Every finding on record at Greendale Forest Nursing and Rehabilitation Center

Based on record reviews and staff interviews, the facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day seven days a week for 3 of 119 days (1/4/26, 2/8/26 and 3/15/26) reviewed for sufficient staffing.The findings included:A review of the daily posted nursing staff forms, daily nursing staff assignment sheets, and staff clock-in sheets from 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 was conducted.A review of the daily census posting sheets for 1/1/26 through 3/31/26 and 5/18/26 through 6/18/26 revealed no RN coverage for eight consecutive hours on 1/4/26, 2/8/26, and 3/15/26.On 6/18/26 at 9:53 AM the scheduler was interviewed. She could not recall the details of the dates of 1/4/26, 2/8/26, and 3/15/26 without any RN coverage. The scheduler indicated that she would have notified the Director of Nursing (DON) immediately if she was aware of no RN coverage for those days. On 6/17/26 at 2:51 PM the DON was interviewed. She could not provide a reason why there was no RN coverage on 1/4/26, 2/8/26, and 3/15/26. However, she stated the scheduler should have notified her, and the facility would have provided RN coverage. On 6/18/26 at 10:51 AM the Administrator was interviewed. She revealed that she was unaware that there was not RN coverage for 3 days in the Federal Fiscal Quarter 2 (January, February, and March) of 2026 (1/4/26, 2/8/26, and 3/15/26). The Administrator stated that there should have been RN coverage 8 hours every day 7 days a week.

Based on observation and staff interviews, the facility failed to provide an environment free of wall damage (room [ROOM NUMBER], 707, and #710), failed to ensure pipes around hand washing sinks were sealed (room [ROOM NUMBER] and #307) and failed to provide privacy curtains free of stains (Rooms #408) for 6 of 26 rooms on 4 of 6 hallways reviewed for the environment. The findings included: 1A. An observation of room [ROOM NUMBER], which was occupied, took place on 6/15/26 at 11:58 AM and revealed deep scratch marks on the wall beside the residents bed, including a brownish-red dried substance in one of the marks and a large approximately 2 inch wide by 18 inch long by 1/2 deep gash in the sheetrock on the wall at the head of the bed. 1B. An observation on 6/16/26 at 2:45 PM of room [ROOM NUMBER], which was occupied, revealed the wall behind the head of the bed had 3 approximately 2 feet long gouges in the sheet rock and the paint was gone in an area approximately one foot in diameter. 1C. An observation of room [ROOM NUMBER], which was occupied, was conducted on 6/16/26 at 2:50 PM and revealed an area exposing brown paper and gouges approximately 2 feet long and the white sheet rock was visible. 1D. Observation of room [ROOM NUMBER], which was occupied, was conducted on 6/15/26 at 12:45 PM revealed the pipe supplying water to the handwashing sink was not sealed, leaving a large gap around the pipe coming out of the wall. The gap was large enough to place a finger in between the sheetrock and the pipe. 1E. Observation of room [ROOM NUMBER] which was occupied, was conducted on 06/15/26 at 12:42 PM revealed the pipe supplying water to the handwashing sink was not sealed, leaving a large gap around the pipe coming out of the wall. The gap was large enough to place a finger in between the sheetrock and the pipe. An interview with Nurse #3 was conducted on 6/16/26 at 2:45 PM; she stated she did not know how long the walls in rooms #707 and #710 had gouges in them. An interview and observation in the rooms with the Maintenance Director was conducted on 6/16/26 at 3:00 PM. He stated the deep marks in the wall in room [ROOM NUMBER], which had dried brown-red substances, could harbor pests and various substances including bodily fluids. The Maintenance Director also stated the gaps around the handwashing sink pipes could allow pests to enter the building. An interview with the Administrator was held on 6/16/26 at 3:25 PM. The Administrator stated the pest control company would notify the facility staff if there were any pest concerns. She added she was not sure if pests could enter the rooms through the approximate 1/2 inch open area around the pipes coming in through the wall to the handwashing sinks in rooms #106 and #307. The Administrator added the rooms with the gashes in the sheet rock could harbor bodily fluids. The Administrator observed the brownish-red substance and stated she could not identify its origin. In a follow-up interview with the Administrator on 6/18/26 at 10:30 AM; she stated the maintenance director had made list of rooms in need of repair. The Administrator added that she had expected the rooms to be repaired in the order listed by priority and the piping under the sinks should have been repaired when staff first noticed they were not sealed properly. 2. During an observation on 6/15/26 at 11:07 AM room [ROOM NUMBER]'s privacy curtain between resident beds was observed to have a dark brown-red splatter stain near the base of the curtain. The stain consisted of splashed dried brown-red substance over approximately 2 inches by 4 inches of the curtain. Resident #11's Minimum Data Set assessment dated [DATE] revealed Resident #11 was assessed as cognitively intact. During an interview on 6/15/26 at 11:02 AM Resident #11 stated the curtain between him and his roommate had the stain on it for at least a month or two. The Resident added that he preferred to keep the curtain pulled at all times between him and his roommate. During an observation on 6/16/26 9:57 AM observation of privacy curtain between resident beds still had the brown-red splatter stain on the curtain. During an interview on 6/16/26 3:39 PM the Housekeeping Supervisor stated housekeeping staff were responsible for the cleanliness of the resident privacy curtains. She stated that when her staff clean resident rooms, they should check the privacy curtains and any curtains that were visibly dirty should be removed. She further stated she was unclear if during rounds the staff would notice that curtain and would then have pulled the curtain to clean it. She stated nurse aides also notify housekeeping staff if any curtains need to be cleaned. Curtains were also cleaned when a room was deep cleaned and as needed. Upon observation of the curtain the housekeeping supervisor stated curtains visibly soiled with liquid splatter should be replaced and cleaned immediately. During an interview on 6/16/26 at 3:54 PM the Administrator stated if privacy curtains were visibly soiled with dried liquid splatter, they should be changed and cleaned.

Based on observation, record review, resident, staff and physician interviews the facility failed to arrange podiatry services for 1 of 1 resident reviewed for foot care (Resident #89).Findings included:Resident #89 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease.Resident #89's provider note dated 4/22/26 revealed the physician documented Resident #89 reported overgrown and protruding toenails causing discomfort and difficulty with trimming and was requesting podiatry evaluation. The physician documented he would order a podiatry consult for nail care and evaluation.Resident #89's orders revealed on 4/22/26 he was ordered to have a podiatrist consult. Nurse #2 was documented as the nurse who confirmed the order.Resident #89's quarterly Minimum Data Set assessment dated [DATE] revealed he was assessed as moderately cognitively impaired. He had no moods or behaviors and was assessed to be dependent on staff for personal hygiene.Review of the resident list seen by podiatry on 5/28/26, provided by the Administrator, revealed Resident #89 had not been seen by podiatry. This list contained the names of residents who were seen by podiatry on 5/28/26.During an interview on 6/16/26 at 11:01 AM Resident #89 stated sometime a couple of months ago he notified the physician he needed to see podiatry and the physician agreed with him. He further stated he was told the physician would put in a referral but had heard nothing since. He stated he had not had any negative outcomes as he was unable to feel very well, but it was slightly uncomfortable and would be nice to be seen by podiatry. During observation on 6/17/26 at 9:27 AM Resident #89's feet were observed and the left foot, third toe toenail was observed to extend away from his toe approximately 3/4 of an inch. Resident #89's toenails were observed to have not been trimmed.During an interview on 6/17/26 at 8:16 AM Nurse #2 stated the Staff Development Coordinator (SDC) was the staff member who works with the in-house podiatry visits to ensure the residents in the facility who need to be seen were seen while podiatry was in the facility. She stated she would verbally let the SDC know if a resident needed to see a podiatrist and then the SDC either put the resident on the list to be seen by podiatry or they set up an appointment to be seen outside the facility if the resident needs to be seen prior to the next podiatry visit. She further stated she did not remember confirming the order in Resident #89's chart and did not inform the SDC that Resident #89 needed to be seen by a podiatrist.During an interview on 6/17/26 at 8:26 AM the Staff Development Coordinator stated she was not aware Resident #89 had been referred to podiatry. During an interview on 6/17/26 at 8:36 AM the Administrator stated if a resident had a referral to podiatry, they first ensure that the in-house podiatrist was coming to the facility within an acceptable amount of time from the referral because the in-house podiatrist comes to the facility quarterly. She stated if the in-house podiatrist had recently visited the facility, then they would accommodate the referral by getting the residents an appointment with an outside provider and arrange transport. She concluded that Resident #89 should have been seen by a podiatrist either when the in-house podiatrist came on 5/28/26 or he should have had an outside podiatrist appointment made.During an interview on 6/17/26 at 12:42 PM Physician #1 stated he remembered placing the order for a podiatry referral for Resident #89 in April of 2026. He stated Resident #89's toenails were thick and disformed and felt the resident should be seen by a podiatrist who would have the tools to trim and care for the toenails. He concluded because podiatry came to the facility in May 2026, he felt Resident #89 should have been seen by podiatry prior to now.

Based on record review, Physician #1, Physician #2, Hospice staff interview and staff interviews the facility failed to implement effective interventions to promote bowel movements. Hospice orders on 2/7/26 included the addition of a stool softener as needed; however, the bowel regimen did not begin until 2/18/26 when the resident returned from the emergency department (ED) on 2/18/26. A pelvic x-ray was performed in the ED on 2/18/26 that displayed fecal impaction. This was for 1 of 1 resident (Resident #16) reviewed for professional standards.The findings included:Resident #16 was readmitted to the facility on [DATE] with diagnoses included failure to thrive, dementia, chronic respiratory failure, diabetes, and congestive heart failure. Resident #16 was admitted to hospice on 2/7/26. She went to the ED on 2/18/26 after a fall and returned to the facility the same day.Resident #16's care plan revised on 2/6/26 included hospice care due to a terminal decline.Interventions included: Consult with hospice and physician regarding pain management, diet as ordered, encourage and assist with feeding as needed, encourage and assist with good oral hygiene, notify the physician of significant changes, and turn and reposition frequently.The Hospice Physician Order form dated 2/7/26 by the Hospice Nurse revealed that Resident #16 was admitted to hospice for hypertensive heart disease with heart failure and was to begin receiving Senna Plus 8.6-50 milligrams (mg) tablet 2 tablets daily as needed for constipation the same day. This order was not implemented until 2/18/26 per Resident #16's medical record.The significant change Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 was severely cognitively impaired and was always incontinent of bowel and bladder. She was totally dependent on staff for toileting. The bowel movement activity history for Resident #16 from 2/4/26 - 2/18/26 revealed that she did not have a bowel movement on the following dates: 2/4/26, 2/6/26, 2/7/26, 2/9/26 (no documentation), 2/10/26, 2/11/26, 2/12/26, 2/15/26, and 2/16/26.The facility standing orders included instructions for if a resident did not have a bowel movement in 3 days, then nurses were to first give the resident 30 milliliters (mL) of Milk of Magnesia. If no results in 12 hours, then give a Fleets Enema. If still no results, then give 1,000 mL of the Soap Suds Enema. If there were still no results, then the provider would need to be notified.The Emergency Department Provider Note for Resident #16 dated 2/18/26 revealed that an xray of the pelvis performed on 2/18/26 showed that the rectum was distended with a large stool ball and significantly dilated measuring up to 10.3 centimeters in diameter. The appearance of the included rectum suggested high-grade fecal impaction. The February 2026 medication administration record (MAR) for Resident #16 revealed that she began receiving Senna Plus 8.6-50 mg tablet 2 tablets daily as needed for constipation on 2/18/26. On 6/16/26 at 3:58 PM Nurse #4, the evening nurse (3:00 PM - 11:00 PM) assigned to Resident #16 from 2/9/26 - 2/12/26, revealed the Nurse Aides were responsible for tracking bowel activity, and if a resident did not have a bowel movement for 24 hours, they needed to notify the nurse. Hospice would have needed to be contacted first if Resident #16 did not have a bowel movement for 24 hours. All communication with hospice would have been documented in the progress notes. Nurse #4 indicated that hospice was responsible for ordering the bowel regimen. Nurse #4 stated she could not recall the details of 2/9/26 - 2/12/26.Multiple attempts to contact Nurse #6, who worked overnight 11:00 PM - 7:00 AM on 2/9/26 and 2/10/26, were conducted; however, she was unable to be reached during the investigation. The Hospice Nurse, who visited Resident #16 in the facility on 2/9/26 and 2/11/26, was interviewed on 6/17/26 8:41 AM. She revealed that she had never given any bowel regimen to Resident #16 on 2/9/26 or 2/11/26. If Resident #16 did not have any symptoms or complaints of constipation, nursing might have not notified hospice. The Hospice Nurse indicated that she usually asked the facility nurses about intake, bowel movements, and other pertinent information related to Resident #16 prior to seeing the resident. The expectation would be for nursing to contact hospice after hours or during visits if constipation was an issue. A bowel regimen would then be ordered, which would be managed by hospice.On 6/17/26 at 9:54 AM Nurse Aide #1, who worked with Resident #16 during the day 7:00 AM - 3:00 PM from 2/9/26 - 2/12/26, was interviewed. She revealed that all bowel activity during her shift needed to be documented. If Resident #16 did not have a bowel movement, then she would have notified the nurse. If the documentation was missing from the bowel movement activity history, then it would be assumed that Resident #16 did not have a bowel movement during her shift. Nurse Aide #1 stated that she could not recall the details of Resident #16's bowel activity from 2/9/26 - 2/12/26.Nurse #7, who worked with Resident #16 during the day 7:00 AM - 3:00 PM on 2/9/26 and 2/12/26, was interviewed on 6/17/26 at 10:30 AM. She revealed that she worked on all halls of the facility. If a resident reported not having a bowel movement in 3 days, an alert would pop up in the orders section of the medical record. First, she would look to see if an order for bowel regimen was already in place. She would also communicate with the nursing staff, and if a Nurse Aide worked with a resident on a regular basis, then they would notify her there was no bowel movement during their shift. Regardless of the alert, she would need to research each resident's bowel movement activity. If Resident #16 did not have a bowel movement for 4 days, then a staff member should have implemented a bowel regimen. If the bowel movement activity history was blank for a specific day, then it was safe to assume that there was no bowel movement for that day. Nurse #7 indicated that she could not recall the details of Resident #16's bowel movement activity in February 2026.An interview with Physician #2, Resident #16's assigned doctor, was interviewed on 6/18/26 at 10:24 AM. He revealed that Resident #16 did not have a bowel regimen implemented until 2/18/26. If Resident #16 did not have a bowel movement for 3-4 days, then he would expect the nursing staff to notify him and follow the standing orders. Physician #2 indicated that he did not feel that Resident #16 had a fecal impaction on 2/18/26 while at the ED. She did not display any symptoms, and the final diagnosis from the ED report listed constipation.Physician #1, the Medical Director, was interviewed on 6/18/26 at 9:25 AM. He revealed that the risks of fecal impaction are small bowel obstruction, significant pain/discomfort, and could affect quality of life. Physician #1 stated that the nursing staff should have notified a provider or the Director of Nursing if Resident #16 did not have a bowel movement for 3-4 days. Then bowel regimen orders could have been provided. The Director of Nursing was interviewed on 6/18/26 at 10:42 AM. She revealed that the nurses assigned to Resident #16 should have implemented the standing orders if Resident #16 did not have a bowel movement for 3 days, and the physician should have been notified.On 6/18/26 at 10:53 AM The Administrator was interviewed. She revealed that the bowel regimen orders from hospice on 2/7/26 should have been implemented when the resident was admitted to hospice on 2/7/26.

Based on record review, Physician #1, Physician #2, Hospice Clinical Manger, the Hospice Nurse and staff interviews, the facility failed to have effective systems in place to ensure hospice orders were processed when a resident was admitted to hospice services for 1 of 1 resident reviewed for hospice services (Resident #16). The findings included:Resident #16 was readmitted to the facility on [DATE] with diagnoses including failure to thrive, congestive heart failure, dementia, chronic respiratory failure, and diabetes. She was admitted to hospice services on 2/7/26. On 2/18/26, Resident #16 was sent to the emergency department after a fall and returned to the facility the same day.The Hospice Physician Order form dated 2/7/26 by the Hospice Nurse and the Hospice Physician revealed that Resident #16 was admitted to hospice for hypertensive heart disease with heart failure and to begin receiving the following medications as of 2/7/26:Acetaminophen, 650 milligrams (mg) rectal suppository every 6 hours as needed for pain/feverHaloperidol intramuscular solution 150 mg monthly for dementiaHyoscyamine sulfate 0.125 mg oral tablet as needed every 4 hours for excess secretionsLorazepam 1 mg tablet by mouth as needed every 4 hours for anxiety/agitationMorphine sulfate (concentrate) 20 mg/milliliter (mL) oral solution 0.25 mL every 4 hours as needed for pain/shortness of breathPromethazine HCl 12.5 mg tablet every 6 hours as needed for nausea/vomitingSenna Plus 8.6-50 mg tablet 2 tablets daily as needed for constipationReview of a nursing progress note dated 2/7/26 at 8:50 PM by Nurse #8 revealed that she had received a telephone call from the Hospice Nurse regarding Resident #16 being admitted to hospice. Physician #2 was made aware via telephone and needed to review the orders prior to being entered. The Hospice Nurse would notify the facility in the morning after Physician #2's review of the admission medications.On 6/18/26 at 10:38 AM Nurse #8 was interviewed via telephone. She revealed that the Hospice Nurse gave her the medication orders for Resident #16 over the phone on 2/7/26. However, she stated that hospice needed to wait to communicate with Physician #2 to notify him that Resident #16 was admitted to hospice. Nurse #8 indicated she contacted Physician #2 via telephone on 2/7/26 and was supposed to wait until Physician #2 reviewed the orders before making any medication changes.Review of Resident #16's medical record revealed no documentation that Physician #2 reviewed, signed, and dated the hospice orders for the added medications on 2/7/26. On 6/16/26 at 3:22 PM the Clinical Manager for Hospice was interviewed via telephone. She revealed that the Hospice Nurse gave all hospice paperwork to Nurse #5 on 2/7/26. The hospice paperwork included which medications needed to be added.On 06/17/26 at 2:46 PM Nurse #5 was interviewed via telephone. She revealed that when a resident was admitted to hospice, she would receive the orders from hospice in the facility and enter the orders into the medical record. Physician #2 would have to approve the orders and must be notified by the hospice nurses prior to Nurse #5 entering the orders upon admission to hospice. Nurse #5 indicated she did not recall when the hospice nurse was in the facility on 2/7/26 or whether or not she received the medication orders for Resident #16 directly from the hospice nurse.Review of the medical record revealed no evidence that Resident #16's medication orders dated 2/7/26 were processed by Nurse #5.A physician progress note dated 2/9/26 by Physician #2 revealed that the purpose of the note was for readmission from the hospital on 2/3/26. He documented that related to her hospice status he planned to discontinue all nonessential medications including atorvastatin, aspirin, Namenda, calcium carbonate, ferrous sulfate, and Atarax. No documentation was included regarding the new medications added on 2/7/26 by hospice.A nursing progress note dated 2/18/26 by Nurse #4 revealed that while hospice was in the building, she was instructed to enter new orders for Resident #16 including acetaminophen rectal suppository, morphine sulfate, hyoscyamine, promethazine, and lorazepam.Nurse #4 was interviewed on 6/16/26 at 3:55 PM. She revealed that hospice was in the facility on 2/18/26 at shift change, and they provided paperwork to add medication orders for Resident #16. Review of Resident #16's February 2026 Medication Administration Record (MAR) revealed the following orders were entered on 2/18/26 for medications previously ordered on 2/7/26:Acetaminophen, 650 milligrams (mg) rectal suppository every 6 hours as needed for pain/feverHaloperidol decanoate 100mg/milliliter (mL) intramuscular solution 150mg monthly for dementiaHyoscyamine sulfate 0.125mg oral tablet as needed every 4 hours for excess secretionsLorazepam 1mg tablet by mouth as needed every 4 hours for anxiety/agitationMorphine sulfate (concentrate) 20mg/mL oral solution 0.25mL every 4 hours as needed for pain/shortness of breathPromethazine HCl 12.5mg tablet every 6 hours as needed for nausea/vomitingSenna Plus 8.6-50mg tablet 2 tablets daily as needed for constipationOn 6/18/26 at 9:25 AM a telephone interview was conducted with Physician #1, who was the facility Medical Director. He revealed that hospice would oversee handling the symptom management and medications for hospice residents. Physician #1 stated that Physician #2 should have signed and dated the hospice medication orders when they were received. An interview with Physician #2 was conducted on 6/17/26 at 11:30 AM. He revealed that hospice orders were not orders but rather only recommendations. He as primary care physician had the ultimate authority of care management, including medication changes. Physician #2 stated that he could take as long as he wanted to accept or reject the hospice recommendations. Physician #2 indicated that from 2/7/26 through 2/18/26 he was evaluating the recommendations made by hospice, and there was no documentation of this activity. Physician #2 stated at some point he was consulted about Resident #16's hospice medication changes, but he could not recall the exact date.The Hospice Physician was interviewed via telephone on 6/17/26 at 9:16 AM. He revealed that when Resident #16 was admitted to hospice on 2/7/26, the medication orders should have been entered within 24 hours. On 6/18/26 at 10:47 AM the Director of Nursing (DON) was interviewed. She revealed that the Hospice Physician medication orders for Resident #16 should have been implemented when they were given to the facility on 2/7/26. The DON indicated Physician #2 should have documented when he reviewed the hospice orders. On 6/18/26 at 10:55 AM the Administrator was interviewed. She revealed that the hospice medication orders should have been reviewed and signed by Physician #2 in a timely manner.

Based on record review and staff interviews, the facility failed to ensure an accurate Medication Administration Record (MAR) when staff documented a scheduled blood draw (a procedure in which a needle is used to take blood from a vein, usually for laboratory testing) was completed twice a week instead of once a week for 1 of 3 residents reviewed for blood draws (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE]. His diagnosis included myelodysplastic syndromes (a group of blood cancers where the bone marrow does not produce enough healthy blood cells), anemia and diabetes. The April 2025 MAR revealed a scheduled CBC blood draw order for every Thursday one time a day for monitoring with a start date of 12/19/2024. It also showed a CBC blood draw order every Wednesday for monitoring with a start date of 3/26/2025. The CBC blood draw was marked as completed on Wednesday, April 2, 2025, Thursday, April 3, 2025. Wednesday, April 9, 2025, Thursday, April 10, 2025, Wednesday, April 16, 2025, Thursday, April 17, 2025, Wednesday, April 23, 2025, Thursday, April 24, 2025, and Wednesday, April 30, 2025. The May 2025 MAR revealed a scheduled CBC blood draw order every Thursday one time a day for monitoring with a start date of 12/19/2024. It also showed a CBC blood draw order every Wednesday for monitoring with a start date of 3/26/2025. The CBC blood draw was marked as completed on Thursday May 1, 2025. The laboratory report dated 03/10/25 through 04/18/25 revealed a CBC blood draw was completed once a week. A telephone interview was conducted with Nurse #1 on 5/1/25 at 3:10 PM. She stated she gives the lab slip to the phlebotomist and then signs off on the MAR that the task has been completed. An interview with Medication Aide #1 on 5/1/25 at 12:35 PM revealed she would not have drawn the blood. She stated on 4/10/25 she must have marked the MAR in error. An interview was conducted with the Phlebotomist on 5/1/25 at 12:55 PM. She stated the blood draws should be completed every Wednesday. In the past she pulled them on Thursdays, and it was changed to Wednesdays in March. An interview was held with the Director of Nursing (DON) on 5/1/25 at 1:05 PM. The DON revealed her expectation would be the nurse completes a laboratory slip and gives it to the phlebotomist. When the phlebotomist brings the blood sample back to the nurse, the nurse would then sign off on the MAR that the task had been completed. She went on to say the 12/19/24 order should have been discontinued when the new order was entered with a start date of 3/26/24. An interview was held with the Administrator on 5/1/25 at 3:30 PM, she revealed her expectation was the task on the MAR is only marked as completed when the task is completed.

Based on record review and staff interviews, the facility failed to have effective systems in place for identifying the development of skin breakdown which delayed treatment and interventions. Resident #39's skin was intact on re-admission on 11/19/24. On 1/4/25 excoriation was noted on her buttocks. There were no further documented assessments until a wound assessment dated [DATE] recorded Resident #39 developed an unstageable (full thickness skin and tissue loss where the extent of tissue damage cannot be determined due to presence of slough, a yellow/white layer of dead skin tissue, or eschar, dry dead tissue, obscuring the wound bed) 5 centimeter (cm) by 5cm right buttocks pressure wound. Resident #39's right buttocks pressure wound deteriorated and required hospitalization for an infected right buttocks/sacral pressure wound on 2/17/2025. Resident #39 received intravenous antibiotic therapy and a debridement (a medical procedure to remove dead, damaged or infected tissue from a wound to promote healing and prevent infection) of the right buttocks pressure wound while in the hospital. Resident #39 was discharged back to the facility on [DATE] with orders for oral antibiotics for 5 days. The deficient practice occurred for 1 of 2 residents reviewed for pressure ulcer care (Resident #39). Findings included: Resident #39 was admitted to the facility on [DATE] with diagnoses including coronary artery disease and renal insufficiency. Resident #39 was discharged to the hospital and readmitted to the facility on [DATE]. Resident #39's skin assessment dated [DATE] recorded there were no skin issues. There was no documentation observed in Resident #39's electronic medical record or on Resident #39's Medication Administration Record (MAR) to alert the nursing staff to conduct a weekly skin assessment. The care plan dated 11/19/2024 indicated Resident #39 was a potential risk for skin breakdown. Interventions included observing the skin weekly and notifying the nurse of any changes in the development of new skin impairments. Physician orders dated 11/19/2024 included a supplement that provided additional calories and protein 60 milliliters (mL) three times a day for weight management. Resident #39's recorded weight in the medical record on 11/20/2024 was 180.2 pounds (lbs). The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #39 was cognitively intact with severely impaired hearing. Resident #39 was always incontinent of urine and stool and required total assistance with bed mobility and activities of daily living. There were no dental issues coded on the MDS for Resident #39. The MDS assessment further indicated Resident #39 was at risk for developing a pressure ulcer but was not marked as having a pressure ulcer or skin impairment. On 12/19/24 Resident #39 was ordered a high protein nutritional supplement 30mL daily for weight management. Resident #39's medical record documented skin assessments were conducted on 12/15/2024 with no skin issues recorded and on 1/4/2025 with skin excoriation (the act of abrading or wearing off the skin) recorded to the buttocks. There was no further documentation of the excoriation or assessment of Resident #39's skin until the Treatment Nurse's pressure wound assessment on 1/17/25. A review of nursing documentation from 11/19/2024 to 1/17/2025 in the electronic medical record recorded Resident #39 was turned and repositioned and provided incontinence care. There was no documentation of the development of a pressure wound for Resident #39. On 3/27/2025 at 1:36 pm in an interview with Nurse Aide (NA) #2, she stated Resident #39 required assistance in turning and incontinent care and Resident #39 was checked for incontinence and repositioned every two hours. She recalled Resident #39 not having any skin breakdown when admitted to the facility and stated she couldn't recall Resident #39's skin on her buttocks being red or irritated. She stated when she observed a quarter size red open area to Resident #39's buttocks while providing care, she informed the Treatment Nurse. NA #2 was unable to recall the date she informed the treatment nurse. Documentation of a wound assessment dated [DATE] by the Treatment Nurse recorded Resident #39 had an unstageable 5cm by 5cm right buttocks pressure wound. The right buttocks pressure wound assessment recorded the pressure wound was 90% dark eschar (dry dead tissue) and 10% pink tissue with moderate amount of serous exudate (drainage). There was no odor, tunnelling (narrow opening or passageway extending from a wound underneath the skin), or undermining (erosion that occurs under the edges of a wound) recorded. The Treatment Nurse recorded the physician and Resident #39's Representative were notified, and treatment was started with the application of silver alginate (highly absorbent, antimicrobial pad) and covered with a foam dressing. Physician orders dated 1/20/2025 included an order to cleanse the unstageable right buttock with normal saline, pat dry with gauze, apply skin prep to the periwound (skin around a wound) and allow to dry. Silver alginate was to be applied to the wound and the wound covered with a foam dressing every Monday, Wednesday and Friday. A review of Resident #39's January 2025 Medication Administration Record recorded Resident #39 received wound care as ordered. Resident #39's weight was recorded in the medical record on 1/24/2025 as 192.3 pounds that was a 12.1 lbs increase in weight. Dietary notes dated 1/30/2025 reported Resident #39 had an unstageable pressure wound to the right buttocks and Resident #39 was receiving a high protein nutritional supplement 30 milliliters daily and a supplement that provides additional calories and protein for persons at high risk for malnutrition 60 milliliters three times a day to aid in wound healing. The dietary note recorded Resident #39 consumed 50-100% of a regular mechanical soft diet and recommended ordering a Multivitamin (MVI) and Ascorbic Acid (Vitamin C) 500milligrams to further aid in wound healing. A review of Resident #39's January 2025 and February 2025 Medication Administration Record recorded Resident #39 was started on a Multivitamin (MVI) and Ascorbic Acid on 1/31/2025 and received the two dietary supplements, MVI and Ascorbic Acid as ordered. Documentation of the wound assessment on 2/4/2025 by the Treatment Nurse recorded Resident #39's unstageable right buttocks pressure wound measured 5 cm by 5 cm with eschar. Moderate serous exudate was recorded with no tunneling, undermining, odor or signs of infection. The wound bed was described as 90% dry, dark eschar and 10% pink tissue. The Treatment Nurse recorded the physician and Resident #39's Representative was notified. The wound was cleansed with normal saline and pat dried with gauze. Skin prep (forms a protective film on the skin) was applied to the periwound and allowed to dry. Silver alginate was applied and covered with a foam dressing. Resident #39's weight was recorded in the medical record on 2/8/2025 as 177.3 lbs that was a 15 lbs weight loss. Physician progress notes dated 2/14/2025 recorded the nursing staff reported Resident #39 was refusing to eat and was unable to chew food due to pain. Resident #39's gum on the left upper canines was observed swollen and Nurse Practitioner #1 ordered Amoxicillin 500 milligrams three times a day for five days. Documentation of the wound assessment on 2/14/2025 recorded a stage IV (most severe form of pressure injury that extends through skin, underlying tissue, muscle and bone) right buttocks pressure wound measured 5cm by 5cm by 0.8 cm and there was 1 cm of undermining in the position of 6-11 o'clock of the wound and 0.7cm from the position of 2-5 o'clock. Heavy serous exudate was documented with no odor or sign of infection. The wound bed was recorded as 50% deep red tissue, 15% fascia (layer of connective tissue below the skin), 15% muscle and necrotic (dead tissue) with 15% stringy gray colored dead tissue and 5% adipose (fat) tissue. The wound assessment recorded the physician and Resident#39's Representative were notified. Treatment of the right buttocks pressure wound included cleaning with normal saline, patting the area dry, applying skin prep to the periwound and allowing it to dry. The wound was packed with saline-moistened polyurethane foam dressing impregnated with methylene blue and covered with a foam dressing. Resident #39's dressing was ordered to be changed every Monday, Wednesday and Friday. On 2/17/2025 a wound assessment note by the Treatment Nurse recorded Resident #39's right buttocks pressure wound was measuring 7cm by 11cm by 2cm and was recorded as a stage IV pressure ulcer with an opened area measuring 7cm by 4cm and a 7cm by 4cm patch of dark dry eschar beside the opened area. Documentation of the wound recorded the opened area was tunneling underneath the eschar area with a heavy serous exudate and 40% of the area was dark, dry eschar, 40% deep pink tissue, and 10 % fascia, 50% adipose tissue and 5% bone. The wound was cleansed with normal saline and packed with saline moistened polyurethane foam dressing impregnated with methylene blue and covered with a foam dressing. The physician and Resident #39's Representative was notified and Resident #39 was scheduled to attend an appointment at the wound clinic on 2/17/2025. On 3/27/2025 at 12:58 pm in an interview with the Treatment Nurse, she stated the nursing staff were to conduct and document skin assessments weekly and notify her when skin breakdown was identified. The Treatment Nurse stated she was aware of the excoriated skin to Resident #39's buttocks documented on the skin assessment dated [DATE] and it was treated with barrier cream. She stated NA #2 informed her on 1/17/2025 of an area to Resident #39 buttocks that was observed as black eschar and weekly assessments and treatments were started based on the skin protocol. She explained Resident #39 wound remained a stable eschar wound tissue until 2/14/2025 when an area of the dry dead tissue was observed opened with no odor or drainage. The Treatment Nurse explained she had called the wound clinic for a referral when the right buttocks pressure wound was identified and was scheduled to go to the Wound Clinic on 2/17/2025. She stated on 2/17/2025, Resident #39's wound was observed worsening due to increase in size, drainage and odor. She explained since Resident #39 was scheduled to attend her first initial visit to the wound clinic on 2/17/2025, she called and notified the wound clinic of the change in Resident #39's right buttocks pressure wound. She stated the wound clinic requested Resident #39 to attend the scheduled appointment at the wound clinic on 2/17/2024 and if needed, the wound clinic would send Resident #39 to the hospital for admission. The wound clinic notes dated 2/17/2025 recorded Resident #39 was presenting to the wound clinic for the first time with an existing stage IV pressure injury that had worsen. The wound clinic note recorded the right buttocks pressure wound was very foul smelling with a necrotizing (death of bodily tissue) appearance at the undermined areas that was very concerning for a necrotizing soft tissue infection (NSTI). The pressure wound located on the right buttock/sacral area was recorded measuring 3.5cm by 8cm by 2 cm with black, green, red and tan colored wound bed with moderate amount of green serous exudate. The periwound was recorded as blanchable erythema (redness) with no tunneling and 4.5 cm of undermining. The wound was cleansed and dressed, and the wound clinic consulted the hospitalist (physician that works at the hospital) to direct admit Resident #39 from the wound clinic to the hospital. A review of the hospital discharge summary dated 2/24/2025 recorded Resident #39 was admitted from the wound clinic due to foul smelling and worsening of right buttock/sacral pressure wound on 2/17/2025. During hospitalization , Resident #39 received debridement on 2/20/2025 of the right buttock/sacral pressure wound and intravenous (medical technique that involves administering fluids, medications and nutrients directly into a vein) antibiotics. Resident #39 was discharged from the hospital and readmitted to the facility on [DATE]. The discharge summary included physician orders for Amoxicillin-Potassium Clavulanate Tablet 875-125 milligram (mg) twice a day for wound infection for five days. There was no order for wound care on the discharge summary. Physician orders dated 2/24/2025 included the following orders: Amoxicillin-Potassium Clavulanate Tablet 875-125 milligram (mg) twice a day for wound infection for five days and cleansing the right buttock/sacrum with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze, pat dry with gauze and apply skin prep to periwound and allow to dry thoroughly. The application of an enzymatic debriding ointment was ordered to the areas of yellow/white dead skin tissue and the wound packed with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze and covered with a bordered foam dressing every day for a stage IV pressure ulcer. A review of Resident #39's February 2025 and March 2025 MAR recorded Resident #39 received the prescribed antibiotic and wound treatments. Physician orders dated 3/25/2025 included cleansing the right buttock/sacral wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze, patting the area dry with gauze, applying a thin layer of zinc-oxide based ointment and then nystatin (antifungal medication) powder to the periwound, applying an ointment that removes dead tissue to the areas of yellow/white dead tissue and packing the wound with a topical super-oxidated solution formulated to combat bacteria and facilitate wound healing moistened gauze and covering with a bordered foam dressing every day and evening shift. On 3/25/2025 at 3:03pm, the Treatment Nurse was observed changing Resident #39's right buttock/sacral pressure wound. The Treatment Nurse stated that when Resident #39 attended a wound clinic visit on the morning of 3/25/2025, the right buttock/sacral pressure wound was measured and wound clinic notes recorded the pressure wound as 5.3cm by 10 cm by 1 cm and ordered wound care to be performed twice a day. Resident #39 right buttocks/sacral open wound was observed with black colored tissue to the lower left portion of the wound, the center of the wound with a small white patch tissue and the remaining tissue was red in color. There was no foul odor detected from the right buttocks/sacral wound. The Treatment Nurse cleansed the wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze, applied a zinc-oxide based ointment to the edges covered with nystatin powder, applied an ointment that removes dead tissue to the dark colored tissue inside the wound and packed the wound with a wound solution that contains pure hypochlorous acid that fights bacteria and infection moistened gauze and covered with a foam dressing as ordered by the physician. On 3/27/2025 at 1:25 pm in an interview with Nurse #4, she stated skin assessments were to be conducted by the nursing staff weekly and documented in Resident #39's medical record. Nurse #4 stated she did not know why Resident #39 skin assessments were not conducted weekly. On 3/27/2025 at 12:50 pm in an interview with the Director of Nursing (DON), she stated skin checks were performed daily on residents during baths, showers, incontinence care and with weekly nursing skin assessments. She stated nursing staff were to observe for any changes in resident's skin and report to the Treatment Nurse as needed. She stated skin assessments should have been conducted and documented by the nursing staff for Resident #39 and she was unable to provide a reason why Resident #39's skin assessment were not performed weekly. She stated Resident #39's right buttocks/sacral pressure wound was discussed in morning and evening meetings and Resident #39's wound worsened because Resident #39 stopped eating due to dental issues that were treated. On 3/27/2025 at 1:45 pm in a phone interview with the Medical Director, he stated the Treatment Nurse started providing wound care to Resident #39 when notified of the skin breakdown on 1/17/2025. He explained he reviewed the Treatment Nurse wound assessments weekly and was scheduled to be evaluated at the wound clinic on 2/17/2025. He stated there were no reports of infection to Resident #39's pressure wound until 2/17/2025 and Resident #39 was seen at the wound clinic as scheduled on 2/17/2025. He stated due to the Resident #39's comorbidities, Resident #39 was at risk for developing the pressure wound and the deterioration of the right buttock pressure wound was unavoidable.

Based on record reviews and staff interviews, the facility failed to conduct and document care plan meetings after completion of quarterly and/or annual Minimum Data Set (MDS) assessments for 6 of 31 residents reviewed for care planning (Resident #27, Resident #100, Resident #91, Resident #45, Resident #18, and Resident #21). The findings included: 1. Resident #27 was admitted to the facility on [DATE]. The last care plan meeting documented in Resident #27's medical record was dated 7/9/2024. MDS assessments were completed for Resident #27 on the following dates: 9/16/2024 (quarterly), 11/11/2024 (quarterly), 1/10/2025 (quarterly) and 3/21/2025 (significant change). The significant change MDS dated [DATE] indicated Resident #27 was moderately cognitively impaired. On 3/27/2025 at 1:37 pm in an interview with the MDS Coordinator, she explained the Social Worker was sent the scheduled timeframe for completion of MDS assessments monthly to use for scheduling care plan meetings. On 3/26/2025 at 9:41 am in an interview with the Social Worker, she recalled Resident #27's Resident Representative changing the care plan meeting to 10/14/2024 at 3:00pm and talking with Resident #27's resident representative on the telephone while Resident #27's Resident Representative was driving home from work. The Social Worker stated she didn't know why she didn't document the care plan meeting held on 10/14/2024 in Resident #27's medical record. The Social Worker stated Resident #27 had not had a care plan meeting since 10/14/2024. She stated Resident #27 should have had a care plan meeting in January 2025 and was unable to provide a reason why a care plan meeting had not been held for Resident #27. On 3/27/2025 at11:20 am in an interview with the Administrator, she stated the Social Worker was responsible for scheduling resident care plan meetings. In a follow up interview on 3/27/2025 at 2:48 pm, she stated care plan meetings were held quarterly and she was unaware quarterly care plan meetings had not been conducted for Resident #27. 2. Resident #100 was admitted to the facility on [DATE]. The last care plan meeting documented in Resident #100's medical record was dated 9/26/2024. Quarterly MDS assessments were completed for Resident #100 on 11/14/2024 and 2/12/2025. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #100 was severely cognitively impaired. On 3/27/2025 at 1:37 pm in an interview with the MDS Coordinator, she explained the Social Worker was sent the scheduled timeframe for completion of MDS assessments monthly to use for scheduling care plan meetings. On 3/26/2025 at 8:19 am in an interview with the Social Worker, she stated she was unable to find documentation Resident #100 had a care meeting since 9/26/2024. She explained she used the MDS schedule for completion of assessments and updating care plans to schedule the care plan meetings. She explained she had not been able to contact Resident #100's representative for a care plan meeting and stated Resident #100's representative not attending did not prevent the facility staff from having a care plan meeting for Resident #100. The Social Worker stated Resident #100 should have had a care plan meeting in November 2024 and did not know why a care plan meeting was not conducted. On 3/27/2025 at11:20 am in an interview with the Administrator, she stated the Social Worker was responsible for scheduling resident care plan meetings. In a follow up interview on 3/27/2025 at 2:48 pm, she stated care plan meetings were held quarterly and she was unaware quarterly care plan meetings had not been conducted for Resident #100. 39731 3. Resident #45 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus and hypertension. Resident #45's electronic medical record revealed the last documented care plan meeting occurred on 8/20/24. Minimum Data Set (MDS) assessments were completed for Resident #45 on the following dates: 9/20/24 (quarterly), 12/2/24 (annual), 12/18/24 (quarterly), 1/20/25 (significant change in status), and 2/13/25 (quarterly). The quarterly MDS assessment dated [DATE] revealed Resident #45 had severely impaired cognition. An interview was conducted with the facility Social Worker on 3/26/25 at 3:04 PM who stated Resident #45 has not had a care plan meeting since 8/20/24. She reported she was unsure why the care plan meetings had not been scheduled as she used the list of upcoming MDS assessments provided by the MDS Coordinator. In an interview with the Administrator on 3/27/25 at 11:20 pm, she stated the Social Worker was responsible for scheduling the care plan meetings. She reported the care plan meetings should be scheduled according to the federal timeframes. 4. Resident 91 was admitted to the facility on [DATE] with diagnoses that included heart disease and congestive heart failure. Minimum Data Set (MDS) assessments were completed for Resident #91 on the following dates: 10/11/24 (quarterly), 11/29/24 (quarterly), and 2/18/25 (quarterly). Resident #91's electronic medical record revealed the last documented care plan meeting occurred on 9/17/24. The quarterly MDS assessment dated [DATE] revealed Resident #91 had moderate cognitive impairment. An interview was conducted with the facility Social Worker on 3/26/25 at 3:04 PM who stated Resident #91 had not had a care plan meeting since 9/17/24. She reported she was unsure why the care plan meetings had not been scheduled as she used the list of upcoming MDS assessments provided by the MDS Coordinator. In an interview with the Administrator on 3/27/25 at 11:20 pm, she stated the Social Worker was responsible for scheduling the care plan meetings. She reported the care plan meetings should be scheduled according to the federal timeframes. 5. Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia and chronic kidney disease. Minimum Data Set (MDS) assessments were completed for Resident #18 on the following dates: 9/23/24 (quarterly), 10/22/24 (quarterly), 1/15/25 (quarterly), and 2/4/25 (quarterly). Resident #18's electronic medical record revealed the last documented care plan meeting occurred on 8/20/24. The quarterly MDS assessment dated [DATE] revealed Resident #18 had severe cognitive impairment. An interview was conducted with the facility Social Worker on 3/26/25 at 3:04 PM who stated Resident #18 has not had a care plan meeting since 8/20/24. She reported she was unsure why the care plan meetings had not been scheduled as she used the list of upcoming MDS assessments provided by the MDS Coordinator. In an interview with the Administrator on 3/27/25 at 11:20 pm, she stated the Social Worker was responsible for scheduling the care plan meetings. She reported the care plan meetings should be scheduled according to the federal timeframes. 6. Resident #21 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and hypertension. Minimum Data Set (MDS) assessments were completed for Resident #21 on the following dates: 9/2/24 (quarterly), 10/10/24 (quarterly), 1/6/25 (annual), and 2/6/25 (quarterly). Resident #21's electronic medical record revealed the last documented care plan meeting occurred on 8/26/24. The quarterly MDS assessment dated [DATE] revealed Resident #21 had moderate cognitive impairment. An interview was conducted with the facility Social Worker on 3/26/25 at 3:04 PM who stated Resident #21 has not had a care plan meeting since 8/26/24. She reported she was unsure why the care plan meetings had not been scheduled as she used the list of upcoming MDS assessments provided by the MDS Coordinator. The Social Worker stated she had a care plan meeting scheduled for 1/28/25 but Resident #21 was in the hospital. She stated she planned to schedule a care plan meeting for Resident #21 in April 2025. In an interview with the Administrator on 3/27/25 at 11:20 pm, she stated the Social Worker was responsible for scheduling the careplan meetings. She reported the care plan meetings should be scheduled according to the federal timeframes.

Based on record review, observation and staff interviews, the facility failed to maintain an accurate medical record in documenting the administration of oxygen for 1 of 31 residents whose medical records were reviewed (Resident #27). Findings included: Physician orders dated 3/20/2025 included an order for continuous oxygen at four liters per minute by nasal cannula every shift for respiratory disease. A review of Resident #27's March 2025 Medication Administration Record (MAR) recorded Resident #27 received four liters of oxygen via nasal cannula each shift on 3/20/2025 through 3/26/2025 and recorded oxygen saturations (measurement of how much oxygen present in the blood) ranged from 95% to 99%. On 3/25/2025 at 9:04 am, Resident #27 was observed lying in bed with the head of bed elevated and receiving oxygen by nasal cannula at two liters per minute. Resident #27 was observed with no signs or symptoms of respiratory distress. On 3/26/2025 at 6:20 am, Resident #27 was observed lying in the bed with her eyes closed and receiving oxygen at two liters per minute by nasal cannula. Resident #27 was observed with no signs or symptoms of respiratory distress. On 3/26/2025 at 7:28 am in an interview with Nurse #3, who worked the 7:00am to 3:00 pm shift, she stated the nursing staff were to check Resident #27's oxygen concentrator every shift to ensure the oxygen concentrator was set at four liters per minute and stated Resident #27 had been on oxygen at four liters per minute for as long as she could remember. In a follow up interview with Nurse #3 on 3/26/2025 at 5:03pm, she stated she had charted Resident #27 on four liters of oxygen on the 3/25/26 for the 7:00 am to 3:00 pm shift because Resident #27 was supposed to receive four liters of oxygen. She stated she had not looked at the oxygen concentrator to verify the oxygen concentrator was set at four liters per minute. On 3/26/2025 at 7:40 am, in an interview with the Director of Nursing (DON) with the Administrator present, the DON stated Resident #27 had always received oxygen therapy at four liters per minute. After reviewing Resident #27's electronic medical record, the DON stated there was no order to titrate Resident #27's oxygen to two liters per minute and the nursing staff had been charting on the MAR Resident #27 was receiving oxygen at four liters per minute.

Based on record review, observations, and staff interviews the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 3 of 3 residents reviewed with urinary catheters (Resident # 8, Resident # 5 and Resident # 14). The findings included: 1. Resident # 8 was admitted to the facility on [DATE] with diagnoses which included acute kidney failure, urinary retention, and acute cystitis without hematuria (a lower urinary tract infection without blood in the urine). A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 8 had severely impaired cognition. The assessment indicated Resident # 8 was dependent upon staff for all of his activities of daily living (ADL). Resident # 8 was coded for an indwelling urinary catheter. Resident #8's care plan dated 3/12/25 revealed Resident #8 was at the risk for infection due to the alteration pattern of urinary elimination with the use of an indwelling urinary catheter. Interventions included maintaining a closed drainage system with an unobstructed urine flow and keeping the urinary collection bag below the level of the urinary bladder. Interventions did not include keeping the urinary collection bag and tubing off the floor. An initial observation was conducted on 3/24/25 at 12:39 pm of Resident # 8 as he was lying in his bed. A urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's left side of the bed (with a solid, blue-colored side of the bag facing the window). The entire bottom of the urinary catheter drainage bag was resting on the floor. An additional observation was conducted on 3/24/25 at 3:03 pm Resident # 8's urinary catheter drainage bag was observed to be hanging off the bedframe on the resident's left side of the bed. The entire bottom of the urinary catheter drainage bag was resting on the floor. During an interview on 3/26/25 at 6:19 am with Nurse Aide (NA) # 1, he stated the urinary catheter bags were not supposed to be touching the floor due to contamination and infection control. NA# 1 repositioned the urinary catheter drainage bag so that it was not resting on the floor. In an interview with Nurse # 1 on 3/26/25 at 6:45 am, she stated she was the hall nurse assigned to care for Resident #8. Nurse # 1 was asked what her thoughts were about the position of the resident's urinary catheter bag. She replied, It shouldn't touch the floor. The nurse stated she thought the urinary catheter drainage bag ended up touching the floor due to the low position of Resident # 8's bed. During a subsequent observation on 3/26/25 at 10:15 am, Resident # 8 was observed in his bed with his urinary catheter drainage bag hanging from the left side of the bed and again the catheter drainage bag was touching the floor. On 3/26/2025 at 7:35 am in an interview with the Director of Nursing, she stated to prevent contamination urinary drainage bags were not to be touching or placed on the floor. 41387 2. Resident #14 was admitted to the facility on [DATE] with diagnoses including neurogenic bladder (lack of bladder control due to brain, spinal cord or nerve problems). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #14 was moderately cognitively impaired, was incontinent of stool and had a indwelling urinary catheter for urine elimination. Resident #14's care plan dated lasted reviewed 2/25/2025 listed Resident #14 at the risk for infection due to the alteration pattern of urinary elimination with the use of an indwelling urinary catheter. Interventions included maintaining a closed drainage system with an unobstructed urine flow and keeping the urinary collection bag below the level of the urinary bladder. Interventions did not include keeping the urinary collection bag off the floor. Review of a hospital discharge summary dated 3/12/2025 reported Resident #14 was treated for a urinary tract infection with antibiotics during the hospitalization . On 3/26/2025 at 6:20 am, Resident #14's urinary collection bag was observed lying on the floor. Nurse Aide #1 was observed in Resident #14's room providing care to Resident #14's roommate. On 3/26/2025 at 6:29 am, NA #1 was observed exiting Resident #14's room and Resident #14's urinary collection bag was observed lying on the floor. NA #1 stated he had attached the urinary collection bag to the bed and Resident #14's urinary collection bag must have fallen to the floor. NA #1 stated Resident #14's urinary collection bag was not to touch the floor to prevent contamination. NA #1 was observed re-entering Resident #14's room to re-attach Resident #14's urinary collection bag to the bed frame. NA #1 was observed placing the urinary collection bag into a dark blue storage bag that was hanging on the bed frame and touching the floor and raising Resident #14's bed enough to prevent the dark blue storage bag from touching the floor. On 3/26/2025 at 7:35 am in an interview with the Director of Nursing, she stated to prevent contamination urinary collection bags were not to be touching or placed on the floor. 3. Resident #5 was admitted to the facility on [DATE] with diagnoses including retention of urine. Resident #5's care plan included a focus dated last revised on 8/6/24 indicating Resident #5 was at risk for an infection due to an altered pattern of urinary elimination with the use of a indwelling catheter. Interventions included the use of a suprapubic catheter ( a thin, sterile tube that is inserted through a small cut in the lower belly used to drain urine from the urinary bladder) and maintaining a closed drainage system with an unobstructed urine flow and keeping the urinary catheter collection bag below the level of the bladder. There was no intervention for keeping the catheter collection bag off the floor. A quality assurance note dated 1/26/2025 recorded Resident #5 was admitted to the hospital from 12/10/2024 to 12/19/2024 for sepsis (a serious condition in which the body responds improperly to an infection) secondary to an urinary tract infection. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #5 was severely cognitively impaired, was incontinent of stool and had an indwelling catheter for urine elimination. On 3/24/2025 at 11:01 am, Resident #5's bed was observed in the lowest position and the urinary collection bag was observed touching the floor. On 3/25/2025 at 9:08 am, a tube on the urinary collection bag that was used to empty the urinary collection bag was observed clamped and touching the floor. There were no staff observed in the hallway near Resident #5's room to address the concern. On 3/26/2025 at 7:35am in an interview with the Director of Nursing (DON), the DON was informed observing Resident #5's urinary collection bag and the tube used to empty the urinary collection bag touching the floor. The DON stated to prevent contamination the urinary collection bag and the tube used to empty the urinary collection bag should not be touching the floor.

Based on record review, observations and staff interviews, the facility failed to administer supplemental oxygen as prescribed by the physician for 1 of 1 resident reviewed for oxygen use (Resident #27). Findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD and congestive heart failure (CHF). Physician orders dated 3/20/2025 included an order for continuous oxygen at four liters per minute by nasal cannula every shift for respiratory disease. The significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was moderately cognitively impaired and was receiving oxygen therapy. Resident #27's care plan dated 3/25/2025 included a focus for the potential or actual ineffective breathing pattern related to COPD and CHF. Interventions included oxygen at four liters per minute by nasal cannula. A review of Resident #27's March 2025 Medication Administration Record (MAR) recorded Resident #27 received four liters of oxygen via nasal cannula each shift on 3/20/2025 through 3/26/2025 and recorded oxygen saturations (measurement of how much oxygen present in the blood) ranged from 95% to 99%. On 3/25/2025 at 9:04 am, Resident #27 was observed lying in bed with the head of bed elevated and receiving oxygen by nasal cannula at two liters per minute. Resident #27 was observed with no signs or symptoms of respiratory distress. On 3/26/2025 at 6:20 am, Resident #27 was observed lying in the bed with her eyes closed and receiving oxygen at two liters per minute by nasal cannula. Resident #27 was observed with no signs or symptoms of respiratory distress. On 3/26/2025 at 7:05 am in an interview with Nurse #2, who worked the 11:00 pm to 7:00 am shift, she stated Resident #27 wore oxygen continuously at four liters per minute and Resident #27 was known to adjust the controller of the oxygen concentrator. Nurse #2 stated the oxygen concentrator was at four liters per minute when she checked it on the 11:00pm to 7:00am shift and was unable to recall specific time it was checked. On 3/26/2025 at 7:26 am, Nurse #2 checked the oxygen concentrator and stated Resident #27's oxygen concentrator was set at two liters per minute. Nurse #2 was observed verifying the physician order for oxygen and adjusted Resident #27's oxygen concentrator to four liters per minute. On 3/26/2025 at 7:28 am in an interview with Nurse #3, who worked the 7:00 am to 3:00 pm shift, she stated the nursing staff were to check Resident #27's oxygen concentrator every shift to ensure the oxygen concentrator was set at four liters per minute and stated Resident #27 had been on oxygen at four liters per minute for as long as she could remember. In a follow up interview with Nurse #3 on 3/26/2025 at 5:03pm, she stated she had charted Resident #27 on four liters of oxygen on the 3/25/26 for the 7:00 am to 3:00 pm shift because Resident #27 was supposed to receive four liters of oxygen. She stated she had not looked at the oxygen concentrator to verify the oxygen concentrator was set at four liters per minute. She stated Resident #27 had been observed turning the controller on the oxygen concentrator in the past. On 3/26/2025 at 7:40 am, in an interview with the Director of Nursing (DON) with the Administrator present, the DON stated Resident #27 had always received oxygen therapy at four liters per minute. After reviewing Resident #27's electronic medical record, the DON stated there was no order to titrate Resident #27's oxygen to two liters per minute and the nursing staff had been charting on the MAR Resident #27 was receiving oxygen at four liters per minute when checking the oxygen concentrator. The Administrator recalled the facility calling to verify Resident #27's oxygen order on 3/20/2025 for four liters per minute by nasal cannula after readmission to the facility.

Based on record review and staff interviews, the facility failed to post accurate Registered Nurse (RN) staffing information for 16 of 114 days reviewed for posted nurse staffing (12/9/24, 12/16/24, 12/30/24, 1/4/25, 1/14/25, 1/22/25, 1/27/25, 1/28/25, 1/30/25, 2/7/25, 2/17/25, 2/21/25, 2/23/25, 2/28/25, 3/11/25, and 3/16/25). The findings included: The daily posted nurse staffing sheets were reviewed for the period of 12/1/24 through 3/24/25 and revealed the following: -December 2024 did not have any RN documented as working for all 3 shifts on the following days: 12/9/24, 12/16/24, and 12/30/24. -January 2025 did not have any RN documented as working for all 3 shifts on the following days: 1/4/25, 1/14/25, 1/22/25, 1/27/25, 1/28/25, and 1/30/25. -February 2025 did not have any RN documented as working for all 3 shifts on the following days: 2/7/25, 2/17/25, 2/21/25, 2/23/25, and 2/28/25. -March 2025, for the period of 3/1/25 through 3/24/25, did not have any RN documented as working for all 3 shifts on the following days: 3/11/25 and 3/16/25. Review of employee timecard punches provided by the Administrator verified there had been RN coverage in the building for all the above dates and the Registered Nurse (RN) staffing information posted was incorrect. During an interview on 3/26/25 at 3:28 pm with the Scheduler, she stated she was responsible for the staff posting and she was unaware of the requirement to adjust the posted staffing information to reflect the actual staff present. She stated she completed the posted staffing sheets ahead of time based on the staff work schedule. She stated when she was off on the weekend or vacation, she completed the posted staffing sheets ahead of time and they were not adjusted to accurately reflect the actual staffing. During an interview on 3/27/25 at 2:15 pm with the Administrator, she stated she was aware of the requirement to adjust the posted staffing to accurately reflect the actual staff present. She also stated she was unaware this was not being done, and the Scheduler did not know the posted staffing should be updated with the actual staff on each shift.

Based on observations and staff interviews, the facility failed to provide a clean and sanitary environment by not removing a dark grey/black colored substance from 20 of 25 ceiling fans observed on 8 of 8 resident halls. Findings included: 1a. During an observation of the 600-hall on 3/27/25 at 8:26 AM 2 ceiling fans were noted with a dark grey/black colored substance on all 5 of the blades. b. During an observation of the 600-hall on 3/27/25 at 8:26 AM the ceiling fan in front of the nurse's station for the 500-hall and 600-hall was noted with a dark grey/black colored substance on all 5 of the blades. c. An observation conducted on 3/27/25 at 8:28 AM of the 500-hall revealed 3 ceiling fans had a dark grey/black colored substance on all 5 of the blades. d. An observation conducted on 3/27/25 at 8:30 AM of the 400-hall revealed 3 ceiling fans had a dark grey/black colored substance on all 5 of the blades. e. An observation conducted on 3/27/25 at 8:32 AM of the 300-hall revealed 1 ceiling fan had a dark grey/black colored substance on all 5 of the blades. f. An observation conducted on 3/27/25 at 8:33 AM of the ceiling fan in front of the nurse's station for the 100-hall and 200-hall revealed the ceiling fan was noted with a dark grey/black colored substance on all 5 of the blades. g. An observation conducted on 3/27/25 at 8:34 AM of the 100-hall revealed 3 ceiling fans had a dark grey/black colored substance on all 5 of the blades. h. An observation conducted on 3/27/25 at 8:37 AM of the 200-hall revealed 2 ceiling fans had a dark grey/black colored substance on all 5 of the blades. i. An observation conducted on 3/27/25 at 8:41 AM of the 700 hall and 800 hall nurse's station revealed 2 ceiling fans had a dark grey/black colored substance on all 5 of the blades. j. An observation conducted on 3/27/25 at 8:42 AM of the 800-hall revealed 1 ceiling fan had a dark grey/black colored substance on all 5 of the blades. k. An observation conducted on 3/27/25 at 8:42 AM of the 700-hall revealed 1 ceiling fan had a dark grey/black colored substance on all 5 of the blades. On 3/27/25 at 8:46 AM an interview was conducted with Housekeeping Staff #1. She stated the housekeeping department was responsible for cleaning the ceiling fans within the facility. She further stated the ceiling fans were cleaned weekly and to her knowledge the fans were last cleaned one week ago. During visual inspection she indicated the fans required cleaning. An interview was conducted with the Housekeeping Manager on 3/27/25 at 8:49 AM. He stated the housekeeping department was responsible for cleaning the ceiling fans, and they were supposed to be cleaned weekly by the Floor Technician staff member who was responsible for this task. An interview was conducted with the Floor Technician on 3/27/25 at 8:52 AM. He stated he was responsible for cleaning the ceiling fans within the facility. He further stated the ceiling fans were usually cleaned weekly, however the ceiling fans were last cleaned 2 weeks ago, as he was on leave from the facility. An observation was conducted on halls 700 and 800 with the Housekeeping Manager and Floor Technician on 3/27/25 at 8:54 AM. Both the Housekeeping Manager and Floor Technician indicated the ceiling fans needed to be cleaned. They stated all ceiling fans in resident halls would be cleaned that day. On 3/27/25 at 10:50 AM an interview was conducted with the Director of Nursing (DON). She stated the housekeeping department was responsible for cleaning the ceiling fans. She further stated it was her expectation that housekeeping staff would clean the ceiling fans weekly and as needed. An interview was conducted with the Administrator on 3/27/25 at 1:37 PM. She stated housekeeping staff were responsible for cleaning the ceiling fans, and they followed a cleaning schedule. She further stated her expectation was that the ceiling fans were cleaned per the cleaning schedule (weekly).

Based on observations, record review, staff and Physician interviews, the facility failed to protect the resident's right to be free from injury of unknown source that resulted in bruising under the eyes and a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1) Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She exhibited no physical or verbal behaviors directed toward others (e.g. hitting, kicking, grabbing, or yelling). She exhibited no other behaviors such as hitting or scratching herself. She required total dependent care by staff for activities of daily living (ADLs). She had no falls and received anticoagulant (prevents clot formation) medications. She had no rejection of care. An Investigation Report dated 04/08/24 revealed that on 04/06/24 Resident #1 presented with swelling and bruising of her nose and under her eyes. A full investigation was conducted on 04/08/24 and it was not determined how the resident sustained the injury. The investigation revealed at approximately 11:00 PM on 04/06/24 Nurse Aide #1 reported swelling on the bridge of Resident #1's nose. Nurse #2 was notified. Nurse #2 instructed Nurse Aide #1 to apply an ice pack to her face. Nurse #2 indicated she administered Tylenol. Nurse Aide #1 stated Resident #1's nose continued to swell and appeared bruised. An x-ray report dated 04/08/24 for Resident #1 revealed a minimally displaced fracture of the nasal bridge. Review of Resident #1's progress notes from 04/05/24 the day prior to the appearance of bruising and swelling under the eyes and the nasal bridge through 04/0624 at 11:00 PM when the injury was identified revealed no documentation of an injury that occurred. There were no reported falls. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #1 received scheduled Plavix (prevents blood clot formation) 75 milligrams (mg) every morning for anticoagulation therapy. A known side effect of this medication included bruising. During an observation on 04/26/24 at 11:30 AM of Resident #1 was observed lying in bed. She was oriented to person only. She could not verbalize the cause of her injury. She was noted to have a small yellow discolored area under her left eye suggestive of an old bruise. A full skin assessment was observed with the assigned nurse. There were no further injuries noted. During an interview on 04/26/24 at 11:45 AM Resident #1's roommate who was alert and oriented reported the bruising suddenly appeared under her eyes, but she didn't know what happened. She indicted she had never witnessed any staff member mistreating Resident #1. She stated Resident #1 had dementia and was resistive to care at times, but she had not witnessed her falling from bed or having any accidents related to her injury. During a phone interview on 04/26/24 at 5:20 PM Nurse #2 stated she came on shift at 11:00 PM on 04/06/24 and was the assigned nurse for Resident #1. She stated Nurse Aide #1 asked her to go down and look at Resident #1. She went down at that time and observed bruising and swelling underneath her left eye. Resident #1 was not able to verbalize what caused the injury. She stated she did not receive any report from the day shift nurse (Nurse #1) who reported to her when she came on duty regarding an injury. She reported that Resident #1 received anticoagulant medication, so she wasn't alarmed because the bruising and swelling was a small area. She asked Resident #1 if her face bothered her and she said yes. She reported she administered Tylenol 650 milligrams once at that time and applied an ice pack. Nurse #2 stated although her eye was bruised and swollen it did not look like a serious injury. She asked Nurse Aide #1 what happened, and she could not provide an answer. She stated when Nurse #1 came in the next day, she mentioned it to her, but Nurse #1 didn't know what could have happened to cause the injury. She stated she gave Nurse #1 report and went home. She stated it was a small bruise with no open areas, and no bleeding or other signs of trauma. She stated she decided she would let the day shift nurse notify the doctor. She stated since the incident she had received in service training on reporting injuries of unknown source, abuse training, and monitoring for an acute change in condition. During an interview on 04/26/24 at 12:45 PM Nurse #1 stated she was Resident #1's assigned nurse on Saturday 04/06/24 from 7:00 AM through 11:00 PM. She stated when she left her shift on 04/06/24 at 11:00 PM there was no bruising, swelling, or injury. She stated Nurse Aide #1 reported to her earlier that day around 4:00 PM on 04/06/24 that Resident #1 had blood on her gown. She assessed Resident #1 and observed blood coming from her mouth and determined she had bitten her tongue. They cleaned her mouth and held pressure and the bleeding stopped. Nurse #1 reported she left the room and finished her medication pass. Before leaving her shift at 11:00 PM she reported Resident #1 did not have anything wrong with her face and her mouth was not bleeding, and there was no bruising or swelling. She stated she returned to work the next morning and Medication Aide #1 reported to her that Nurse Aide #1 reported that Resident #1 had a black and bruised eye. Nurse #1 stated Nurse #2 who was on duty during the night shift, did not report anything to her regarding the injury. Nurse #1 stated she assessed Resident #1 just after 7:00 AM and noted that her left eye was bruised and red. She reported she reviewed her electronic medical record and there was no documentation as to what happened. She stated she called and informed the Director of Nursing (DON) about the unexplained injury sometime that day on 04/07/24 but thought it was before 5:00 PM and the DON stated she would take care of it. She reported Resident #1 never complained of pain on 04/07/24. She indicated that although Resident #1 had dementia she was oriented to person and could voice her needs. She stated Resident #1 had been in the facility for years and did not have a history of falls that she was aware of. She stated Resident #1 would tense up when turning her and providing care. She required total care by staff and used the mechanical lift for transfers but stayed in bed most of the time. She stated Resident #1 would push staff away at times when they attempted to administer medications or provide care. She stated Resident #1 was not able to turn or reposition herself without assistance. She stated since the incident Resident #1 had no changes in her behavior and remained at baseline. Nurse #1 stated since the incident she had received training on monitoring for an acute change in condition, abuse training, and reporting a change in condition, reporting skin issues, and signs and symptoms of fractures. During an interview on 04/26/24 at 1:20 PM Nurse Aide #1 stated she worked a double shift on 04/06/24 from 3:00 PM through 7:00 AM on 04/07/24 and was assigned to Resident #1. She stated when she arrived for work around 3:30 PM she provided incontinence care and saw a speck of blood on her gown near her neckline. She called for Nurse #1 to look at her. There were no skin tears and at that moment she started spitting out a small amount of blood. She thought she may be losing a tooth. The nurse assessed her and thought she bit her tongue and instructed her to get her cleaned up. She stated Resident #1 had no complaints of pain and they checked her teeth to make sure none were loose. Resident #1 seemed okay, and she continued on with her shift. Later that evening around 11:30 PM she noticed Resident #1's face turning red, and she had bruising under her eyes. She reported this to Nurse #2, the oncoming 11:00 PM to 7:00 AM nurse. Nurse #2 went in around 11:15 PM and told her to get an ice pack and put the ice pack on her face for 1 hour. Nurse Aide #1 went back to remove the ice pack an hour later and noticed her eye was getting darker on both sides under her eyes. She reported this to Nurse #2 right away and the nurse told her she was going to leave it for the morning nurse at 7:00 AM since it was late. She indicated she was not given any further instruction that night from Nurse #2. She stated Resident #1 required total care and used the mechanical lift for transfers. She indicated she could not turn or reposition herself without staff assistance. She was disoriented most of the time. She stated she was called in to work the next week during the investigation and was told that Resident #1 had a broken nose. She stated she had no idea of how the injury occurred. She stated she received in-service training regarding abuse and reporting injuries. During an interview on 4/26/24 at 1:50 PM Nurse Aide #2 stated she worked Saturday 04/06/24 from 7:00 AM to 10:00 PM and was assigned to Resident #1 from 7:00 AM until 3:00 PM. She stated after she arrived for her shift, she checked on her residents and reported nothing unusual regarding Resident #1. She reported there was no redness, or bruising. She gave her a bath around 10:30 AM Saturday morning. She moved her bed away from the wall due to her pushing against the wall and resisting when trying to change or reposition her. She stated she acts as though she doesn't like to be repositioned, so she uses her arms to block. She indicated Resident #1 could not turn and reposition without staff assistance. She reported she did not have bed rails on the bed. She gave the bath, repositioned her, and sat her up in the bed to get ready for lunch at that time and there was nothing unusual noticed. She checked on her again at lunch and nothing was unusual. She went in her room again around 2:30 - 2:45 PM to change her and there were no signs of bruising or swelling. She stated around 3:15 PM the nurse aide for 2nd shift reported her mouth was bleeding. Nurse #1 told her she had just checked her, and nothing was wrong with her mouth. She stated she was surprised to hear of her mouth bleeding because she had just left her at 2:45 PM and she was fine. She stated at 3:00 PM she changed assignments and only saw her at a glance later that day. When she returned to work Sunday morning, she was assigned to Resident #1 again. When she went in to see her at the beginning of her shift she had two black eyes. She stated she immediately reported it to Nurse #1. Nurse #1 went in to assess her and didn't know what had happened. She stated she thought the injury happened overnight. She stated she received in service training since this incident on abuse turning and repositioning, falls, skin tears, reporting changes in behaviors, and reporting signs of bruising. During an interview on 4/26/24 at 1:00 PM Nurse Aide #3 stated she worked on Friday 04/05/24 from 7:00 AM until 3:00 PM the day prior to the reported injury and was assigned to Resident #1. She reported there was no bruising or swelling observed during that time. She didn't know how the injury occurred but was later told she had a broken nose. She stated Resident #1 was total care and required the mechanical lift with 2-person assistance for transfers. She was cooperative with care most days, but she did try to pull on your clothes or would push against the wall when you tried to turn and reposition her or provide any care for her. She stated she typically moved her bed slightly from the wall during care, so she didn't push against the wall, but stated she always pushed the bed back against the wall following care. She stated Resident #1 had dementia but could voice her needs. She had no complaints of pain and no history of falls that she was aware of. She reported it was never determined what caused the injury. She stated she received in-service training on abuse, sliding residents in bed, signs, and symptoms of fractures, and reporting injuries. During a phone interview on 04/26/24 at 4:40 PM the Physician stated he was notified of the injury of unknown source on Monday 04/08/24. He stated he ordered an x-ray that showed a minimally displaced fracture to the nose. He reported he evaluated Resident #1 on Tuesday 04/07/24 and interviewed staff and her roommate and asked if she had been dropped or fallen. He stated he could not determine how the injury occurred. He reported Resident #1 had been bedridden for many years. He stated there was no delay in treatment by doing the x-ray on Monday. He stated Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician on 04/11/24 and from the outcome of that evaluation along with conversations with her Responsible Party it was decided that no treatment would be indicated for the nasal fracture. During an interview on 04/26/24 at 3:50 PM the Director of Nursing (DON) stated she was not made aware until Monday 04/08/24 of the injury of unknown source. She reported she found out about Resident #1's injury on Monday morning from either a nurse or nurse aide but could not recall exactly. She went to assess Resident #1's nose and she had bilateral bruising under her eyes and across the bridge of her nose. She started an investigation at that time and the Responsible Party was notified. She stated the Physician was notified on 04/08/24 and ordered an x-ray which resulted in a nasal fracture. The Physician evaluated her on 04/09/24. Resident #1 was evaluated by an Ear, Nose, and Throat (ENT) physician on 04/11/24. She stated the Police came on 04/08/24 and talked with Resident #1 and her roommate. The Police determined no foul play and could not determine what caused the injury. During an interview on 04/26/24 at 6:00 PM the Administrator stated she was notified of the injury late in the day on 04/08/24. She stated an investigation was initiated at that time related to the injury. She stated the Physician, and the Responsible Party were made aware immediately. She stated an x-ray was ordered and showed the nasal fracture. She stated staff statements were obtained during their investigation. Resident interviews were conducted regarding abuse, or injuries that had not been reported and no concerns were identified. She stated they could not determine how the fracture occurred and thought she could have turned into the wall. She stated since the incident they have placed a pad between her bed and the wall. She stated education was provided to all nursing staff regarding the provision of care including abuse training, and monitoring for an acute change in condition including injuries of unknown source. She stated an ad hoc Quality Assurance (QA) meeting was held on 04/09/24 and the decision was made by the Quality Assurance (QA) Committee to initiate a Performance Improvement Plan regarding this occurrence. She reported the Plan of Correction was initiated on 04/08/24 which included monitoring for an acute change in condition to include new bruising, pain, or injury of unknown source. Reporting of an acute change in condition to the DON, physician, and the Responsible Party, and follow through of interventions and monitoring for a change in condition. The Plan of Correction included: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 04/08/24 Resident #1 was assessed by the Director of Nursing. Resident #1 was noted to have bilateral bruising under her eyes and across the bridge of her nose. On 04/08/24 the physician was notified, an x-ray was ordered which resulted in a minimally displaced fracture of the nasal bridge. The Responsible Party was notified. On 04/08/24 Adult Protective Services and law enforcement were notified. On 04/08/24 through 04/09/24 interviews were conducted with all alert and oriented residents regarding resident abuse and how to report abuse and neglect, and injuries of unknown source. There were no concerns identified. On 04/08/24 through 04/09/24 skin assessments were completed on all non-alert and oriented residents for signs of abuse and neglect. There were no concerns identified. On 04/08/24 through 04/09/24 grievance logs were reviewed for the past 30 days to ensure all allegations were reported timely. There were no concerns identified. On 04/08/24 through 04/09/24progress notes were reviewed for the last 7 days to ensure documented acute change in condition to include new/worsening pain, bruising, or signs of a fracture were assessed and reported timely to the physician, DON, and Responsible Party. There were no concerns identified. On 04/08/24 the Administrator, and the Director of Nursing were educated by the Clinical Director regarding reportable events including injuries of unknown source or events that were suspicious of a crime and it must be reported to the State Agency within 2 hours. On 04/09/24 through 04/10/24 education was conducted with all nursing staff regarding the facility's abuse and neglect policy, reporting changes in condition, interventions for an acute change in condition, signs/symptoms of fractures, performing neurological checks, and turning and repositioning residents. On 04/09/24 Resident #1 was evaluated by the Physician. There was no new treatment implemented. On 04/11/24 Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician. There was no new treatment implemented. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 04/08/24 the DON and Staff Facilitator performed skin assessments on cognitively impaired residents to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. There were no negative findings. On 04/08/24 the DON and Staff Facilitator initiated questionnaires of all alert and oriented residents regarding new/worsening pain, injuries not reported to the nurse, and signs/symptoms of a fracture. The questionnaire was to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 04/09/24 the DON and Staff Facilitator initiated education with all nursing staff regarding abuse, notification of an acute change with emphasis on assessing a change to include new/worsening pain, signs of a fracture, obtaining vital signs, initiating interventions for an acute change, notification of the physician for further recommendations, and notifying the responsible party to include documentation in the medical record. Education was provided on signs/symptoms of a fracture to include bruising and swelling. Completing neurological checks per the standing order for all known or suspected head injuries or unwitnessed fall. Education was completed by 04/10/24 . After 04/10/24 any staff who had not completed their education would be required to do so prior to the next shift. Newly hired staff would be educated during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The decision to monitor and take to QA was made on 04/09/24. The unit managers will review progress notes 5 times per week for 4 weeks utilizing the acute change auditing tool. The unit manager will address any concerns identified. The Social Worker will complete 5 resident questionaries weekly for 4 weeks to identify any concerns. The unit managers will address any concerns identified. The Administrator and DON will review the audits weekly for 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools/questionaries to the QAPI committee for 1 month to review and to determine trends or issues, or the need for continued monitoring. A QAPI (Quality Assurance Performance Improvement ) meeting was held again on 04/16/24 with the Interdisciplinary team where the plan of correction was discussed. The facility alleged compliance with the corrective action plan on 04/12/24. Validation of the corrective action was completed on 04/26/24. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. The initial audits were verified. There were no concerns identified.

Based on record review, staff and Physician interviews the facility failed to monitor a resident following the identification of an injury of unknown source that resulted in bruising and a fracture of the nasal bridge. Neurological checks were not conducted following the unwitnessed head injury, vital signs were not obtained, and pain assessments were not conducted. This occurred for 1 of 1 cognitively impaired resident reviewed for an injury of unknown source. (Resident #1) Findings included. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She exhibited no physical or verbal behaviors directed toward others (e.g. hitting, kicking, grabbing, or yelling). She exhibited no other behaviors such as hitting or scratching herself. She required total dependent care by staff for activities of daily living (ADLs). She had no falls and received anticoagulant (blood thinning) medications. She had no rejection of care. An Investigation Report dated 04/08/24 revealed that on 04/06/24 Resident #1 presented with swelling and bruising of her nose and under her eyes. A full investigation was conducted on 04/08/24 and it was not determined how the resident sustained the injury. The investigation revealed at approximately 11:00 PM on 04/06/24 Nurse Aide #1 reported swelling on the bridge of Resident #1's nose. Nurse #2 was notified. Nurse #2 instructed Nurse Aide #1 to apply an ice pack to her face. Nurse #2 indicated she administered Tylenol. Nurse Aide #1 stated Resident #1's nose continued to swell and appeared bruised. An x-ray report dated 04/08/24 for Resident #1 revealed a minimally displaced fracture of the nasal bridge. Review of Resident #1's progress notes from 04/06/24 through 04/08/24 revealed no documentation of an injury. There was no documentation of the swelling and bruising that was observed on 04/06/24. There was no documentation that neurological checks were conducted for an unwitnessed head injury, or that vital signs were obtained. There was no record of pain assessments or that as needed Tylenol was administered. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #1 received scheduled Plavix (a medication to prevent clot formation) 75 milligrams (mg) every morning for anticoagulation therapy. A known side effect of this medication included bruising. Review of the Medication Administration Record (MAR) dated April 2024 revealed Resident #1 had an order to administer Tylenol 650 mgs every 4 hours as needed for pain. There was no documentation that Tylenol was administered to Resident #1 from 04/06/24 through 04/11/24. An observation was conducted on 04/26/24 at 11:30 AM of Resident #1. She was observed lying in bed. She was oriented to person only. She could not verbalize the cause of her injury. She was noted to have a small yellow area under her left eye suggestive of an old bruise. A full skin assessment was observed with the assigned nurse. There were no further injuries noted. During a phone interview on 04/26/24 at 5:20 PM Nurse #2 stated she came on shift at 11:00 PM on 04/06/24 and was the assigned nurse for Resident #1. She stated Nurse Aide #1 asked her to go down and look at Resident #1. She went down at that time and observed bruising and swelling underneath her left eye. She stated Resident #1 was not able to verbalize what caused the injury. She stated she did not receive any report from Nurse #1 regarding an injury. She reported that Resident #1 received anticoagulant medication, so she wasn't alarmed because the bruising and swelling was a small area. She asked Resident #1 if her face bothered her and she said yes. She reported she administered Tylenol 650 mgs. once at that time and applied an ice pack. Nurse #2 stated although her eye was bruised and swollen it did not look like a serious injury. She asked Nurse Aide #1 what happened, and she could not provide an answer. She stated she didn't think about doing anything else that night to address the unexplained injury. She indicated she did not complete neurological checks to determine any concerns such as ongoing headache, dizziness, or difficulty speaking. She asked Nurse Aide #1 to obtain vital signs, but stated she did not know if the vital signs were ever obtained, and she did not follow up with the nurse aide. She stated she did not receive any further reports during the shift that Resident #1 had ongoing pain but indicated she did not provide further monitoring to address her pain. She reported she wanted to speak to Nurse #1 who worked on 04/06/24 to find out if she had observed anything. She stated when Nurse #1 came in the next day, she mentioned it to her, but Nurse #1 didn't go into any details of what could have happened to cause the injury. She stated she gave Nurse #1 report and went home. She stated outside of the paperwork she was instructed to fill out on Monday 04/08/24 regarding the injury of unknown source, she didn't do any paperwork or notification on the night the area was first observed. She stated she did not notify the Director of Nursing regarding the injury of unknown source and did not notify the Physician or Resident #1's Responsible Party. She stated it was a small bruise with no open areas, and no bleeding or other signs of trauma, so she didn't think it was necessary to call the physician. She stated she decided she would let the day shift nurse notify the doctor. She stated since the incident she had received in service training on reporting injuries of unknown source, monitoring for an acute change in condition including conducting neurological checks, obtaining vital signs, and conducting pain assessments. During an interview on 04/26/24 at 12:45 PM Nurse #1 stated she was Resident #1's assigned nurse on Saturday 04/06/24 from 7:00 AM through 11:00 PM. She stated when she left her shift on 04/06/24 at 11:00 PM there was no bruising, swelling, or injury. She stated Nurse Aide #1 reported to her earlier that day around 4:00 PM on 04/06/24 that Resident #1 had blood on her gown. She assessed Resident #1 and observed blood coming from her mouth and determined she had bitten her tongue. They cleaned her mouth and held pressure and the bleeding stopped. Nurse #1 reported she left the room and finished her medication pass. Before leaving her shift at 11:00 PM she reported Resident #1 did not have anything wrong with her face and her mouth was not bleeding. There was no bruising or swelling. She stated she returned to work the next morning and Medication Aide #1 reported to her that Nurse Aide #1 reported that Resident #1 had a black and bruised eye. Nurse #1 stated Nurse #2 who was on duty during the night shift, did not report anything to her regarding the injury. Nurse #1 stated she assessed Resident #1 just after 7:00 AM and noted that her left eye was bruised and red. She reported she reviewed her electronic medical record and there was no documentation as to what happened. She stated she called and informed the Director of Nursing (DON) about the unexplained injury sometime that day on 04/07/24 but thought it was before 5:00 PM and the DON stated she would take care of it. She stated she was busy that day and that was why the DON was not notified sooner. She reported Resident #1 never complained of pain on 04/07/24. She indicated that although Resident #1 had dementia she was oriented to person and could voice her needs. She stated Resident #1 had been in the facility for years and did not have a history of falls that she was aware of. She stated Resident #1 would tense up when turning her and providing care. She stated she required total care by staff and required the mechanical lift for transfers but stayed in bed most of the time. She stated Resident #1 would push staff away at times when they attempted to administer medications or provide care. She stated since the incident Resident #1 had no changes in her behavior and remained at baseline. Nurse #1 stated since the incident she had received training on monitoring for an acute change in condition, and reporting a change in condition, reporting skin issues, and signs and symptoms of fractures. She stated in hindsight she should have completed an incident report when she observed the facial bruising and swelling on the morning of 04/07/24 and notified the DON right away since she was uncertain if the night shift nurse had reported it. During an interview on 04/26/24 at 1:20 PM Nurse Aide #1 stated she worked a double shift on 04/06/24 from 3:00 PM through 7:00 AM on 04/07/24 and was assigned to Resident #1. She stated when she arrived for work around 3:30 PM she provided incontinence care and saw a speck of blood on her gown near her neckline. She called for Nurse #1 to look at her. There were no skin tears and at that moment she started spitting out a small amount of blood. She thought she may be losing a tooth. The nurse assessed her and thought she bit her tongue and instructed her to get her cleaned up. She stated Resident #1 had no complaints of pain and they checked her teeth to make sure none were loose. Resident #1 seemed okay, and she continued on with her shift. Later that evening around 11:30 PM she noticed Resident #1's face was turning red and had bruising under her eyes. She reported this to Nurse #2, the oncoming 11:00 PM to 7:00 AM nurse. Nurse #2 went in around 11:15 PM and told her to get an ice pack and put the ice pack on her face for 1 hour. Nurse Aide #1 went back to remove the ice pack an hour later and noticed her eye was getting darker on both sides under her eyes. She reported this to Nurse #2 right away and the nurse told her she was going to leave it for the morning nurse at 7:00 AM since it was late. She indicated she was not given any further instruction that night from Nurse #2. She stated she was called in to work the next week during the investigation and was told that Resident #1 had a broken nose. She stated she had no idea of how the injury occurred. She stated she received in-service training regarding reporting injuries such as a change in behavior and reporting bruising and swelling. During an interview on 04/26/24 at 3:50 PM the Director of Nursing (DON) stated she was not made aware until Monday 04/08/24 of the injury of unknown source. She reported she found out about Resident #1's injury on Monday morning from either a nurse or nurse aide but could not recall exactly. She went to assess Resident #1's nose and she had bilateral bruising under her eyes and across the bridge of her nose. She started an investigation at that time and the Responsible Party was notified. She stated the Physician was notified on 04/08/24 and ordered an x-ray which resulted in a nasal fracture. The physician evaluated her on 04/09/24. Resident #1 was evaluated by an Ear, Nose, and Throat (ENT) physician on 04/11/24. The DON stated Nurse #2 who initially observed the bruising and swelling should have notified her right away. She stated Nurse #2 should have followed the facility protocol for injuries of unknown source which included to notify the DON, and the Physician for further orders and that was not done. She stated there was no record that Nurse #2 provided monitoring on the night shift after the injury was identified. She stated there were no neurological checks, and no record of vital signs. She stated nurses must initiate neurological checks for any resident with a known or suspected head injury when the resident was unable to report hitting their head per the facility standing order. She indicated if there was no order for neurological checks the nurse was to notify the physician of the injury to obtain orders for neurological checks to include frequency, duration, and parameters for notifying the physician. She indicated neurological checks were to be documented in the residents progress notes. She indicated that during the investigation it was determined that Nurse #2 did not complete neurological assessments, obtain vitals signs, and there was no documentation that Tylenol was administered to Resident #1. She stated the Police came on 04/08/24 and talked with Resident #1 and her roommate. The Police determined no foul play and could not determine what caused the injury. During a phone interview on 04/26/24 at 4:40 PM the Physician stated he was notified of the injury of unknown source on Monday 04/08/24. He stated he ordered an x-ray that showed a minimally displaced fracture to the nose. He reported he evaluated Resident #1 on Tuesday 04/07/24 and interviewed staff and her roommate and asked if she had been dropped or fallen. He stated he could not determine how the injury occurred. He reported Resident #1 had been bedridden for many years. He stated he should have been notified at least by the following day since the injury occurred at 11:00 PM at night. He stated there was no delay in treatment by doing the x-ray on Monday. He stated Resident #1 was evaluated by the ENT physician on 04/11/24 and from the outcome of that evaluation along with conversations with her Responsible Party it was decided that no treatment would be indicated for the nasal fracture. During an interview on 04/26/24 at 6:00 PM the Administrator stated she was notified of the injury late in the day on 04/08/24. She stated Nurse #2 should have reported the injury of unknow source on the night of 04/06/24. She stated education was provided to all nursing staff regarding monitoring for an acute change in condition including injuries of unknown source. She stated Nurse #2 should have conducted ongoing monitoring for a change in condition during the night and indicated that was not done. She stated education was provided to nursing staff on reporting injuries of unknown source and the protocol on what to do when an injury was identified. She stated a full investigation was completed and it was never determined how the injury occurred. She stated an ad hoc Quality Assurance (QA) meeting was held on 04/09/24 and the decision was made by the Quality Assurance (QA) Committee to initiate a Performance Improvement Plan regarding this occurrence. She reported the Plan of Correction was initiated on 04/08/24 which included monitoring for an acute change in condition to include new bruising, pain, or injury of unknown source. Reporting of an acute change in condition to the DON, physician, and the Responsible Party, and follow through of interventions and monitoring for a change in condition. The Plan of Correction included: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 04/08/24 Resident #1 was assessed by the Director of Nursing. Resident #1 was noted to have bilateral bruising under her eyes and across the bridge of her nose. On 04/08/24 the physician was notified, an x-ray was ordered which resulted in a minimally displaced fracture of the nasal bridge. The Responsible Party was notified. On 04/08/24 Adult Protective Services and law enforcement were notified. On 04/08/24 through 04/09/24 interviews were conducted with all alert and oriented residents regarding resident abuse and how to report abuse and neglect, and injuries of unknown source. There were no concerns identified. On 04/08/24 through 04/09/24 skin assessments were completed on all non-alert and oriented residents for signs of abuse and neglect. There were no concerns identified. On 04/08/24 through 04/09/24 grievance logs were reviewed for the past 30 days to ensure all allegations were reported timely. There were no concerns identified. On 04/08/24 through 04/09/24progress notes were reviewed for the last 7 days to ensure documented acute change in condition to include new/worsening pain, bruising, or signs of a fracture were assessed and reported timely to the physician, DON, and Responsible Party. There were no concerns identified. On 04/08/24 the Administrator, and the Director of Nursing were educated by the Clinical Director regarding reportable events including injuries of unknown source or events that were suspicious of a crime and it must be reported to the State Agency within 2 hours. On 04/09/24 through 04/10/24 education was conducted with all nursing staff regarding the facility's abuse and neglect policy, reporting changes in condition, interventions for an acute change in condition, signs/symptoms of fractures, performing neurological checks, and turning and repositioning residents. On 04/09/24 Resident #1 was evaluated by the Physician. There was no new treatment implemented. On 04/11/24 Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician. There was no new treatment implemented. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 04/08/24 the DON and Staff Facilitator performed skin assessments on cognitively impaired residents to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. There were no negative findings. On 04/08/24 the DON and Staff Facilitator initiated questionnaires of all alert and oriented residents regarding new/worsening pain, injuries not reported to the nurse, and signs/symptoms of a fracture. The questionnaire was to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 04/09/24 the DON and Staff Facilitator initiated education with all nursing staff regarding abuse, notification of an acute change with emphasis on assessing a change to include new/worsening pain, signs of a fracture, obtaining vital signs, initiating interventions for an acute change, notification of the physician for further recommendations, and notifying the responsible party to include documentation in the medical record. Education was provided on signs/symptoms of a fracture to include bruising and swelling. Completing neurological checks per the standing order for all known or suspected head injuries or unwitnessed fall. Education was completed by 04/10/24 . After 04/10/24 any staff who had not completed their education would be required to do so prior to the next shift. Newly hired staff would be educated during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The decision to monitor and take to QA was made on 04/09/24. The unit managers will review progress notes 5 times per week for 4 weeks utilizing the acute change auditing tool. The unit manager will address any concerns identified. The Social Worker will complete 5 resident questionaries weekly for 4 weeks to identify any concerns. The unit managers will address any concerns identified. The Administrator and DON will review the audits weekly for 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools/questionaries to the QAPI committee for 1 month to review and to determine trends or issues, or the need for continued monitoring. A QAPI (Quality Assurance Performance Improvement ) meeting was held again on 04/16/24 with the Interdisciplinary team where the plan of correction was discussed. The facility alleged compliance with the corrective action plan on 04/12/24. Validation of the corrective action was completed on 04/26/24. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. The initial audits were verified. There were no concerns identified.

Based on record review and staff interviews the facility failed to implement their policy for injuries of unknown source that required facility staff to immediately report the injury to facility management. A staff member failed to report unexplained bruising under the eyes and over the nose to facility management as soon as the injury was observed for 1 of 1 residents (Resident #1) reviewed for injuries of unknown source. Findings included. The facility policy dated 11/28/18 included an action checklist for injuries of unknown source. The checklist included in part to notify the Administrator and/or the Director of Nursing immediately of an incident. Resident #1 was admitted to the facility on [DATE] with diagnoses including in part cerebral vascular accident (CVA), quadriplegia, and dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. She required total dependent care with activities of daily living. An Investigation Report dated 04/08/24 revealed that on 04/06/24 Resident #1 presented with swelling and bruising of her nose and under her eyes. A full investigation was conducted on 04/08/24 and it was not determined how the resident sustained the injury. The investigation revealed at approximately 11:00 PM on 04/06/24 Nurse Aide #1 reported swelling on the bridge of Resident #1's nose. Nurse #2 was notified. Nurse #2 instructed Nurse Aide #1 to apply an ice pack to her face. Nurse #2 indicated she administered Tylenol. Nurse Aide #1 stated Resident #1's nose continued to swell and appeared bruised. An x-ray report dated 04/08/24 for Resident #1 revealed a minimally displaced fracture of the nasal bridge. During a phone interview on 04/26/24 at 5:20 PM Nurse #2 stated she came on shift at 11:00 PM on 04/06/24 and was the assigned nurse for Resident #1. She stated Nurse Aide #1 asked her to go down and look at Resident #1. She went down at that time and observed bruising and swelling underneath her left eye. She stated Resident #1 was not able to verbalize what caused the injury. She stated she did not receive any report from Nurse #1 regarding an injury. She reported that Resident #1 received anticoagulant medication, so she wasn't alarmed because the bruising and swelling was a small area. She asked Resident #1 if her face bothered her and she said yes. She reported she administered Tylenol 650 milligrams once at that time and applied an ice pack. Nurse #2 stated although her eye was bruised and swollen it did not look like a serious injury. She asked Nurse Aide #1 what happened, and she could not provide an answer. She stated she didn't think about doing anything else that night to address the unexplained injury. She stated when Nurse #1 came in the next day, she mentioned it to her, but Nurse #1 didn't go into any details of what could have happened to cause the injury. She stated she did not notify the Administrator or the Director of Nursing regarding the injury of unknown source. She stated it was a small bruise with no open areas, and no bleeding or other signs of trauma, so she didn't think it was necessary. She stated she decided she would let the day shift nurse notify the doctor. She stated since the incident she had received in service training on reporting injuries of unknown source. During an interview on 04/26/24 at 12:45 PM Nurse #1 stated she was Resident #1's assigned nurse on Saturday 04/06/24 from 7:00 AM through 11:00 PM. She stated when she left her shift on 04/06/24 at 11:00 PM there was no bruising, swelling, or injury. She stated she returned to work the next morning and Medication Aide #1 reported to her that Nurse Aide #1 reported that Resident #1 had a black and bruised eye. Nurse #1 stated Nurse #2 who was on duty during the night shift, did not report anything to her regarding the injury. Nurse #1 stated she assessed Resident #1 just after 7:00 AM and noted that her left eye was bruised and red. She reported she reviewed her electronic medical record and there was no documentation as to what happened. She stated she called and informed the Director of Nursing (DON) about the unexplained injury sometime that day on 04/07/24 but thought it was before 5:00 PM and the DON stated she would take care of it. She stated she was busy that day and that was why the DON was not notified sooner. Nurse #1 stated since the incident she had received training on reporting a change in condition. She stated she should have completed an incident report when she observed the facial bruising and swelling on the morning of 04/07/24 and notified the DON right away since she was uncertain if the night shift nurse had reported it. During an interview on 04/26/24 at 3:50 PM the Director of Nursing (DON) stated she was not made aware until Monday 04/08/24 of the injury of unknown source. She reported she found out about Resident #1's injury on Monday morning from either a nurse or nurse aide but could not recall exactly. She went to assess Resident #1's nose and she had bilateral bruising under her eyes and across the bridge of her nose. She started an investigation at that time. She stated the Physician was notified on 04/08/24 and ordered an x-ray which resulted in a nasal fracture. The DON stated Nurse #2 who initially observed the bruising and swelling should have notified her right away. She stated Nurse #2 should have followed the facility protocol for injuries of unknown source which included to notify the Administrator or the DON immediately and that was not done. During an interview on 04/26/24 at 6:00 PM the Administrator stated she was notified of the injury late in the day on 04/08/24. She indicated Nurse #2 should have reported the injury of unknow source to her or the Director of Nursing (DON) on the night of 04/06/24. She stated education was provided to all nursing staff regarding notifying facility management of injuries of unknown source. She stated education was provided to nursing staff on reporting injuries of unknown source immediately and the protocol on what to do when an injury was identified. She stated a full investigation was completed and it was never determined how the injury occurred. She stated an ad hoc Quality Assurance (QA) meeting was held on 04/09/24 and the decision was made by the Quality Assurance (QA) Committee to initiate a Performance Improvement Plan regarding this occurrence. She reported the Plan of Correction was initiated on 04/08/24 which included reporting injuries of unknown source. The Plan of Correction included. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 04/08/24 Resident #1 was assessed by the Director of Nursing. Resident #1 was noted to have bilateral bruising under her eyes and across the bridge of her nose. On 04/08/24 the physician was notified, an x-ray was ordered which resulted in a minimally displaced fracture of the nasal bridge. The Responsible Party was notified. On 04/08/24 through 04/09/24 interviews were conducted with all alert and oriented residents regarding resident abuse and how to report abuse and neglect, and injuries of unknown source. There were no concerns identified. On 04/08/24 through 04/09/24 grievance logs were reviewed for the past 30 days to ensure all allegations were reported timely. There were no concerns identified. On 04/08/24 through 04/09/24progress notes were reviewed for the last 7 days to ensure documented acute change in condition to include injuries of unknown source were assessed and reported timely to the physician, DON, and Responsible Party. There were no concerns identified. On 04/08/24 the Administrator, and the Director of Nursing were educated by the Clinical Director regarding reportable events including injuries of unknown source or events that were suspicious of a crime and it must be reported to the State Agency within 2 hours. On 04/09/24 through 04/10/24 education was conducted with all nursing staff regarding the facility's abuse and neglect policy, reporting changes in condition including injuries of unknown source. On 04/09/24 Resident #1 was evaluated by the Physician. There was no new treatment implemented. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 04/08/24 the DON and Staff Facilitator performed skin assessments on cognitively impaired residents to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. On 04/08/24 the DON and Staff Facilitator initiated questionnaires of all alert and oriented residents regarding new/worsening pain, injuries not reported to the nurse, and signs/symptoms of a fracture. The questionnaire was to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, and the Responsible Party had been notified with documentation in the electronic medical record. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 04/09/24 the DON and Staff Facilitator initiated education with all nursing staff regarding notification of an acute change with emphasis on assessing a change to include new/worsening pain, signs of a fracture, obtaining vital signs, initiating interventions for an acute change, notification of the physician for further recommendations, and notifying the responsible party to include documentation in the medical record. Education was provided on signs/symptoms of a fracture to include bruising and swelling. Completing neurological checks per the standing order for all known or suspected head injuries or unwitnessed fall. Education was completed by 04/10/24 . After 04/10/24 any staff who had not completed their education would be required to do so prior to the next shift. Newly hired staff would be educated during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The unit managers will review progress notes 5 times per week for 4 weeks utilizing the acute change auditing tool. The unit manager will address any concerns identified. The Social Worker will complete 5 resident questionaries weekly for 4 weeks to identify any concerns. The unit managers will address any concerns identified. The Administrator and DON will review the audits weekly for 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools/questionaries to the QAPI committee for 1 month to review and to determine trends or issues, or the need for continued monitoring. A QAPI (Quality Assurance Performance Improvement ) meeting was held again on 04/16/24 with the Interdisciplinary team where the plan of correction was discussed. The facility alleged compliance with the corrective action plan on 04/12/24. Validation of the corrective action was completed on 04/26/24. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. The initial audits were verified. There were no concerns identified.

Based on observations, record review, staff and Physician interviews the facility failed to notify the Physician of a residents change in condition when an injury of unknown source was identified. The resident was observed with unexplained bruising and swelling under the eye and x-rays confirmed a fracture of the bridge of the nasal bones. This occurred for 1 of 1 cognitively impaired resident (Resident #1) reviewed for an injury of unknown source and notification of the Physician. Findings included. Resident #1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severely impaired cognition. An Investigation Report dated 04/08/24 revealed that on 04/06/24 Resident #1 presented with swelling and bruising of her nose and under her eyes. A full investigation was conducted on 04/08/24 and it was not determined how the resident sustained the injury. The investigation revealed at approximately 11:00 PM on 04/06/24 Nurse Aide #1 reported swelling on the bridge of Resident #1's nose. Nurse #2 was notified. An x-ray report dated 04/08/24 for Resident #1 revealed a minimally displaced fracture of the nasal bridge. Review of Resident #1's progress notes from 04/06/24 through 04/08/24 revealed no evidence that the Physician was notified when the injury was identified. During a phone interview on 04/26/24 at 5:20 PM Nurse #2 stated she came on shift at 11:00 PM on 04/06/24 and was the assigned nurse for Resident #1. She stated Nurse Aide #1 asked her to go down and look at Resident #1. She went down at that time and observed bruising and swelling underneath her left eye. Nurse #2 stated although her eye was bruised and swollen it did not look like a serious injury. She indicated she did not notify the Physician. She stated it was a small bruise with no open areas, and no bleeding or other signs of trauma, so she didn't think it was necessary to call the Physician. She stated she decided she would let the day shift nurse notify the Physician. She stated since the incident she had received in-service training on reporting injuries of unknown source immediately to the Director of Nursing and the Physician. During an interview on 04/26/24 at 12:45 PM Nurse #1 stated she was Resident #1's assigned nurse on Saturday 04/06/24 from 7:00 AM through 11:00 PM. She stated when she left her shift on 04/06/24 at 11:00 PM there was no bruising, swelling, or injury. She stated she returned to work the next morning and Medication Aide #1 reported to her that Nurse Aide #1 reported that Resident #1 had a black and bruised eye. Nurse #1 stated Nurse #2 who was on duty during the night shift did not report anything to her regarding the injury. She indicated there was no record that the Physician was notified. She stated she called and informed the Director of Nursing (DON) about the unexplained injury sometime that day on 04/07/24 but thought it was before 5:00 PM and the DON stated she would take care of it. She indicated she did not notify the Physician of the injury. Nurse #1 stated since the incident she had received training on reporting a change in condition including notification of the Physician. During an interview on 04/26/24 at 3:50 PM the Director of Nursing (DON) stated she was not made aware until Monday 04/08/24 of the injury of unknown source. She stated the Physician wasn't notified until 04/08/24 and ordered an x-ray which resulted in a nasal fracture. The DON indicated Nurse #2 who initially observed the bruising and swelling should have notified the Physician at that time regarding a change in condition due to unexplained bruising and swelling so that treatment decisions could be initiated. She stated Nurse #2 should have followed the facility protocol for injuries of unknown source which included to notify the DON and the Physician for further orders and that was not done. During a phone interview on 04/26/24 at 4:40 PM the Physician stated he wasn't notified of the injury of unknown source until Monday 04/08/24. He stated he ordered an x-ray that showed a minimally displaced fracture to the nose. He reported he evaluated Resident #1 on Tuesday 04/09/24. He stated he should have been notified at least by the following day since the injury occurred at 11:00 PM at night. He stated there was no delay in treatment by doing the x-ray on Monday. He stated Resident #1 was evaluated by the Ear, Nose, & Throat (ENT) physician on 04/11/24 and from the outcome of that evaluation along with conversations with her Responsible Party it was decided that no treatment would be indicated for the nasal fracture. During an interview on 04/26/24 at 6:00 PM the Administrator stated she was notified of the injury late in the day on 04/08/24. She indicated Nurse #2 should have reported the injury of unknow source on the night of 04/06/24 to the Director of Nursing and to the Physician. She stated education was provided to all nursing staff regarding monitoring for an acute change in condition including injuries of unknown source and including notification of the Physician. She stated an ad hoc Quality Assurance (QA) meeting was held on 04/09/24 and the decision was made by the Quality Assurance (QA) Committee to initiate a Performance Improvement Plan regarding this occurrence. She reported the Plan of Correction was initiated on 04/08/24 which included reporting of an acute change in condition to the DON, and Physician. The Plan of Correction included: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 04/08/24 Resident #1 was assessed by the Director of Nursing. Resident #1 was noted to have bilateral bruising under her eyes and across the bridge of her nose. On 04/08/24 the physician was notified, an x-ray was ordered which resulted in a minimally displaced fracture of the nasal bridge. On 04/08/24 through 04/09/24 progress notes were reviewed for the last 7 days to ensure documented acute change in condition to include new/worsening pain, bruising, or signs of a fracture were assessed and reported timely to the physician, and the DON. There were no concerns identified. On 04/09/24 through 04/10/24 education was conducted with all nursing staff regarding the facility's abuse and neglect policy and reporting changes in condition to the DON and Physician. On 04/09/24 Resident #1 was evaluated by the Physician. There was no new treatment implemented. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 04/08/24 the DON and Staff Facilitator performed skin assessments on cognitively impaired residents to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, with documentation in the electronic medical record. There were no negative findings. On 04/08/24 the DON and Staff Facilitator initiated questionnaires of all alert and oriented residents regarding new/worsening pain, injuries not reported to the nurse, and signs/symptoms of a fracture. The questionnaire was to ensure that any concerns or change in condition had been assessed, and interventions initiated if indicated, and the physician notified for further recommendations, with documentation in the electronic medical record. There were no negative findings. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 04/09/24 the DON and Staff Facilitator initiated education with all nursing staff regarding notification of an acute change including notification of the physician for further recommendations, and to include documentation in the medical record. Education was completed by 04/10/24 . After 04/10/24 any staff who had not completed their education would be required to do so prior to the next shift. Newly hired staff would be educated during orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The decision to monitor and take to QA was 04/08/24. The unit managers will review progress notes 5 times per week for 4 weeks utilizing the acute change auditing tool. The unit manager will address any concerns identified. The Social Worker will complete 5 resident questionaries weekly for 4 weeks to identify any concerns. The unit managers will address any concerns identified. The Administrator and DON will review the audits weekly for 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or DON will present the findings of the audit tools/questionaries to the QAPI committee for 1 month to review and to determine trends or issues, or the need for continued monitoring. A QAPI (Quality Assurance Performance Improvement ) meeting was held again on 04/16/24 with the Interdisciplinary team where the plan of correction was discussed. The facility alleged compliance with the corrective action plan on 04/12/24. Validation of the corrective action was completed on 04/26/24. This included staff interviews regarding the incident, and in-service training that was received to ensure understanding and knowledge of the training provided. The initial audits were verified. There were no concerns identified. The corrective action plan was validated to be completed as of 04/12/24.

Based on observation, staff interviews and review of the daily nursing staff postings, the facility failed to post accurate census numbers for 35 of 35 days. Findings included: During the entrance conference with the Administrator and Director of Nursing on 1/2/24 at 9:44 AM, the Administrator reported the resident census for 1/2/24 was 107, which included 98 certified beds and 9 licensed only beds. During a tour of the facility on 1/2/24 at 2:25 PM, the daily nursing staff posting was observed in the front lobby on the windowsill of the reception desk. The posting stated the census was 107. The daily nursing staff postings were reviewed for 12/1/23-1/4/24. On 1/5/24 at 9:14 AM, the Administrator provided additional information to the postings that revealed the certified bed census as follows: 12/1/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 100. 12/2/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 102. 12/3/23- Certified bed census was 94. The daily nursing staff posting indicated the census was 102. 12/4/23- Certified bed census was 95. The daily nursing staff posting indicated the census was 103. 12/5/23- Certified bed census was 95. The daily nursing staff posting indicated the census was 104. 12/6/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 103. 12/7/23- Certified bed census was 97. The daily nursing staff posting indicated the census was 103. 12/8/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 103. 12/9/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 103. 12/10/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 103. 12/11/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 103. 12/12/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 103. 12/13/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 103. 12/14/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 103. 12/15/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 108. 12/16/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 107. 12/17/23- Certified bed census was 97. The daily nursing staff posting indicated the census was 107. 12/18/23- Certified bed census was 97. The daily nursing staff posting indicated the census was 108. 12/19/23- Certified bed census was 97. The daily nursing staff posting indicated the census was 108. 12/20/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 108. 12/21/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 108. 12/22/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 108. 12/23/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 105. 12/24/23- Certified bed census was 95. The daily nursing staff posting indicated the census was 105. 12/25/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 107. 12/26/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 108. 12/27/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 105. 12/28/23- Certified bed census was 99. The daily nursing staff posting indicated the census was 105. 12/29/23- Certified bed census was 98. The daily nursing staff posting indicated the census was 108. 12/30/23- Certified bed census was 97. The daily nursing staff posting indicated the census was 108. 12/31/23- Certified bed census was 96. The daily nursing staff posting indicated the census was 108. 1/1/24- Certified bed census was 99. The daily nursing staff posting indicated the census was 108. 1/2/24- Certified bed census was 98. The daily nursing staff posting indicated the census was 107. 1/3/24- Certified bed census was 99. The daily nursing staff posting indicated the census was 107. 1/4/24- Certified bed census was 99. The daily nursing staff posting indicated the census was 107. On 1/04/24 at 1:31 PM an interview was conducted with the Scheduler. She reported she scheduled staff for the entire building, both the certified beds and the licensed beds and completed the daily nursing staff postings. The Scheduler explained when she completed the daily staff posting, she included all residents in the census number, both certified beds and licensed only beds. She shared she was unaware that the daily posting should only reflect certified beds. The Administrator was interviewed on 1/5/24 at 9:38 AM. She confirmed the Scheduler completed the daily nursing staff postings. The Administrator said she didn't know the certified beds needed to be separated from the licensed beds when the census was reported on the posting.

Based on staff interviews, interview with the Ombudsman and record review, the facility failed to provide a copy of the transfer/discharge notice to the Ombudsman for 1 of 1 resident (Resident #78) reviewed for hospitalization . Findings included: Resident #78 was admitted to the facility on [DATE]. The medical record demonstrated the resident was transferred to the hospital on 9/4/23 due to a change in condition. Resident #78 returned to the facility on [DATE]. No written notice of transfer was documented to have been provided to the Ombudsman. On 1/4/24 at 2:05 PM, an interview was completed with the Social Worker. She explained she typically sent electronic mail (e-mail) to the Ombudsman quarterly with a list of residents who transferred or discharged from the facility for the prior three months. The Social Worker reviewed her e-mail history and shared she was unsure if she sent the Ombudsman the list of residents who transferred or discharged from the facility in September 2023. She added she had not sent an e-mail to the Ombudsman in a while. During an interview with the Administrator on 1/5/24 at 9:47 AM, she stated the Social Worker was responsible for notifying the Ombudsman of residents who transferred/discharged from the facility. The Administrator was not sure if the Social Worker e-mailed the information to the Ombudsman weekly or every other week. She added she didn't typically follow up with the Social Worker but assumed she e-mailed the list of transfers/discharges to the Ombudsman. A follow up interview with the Social Worker on 1/5/24 at 11:18 AM revealed it had been at least six months since she last sent an e-mail to the Ombudsman notifying her of residents who had transferred/discharged from the facility. A telephone interview was conducted with the Ombudsman on 1/8/24 at 8:38 AM. She reported the facility had not notified her of transfers/discharges since July 2023.

Based on observations, resident interviews and staff interviews, the facility failed to inform residents (Resident #11, Resident #6 and Resident #22) of the location of the state inspection results and failed to display state inspection results in a location accessible to residents for 3 of 14 residents present in a Resident Council meeting. The findings included: On 1/3/24 at 11:48 am the survey inspection results binder for the facility was observed in a holder across from the 500/600 hall nurse's station, approximately fifty inches from the floor with a sign above which said survey inspection results. The survey inspection binder was chained to the wall with a chain approximately 2 feet long. On 1/4/24 at 11:40 am during a Resident Council meeting, Resident #11, Resident #6, and Resident #22 stated state inspection results were not made available for residents to read and they did not know the location of the state inspection results. During observation conducted with Resident #22 on 1/4/24 at 1:34 PM he pulled the survey book out of the holder. Due to the chain attached to the book he was not able to open the book or bring it down to reading level. An interview was conducted with the Administrator, Corporate Nurse Consultant, and Director of Nursing on 1/4/24 at 1:40 PM. The Administrator stated she was unaware the survey inspection results binder should be accessible to residents without assistance. The DON measured the distance from the floor to the top of the holder and it measured 52 inches. The Administrator reported she would have the survey book moved to a lower position so it would be within reach of wheelchair bound residents and remove the chain. The Administrator stated the residents would be educated on the location of the survey inspection results.

Based on observations, record review, and staff and physician interviews, the facility failed to secure a resident in a mechanical lift for 1 of 3 sampled residents (Resident #3) reviewed for supervision to prevent accidents during transfers. The resident fell from the total mechanical lift, hit her head on the floor and sustained a hemorrhage contusion to the right frontal lobe of the brain. Findings included: Resident #3 was most recently re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] specified the resident was severely cognitively impaired, had no behaviors noted, and required total assistance for bed mobility and transfers. The MDS also revealed the resident had not had any falls since the prior assessment on 8/7/17. Resident #3's Care Plan (revised 12/1/17) stated the resident was to be transferred with a total mechanical lift, using a medium sling. Review of the clinical record revealed a Progress Note by Nurse #1 which included that at approximately 11 AM on 1/27/18, Heard a scream and a loud noise from (Resident #3's room). Entered room and saw resident under the (total mechanical) lift with body across the (lift's) legs and head on the floor. The note went on to say the resident was not moved and that the Emergency Medical System (911) was called and the resident was transferred to Hospital #1. The note also indicated the Physician Assistant and Resident Representative were notified. Review of the Emergency Department (ED) Physician Evaluation from Hospital #1 revealed a Computed Tomography (CT) scan was negative for injury. The ED Physician's finding specified there was no evidence of [MEDICATION NAME], subarachnoid or subdural hemorrhage and no evidence of skull fracture. The resident's vital signs revealed a pulse of 82, respirations were 16 and blood pressure was 179/95. The ED Physician's note indicated the physician had spoken with the Resident Representative and explained symptoms to watch for and that follow-up should be with the physician at the facility. The note also indicated the elevated blood pressure could have been elevated as a result of the pain from the fall and that there was no sign of a hypertensive emergency. Another note from Nurse #1 on 1/27/18 indicated the resident returned to the facility at approximately 4:15 PM and neurological checks were started. Her vital signs included a blood pressure of 167/100 and the note indicated Resident #3 had a dark bruise surrounding the right eye. The Progress Note on 1/27/18 at 9:30 PM, was by Nurse #2 and indicated the Resident Representative was in to visit with Resident #3. During the visit, the resident's blood pressure was 142/100. The Resident Representative became concerned about the elevated blood pressure and requested the resident be sent to Hospital #2. A call was placed to the physician and the resident was transferred out of the facility to Hospital #2 at 10:30 PM on 1/27/18. Review of ED Physician's documentation from Hospital #2 revealed that a CT scan showed a small right intraparenchymal bleed (bleeding into the brain tissue itself). It also specified that a Neurosurgeon was consulted, intervention was not deemed necessary and the resident was appropriate to return to the nursing home where she lived. A Progress Note on 1/28/18 at 6:33 PM by Nurse #1, revealed Resident #3 had returned to the facility at 2:30 PM. Nurse #1 specified in the note that neuro checks were within normal limits and that the resident indicated she was glad to be back. On 2/1/18 the facility provided documentation that an investigation of the incident was initiated on 1/27/18. It was determined the root cause of the fall was failure of Nursing Assistant (NA) #1 to inspect the mechanical lift before initiating the Resident #3's transfer and failure to assess for the appropriate lift pad size according to the manufacturers recommendations for Resident #3's weight. The facility investigation included, NA #1 placed a yellow lift pad size medium per the resident care guide under (Resident #3). NA #1 hooked the top straps of the (full mechanical lift) sling to the right side of the lift sling bar, then applied the top strap to the left side of lift sling bar. NA #1 crisscrossed the bottom strap of the (full mechanical lift) sling and pulled up the left strap and hooked it to the right side bar. Then NA#1 pulled up the right strap and hooked it to the left side of the sling bar. NA #1 did not inspect lift prior to initiating transfer. NA #1 next raised the lift using the manual control and pulled resident off the edge of the bed. NA #2 was positioned between the (Resident #3's specialty wheelchair) and the (full mechanical lift) with her back to (Resident #3). The lift strap on the right side of the sling bar came loose and (Resident #3) fell to the floor striking head on the floor. The investigation specified the resident was sent to Hospital #1 and that the physician, the resident representative and the Director of Nursing (DON) were notified about the fall. The lift was removed from service immediately. The Administrator and DON began an investigation within 30 minutes of the fall. They obtained statements from staff and NAs #1 and 2 were suspended from work. The Investigation indicated the resident returned from Hospital #1 at 4:15 PM, an assessment was completed and neuro checks were initiated per facility protocol. At 9:30 PM the same day, the Resident Representative requested a second evaluation at Hospital #2 due to Resident#3's elevated blood pressure. The resident's physician was contacted, gave an order for [REDACTED]. Both hospital reports were attached to the investigation. The investigation specified the resident returned from Hospital #2 the next day (1/28/18) at 2:28 PM and neuro checks were resumed per protocol. The investigation also included evidence that on March 23, 2017 NA #1 was observed with return demonstration for use of the full mechanical lift utilizing the annual nurse assistant skills checklist by the staff facilitator and on March 17, 2017, NA #2 had been observed with return demonstration for use of the full mechanical lift utilizing the annual nurse assistant skills checklist by the staff facilitator. An interview was conducted with NA #2 on 2/1/18 at 1:44 PM. As she had written in her statement, NA #2 said she had not participated in putting the resident onto the sling or hooking the sling straps to the mechanical lift, but instead was positioning the resident's chair to receive the resident from the lift transfer. NA #2 said, I turned around with the chair and saw the clip pop out and the straps came off of the bar. I tried to get to her but the chair was in front of me. When asked how the straps had popped off the sling bar, NA #2 said I have no idea. It has never happened to me. NA #2 stated the resident slid out of the pad and her head hit the floor. The NA specified that she stayed with the resident until she was transferred to the hospital and then gave a written statement to the DON and has been suspended from work since the incident. An interview was conducted with NA #1 on 2/1/18 at 2:56 PM. As she had written in her statement, NA #1 said she had checked Resident #3's care guide in the closet which indicated the full mechanical lift and medium sling were to be used for transfers. I went to get her up, put the pad under her and hooked up the straps. When I was lifting her off the bed, (NA #2) was getting the chair. When I was pushing her toward the chair the straps came off (the sling bar) and she fell . When asked how the straps had come off the sling bar hook, NA #1 said, I don't know. It happened so fast. When I saw her falling I tried to reach and catch her but the right side gave out and she fell away to the side. The nurse was coming down the hall and I had screamed and she came in and said 'don't move her' and she called 911. NA #1 stated she was suspended after she gave her written statement. When asked what she might do differently next time NA #1 said, Double check everything. Make sure the lift is in working order and straps are where they are supposed to be. The full mechanical lift used to transfer Resident #3 was observed on 2/1/18 at 5:55 PM. The sling bar had a hook on each end that was approximately 2 inches deep to hold the sling straps. Each hook also had a clip to help prevent the sling strap from sliding up/off the sling bar. The sling bar clip on the right side of the sling bar was dislodged from it's position. Resident #3's Physician was interviewed by phone on 2/2/18 at 8:30 AM. The Physician stated she had been made aware of Resident #3's fall and that the resident had been sent out to the two different hospitals on 1/27/18 with the resulting [DIAGNOSES REDACTED]. Nurse #1 was interviewed on 2/2/18 at 9:31 AM regarding Resident #3's fall on 1/27/18. Nurse #1 said she had been at the computer near Resident #3's room when she heard a scream. Nurse #1 went immediately to the room and saw the resident on the floor. When asked how far the resident was from the bed, Nurse #1 said They had not gotten far from the bed from what I could determine. Her head was on the floor and turned to the right, her back was across one of the lift legs and her legs were across the other lift leg. Nurse #1 went on to say, I said don't move her. She was breathing and looking around and I wanted 911 fast so I went across the hall, called 911 to tell them we had a resident fall from the lift. Nurse #1 returned to the room to further assess the resident, and asked what happened. A pillow was placed under the resident's head. I sent (NA #1 out to get equipment for vital signs but by the time she got back 911 was here. Nurse #1 indicated that after the resident left for Hospital #1, the physician's office was notified, the family was called and she called the DON. Both the DON and the Administrator came in and started an investigation. Nurse #1 said both she and the DON assessed the resident when she returned from Hospital #1 about 4:15 PM. Neurological checks were started at that time. The Maintenance Director was interviewed on 2/2/18 at 11:04 AM about the condition of the lifts. He stated, We check them weekly but also when I walk by in the halls I am always looking at them. The Maintenance Director said the full mechanical lift in question had been checked the morning of 1/27/18 and it was in good working condition. He said that after Resident #3's fall, I found the sling bar clip was askew on the right hand side. but he couldn't say when the clip had become dislodged from its proper position. He further explained that the sling bar clips were intended to keep the sling straps in place on the lift sling bar. The Maintenance Director indicated the full mechanical lift used for Resident #3 remained out of service. Nurse #2, who worked the evening shift on 1/27/18, was interviewed by phone on 2/2/18 at 11:39 AM. Nurse #2 said, I came on at 7:00 PM that Saturday. I did an assessment then, and did neuro checks through the evening. She stated the family came in around 9:30 PM and were concerned about Resident #3's blood pressure being high at the hospital and that it continued to be a little higher than usual. They wanted her sent out for a second evaluation and specified Hospital #2. The Administrator and Director of Nursing were interviewed on 2/2/18 at 4:32 PM. They stated they had done an investigation, initiated audits and in-services for nursing staff and put a Plan of Correction (P(NAME)) in place that began on 1/27/18. The DON explained that they had determined that in addition to the sling straps that had come off the sling bar, the large lift sling should have been used for Resident #3's transfer on 1/27/18. Resident #3 was 2 pounds over the manufacture recommended weight for the medium sling. They had addressed this by auditing and listing the residents who required a mechanical lift for transfers and reviewed all the Care Plans and Care Guides to ensure staff were using correct the slings. The DON added that if a resident's weight changed, the MDS Coordinator was made aware in the weekly Weight Committee meetings, so she would update the Care Plan and put out a new Care Guide in the resident's room. The Quality Assurance Nurse also received a list of weights as they were completed and she was to contact the MDS nurses with changes. The Administrator stated she and the DON had begun audits and inservices within hours of Resident #3's fall. She stated the Corporate Consultants came in and helped inservice on Sunday, 1/28/18 and Monday, 1/29/18. When asked how the sling strap had come off the sling bar in Resident #3's fall, neither the DON nor the Administrator could explain how it might have happened. The DON added that she would expect her residents to be safe during a transfers. The Administrator said, I would expect the staff to follow the manufacture instructions for transfers. CORRECTIVE ACTION On 1/29/2018 the DON ordered new safety latch composite clips to replace safety latch universal sling bar clips for 3 of 4 (full mechanical lifts). The composite clips will provide an extra safety feature and a friction clip that will not allow the harness to come out of hook on slide bar. 100% Audit of all (sit-to-stand and full mechanical lifts) to include Viking lift #1 was completed by the Maintenance Supervisor on 1/27/18 to assure that all lifts are working properly; sling bar will lift and lower, sling bar is secure, sling bar clips are in place, manual emergency lowering works, lift wheels roll without problems, remote works properly, and battery charged. There was a total of 4 (full mechanical lifts)and 2 (sit-to-stand mechanical lifts) inspected. 100% audit of all (full mechanical and sit-to-stand lifts) slings were completed on 1/29/18 by the DON to assure that all lift pads were free of tears, fraying or damage from excessive wear. Any lift pad with noted tears, fraying or damage were immediately removed and discarded by the DON. No areas of concern were noted. 100% audit of all residents to include resident #1 was completed by the Nurse Managers on 1/29/18 to assure any resident who utilize mechanical lifts for transfers are care planned and have updated care guide for the appropriate lift sling size based on resident current weight. Any issues will be immediately corrected by the Quality Improvement (QI) nurse and care plan/care guides updated. There were no other issues noted. Care plan and care guide of resident #1 was updated by the Minimum Data Set (MDS) nurse for Viking lift size large on 1/29/18 and care guide place in room. 100% re-training was initiated by the DON on 1/27/18 with all licensed nurses and NAs on the proper procedure for using Sabina and Viking mechanical lifts with return demonstration utilizing the (full mechanical and sit-to-stand lifts) Skills Checklist to include: 1. Checking the resident care guide and using correct size and type of sling for the resident and specified lift. 2. Visually inspect lift for external damage or excessive wear. 3. Checking that the lift pad is not torn, frayed or damaged from excessive wear. 4. Inspect lift to make sure that it is working properly: sling bar will lift and lower, sling bar is secure, sling bar clips are in place, manual emergency lowering works, lift wheels roll without problems, remote works properly, battery charged. Remember that wheel locks are unlocked during routine lifts. 5. If any areas of concern are noted during lift inspection, remove lift immediately from care area. Tag lift to indicate out of order, complete a work order and report any broken area to the Administrator, DON, or Maintenance Supervisor immediately. 6. Before using lift always check the clips on the sling bar to ensure they are attached according to manufacture instructions. Staff will visually inspect the clips on the lift bar, to ensure the clips are properly secured in the hole of the sling bar, and not completely out on one or both ends of the sling bar. 7. Checking that lift pads are properly positioned on resident: leg straps secure and crisscross on Viking lift, head straps always go on sling bar first. 8. Making sure that before the resident is clear of the lifting surface, that sling loops are fastened according to manufacture instructions once the straps are fully extended. No licensed nurse or NA will be allowed to work until training with return demonstration is completed. All newly hired licensed nurses and NAs will be trained by the Staff Facilitator during orientation on the proper procedure for using all mechanical lifts with return demonstration utilizing the (full mechanical and sit-to-stand lifts) Skills Checklist to include: 1. Checking the resident care guide and using correct size and type of sling for the resident and specified lift. 2. Visually inspect lift for external damage or excessive wear. 3. Checking that the lift pad is not torn, frayed or damaged from excessive wear. 4. Inspect lift to make sure that it is working properly: sling bar will lift and lower, sling bar is secure, sling bar clips are in place, manual emergency lowering works, lift wheels roll without problems, remote works properly, battery charged. Remember that wheel locks are unlocked during routine lifts per manufacture instructions. 5. If any areas of concern are noted during lift inspection, remove lift immediately from care area. Tag lift to indicate out of order, complete a work order and report any broken area to the Administrator, DON, or Maintenance Supervisor immediately. 6. Before using lift always check the clips on the sling bar to ensure they are attached per manufacture instructions. 7. Checking that lift pads are properly positioned on resident: leg straps secure and crisscross on Viking lift, head straps always go on sling bar first. 8. Making sure that before the resident is clear of the lifting surface, that sling loops are fastened per manufacture instructions once the straps are fully extended. An in-service was completed by the Facility Nurse Consultant with the DON, QI Nurse, MDS Coordinator and MDS nurse on 1/29/18 on updating care plan/care guides with weight changes to include: 1. QI nurse will review all weights obtained. Any change in weight must be checked against (full mechanical and sit-to-stand lifts) pad sizing chart to assure resident is using correct lift size for new recorded weight. 2. QI nurse will notify MDS nurse with any weight change requiring re-evaluation/change in lift pad size. 3. MDS/QI nurse will update care plan/care guide with new lift pad size and place new care guide in resident room 100% staff questionnaires were initiated and completed by the DON on 1/28/18 with all licensed nurses and NAs on lift transfers to include: 1. Have you had a lift that did not work properly (per manufacture instructions) during the last 2 weeks? 2. If so, who did you report it too? 3. What kind of issues did you report? No staff will be allowed to work until lift questionnaire is completed. Administrator/DON will review and initialed all lift transfer questionnaires, any areas of concern were immediately addressed by the DON. The Maintenance Supervisor will inspect all (full mechanical and sit-to-stand lifts) to include (full mechanical lift) #1 3 x week for 4 weeks, 2 x a week for 4 weeks then weekly x 1 month and document findings utilizing the Lift Inspection Tool to ensure lift is working properly; sling bar will lift and lower, cling bar is secure, sling bar clips are in place, manual emergency lowering works, lift wheels roll without problems, remote works per manufacture instructions, and battery is charged. The Administrator will initial Lift Inspection Tool weekly x 8 months then monthly x 1 month. The Nurse Managers will audit 10% of all residents needing (full mechanical and sit-to-stand lifts) for transfers to include resident #1 utilizing the Lift Transfer Audit Tool to ensure proper placement, functionality and staff technique to include (1) checking care guide for appropriate lift and lift pad size and (2) inspection of lift before initiating transfer 3x a week for four weeks, then weekly for x 4 weeks, then monthly x 1 month. Any areas of concern will be immediately addressed by the DON and staff will be re-trained on lift transfers utilizing the Skills Checklist for Lift Transfers. The Administrator/DON will review and initial all Lift Transfer Audit Tools weekly x 8 weeks then monthly x 1 month. 10 % of all licensed nurses and NA staff will complete a staff Lift Transfer Questionnaire to ensure lifts are working per manufacture instructions and any areas of concern are reported immediately to the Maintenance Supervisor, DON or Administrator 3 x a week for 4 weeks, weekly X 4 weeks and monthly X 1 month. The Administrator/DON will review and sign the lift transfer questionnaires for completion weekly x 8 weeks then monthly x 1 month to ensure that any areas of concern are addressed appropriately. The Patient Care Coordinator will review all weights obtained to ensure any resident requiring use of mechanical lift for transfer with a weight change has been reassessed for the appropriate lift pad size based on weight and that the care plan/care guide has been updated utilizing the Weight/Lift Pad Audit Tool 5 x a week for 4 weeks, weekly x 4 weeks, then monthly x 1 month. The DON will review and initial the Weight/Lift Pad Audit Tool weekly x 8 weeks then monthly x 1 month. On 1/30/18 the Administrator (via phone), Director of Nursing, and facility Medical Director had an impromptu Quality Improvement Executive Committee Meeting to specifically review the facility four point plan related to the in-services, completed audits, the Lift Transfer Audit Tool, Lift Inspection Tool and the Weight/Lift Pad Audit Tool with transfers. The Administrator will forward the results of the Lift Transfer Questionnaires, Lift Transfer Audit Tool, Lift Inspection Tool, the Weight/Lift Pad Audit Tool and the Acute Change Audit Tool to the Executive QI Committee monthly x 3 months. The Executive QI Committee will meet monthly x 3 months and review the Lift Transfer Questionnaires, Lift Transfer Audit Tool, Lift Inspection Tool and the Weight/Lift Pad Audit Tool to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring. Final date of compliance 1/29/2018. The Administrator and Director of Nursing will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the credible allegation of compliance for prevention of accidents. As part of the validation process on 2/1/18 through 2/2/18, the plan of correction was reviewed including the re-education of staff and observations of interventions put into place to ensure correct use of the slings and lift status. Resident #3 was not in the facility at the time of the investigation. Observations were made of other residents who required mechanical lifts and the transfers were all conducted according to Manufacturer's instructions. Interviews with licensed staff and nursing assistants revealed they were retrained to inspect the lifts before each transfer and to select the correct lift sling. A review of the monitoring tools revealed that the facility completed the audits of resident weights, who required mechanical lift transfers, which lifts were to be used, and sling sizes were noted for each resident. The facility alleges full compliance with this plan of correction effective 1/29/18.

Based on observation, record review, family, staff and law enforcement interviews the facility failed to protect one of three sampled residents (Resident #1) from being physically abused by a staff member who applied baby oil to Resident #1 ' s feet with intent for Resident #1 to fall and placed a pillow on Resident #1 ' s face and attempted to force Resident #1 to remain in place by grabbing his arm while he called out for help. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. Resident #1 required limited assistance with the assistance of one staff member with bed mobility and transfers, extensive assist with the assistance of one staff member with toileting, hygiene, and dressing, and supervision with set up only with ambulating in the room. He had no impairments and used a walker. Resident #1 was frequently incontinent of bowel and bladder. Resident #1 was coded as having one fall with no injury and one fall with injury during this look back period. Resident #1 was not coded as having any behaviors or resistance to care. A review of Resident #1 ' s care plan revealed a plan of care updated on 9/1/17 for a problematic manner in which resident had inappropriate behavior; including urinating in inappropriate places. Interventions included to document episodes of urinating in inappropriate places and monitor resident ' s room daily including trash can. A plan of care dated 9/1/17 was in place for at risk for falls characterized by history of falls/actual falls, injury, and multiple risk factors related to the disease process including Alzheimer ' s disease, hearing deficit, impaired cognition, impaired mobility, unsteady gait and wandering. Interventions included fall risk protocol, commonly used articles within easy reach, assistive ambulation device within reach, personal bed alarm, wearing proper and non-slip footwear. The fall care plan was updated on 11/26/17 to include anti-slip strips on the floor at bedside and padded bed rails. A record review of the daily shift assignment for Saturday, 11/25/17, for the 3-11 shift and 11-7 shift revealed NA (Nursing Assistant) #1 was assigned to Resident #1. NA #2 was assigned on 11/25/17 for the 3-11 shift only and worked on a different hall. An interview was conducted with the Responsible Party (RP #1) of Resident #1 on 12/10/17 at 2:51 pm via phone. RP #1 revealed she was out of town the weekend of 11/25/17. RP #1 stated she was informed by another family member of Resident #1 that a female person in the community who was a family member (FM #1) of NA #2 and NA #3 sent a video to RP #1 of Resident #1 being abused by NA #1 and was informed NA #2 videotaped the incident. RP #1 reported the video showed NA #1 was putting a pillow over Resident #1 ' s face, she had her hand around his throat, and her knee was in between the resident ' s legs and she was unbuckling his pants. RP #1 reported she saw this video on 11/26/17 and called 911. RP #1 stated she spoke with Detective #1 at the local County Sherriff ' s Department and shared the video she had on her phone with Detective #1. RP #1 indicated she notified the Administrator with Detective #1 via phone. RP #1 stated Detective #1 went to the facility and interviewed NA #1, NA #2 and NA #3. RP #1 reported that NA #2 and FM #1 who shared the video with Resident #1 ' s RP, shared a cell phone and that was how the FM #1 of NA #2 and NA #3 became aware of the incident. A review of the video was conducted. The video revealed NA #1 standing in front of Resident #1 ' s bed. Resident #1 was sitting upright in the bed with his feet on the floor. Resident #1 was fully dressed and shoes were on his feet. NA #1 had one knee up on the bed between Resident #1 ' s legs. NA #1 was observed pulling Resident #1 ' s right arm as he attempted to move away from NA #1. Resident #1 was observed yelling, Help, help, somebody call the police! NA #1 was observed placing a pillow over Resident #1 ' s face. A record review of incident reports were reviewed for Resident #1. The record revealed Resident #1 had an injury of unknown origin on 11/26/17. A review of the incident report for injury of unknown origin on 11/26/17 at 6:45 am revealed Nurse #1 was called to Resident #1 ' s room. Resident #1 was observed sitting in a recliner with a skin tear noted on the right elbow and an abrasion on the right side of his face. The resident was alert, however he was unable to determine the cause of injury. The resident was checked for other injuries. Resident #1 was noted to have good range of motion and had no complaints or signs or symptoms of pain. The skin tear was cleansed with normal saline and foam dressing was applied. The abrasion to Resident #1 ' s face was cleansed. The report indicated padded side rails were placed on the bed and the physician, RP and Administrator were notified. The report indicated predisposing physiological factors included, decreased functional status, decreased safety awareness, fragile skin, cognitive status, incontinence, Alzheimer ' s disease and noncompliance. An interview was conducted with Nurse #1 on 12/12/17 at 6:00 am. Nurse #1 revealed on 11/26/17 at 6:45 am, she was called to go to Resident #1 ' s room from the on-coming nurse (Nurse #2) because she was needed. Nurse #1 stated NA #1 told her he had a skin tear. Nurse #1 stated NA #1 did not say anything about Resident #1 having a fall. Upon arrival to Resident #1 ' s room, Nurse #1 stated she noted the resident had a skin tear to his right elbow and an abrasion to the right side of his face and he was sitting on the recliner with both feet on the floor. The nurse did not remember if he had socks or shoes on his feet. The nurse reported she asked the resident what happened, but he was unable to give a clear statement due to his cognitive status. Nurse #1 stated by the time she finished the treatment on Resident #1, NA #1 had already left the facility. Nurse #1 stated she did not notice if the floor was wet or slippery. Nurse #1 stated she notified the DON, RP #1, and physician of the injury. Nurse #1 stated the staff padded the bed rails on his bed as an intervention. An interview was conducted with Detective #2 on 12/11/17 at 3:49 pm. Detective #2 stated Detective #1 did the initial interview with NA #1 and NA #2 on 11/26/17. Detective #2 stated on 11/26/17 when Detective #1 interviewed NA #2, she denied she took the video of NA #1. Detective #2 stated during her interview with NA #2, she admitted she took the video of NA #1 and also stated NA #1 told her she put baby oil on Resident #1 ' s feet so he would not get up, and if he did, he would fall. Detective #2 stated during an interview with FM #1 she stated that FM #1 and NA #2 shared a phone and while she was at church services on 11/26/17, she saw the video of the abuse on the shared cell phone. FM #1 stated she sent the video to RP #1. FM #1 also reported to Detective #2 during this interview that NA #2 stated NA #1 said she puts baby oil on Resident #1 ' s feet and she messed up one night because he fell . FM #1 stated she spoke with NA #4 and NA #4 stated that NA #1 only put baby oil on the resident ' s feet once. Detective #2 stated she interviewed NA #1 on 11/27/17. Detective #2 stated NA #1 stated she never hit Resident #1 or put her hands on him. She stated Resident #1 got up a lot at night and would fall. NA #1 confirmed NA #1 put baby oil on his feet but stated he did not have a fall as a result of this. NA #1 stated she put baby oil on his feet the night of 11/26/17. NA #1 admitted to putting baby oil on the residents ' feet to cause him to fall, but she had nothing to say about the video recording of her hitting the resident and putting a pillow over his face. NA #1 stated she did not think putting baby oil on the resident ' s feet was considered abuse and confirmed that he did actually fall from the baby oil. NA #1 was charged with felony of patient abuse and neglect as well as misdemeanor assault on a handicapped person. An interview was conducted with Detective #1 on 12/13/17 at 1:11 pm. Detective #1 reported he responded to a 911 call by Resident #1 ' s FM on 11/26/17. Detective #1 reported he arrived to their home and was informed about concerns the FM had regarding falls and abuse at the facility. Detective #1 stated while he was at the FM ' s home a video was presented without sound of NA #1 pushing and shoving Resident #1 and putting a pillow over his face. Detective #1 stated he notified the facility and made the Administrator aware. Detective #1 stated when he arrived at the facility, he interviewed NA #1. Detective #1 stated NA #1 admitted she was aware of the video and said it look bad, like she was being aggressive. NA #1 stated her and the resident were just joking around. NA #1 said she was getting the resident ready for bed and he was not complying so she put the pillow on his head and pushed him back just joking around. Detective #1 stated NA #1 reported one time she put baby oil on her finger and ran it on the bottom of his foot so he would not be able to get out of bed because she did not like to have falls on her assigned floor. NA #1 stated she told NA #4 and NA #4 stated you can ' t do that and after that night she did not do it anymore. During the interview with Detective #1, he reported while interviewing NA #1, the family of Resident #1 arrived to the facility. Detective #1 stated he informed the family NA #1 had been terminated. At this time, Detective #1 was shown the video of NA #1 abusing Resident #1 but this time with sound by the FM. The detective reported that during these interview questions, NA #1 spoke of the incident on 11/25 and stated she was doing rounds and getting ready to change Resident #1. When she arrived to the room, the bed alarm was going off and Resident #1 was standing in the corner of the room, urinating. NA #1 stated she advised Resident #1 to get back in bed, he turned and walked toward her. NA #1 stated he was not steady and looked aggressive, she was concerned he would hurt her so she put her arms and hands out to stop him, he bumped her hands and turned back toward the chair. NA #1 stated he did not fall. NA #1 stated she left the room to go take care of another resident and when she returned he was on the floor. Detective #1 reported NA #1 then changed her story and said when she went to stop him, he turned around and fell and she got scared and she left to change someone else. When she came back he was back in bed and he was bleeding on his head. NA #1 stated she got the nurse and she treated it. A record review of an investigation report written by the Administrator on 11/26/17 was reviewed. The report stated On Sunday, 11/26/17, it was reported to the Administrator that Resident #1 was hit in the face and had a pillow put over his face by one of the staff. RP #1 reported to the local Sherriff ' s Department they had a video of a staff member at the facility mistreating Resident #1. The Administrator received a phone call from RP #1 of Resident #1 who placed Detective #1 on the phone. Detective #1 stated we have a video of Resident #1 being mistreated by one of your staff members at the facility. Detective #1 met the Administrator at the facility on 11/26/17. NA #1 was immediately removed from the hall and questioned. The Administrator and the DON interviewed NA #1 and she reported that NA #1 and Resident #1, were laughing and joking like always and Resident #1 started yelling help, help, somebody call the police. NA #1 stated she then placed the pillow on his face, not to suffocate or harm him. The police escorted NA #1 out of the facility. The investigation report indicated based on the facility investigation, it was determined abuse did occur. NA #1 was terminated. The report stated the Sherriff ' s Department had an on-going investigation to determine if any criminal charges would be filed against NA #1. An interview was conducted with the Administrator on 12/11/17 at 4:40 pm. The Administrator reported what had happened on the evening of 11/26/17 as follows: The Administrator reported on the morning of 11/26/17 when she learned of an injury of unknown origin on Resident #1 she came to the facility with the DON to assess the resident. She reported there was a laceration on his face and a skin tear to his right arm. The Administrator stated the floor was not noted to be wet or slick or slippery. The Administrator stated the first time she heard of anything having to do with baby oil on Resident #1 ' s feet was when RP #1 reported it. The Administrator reported on 11/26/17 at 7:30 pm, she arrived at the facility to meet with Detective #1 and interview NA #1 in regards to the video. Once she arrived at the facility, Detective #1 allowed her to view the video. The Administrator stated she observed NA #1 placing a pillow over Resident #1 ' s face and then grabbing Resident #1 ' s arm and pulling the resident back in the bed. The Administrator reported on 11/26/17 at 7:30 pm, she interviewed NA #1 in regards to the video showing NA #1 placing a pillow over Resident #1 ' s face and grabbing his arm and pulling him back in bed. The Administrator stated NA #1 started to deny the abuse until she told NA #1 there was a video. NA #1 stated that she and Resident #1 were joking and laughing and Resident #1 stated he yelled help, help, call the police. NA #1 stated at this time she started giggling and placed a pillow on Resident #1 ' s face not to suffocate or harm Resident #1. NA #1 stated she was not aware at the time of the incident that NA #2 had videoed the incident until after the incident had taken place. The Administrator reported NA #1 was terminated on 11/26/17 due to abuse substantiated on 11/25/17 and the local county Sherriff ' s Department had an on-going investigation to determine if any criminal charges will be filed against NA #1 for allegation of abuse. A review of a written statement from NA #1 written on 11/26/17 revealed: NA #2 took the video without my knowledge of it. I did not know until after the fact. But we, me and Resident #1 were laughing and joking like always and he started yelling help, help, somebody call the police. I started giggling and took the pillow and placed it on his face, not to suffocate or harm him. On 12/13/17 at 11:15 am attempted to interview NA #1 via phone. NA #1 was unavailable for an interview. A review of a written statement from NA #3 revealed in part: As far as the video, I have not seen the video but my mother (FM #1) told me FM #1 recorded NA #1 abuse Resident #1. Also, NA #1 told NA #3 NA #1 hated coming in Resident #1 ' s room because he got up too much and urinates on the floor, which was why NA #1 put baby oil on his feet so he can fall when he gets up. On 12/13/17 at 11:17 am attempted to interview NA #3 via phone. NA #3 was unavailable for an interview. The medication aide/NA #4 who was working on the 11-7 shift from 11/25 – 11/26/17 morning was suspended pending an investigation for Resident #1 and was unable to be interviewed. An observation of Resident #1 on 12/11/17 at 11:15 am revealed the resident was in a private room. Resident #1 was alert but not oriented. He was lying in bed. He was fully clothed with a hat on his head and well groomed. He was not noted to have any bruising to face or arms. His lower body was covered with blankets. The bed was in low position, there were 3 anti-slip strips next to his bed on the floor with a call light on his lap. There were pads noted on bilateral side rails and a wheeled seating walker was noted to be in the room near the resident ' s bed. The room was clean and free of clutter. On 12/13/17 at 3:00 pm an interview was conducted with the Administrator. The Administrator stated she had initiated in services for all staff regarding abuse and put a plan of correction in place. The corrective action for non-compliance dated 11/26/17 was as follows: 1. A thorough investigation was initiated on 11/26/17 to ascertain the root cause was failure of NA #1 to follow the abuse/neglect policy. On Sunday, 11/26/17 at 7:14 pm, it was reported to the Administrator that Resident #1 was hit in the face and had a pillow put over his face by one of the staff. The family reported to the local Sherriff ' s Department they had a video of a staff member at the facility mistreating Resident #1. The Administrator received a phone call from a FM of Resident #1 who placed Detective #1 on the phone. Detective #1 stated we have a video of Resident #1 being mistreated by one of your staff members at the facility. Detective #1 met the Administrator at the facility on 11/26/17. NA #1 was immediately removed from the hall and questioned. The Administrator and the DON interviewed NA #1 and she reported that her and Resident #1 were laughing and joking like always and Resident #1 started yelling help, help, somebody call the police. NA #1 stated she then placed the pillow on his face, not to suffocate or harm him. The police escorted NA #1 out of the facility. The investigation report indicated based on the facility investigation, it was determined abuse did occur. NA #1 was terminated. The report stated the Sherriff ' s Department had an on-going investigation to determine if any criminal charges would be filed against NA #1. The DON provided statements from staff that were working on 11/25/17 and 11/26/17, skin assessment audits of all the residents, in services and education provided to all staff regarding abuse policy and procedures, HIPPA regulations, and the use of electronic devices in the facility. The DON reported the in services and audits were put in place on 11/26/17. The DON reported the initial 24 hour report was sent indicating injury of unknown origin, however it was amended once the video was discovered of NA #1 abusing Resident #1 and was faxed to the Health Care Investigations. 2. The facility created a QI (Quality Improvement) team to direct and implement this plan of correction. The team was formed and met for the first time on 11/28/17. Team members included the Nursing Home Administrator, DON, Medical Director, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses. Additional members can be added at the discretion of the Facility Administrator as/if needed. This QI team collaborated to create the in service, the schedule for in servicing all staff, the QA tool (15 minute checks QA Monitoring Tool) for monitoring and the review Resident #1. To address this issue and to prevent future similar issues: The facility initiated a 100% skin assessments of all residents to include Resident #1 which were completed on 11/26/17 by the Staff Facilitator, Patient Care Coordinator and facility staff nurses. No other abnormalities were noted at this time. The facility created a QI team including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses on 11/26/17 to continuously review and monitor the interventions put into place specific to the plan of correction. The facility QI team including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses initiated on 11/26/17 to create an improved system of implementation and follow up on all accident and incident reports and skin assessments. The facility QI team members including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses initiated 100% in services with all staff in the facility on 11/26/17 at 9:00 pm regarding the abuse policy to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler and resident care coordinator to be completed by 11/28/17. No staff will be allowed to work until staff has been in serviced in regards to abuse. The facility initiated abuse questionnaires with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler and resident care coordinator to be completed on 11/28/17 in regards to : 1. Have you ever observed any resident abuse? If so, did you report the abuse? 2. Has anyone ever talked to you or have you ever heard of anyone talking about a resident being abused? If so, did you report the abuse? 3. Do you know the process of how to and when to report abuse? Please explain. No staff will be allowed to work until abuse questionnaire is completed. Administrator reviewed and initiated all abuse questionnaires. Any areas of concern were immediately addressed by the Administrator. No new areas of concerns identified. The facility initiated 100% of abuse quizzes with all staff in the facility at 9:00 pm on 11/26/17 by the DON and to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator to be completed by 11/28/17 in regards to: 1. Who should you report abuse to? 2. When should you report abuse? 3. Give 2 examples of abuse. 4. What is the first thing you do if you see or hear a resident being abused from a staff member, visitor or another resident? No staff would be allowed to work until abuse quizzes were completed. The DON will re-educate any employee who did not answer the quizzes at the time quiz was completed. No areas of concern identified during quizzes. The facility initiated interviews for 100% of alert and oriented residents on 11/26/17 by the Social Worker and completed on 11/27/17 in regards to: 1. Do you know what it means to be abused? 2. Are there any instances that you felt you were verbally or physically abused? 3. Do you know of any residents that have been verbally or physically abused? 4. Do you know who to report abuse to? No new allegations of abuse noted. The facility initiated 100% staff in services with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator in regards to burn out and to be completed on 11/28/17. No staff will be allowed to work until burn out in servicing completed. The facility initiated 100% staff in services with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator to be completed 11/28/17 in regards to: 1. Was care performed using correct procedure (Staff interacted in an appropriate manner? 2. If care performed incorrectly, Administrator/DON immediately notified? Interaction tool revised on 11/28/17: 1. Was care performed using correct procedure? (Staff interaction with resident in an appropriate manner (observed for any signs of abuse/neglect) 2. If care performed incorrectly, Administrator/DON immediately notified? All staff interactions completed after 11/28/17 will be completed on revised tool. Any areas of concern will be addressed during the interaction. No staff will be allowed to work until staff interactions completed. The facility initiated 100% review of incident reports to include Resident #1 for the last 30 days and was completed on 11/27/17 by the Facility Nurse Consultant for proper investigation and appropriate interventions of the incident. During the audit, it was determined that licensed nurses were not completing the incident report when an incident occurred and to include obtaining a witness statement and putting an intervention in place at time of the incident. 100% in service started with all licensed nurses by the DON/Staff Facilitator on 11/27/17 on the incident report process to include completing the incident report at the time of incident and obtain a witness statement and putting an intervention in place at the time of the incident to be completed by 11/28/17. The DON addressed all identified areas of concern. The facility initiated 100% of review of all residents to include Resident #1 ' s progress notes on 11/27/17 by the Facility Nurse Consultant to ensure that there was no other allegations of abuse noted in the progress notes without proper investigation to be completed on 11/28/17. The DON addressed all identified areas of concern. The facility initiated a Geriatric/Adult Mental health Specialty Group to come to the facility to in service staff to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator in regards to burn out and stress management. 3. 25% of all staff to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator will complete an abuse quiz weekly to ensure that staff are knowledgeable on the policy of abuse. Quizzes will occur weekly X 8 weeks and monthly X 1 month. The Administrator will review and sign the abuse quizzes for completion and that any areas of concern are addressed appropriately. 25% of all staff will be audited by the Staff Facilitator, QI Nurse, MDS Nurses and the patient care coordinator utilizing a staff interaction tool to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator weekly X 8 weeks and monthly X 1 month. The DON will review and initial all staff interaction tools to ensure completion and that any areas of concern are addressed appropriately. The Social Worker will interview 100% of alert and oriented residents utilizing a resident abuse questionnaire for resident ' s understanding of abuse and if abuse has occurred to the resident weekly X 8 weeks and monthly X 1. The Administrator will forward the results of the staff abuse questionnaires, abuse quizzes, resident abuse questionnaires, staff interaction tool and QI tool Abuse/injury of unknown origin to the Executive QI committee monthly X 3 months. The Executive QI committee will meet monthly X 3 months and review the staff abuse questionnaires, abuse quizzes, resident abuse questionnaires and the QI tool/Injury of Unknown Origin to determine trends and or issues that may need further interventions put into place and to determine the need for further and or frequency of monitoring. 4. The QI team met on 11/28/17 and have met daily since 11/28/17. They plan to meet again on 12/19/17. The purpose of these QI meetings being to gauge the plan of correction progress and to ensure ongoing compliance. The QI team will meet at least monthly for the next 12 months. The Administrator will be responsible for chairing this QI team in addition to assign new members, changes or updates to the plan of correction and the responsibility of ensuring monitoring of the abuse interventions. As part of the validation process on 12/11/17 through 12/13/17, the plan of correction was reviewed and included the in services, questionnaires and quizzes in regards to abuse, staff burn out and staff interaction for all staff members, questionnaires regarding abuse for all alert and oriented residents and the skin assessments and incident report audits for all residents. The Abuse Prohibition Review was completed. The licensed staff, nursing assistants, supervisors who interact with residents and alert and oriented residents that were interviewed were aware of to whom and how to report allegations, incidents, and or complaints. Five direct care staff representing all three shifts were interviewed to determine whether each staff member was trained in and knowledgeable about, how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions and knowledgeable regarding what, when, and to who to report according to the facility policies. A review of an ongoing log revealed Resident #1 was being observed by nursing staff every 15 minutes since 11/26/17 as well as an observation for one hour revealing Resident #1 was being observed by nursing every 15 minutes. The facility alleges full compliance with this plan of correction effective 11/28/17.

Based on record review, family, staff and law enforcement interviews the facility failed to follow the policy and procedure for reporting abuse that occurred on one of three sampled residents (Resident #1). Staff were aware of physical abuse by a staff member who applied baby oil to Resident #1 ' s feet with intent for Resident #1 to fall, placed a pillow on Resident #1 ' s face, and attempted to force Resident #1 to remain in place by grabbing his arm while he called out for help. As a result of not reporting, there was a delay in law enforcement involvement and a delay in protection of all residents. Findings included: The policy and procedure for Resident Abuse/Neglect revised on 11/21/16 stated, in part, It is every employee ' s responsibility to immediately report any incident of resident abuse or suspected resident abuse to his or her supervisor. The supervisor and/or employee must then report immediately to the Administrator. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. A record review of the daily shift assignment for Saturday, 11/25/17, for the 3-11 shift and 11-7 shift revealed NA (Nursing Assistant) #1 was assigned to Resident #1. NA #2 was assigned on 11/25/17 for the 3-11 shift only and worked on a different hall. An interview was conducted with the Responsible Party (RP #1) of Resident #1 on 12/10/17 at 2:51 pm via phone. RP #1 revealed she was out of town the weekend of 11/25/17. RP #1 stated she was informed by another family member of Resident #1 that a female person in the community who was a family member (FM #1) of NA #2 and NA #3 sent a video to RP #1 of Resident #1 being abused by NA #1 and was informed NA #2 videotaped the incident. RP #1 reported the video showed NA #1 was putting a pillow over Resident #1 ' s face, she had her hand around his throat, and her knee was in between the resident ' s legs and she was unbuckling his pants. RP #1 reported she saw this video on 11/26/17 and called 911. RP #1 stated she spoke with Detective #1 at the local County Sherriff ' s Department and shared the video she had on her phone with Detective #1. RP #1 indicated she notified the Administrator with Detective #1 via phone. RP #1 stated Detective #1 went to the facility and interviewed NA #1, NA #2 and NA #3. RP #1 reported that NA #2 and FM #1 who shared the video with Resident #1 ' s RP, shared a cell phone and that was how FM #1 of NA #2 and NA #3 became aware of the incident. An interview was conducted with the Administrator on 12/11/17 at 4:40 pm. The Administrator reported what had happened. The Administrator reported on the morning of 11/26/17 when she learned of an injury of unknown origin on Resident #1 she came to the facility with the DON to assess the resident. She reported there was a laceration on his face and a skin tear to his right arm. The Administrator stated the floor was not noted to be wet or slick or slippery. The Administrator stated the first time she heard of anything having to do with baby oil on Resident #1 ' s feet was when RP #1 reported it. The Administrator reported on 11/26/17 at 7:00 pm, RP #1 called and made the facility Administrative Assistant (AA) aware she had received a video of Resident #1 being abused. The Administrator reported on 11/26/17 at 7:16 pm, she made the Director of Nursing (DON) aware of the call received from the AA in regards to RP #1 having a video of Resident #1 being abused. The Administrator reported on 11/26/17 at 7:20 pm, RP #1 called her so she could speak to Detective #1 at the local County Sherriff ' s Department via phone. Detective #1 made the Administrator aware of a video showing NA #1 abusing Resident #1. The Administrator reported on 11/26/17 at 7:25 pm, she called the DON at the facility and made the DON aware of a video that showed NA #1 was abusing Resident #1. The DON immediately removed NA #1 from the hall. The Administrator reported on 11/26/17 at 7:30 pm, she arrived at the facility to meet with Detective #1 and interview NA #1 in regards to the video. Once she arrived at the facility, Detective #1 allowed her to view the video. The Administrator stated she observed NA #1 placing a pillow over Resident #1 ' s face and then grabbing Resident #1 ' s arm and pulling the resident back in the bed. The Administrator reported on 11/26/17 at 7:30 pm, she interviewed NA #1 in regards to the video showing NA #1 placing a pillow over Resident #1 ' s face and grabbing his arm and pulling him back in bed. The Administrator stated NA #1 started to deny the abuse until she told NA #1 there was a video. NA #1 stated that she and Resident #1 were joking and laughing and Resident #1 stated he yelled help, help, call the police. NA #1 stated at this time she started giggling and placed a pillow on Resident #1 ' s face not to suffocate or harm Resident #1. NA #1 stated she was not aware at the time of the incident that NA #2 had videoed the incident until after the incident had taken place. NA #1 made the Administrator aware that NA #3 and NA #4 were aware of the video in regards to NA #1 placing a pillow on Resident #1 ' s face. A review of a written statement from NA #1 written on 11/26/17 revealed: NA #2 took the video without my knowledge of it. I did not know until after the fact. But we, me and Resident #1 were laughing and joking like always and he started yelling help, help, somebody call the police. I started giggling and took the pillow and placed it on his face, not to suffocate or harm him. NA #2 showed NA #3 and NA #4 the video. Those are the only two of my knowledge that knows. On 12/13/17 at 11:15 am attempted to interview NA #1 via phone. NA #1 was unavailable for an interview. The Administrator reported on 11/26/17 at 8:30 pm she interviewed NA #2 regarding the video of NA #1 placing a pillow on Resident #1 ' s face. NA #2 stated she did not take a video of NA #1 abusing Resident #1. A review of a written statement written on 11/26/17 revealed, in part, NA #2 never recorded NA #1 in the room with Resident #1. On 12/13/17 at 11:48 am attempted to interview NA #2 via phone. NA #2 was unavailable for an interview. The Administrator reported on 11/26/17 at 8:45 pm, she interviewed NA #3 regarding the video of NA #1 placing a pillow on Resident #1 ' s face. NA #3 stated he did not see the video but NA #2 and NA #3 ' s FM #1 told NA #3 about the video. NA #3 stated he did not report the abuse of Resident #1. A review of a written statement from NA #3 written on 11/26/17 revealed, in part, as far as the video, I have not seen the video but my mother (FM #1) told me FM #1 recorded NA #1 abusing Resident #1 and I needed to report it, but I never did. Also, NA #1 told NA #3 that NA #1 hated coming in Resident #1 ' s room because he got up too much and urinates on the floor, which was why NA #1 put baby oil on his feet so he can fall when he gets up. On 12/13/17 at 11:17 am attempted to interview NA #3 via phone. NA #3 was unavailable for an interview. The Administrator reported at about 11:00 pm on 11/26/17, a female person (FM #1) appeared at the facility and stated I took the video of NA #1 and Resident #1. The Administrator stated she asked who she was and FM #1 reported she was a FM of NA #2 and NA #3. The Administrator stated she asked why she did not report the incident to her or the DON. FM #1 replied I reported it to who I felt it needed to be reported to, the parents! FM #1 stated she did not show the video to NA #2 and NA #3, but told them they needed to report it to the facility. A review of the video was conducted. The video revealed NA #1 standing in front of Resident #1 ' s bed. Resident #1 was sitting upright in the bed with his feet on the floor. Resident #1 was fully dressed and shoes were on his feet. NA #1 had one knee up on the bed between Resident #1 ' s legs. NA #1 was observed pulling Resident #1 ' s right arm as he attempted to move away from NA #1. Resident #1 was observed yelling, Help, help, somebody call the police! NA #1 was observed placing a pillow over Resident #1 ' s face. An interview was conducted with Detective #2 on 12/11/17 at 3:49 pm. Detective #2 stated Detective #1 did the initial interview with NA #1 and NA #2 on 11/26/17. Detective #2 stated on 11/26/17 when Detective #1 interviewed NA #2, she denied she took the video of NA #1. Detective #2 stated during her interview with NA #2, she admitted she took the video of NA #1 and also stated NA #1 told her she put baby oil on Resident #1 ' s feet so he would not get up, and if he did, he would fall. Detective #2 stated during an interview with FM #1 she stated that FM #1 and NA #2 shared a phone and while she was at church services on 11/26/17, she saw the video of the abuse on the shared cell phone. FM #1 stated she sent the video to RP #1. FM #1 also reported to Detective #2 that NA #2 stated NA #1 said she puts baby oil on Resident #1 ' s feet and she messed up one night because he fell . FM #1 stated she spoke with NA #4 and NA #4 stated that NA #1 only put baby oil on the resident ' s feet once. An interview was conducted with Detective #1 on 12/13/17 at 1:11 pm. Detective #1 reported he responded to a 911 call by RP #1 of Resident #1 on 11/26/17. Detective #1 reported he arrived to RP #1 ' s home and was informed about concerns the RP #1 had regarding falls and abuse at the facility. Detective #1 stated while he was at the RP ' s home a video was presented without sound of NA #1 pushing and shoving Resident #1 and putting a pillow over his face. Detective #1 stated he notified the facility and made the Administrator aware. Detective #1 stated when he arrived at the facility, he interviewed NA #1. Detective #1 stated NA #1 admitted she was aware of the video and said it look bad, like she was being aggressive. NA #1 stated her and the resident were just joking around. NA #1 said she was getting the resident ready for bed and he was not complying so she put the pillow on his head and pushed him back just joking around. Detective #1 stated NA #1 reported one time she put baby oil on her finger and ran it on the bottom of his foot so he would not be able to get out of bed because she did not like to have falls on her assigned floor. NA #1 stated she told NA #4 and NA #4 stated you can ' t do that and after that night she did not do it anymore. The medication aide/NA #4 who was working on the 11-7 shift from 11/25 – 11/26/17 morning was suspended pending an investigation for Resident #1 and was unable to be interviewed. On 12/13/17 at 3:00 pm an interview was conducted with the Administrator. The Administrator stated she had initiated in services for all staff regarding the use of electronic communication devices and put a plan of correction in place. The corrective action for non-compliance dated 11/26/17 was as follows: 1. A thorough investigation was initiated on 11/26/17 to ascertain the root cause was failure of NA #2 to follow the electronic communications device policy by utilizing a cell phone to video tape Resident #1 being abused by NA #1. On Sunday, 11/26/17 at 7:14 pm, it was reported to the Administrator that Resident #1 was hit in the face and had a pillow put over his face by one of the staff. The family reported to the local Sherriff ' s Department they had a video of a staff member at the facility mistreating Resident #1. The Administrator received a phone call from RP #1 of Resident #1 who placed Detective #1 on the phone. Detective #1 stated we have a video of Resident #1 being mistreated by one of your staff members at the facility. Detective #1 met the Administrator at the facility on 11/26/17. NA #1 was immediately removed from the hall and questioned. The Administrator and the DON interviewed NA #1 and she reported that her and Resident #1 were laughing and joking like always and Resident #1 started yelling help, help, somebody call the police. NA #1 stated she then placed the pillow on his face, not to suffocate or harm him. The police escorted NA #1 out of the facility. The investigation report indicated based on the facility investigation, it was determined abuse did occur. NA #1 was terminated. The report stated the Sherriff ' s Department had an on-going investigation to determine if any criminal charges would be filed against NA #1. The DON provided statements from staff that were working on 11/25/17 and 11/26/17, skin assessment audits of all the residents, in services and education provided to all staff regarding abuse policy and procedures, HIPPA regulations, and the use of electronic devices in the facility. The DON reported the in services and audits were put in place on 11/26/17. The DON reported the initial 24 hour report was sent indicating injury of unknown origin, however it was amended once the video was discovered of NA #1 abusing Resident #1 and was faxed to the Health Care Investigations. 2. The facility created a QI (Quality Improvement) team to direct and implement this plan of correction. The team was formed and met for the first time on 11/28/17. Team members included the Nursing Home Administrator, DON, Medical Director, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses. Additional members can be added at the discretion of the Facility Administrator as/if needed. This QI team collaborated to create the in service, the schedule for in servicing all staff, the QA tool (15 minute checks QA Monitoring Tool) for monitoring and the review Resident #1. To address this issue and to prevent future similar issues: The facility created a QI team including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses on 11/26/17 to continuously review and monitor the interventions put into place specific to the plan of correction. The facility QI team members including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses initiated 100% in services with all staff in the facility on 11/26/17 at 9:00 pm regarding the abuse policy to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler and resident care coordinator to be completed by 11/28/17. No staff will be allowed to work until staff has been in serviced in regards to abuse. The facility initiated abuse questionnaires with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler and resident care coordinator to be completed on 11/28/17 in regards to : 1. Have you ever observed any resident abuse? If so, did you report the abuse? 2. Has anyone ever talked to you or have you ever heard of anyone talking about a resident being abused? If so, did you report the abuse? 3. Do you know the process of how to and when to report abuse? Please explain. No staff will be allowed to work until abuse questionnaire is completed. Administrator reviewed and initiated all abuse questionnaires. Any areas of concern were immediately addressed by the Administrator. No new areas of concerns identified. The facility initiated 100% of abuse quizzes with all staff in the facility at 9:00 pm on 11/26/17 by the DON and to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator to be completed by 11/28/17 in regards to: 1. Who should you report abuse to? 2. When should you report abuse? 3. Give 2 examples of abuse. 4. What is the first thing you do if you see or hear a resident being abused from a staff member, visitor or another resident? No staff would be allowed to work until abuse quizzes were completed. The DON will re-educate any employee who did not answer the quizzes at the time quiz was completed. No areas of concern identified during quizzes. The facility initiated interviews for 100% of alert and oriented residents on 11/26/17 by the Social Worker and completed on 11/27/17 in regards to: 1. Do you know what it means to be abused? 2. Are there any instances that you felt you were verbally or physically abused? 3. Do you know of any residents that have been verbally or physically abused? 4. Do you know who to report abuse to? No new allegations of abuse noted. The facility initiated 100% staff in services with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator in regards to burn out and to be completed on 11/28/17. No staff will be allowed to work until burn out in servicing completed. The facility initiated 100% staff in services with all staff in the facility on 11/26/17 at 9:00 pm by the DON to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator to be completed 11/28/17 in regards to: 1. Was care performed using correct procedure (Staff interacted in an appropriate manner? 2. If care performed incorrectly, Administrator/DON immediately notified? Interaction tool revised on 11/28/17: 1. Was care performed using correct procedure? (Staff interaction with resident in an appropriate manner (observed for any signs of abuse/neglect) 2. If care performed incorrectly, Administrator/DON immediately notified? All staff interactions completed after 11/28/17 will be completed on revised tool. Any areas of concern will be addressed during the interaction. No staff will be allowed to work until staff interactions completed. The facility initiated 100% of review of all residents to include Resident #1 ' s progress notes on 11/27/17 by the Facility Nurse Consultant to ensure that there was no other allegations of abuse noted in the progress notes without proper investigation to be completed on 11/28/17. The DON addressed all identified areas of concern. 3. 25% of all staff to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator will complete a staff abuse questionnaire to ensure that staff are reporting abuse. Questionnaires will occur weekly X 8 weeks and monthly X 1 month. The Administrator will review and sign the staff abuse questionnaires for completion and that any areas of concern were addressed appropriately. Nurse ' s Progress Notes and Risk Management Reports will be reviewed for all residents to include Resident #1 5X week X 4 weeks, weekly X 4 weeks, then monthly X 1 month to ensure that the incident report was completed to include witness statement and interventions in place and to ensure that abuse or injury of unknown origin was investigated utilizing a QI Tool abuse/injury of unknown origin by the staff facilitator, QI Nurse and patient care coordinator. Notification to the Administrator for any abuse/injury of unknown origin will be completed by the staff facility, QI nurse and patient care coordinator during the audit for any identified areas of concern. The DON will review and initial the QI tool abuse/injury of unknown origin 5 x a week X 4 weeks weekly for 4 weeks then monthly X 1 month for completion and to ensure all areas of concern are addressed. 25% of all staff to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator will complete an abuse quiz weekly to ensure that staff are knowledgeable on the policy of abuse. Quizzes will occur weekly X 8 weeks and monthly X 1 month. The Administrator will review and sign the abuse quizzes for completion and that any areas of concern are addressed appropriately. 25% of all staff will be audited by the Staff Facilitator, QI Nurse, MDS Nurses and the patient care coordinator utilizing a staff interaction tool to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator weekly X 8 weeks and monthly X 1 month. The DON will review and initial all staff interaction tools to ensure completion and that any areas of concern are addressed appropriately. The Social Worker will interview 100% of alert and oriented residents utilizing a resident abuse questionnaire for resident ' s understanding of abuse and if abuse has occurred to the resident weekly X 8 weeks and monthly X 1. The Administrator will forward the results of the staff abuse questionnaires, abuse quizzes, resident abuse questionnaires, staff interaction tool and QI tool Abuse/injury of unknown origin to the Executive QI committee monthly X 3 months. The Executive QI committee will meet monthly X 3 months and review the staff abuse questionnaires, abuse quizzes, resident abuse questionnaires and the QI tool/Injury of Unknown Origin to determine trends and or issues that may need further interventions put into place and to determine the need for further and or frequency of monitoring. 4. The QI team met on 11/28/17 and have met daily since 11/28/17. They plan to meet again on 12/19/17. The purpose of these QI meetings being to gauge the plan of correction progress and to ensure ongoing compliance. The QI team will meet at least monthly for the next 12 months. The Administrator will be responsible for chairing this QI team in addition to assign new members, changes or updates to the plan of correction and the responsibility of ensuring monitoring of the abuse interventions. As part of the validation process on 12/11/17 through 12/13/17, the plan of correction was reviewed and included the in services, questionnaires and quizzes in regards to abuse, staff burn out and staff interaction for all staff members, questionnaires regarding abuse for all alert and oriented residents and the skin assessments and incident report audits for all residents. The Abuse Prohibition Review was completed. The licensed staff, nursing assistants, supervisors who interact with residents and alert and oriented residents that were interviewed were aware of to whom and how to report allegations, incidents, and or complaints. Five direct care staff representing all three shifts were interviewed to determine whether each staff member was trained in and knowledgeable about, how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions and knowledgeable regarding what, when, and to who to report according to the facility policies. A review of an ongoing log revealed Resident #1 was being observed by nursing staff every 15 minutes since 11/26/17 as well as an observation for one hour revealing Resident #1 was being observed by nursing every 15 minutes. The facility alleges full compliance with this plan of correction effective 11/28/17.

Based on observation, record review, family, staff and law enforcement interviews the facility failed to maintain privacy for one of three sampled residents (Resident #1) when a staff member utilized a cell phone to video record physical abuse by another staff member who placed a pillow on Resident #1 ' s face and attempted to force Resident #1 to remain in place by grabbing his arm while he called out for help. The video was discovered by a non-employee of the facility which resulted in a violation of Resident #1 ' s privacy. Findings included: Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident was severely cognitively impaired. A record review of the daily shift assignment for Saturday, 11/25/17, for the 3-11 shift and 11-7 shift revealed NA (Nursing Assistant) #1 was assigned to Resident #1. NA #2 was assigned on 11/25/17 for the 3-11 shift only and worked on a different hall. An interview was conducted with the Responsible Party (RP #1) of Resident #1 on 12/10/17 at 2:51 pm via phone. RP #1 revealed she was out of town the weekend of 11/25/17. RP #1 stated she was informed by another family member of Resident #1 that a female person in the community who was a family member (FM #1) of NA #2 and NA #3 sent a video to RP #1 of Resident #1 being abused by NA #1 and was informed NA #2 videotaped the incident. RP #1 reported the video showed NA #1 was putting a pillow over Resident #1 ' s face, she had her hand around his throat, and her knee was in between the resident ' s legs and she was unbuckling his pants. RP #1 reported she saw this video on 11/26/17 and called 911. RP #1 stated she spoke with Detective #1 at the local County Sherriff ' s Department and shared the video she had on her phone with Detective #1. RP #1 indicated she notified the Administrator with Detective #1 via phone. RP #1 stated Detective #1 went to the facility and interviewed NA #1, NA #2, and NA #3. RP #1 reported that NA #2 and FM #1 who shared the video with Resident #1 ' s RP, shared a cell phone and that was how FM #1 of NA #2 and NA #3 became aware of the incident. An interview was conducted with the Administrator on 12/11/17 at 4:40 pm. The Administrator reported what had happened. The Administrator reported on 11/26/17 at 7:00 pm, RP #1 called and made the facility Administrative Assistant (AA) aware she had received a video of Resident #1 being abused. The Administrator reported on 11/26/17 at 7:16 pm, she made the Director of Nursing (DON) aware of the call received from the AA in regards to RP #1 having a video of Resident #1 being abused. The Administrator reported on 11/26/17 at 7:20 pm, RP #1 called her so she could speak to Detective #1 at the local County Sherriff ' s Department via phone. Detective #1 made the Administrator aware of a video showing NA #1 abusing Resident #1. The Administrator reported on 11/26/17 at 7:30 pm, she arrived at the facility to meet with Detective #1 and interview NA #1 in regards to the video. Once she arrived at the facility, Detective #1 allowed her to view the video. The Administrator stated she observed NA #1 placing a pillow over Resident #1 ' s face and then grabbing Resident #1 ' s arm and pulling the resident back in the bed. The Administrator reported on 11/26/17 at 7:30 pm, she interviewed NA #1 in regards to the video showing NA #1 placing a pillow over Resident #1 ' s face and grabbing his arm and pulling him back in bed. The Administrator stated NA #1 started to deny the abuse until she told NA #1 there was a video. NA #1 stated that she and Resident #1 were joking and laughing and Resident #1 stated he yelled help, help, call the police. NA #1 stated at this time she started giggling and placed a pillow on Resident #1 ' s face not to suffocate or harm Resident #1. NA #1 stated she was not aware at the time of the incident that NA #2 had videoed the incident until after the incident had taken place. NA #1 made the Administrator aware that NA #3 and NA #4 were aware of the video in regards to NA #1 placing a pillow on Resident #1 ' s face. A review of a written statement from NA #1 written on 11/26/17 revealed: NA #2 took the video without my knowledge of it. I did not know until after the fact. But we, me and Resident #1 were laughing and joking like always and he started yelling help, help, somebody call the police. I started giggling and took the pillow and placed it on his face, not to suffocate or harm him. NA #2 showed NA #3 and NA #4 the video. Those are the only two of my knowledge that knows. On 12/13/17 at 11:15 am attempted to interview NA #1 via phone. NA #1 was unavailable for an interview. The Administrator reported on 11/26/17 at 8:30 pm she interviewed NA #2 regarding the video of NA #1 placing a pillow on Resident #1 ' s face. NA #2 stated she did not take a video of NA #1 abusing Resident #1. A review of a written statement written on 11/26/17 revealed, in part, NA #2 never recorded NA #1 in the room with Resident #1. On 12/13/17 at 11:17 am attempted to interview NA #3 via phone. NA #3 was unavailable for an interview. On 12/13/17 at 11:48 am attempted to interview NA #2 via phone. NA #2 was unavailable for an interview. The medication aide/NA #4 who was working on the 11-7 shift from 11/25 – 11/26/17 morning was suspended pending an investigation for Resident #1 and was unable to be interviewed. A review of the video was conducted. The video revealed NA #1 standing in front of Resident #1 ' s bed. Resident #1 was sitting upright in the bed with his feet on the floor. Resident #1 was fully dressed and shoes were on his feet. NA #1 had one knee up on the bed between Resident #1 ' s legs. NA #1 was observed pulling Resident #1 ' s right arm as he attempted to move away from NA #1. Resident #1 was observed yelling, Help, help, somebody call the police! NA #1 was observed placing a pillow over Resident #1 ' s face. An interview was conducted with Detective #2 on 12/11/17 at 3:49 pm. Detective #2 stated Detective #1 did the initial interview with NA #1 and NA #2 on 11/26/17. Detective #2 stated on 11/26/17 when Detective #1 interviewed NA #2, she denied she took the video of NA #1. Detective #2 stated during her interview with NA #2, she admitted she took the video of NA #1. Detective #2 stated during an interview with FM #1, she stated that FM #1 and NA #2 shared a phone and while FM #1 was at church services on 11/26/17, she saw the video of the abuse on the shared cell phone. FM #1 stated she sent the video to RP #1. The corrective action for non-compliance dated 11/26/17 was as follows: 1. A thorough investigation was initiated on 11/26/17 to ascertain the root cause was failure of NA #2 to follow the electronic communications device policy by utilizing a cell phone to video tape Resident #1 being abused by NA #1. On Sunday, 11/26/17 at 7:14 pm, it was reported to the Administrator that Resident #1 was hit in the face and had a pillow put over his face by one of the staff. The family reported to the local Sherriff ' s Department they had a video of a staff member at the facility mistreating Resident #1. The Administrator received a phone call from RP #1 of Resident #1 who placed Detective #1 on the phone. Detective #1 stated we have a video of Resident #1 being mistreated by one of your staff members at the facility. Detective #1 met the Administrator at the facility on 11/26/17. An interview was conducted with Detective #2 on 12/11/17 at 3:49 pm. Detective #2 stated Detective #1 did the initial interview with NA #1 and NA #2 on 11/26/17. Detective #2 stated on 11/26/17 when Detective #1 interviewed NA #2, she denied she took the video of NA #1. Detective #2 stated during her interview with NA #2, she admitted she took the video of NA #1. Detective #2 stated during an interview with FM #1, she stated that FM #1 and NA #2 shared a phone and while FM #1 was at church services on 11/26/17, she saw the video of the abuse on the shared cell phone. FM #1 stated she sent the video to RP #1. The DON provided statements from staff that were working on 11/25/17 and 11/26/17, skin assessment audits of all the residents, in services and education provided to all staff regarding abuse policy and procedures, HIPAA regulations, and the use of electronic devices in the facility. The DON reported the in-services and audits were put in place on 11/26/17. The DON reported the initial 24 hour report was sent indicating injury of unknown origin, however it was amended once the video was discovered of NA #1 abusing Resident #1 and was faxed to the Health Care Investigations. 2. The facility created a QI (Quality Improvement) team to direct and implement this plan of correction. The team was formed and met for the first time on 11/28/17. Team members included the Nursing Home Administrator, DON, Medical Director, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses. Additional members can be added at the discretion of the Facility Administrator as/if needed. This QI team collaborated to create the in-service, the schedule for in-servicing all staff, the Quality Assurance (QA) tool (15 minute checks QA Monitoring Tool) for monitoring and the review of Resident #1. To address this issue and to prevent future similar issues: The facility created a QI team including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses on 11/26/17 to continuously review and monitor the interventions put into place specific to the plan of correction. The facility QI team members including the Nursing Home Administrator, DON, QI Nurse, Patient Care Coordinator, Staff Facilitator and the MDS nurses initiated 100% in-services with all staff in the facility on 11/26/17 at 9:00 pm regarding the electronic communications device policy to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler and resident care coordinator to be completed by 11/28/17. No staff will be allowed to work until staff has been in-serviced in regards to use of electronic communications devices. 3. 25% of all staff to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator will complete a staff questionnaire to ensure that staff are adhering to the electronic communications device policy. Questionnaires will occur weekly X 8 weeks and monthly X 1 month. The Administrator will review and sign the staff questionnaires for completion and that any areas of concern were addressed appropriately. 25% of all staff will be audited by the Staff Facilitator, QI Nurse, MDS Nurses and the patient care coordinator utilizing a staff interaction tool to include licensed nurses, nursing assistants, dietary staff, housekeeping staff, therapy staff, Administrator, DON, administrative assistant, admissions coordinator, accounts receivable, accounts payable, activities director, activities assistant, QI Nurse, medical records, MDS Nurses, staff facilitator, central supply clerk, maintenance director, maintenance assistant, Social Worker, scheduler, and resident care coordinator weekly X 8 weeks and monthly X 1 month. The DON will review and initial all staff interaction tools to ensure completion and that any areas of concern are addressed appropriately. The Administrator will forward the results the use of electronic communications device questionnaires and the staff interaction tool to the Executive QI committee monthly X 3 months. The Executive QI committee will meet monthly X 3 months and review the results the use of electronic communications device questionnaires and the staff interaction tool questionnaires to determine trends and or issues that may need further interventions put into place and to determine the need for further and or frequency of monitoring. 4. The QI team met on 11/28/17 and have met daily since 11/28/17. They plan to meet again on 12/19/17. The purpose of these QI meetings being to gauge the plan of correction progress and to ensure ongoing compliance. The QI team will meet at least monthly for the next 12 months. The Administrator will be responsible for chairing this QI team in addition to assign new members, changes or updates to the plan of correction and the responsibility of ensuring monitoring of the electronic communications device policy interventions. As part of the validation process on 12/11/17 through 12/13/17, the plan of correction was reviewed and included the in-services and questionnaires in regards to the use of electronic communications device policy. The facility alleges full compliance with this plan of correction effective 11/28/17.