4 ' s room Certified Nurse Aide (CNA) A stated that the nurse gave Resident #4 all of the pain medication that they could give her for right now. In an interview at 1:12 PM Resident #4 stated her left knee was hurting her. Observation at this time revealed that Resident #4's left knee appeared to be swollen. In an interview on 11/9/11 at 1:17 p.m. the Director of Nurses (DON) was asked what Resident #4 was given for pain and at what time. At this time the DON instructed the Surveyor to ask Licensed Vocational Nurse (LVN) B. In an interview on 11/9/11 at 1:20 p.m. LVN B stated that she would check on Resident #4 and she did. Observation at this revealed that Resident #4 told LVN B that her knee was killing. Continued observation at this time revealed that LVN B did not assess Resident #4's knee. LVN B stated that Resident #4 sometimes complained of hip pain and sometimes knee pain. LVN B stated that she would see what she could get for Resident #4 and left the room. In an interview at this time LVN B was asked if she was going to assess Resident #4's knee, she said yes. The LVN assessed Resident #4's left knee. Observation at this time revealed that while assessing Resident #4's knee LVN B said that Resident #4 's knee was swollen, LVN B asked Resident #4 if her knee hurt and if she was hurting anywhere else. Resident #4 said only her knee was hurting her. Resident #4 stated that she had had a knee replacement. Continued observation revealed that LVN B asked Resident #4 what was her worst pain on a scale of 1 to 10 and ten being the worst pain. Observation at this time revealed that Resident #4 said her pain was a 12. In an interview on 11/9/11 at 1:28 pm LVN B stated that she was going to call the doctor to let the doctor know what was going on. In an interview on 11/9/11 at 1:33 pm Registered Nurse (RN) C stated that she gave Resident #4 Norc 7.5/ 325 mg at 12:30 p.m. and she stated that that was the only pain medication that she could give Resident #4. Record review of Resident #4's Physician telephone order dated 10/19/11 revealed 1. Increase pain meds to [MEDICATION NAME] 10/325. 2. Please give on patient request even in middle of night every three hours as needed. Observation on 11/9/11 at 1:55 p.m. of Resident #4's blister pack of [MEDICATION NAME] revealed [MEDICATION NAME]/APAP 7.5/ 325 mg tab 30 tabs, 13 pills had been given and the medication was ordered on [DATE]. Record review of Resident #4's care plans dated 8/20/11 revealed Rap/problem/need: Resident complains of increased pain/discomfort and is at risk for injury from decrease in ADLs hip pain, bone pain and generalized pain, [MEDICATION NAME]., Goal will maintain current ADLs and pain/discomfort will be relived within one hour after intervention over next 90 days, Approach 1. Monitor for s/s of increased pain/ discomfort assess resident for possible causes give meds, tx. s, physical and relaxation modalities, etc. assess for relief..." Record review of Resident #4's physician telephone and monthly recap from 10/19/11 to 11/9/11 revealed that there was no physician order to discontinue [MEDICATION NAME] 10/325 mg and no clarification order to let the doctor know that Resident #4 was receiving 7.5/325 mg of [MEDICATION NAME] instead of the [MEDICATION NAME] 10/325 mg. In an interview on 11/9/11 at 1:53 p.m. LVN B stated that she faxed the order for [MEDICATION NAME] 10/ 325 mg to the pharmacy, she would get the code to the safe to see if the facility had [MEDICATION NAME] 10/325 mg and go give it to Resident #4, let the doctor know that Resident #4 was not getting the correct dose of pain medication. In continued interview she stated that she did not know how Resident #4's physician pain medication order for [MEDICATION NAME] 10/325 mg was missed. In an interview on 11/9/11 at 2:35 p.m. RN C stated that she pulled the 10/325 mg [MEDICATION NAME] from the safe and she was going to give the medication to Resident #4. In continued interview she stated that she was also going to call the doctor to see what she could give Resident #4 for breakthrough pain. In an interview on 11/9/11 at 3:59 p.m. the DON stated that the staff had informed her about Resident #4's [MEDICATION NAME]. She stated that they have changed the procedure for monthly reconciliation of physician orders. In further interview she stated that staff are comparing monthly orders and telephone orders to the medication administration record. Then the staff will make corrections if needed. Record review of the facility's pain Manage Program policy revised dated 2/1/05 revealed: " Process of Pain Assessment:.. 3. Obtain orders for pharmaceutical interventions, pain medications, and non- pharmaceutical interventions such as heat, cold, massage and relaxation. 4. On a daily basis the nurse will assess the resident for pain, on Medication Administration Record... Follow up: a. If pain management continues to be ineffective, physician is notified for alternate interventions ... " Record review of the facility's Administering Medications policy dated revised April 2010 revealed: " ...3. Medications must be administered in accordance with the orders, including any required time frame ... " The CMS 672 listed 38 residents on a pain management program.

Based on observation, interview and record review the facility failed to maintain their Infection Control Program and ensure that the assigned licensed vocational nurse ( LVN) observed, performed hand washing, utilized gloves, changed gloves and maintained clean supplies during care for two of five sampled residents. (Residents #s3 and 6) 1. LVN A performed tracheostomy suctioning without maintaining clean/sterile technique for Resident #3. 2. LVN A utilized respiratory suction equipment set-up for Resident #3 that had unprotected port covers, undated tubing, equipment and excessive secretions in the suction reservoir. 3. LVN A administered medications and fluids through a gastrostomy tube without hand washing, changing gloves after taking resident's medication cups into the resident bathroom. The LVN placed the piston syringe plunger on unprotected surfaces, stored the plunger and piston syringe in the plastic storage bag without rinsing or cleaning them for Residents #3 and #6. These failures caused one resident with a tracheostomy to develop a chest infection and could lead to facility acquired infection, discomfort and illness for 8 other residents receiving tube feedings. Complaint # 4 Findings include: 1. Tracheostomy suctioning without maintaining clean/sterile technique Review of Resident #3's hospital discharge orders dated 09/15/10 revealed he was a [AGE] year old male with [DIAGNOSES REDACTED]. Resident had a tracheostomy, a [DEVICE], a foley catheter. Medication orders did not present any antibiotic therapy or treatments. Review of Resident #3's face sheet revealed resident was admitted to the facility on [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. Review of Resident #3's Minimum data set (MDS) assessment dated [DATE] revealed that resident was coded for activities of daily living as total dependence, for cognitive skills for daily decision-making as decisions were consistent and reasonable, and communication patterns were coded as being able to express needs clearly and understanding communications. Resident's range of motion was coded as full loss on both sides except one- arm had partial loss and the neck area had no loss. The MDS assessment revealed Resident # 3 had an indwelling catheter, a gastrostomy tube and a tracheostomy. Review of the care plan dated 09/25/10 for Resident #3 revealed resident required suctioning and approaches included "1. monitor congestion and suction as needed, 2. monitor colors of secretions and report any abnormalities to medical doctor, 3. monitor for increase in secretions ... 4. suction machine at bedside ... 5. apply oxygen if short of breath ... 6. suction techniques per facility policy and procedure. ..." Observation during the initial tour on 10/20/10 at 8:15 a.m. revealed Resident #3 in bed on his back, presented with loud gurgling throat sounds, rapid irregular, shallow breathing pattern, flushed red with blue tone colored facial skin. He was banging on his chest with his left hand. The call light was out of resident's reach, with the call activator hanging over the edge of the bedside table between the wall and the bedside table. The resident's tracheostomy presented with large amount of greenish yellow colored secretion and the surrounding tracheostomy dressing and resident's gown were saturated with the same. The tracheostomy mask was not positioned over the tracheostomy tube but was positioned to the left side of the tracheostomy tube. The bed-side suction machine was filled with 900 ml. of yellowish sedimented secretions, and the suction connected tube was lying unpacked over the it. A suction catheter was lying unpacked on the unprotected bed table surface. The resident's call light was activated. A CNA immediately came into the room and the Resident said he needed to be suctioned. The CNA said she would get the nurse and then left the room. Several minutes later at 8:25 a.m. LVN A entered the room, walked around the room, turned off the resident's call light. Resident #3 continued to bang on his chest and told LVN A he needed to be suctioned. LVN A removed his stethoscope from around his neck and then walked out of the room and went down the hall towards the other side of the building. LVN A left the room and did not assess or suction Resident #3. The resident continued to bang his chest and asked to be suctioned. The surveyor observed LVN B at 8:27 a.m. in the hallway and asked LVN B for assistance. The LVN immediately came to the room with CNA D. Observation on 10/20/10 at 8:45 a.m. revealed the DON was applying a new tracheostomy dressing to Resident #3's tracheostomy tube site, changing the trach tapes and a breathing treatment was applied over the tracheostomy tube site. The DON assessed the resident's oxygen saturation (SAT) level and reported that the SAT never got less than 98%. The resident presented with a clean gown and no secretions on body or at the tracheostomy site. The resident's facial skin color presented as pink tone and his respiratory pattern was an equal interval rate of breathing. A green colored cylinder of oxygen was positioned in the corner of the room with a face cloth positioned over the top. During this observation, the DON asked LVN A if Resident #3 was on antibiotics. The LVN responded "no." The DON told LVN A to get a chest x-ray for the resident as he was congested. The DON said, "This was an exception. I apologize as the resident has never been like this before." Observation on 10/20/10 at 10:30 a.m. revealed LVN B administering wound dressing change to Resident #3. The bedside suction machine reservoir container presented with 100 ml. of greenish sedimented secretions. The suction catheter presented as packed into an open, undated crumpled paper package attached to the suction reservoir. Observation on 10/20/10 at 1:00 p.m. revealed LVN A administering suctioning to the tracheostomy of Resident #3. Green exudate was draining out of the tracheostomy tube with a large amount of clear liquid. LVN A went to the medication cart outside of the room, collected gloves and returned to the room and applied the non-sterile gloves to his hands. With the gloved hands, he picked up the resident's food tray and placed it on the Resident's chair. He changed his gloves and picked up and opened a bottle of solution and repositioned it on the unwiped, unsanitized bedside table surface. He opened the disposable container used to hold the fluid. He collected the opened bottle of fluid and poured the fluid into the container with the right hand. With gloved hands, he pushed the bedside table closer to the bed. Without changing gloves or hand hygiene, he opened the sterile gloves and applied them directly over the soiled gloves. With the gloved left hand, he turned the switch on the suction machine and the machine was activated. At the same time, with the gloved right hand, he moved the white trach tube that was lying on top of the resident's bed linens. LVN A turned towards the bedside table and with gloved hands, he held the tube from the suction machine reservoir. He connected the suction catheter from package that had been lying on the table. LVN A held the suction catheter in the right hand and placed the tip in the container, removed the suction catheter and suctioned the resident's tracheostomy. He conducted the suction procedure two mores times, holding the suction catheter in the contaminated right hand. Observation on 10/20/10 at 2:30 p.m. of Resident #3 in bed with the tracheostomy mask over the tracheostomy site. The tracheostomy dressing was dry and resident was breathing with an equal interval respiration pattern. The bedside suction presented with the suction tube hanging freely over the suction machine unbagged, undated and uncapped. In an interview on 10/20/10 at 1:15 p.m. LVN A was asked about the tracheostomy suction technique he conducted on Resident #3. He said, "I wore the sterile gloves over the used gloves. I guess because if one got dirty, I'd have the others on and available to use." He said he did not realize he had touched the resident's white tracheostomy tube with his sterile gloved right hand. During this interview he said he did not contaminate his gloves when he connected the suction cannula to the suction reservoir tube. In an interview on 10/21/10 at 10:00 a.m. with the DON about how staff conducted tracheostomy suctioning on Resident #3 he said staff should never wear sterile gloves over used, soiled gloves as the sterile gloves were contaminated. The dominant hand was to remain sterile to conduct the suction of the tracheostomy Review of nurse notes dated 09/25/10 for Resident #3 revealed that the resident was suctioned and thin white copious secretions were retrieved from the tracheostomy. Review of the physician admission orders [REDACTED]. Review of the nurse notes dated 10/17/10 for Resident #3 revealed documentation that "Resident was coughing, congestion. Noted some thick mucous, noted with suction of trach. Physician called and a stat(immediate) chest x-ray was ordered". Resident's temperature was 98.8 Farenheit. Record review of the physician orders dated 10/17/10 for Resident # 3 revealed documentation of cough, congestion, stat x-ray for chest. Review of the chest x-ray results dated 10/17/10 for Resident #3 revealed documentation of impression of very slight right lower lobe atelectasis, no infiltrate. Improved from 09/17/10. Review of the nurse notes dated 10/20/10 for Resident #3 revealed "called GAA (physician) for chest x-ray. Resident's lungs sound congested in lower lobes. ..." Review of the second set of chest x-ray results dated 10/20/10 at 2:57 p.m. for Resident # 3 revealed impression of slight left lower lobe infiltrate. Review of the physician's orders dated 10/20/10 at 7:00 p.m. revealed that a new order was received for [MEDICATION NAME] (antibiotic) 500 milligrams per [DEVICE] every day for 10 days. Review of the medication administration record dated 10/10 for Resident #3 revealed that [MEDICATION NAME] 500mg per [DEVICE] was administered on 10/20/10 at 4:00 p.m. Record review of Resident # 3's nurse notes dated 10/18/10 to end of the day shift on 10/21/10 revealed no documentation related to monitoring resident condition, vital signs or response to the initial dose of [MEDICATION NAME] (antibiotic). In an interview on 10/21/10 at 3:00 p.m. with LVN C, the assigned evening nurse for Resident #3 about where documentation about the initial dose of an antibiotic and resident's vital signs and temperature should be recorded, she said she had been off and did not understand why there was no documentation and monitoring. She said, "I don't why he (LVN A) did his work, why no documentation. I wouldn't do it like that, I'd do it the right way." She also said "the only area we document the temperature, the oxygen saturation rates, the trach care and findings is in the nurse notes." Review of the facility's In-service book dated 2010 revealed inservice for tracheostomy care was conducted on 09/15/10 and included, -emergency management of a patient, -how to suction a patient with a tracheostomy, -how to set-up the equipment needed to care for a tracheostomy patient, -emergency supplies needed for a patient with a tracheostomy, -bedside supplies needed for a patient with a tracheostomy. LVN A signed the attendance report, however no documentation of return demonstrations was provided. Review of the facility's policy and procedure on Tracheostomy suctioning dated 03/04 revealed " ...1. Use sterile equipment to avoid widespread pulmonary and systemic infection. Suctioning of the lower airway is a sterile procedure. ... Supplies and equipment necessary when performing this procedure include ... 4. Sterile gloves ..." Steps in the procedure include " ... 3. perform hand antisepsis, put on gloves and connect one end of the suction tubing to the suction unit, turn on suction and remove gloves. Open suction kit, pour sterile water or sterile saline, apply sterile gloves, the dominant hand will remain sterile. ... Document in the resident's medical record the date and time of procedure, equipment used, secretions characteristics and amounts, describe the condition of stoma skin as well as resident's response to procedure. ..." Review of the facility's policy and procedure on Handwashing/Hand hygiene dated 06/05 revealed " ... Employees must wash hands after handling items potentially contaminated with blood, body fluids or secretions; and 4. before eating and after using the restroom. ... 3. if hands are not visibly soiled, use an alcohol-based hand rub ... for all the following situations: ... b. before donning sterile gloves, ... h. after handling used dressings, contaminated equipment, etc. ..." 2. Utilized respiratory suction equipment set-up with unprotected port covers, undated tubing, equipment and excessive secretions in the suction reservoir Observation during the initial tour on 10/20/10 at 8:15 a.m.revealed Resident #3 in bed on his back. He presented with loud gurgling sound, rapid irregular, shallow breathing pattern, flushed red with blue tone colored facial skin. He was banging on his chest with his left hand. The call-bell was out of resident's reach with the call activator hanging over the edge of the bedside table between the wall and the bedside table. The resident's tracheostomy presented with large amount of greenish yellow colored secretions and the surrounding tracheostomy dressing. The neck of the resident's gown was saturated with the same. The tracheostomy mask was not positioned over the tracheostomy tube but was positioned to the left side of the tracheostomy tube. The bed-side suction machine was filled with 900 ml. of yellowish sedimented secretions, and the suction connected tube was lying unpacked. A suction catheter was lying unpacked on the unprotected over-the-bed table surface. The surveyor activated the resident's call light. A CNA quickly came to the room and the resident said he needed to be suctioned. The CNA said she would get the nurse and left the room. Several minutes later at 8:25 a.m. LVN A entered the room, turned off the resident's call light. Resident #3 said he needed suctioning and continued to bang on his chest. LVN A started to remove his stethoscope from around his neck and then, without assessing or suctioning the resident, walked out of the room towards the other side of the building. At 8:27 p.m. the surveyor observed LVN B in the hallway and asked her for assistance. She immediately came to the room with CNA D. Observation on 10/20/10 at 10:30 a.m. revealed LVN B administering wound dressing change to Resident #3. The bedside suction machine reservoir container presented with 100 ml. of greenish sedimented secretions. A suction catheter packed into an open, undated crumpled paper package was attached to the suction machine reservoir. Observation on 10/20/10 at 12:45 p.m. of LVN A administering medication by [DEVICE] to Resident #3. During this observation the resident's suction machine presented with a suction catheter connected to the machine's secretion reservoir tube and the catheter was hanging unbagged freely over the machine. The reservoir container had 250 ml. of yellow green colored sedimented secretions. Observation on 10/20/10 at 2:30 p.m. revealed Resident #3 in bed with the tracheostomy mask over the tracheostomy site. The tracheostomy dressing was dry and the resident was breathing with an equal interval respiration pattern. The bedside suction presented with the suction secretion reservoir tube was hanging freely over the suction machine and the end of the tube was unbagged and open ended. Observation on 10/20/10 at 4:30 p.m. with the DON of the tracheostomy and respiratory equipment set-up for Resident #3 revealed an oxygen cylinder was positioned in the corner of the room and a soiled unpackaged nasal cannula was attached to the oxygen tank. There was an open cup of fluid used to suction resident on the resident's over-the-bed table and an undated, opened suction catheter was lying unprotected on the table surface beside the suction machine. The suction machine reservoir suction tube was uncovered and dangling over the suction machine. The DON said the suction catheters were to be changed with each tracheostomy suction conducted and the reservoir suction tube should be bagged and dated, not hanging open. The DON said he did not know why there was a nasal cannula attached to the oxygen tank. Observation on 10/21/10 at 5:30 a.m. revealed Resident #3 was lying in bed with eyes open. The tracheostomy bag was not positioned over the tracheostomy tube. He said he was feeling better, his breathing was better and he slept pretty well. The bedside suction machine reservoir tube end was enclosed in a dated plastic bag. In an interview on 10/20/10 at 1:15 p.m. with LVN A about Resident #3's suction equipment he said the reservoir should have been emptied before it was half full (500 ml.) but I had the dining room. We start feeding about 6:00 or 6:30 a.m. so I didn't get here to change it out. The suction reservoir tube should be in a bag not left open." Review of the facility's policy and procedure on Tracheostomy suctioning dated 03/04 revealed " ... steps in procedure ... 31. Disconnect catheter from tubing. Wrap catheter around gloved hand, pull the glove off and over the catheter, discard in designated receptacle. ... 33. Discard water or saline in commode. Dispose of cup in designated receptacle. ... 34. Empty and rinse collection container if necessary. ... Document in the resident's medical record include date and time of procedure, secretions qualities, resident response to procedure ... " 3. Administered medications and fluids through a gastrostomy tube without hand washing, changing gloves Observation on 10/20/10 at 12:15 p.m. revealed LVN A administering medication by gastrostomy tube to Resident #3. He came into the room with gloved hands, carrying a piston syringe. He placed the syringe on the unwiped, unsanitized table top beside the television. With gloved hands, LVN A took medication cups into the resident's bathroom and turned on the water taps. He filled the cups with water, turned off the water taps and placed the water cups on the resident's unprotected over-the-bed table. Without changing gloves, LVN A opened the piston syringe, opened the [DEVICE], inserted the syringe into the [DEVICE] and placed the plunger on the resident's bed. LVN A checked for gastric residual and administered medication to the resident thru the syringe attached to the [DEVICE]. LVN A disconnected the syringe and placed the syringe and plunger into the storage bag without rinsing or cleaning the piston syringe. Resident #6 Review of Resident # 6's record revealed she was an [AGE] year old female originally admitted on [DATE] and re-admitted on [DATE]. [DIAGNOSES REDACTED]. Resident received [MEDICATION NAME] [DEVICE] feedings. Review of the Minimum data set (MDS) assessment dated [DATE] for Resident #6 revealed documentation that Resident's cognitive skills for daily decision-making were assessed as severely impaired. Resident was assessed as total dependence for all activities of daily living. Nutritional approach was by feeding tube for 76% to 100%. Observation on 10/20/10 at 12:30 p.m. revealed LVN A administering medication through [DEVICE] to Resident #6. Resident was sitting in a wheelchair. LVN A, with gloved hands, carried the medications and empty med cups into the resident's room. LVN A took the medication cups into the Resident's bathroom, turned on the water taps, filled the cups, turned off the water taps and placed the water filled medication cups on the Resident #6's bedside table. LVN A, without changing gloves, took the piston syringe from the plastic storage bag and checked for [DEVICE] placement. LVN A removed the plunger and placed the plunger on the Resident's blanket. LVN A administered medications, removed the syringe and closed the tube. While holding onto the syringe, LVN A repositioned resident's legs and moved her foot by holding onto the bottom of resident's heel. LVN A, without changing gloves, took the syringe, collected empty med cups and went into resident's bathroom. LVN A turned on the water taps filled the cups, turned off the taps and placed the medication cups on the Resident's un-wiped television stand surface. Without changing gloves, LVN A opened the [DEVICE], inserted the piston syringe and poured the prescribed Medpass fluid into the attached syringe and followed it with the water from the medication cups. Without de-gloving, he poured a can of Glucerna 1.0 into the syringe followed by a water flush and removed the syringe. Without de-gloving, LVN A collected the syringe and plunger and without rinsing or cleaning either piece, he placed them back in the plastic storage bag and positioned the bag beside the Resident's television. In an interview on 10/20/10 at 2:00 p.m. with LVN A about when to wash hands or change gloves he said he should wash before and after giving medications and if he had been in the bathroom. During this interview LVN A was asked about when to clean or rinse the piston syringe. LVN A would not respond. Review of the facility policy and procedure dated 04/01 for checking residual of gastric contents revealed to wash hands at the following intervals; "1. a. before the procedure, before resuming the procedure after an interruption ie., assisting another Resident, toileting ... e.whenever in doubt and after completion of your task or procedure ... 3. ... maintain clean technique and isolation precautions as indicated, 4. ... follow the manufacturer's instructions,clean and disinfect reusable parts. ..." The CMS 672 dated 10/20/10 revealed 10 residents with a tracheostomy and gastrostomy tubes.