Every finding on record at Heritage at Turner Park Health & Rehab

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accident, hazards and supervision. The facility failed to maintain the resident environment as free of hazards as possible and failed to ensure each resident received adequate supervision when Resident #1, who was known to be non-compliant with his NPO status, entered the employee breakroom, which was not secured, used a microwave to heat water and sustained second degree burns to his hand after spilling the hot liquid. Staff were unaware of the incident or injury until they were notified by a hospice nurse. This failure could place residents at risk of serious injury or harm. Record review of Resident #1's significant change MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included malignant neoplasm of pharynx (throat cancer), anemia (disorder where the body lacks sufficient healthy red blood cells), thyroid disorder (production of too much or too little hormone), aphasia (language disorder caused by brain damage), malnutrition (lack of proper nutrition), depression (persistent sadness, loss of interest, and functional impairment), dysphagia (a swallowing disorder) and adult failure to thrive (unintended weight loss, malnutrition, dehydration, cognitive decline, and functional impairment). The MDS reflected a BIMS of 14, cognitively intact. The MDS reflected Resident #1 was set up assistance with toilet transfer, chair/bed-to-chair transfers, toileting hygiene and eating. The MDS further reflected Resident #1 did not use a mobility device. Resident #1's nutritional approach was a feeding tube. Review of Resident #1's care plan, revision date of 04/10/26, reflected as follows:*Resident #1 had an ADL self-care performance deficit: assist with personal hygiene as needed, requires staff assistance of one person for bathing, supervision as needed for bed mobility, praise all efforts of self-care, supervision with dressing as needed and supervision as needed with toileting.*Resident #1 has impaired communication as evidence by confusion related to memory deficits.*Resident #1 is NPO, with a peg tube feeding (a tube inserted through the abdomen into the stomach). Resident #1 is noncompliant with tube feeding and NPO. On 04/27/26 Resident #1 has potential/actual impairment to skin integrity related burn to right hand: resident educated to ask for assistance with ADL's and meals. Staff will continue to encourage resident not to heat water at any time and to wait for assistance. On 04/27/26 Resident #1 has impaired safety awareness/judgement when interacting with environment hazards related burning himself on right hand with hot water. Staff to reinforce safety awareness regularly. Staff to educate resident to call staff when it comes to handling of hot liquids and other environmental hazards. Review of Resident #1's physician order dated 04/27/26 signed by MD revealed Cleanse wound to right hand wit normal saline, pat dry, apply Xeroform gauze and cover with bordered dry dressing daily and PRN if soiled or dislodged. Review of the facility's Provider Investigation Report dated 04/27/26 completed by ADM revealed the following:Resident #1 reported today to the nurse that he went to the breakroom to get hot water without asking for assistance, he sustained a burn to right arm from the hot water. The investigation confirmed the resident entered the breakroom and microwaved hot water without asking for assistance. The resident has a BIMS score of 14 and is alert and oriented. During the investigation, he stated he did not need help and believed he could do it on his own. He also acknowledged opening the breakroom door independently and reported that he did not notify staff because it did not hurt and he was not in pain. The resident has a history of non-compliance and often attempts to perform tasks independently with requesting assistance. Review of Resident #1's hospice visit note report for 04/27/26 completed by Hospice RN D revealed the following: .Summary of today's visit finding: the patient was up in his bed resting. His speech is garbled. He is alert and oriented times four. He denies any pain at this time. The patient has a burn wound to the right hand. Notified the facility wound nurse and DON. Review of the facility incident report, Event Nurses' Note-Burn dated 04/27/26 completed by ADON/LVN A revealed the following: .Location: breakroom, caused by coffee, tea or other hot liquid. Part of body burned: right hand. Details of injury: burn to right hand measuring approximately 5.5cm x 4.5cm x 0.1cm, skin with redness, no bleeding. Cognition: oriented/no problem. Nursing description of the event: Resident #1 reported to the nurse that he went to the breakroom to get hot water without asking for assistance, he sustained burn to right hand and he didn't report because he was not in pain at that time.Resident statement related to event. I was trying to get hot water and burnt my right hand. Interventions: Resident educated to ask for assistance with ADLs and meals. Review of Resident #1's progress noted dated 04/27/26 at 2:00 PM completed by ADON/LVN A revealed the following:Resident reported to the nurse that he went to the breakroom to get hot water without asking for assistance, he sustained burn to right hand and he didn't report because he was not in pain at that time. Head to toe assessment performed. Vital signs blood pressure was 126/66; pulse 65; respirations 18, oxygen saturation on room air was 96% temperature 97.8, open wound noted to right hand, no bleeding noted and no complaints of pain, MD notified gave new order to cleanse wound to right hand with normal saline, pat dry, apply Xeroform (a sterile, non-adherent petrolatum-based gauze dressing) gauze and wrap with Kerlix and secure with tape daily and PRN if dislodged. Hospice, DON, Administrator and RP notified. Resident educated to ask for assistance with ADLs and meals. Review of Resident #1's weekly skin assessment dated [DATE] at 2:25 PM completed by ADON/LVN A revealed the following: .Skin color: normalTemperature of skin: warmBruise present: Yes: Location: measurements of bruising: Discoloration to right hand between first and second finger measuring approximately 6.0cm x 5.0cmOther skin findings present: Yes. Other skin findings: Wound from burn to right hand between first and second fingers measuring approximately 5.5 cm x 4.5cm x 0.1cmThe MD/NP notified of the above skin assessment. New orders: Cleanse wound to right hand with normal saline, pat dry, apply Xeroform gauze and cover with bordered dry dressing daily and PRN if soiled or dislodged. Review of Resident #1's Negotiated Risk Agreement dated 04/27/26 at 3:41 PM completed by ADON/LVN A and DON revealed the following: .What is the final agreement: The resident has agreed to sign this agreement because he states that he is going to continue to do what he thinks is best for hisneeds. Review of Acute Episodic Visit Note for Resident #1 dated 04/29/26 completed by NP C revealed the following: .Resident #1 was seen today for an acute episode visit of burn to dorsum of his right hand. He voices he wanted hot water and went to the employee breakroom and heated water in the microwave. He is not willing to give all the details on why he needed hot water or why he did not ask for help. He does not explain why he went into the employee breakroom without asking for help. He also did not explain what he needed water for when he is a g-tube (a device inserted through the abdomen into the stomach to provide long-term nutrition, fluids, and medications). He is alert and oriented times four. He has a signed waiver for his g-tube. He laughed and typed on his phone, Don't worry, I will be okay. Treatment at hand is Xeroform daily and PRN. He denies pain at this time. Review of Resident #1's Wound Assessment Report dated 04/30/26 completed by NP B revealed the following: .location: right thumb. Measurements: length 5.00cm, width 4.00cm, depth 0.10cm. Etiology: burn-second degree. Dressing change frequency: every other day and PRN. Clean wound with: cleanse with wound cleanser. Primary treatment: Xeroform. Other dressings: bordered dressing. Observation on 05/04/26 at approximately 8:00 AM revealed signage on employee breakroom door revealed Breakroom is for staff use only. Observation and interview on 05/04/26 at approximately 8:15 AM with Resident #1. Resident #1 was alert and sitting up in the corner of his bed. Resident #1 indicated by using his hands he was hard of hearing. Observation of the bandage to Resident #1's right hand, bandage was clean, dry and dated. Resident #1 was talkative however it was difficult to understand him. Surveyor E was unable to obtain details of his right-hand injury, however he did use the word microwave and stated he was not in pain. Interview on 05/04/26 at 8:20 AM with the DON revealed Resident #1 reported the injury on Monday 04/27/26. The DON stated that Resident #1 did not report the injury immediately, the DON stated it appears to have happened the weekend of 04/25-04/26/26. The DON stated that the resident was difficult to understand and that Resident #1 has provided different details regarding the incident. The DON stated that the facility did not know what time the incident occurred, however Resident #1 stated that it happened in the employee breakroom. The DON stated that Resident #1 heated up water using the microwave in the employee breakroom without asking for assistance and accidentally spilled water on himself which was what the investigation concluded. The DON stated that the microwave was immediately removed from the employee breakroom on 04/27/26 and relocated to a new room with a code entry lock on the door. Observation on 05/04/26 at 8:34 AM of the code entry lock storage room with the Maintenance Director and the DON revealed two microwaves. Observation of signage on outside of door revealed Microwave in use, staff only allowed, door to microwave to remain closed and locked at all times. Interview on 05/04/26 at 9:34 AM with the ADM revealed Resident #1 reported to Hospice RN D on Monday 04/27/26 that Resident #1 went to the employee breakroom without assistance to heat up water. The ADM stated she interviewed Resident #1 on Monday 04/27/26 about the incident. The ADM stated Resident #1 accidentally spilled water on himself and got a burn to his right hand. The ADM stated when she interviewed Resident #1 about the incident, Resident #1 stated he felt like he could use the microwave himself and he didn't need help. The ADM reported that Resident #1 stated he had no pain at the time of the incident, that is why he didn't report it to any of the staff. The ADM stated that Resident #1 is alert and oriented, Resident #1 has a BIMS score of 14-15. The ADM stated that Resident #1 is noncompliant with being NPO and it was care planned. The ADM stated that when she asked Resident #1 when the incident occurred he stated to her sometime last week. The ADM stated that Resident #1 has never asked to use the microwave before this was the first time of knowing Resident #1 to use a microwave. The ADM stated that the MD ordered wound treatment immediately and Resident #1 did not require hospital transport. When asked if Resident #1 had a hot beverage risk assessment, ADM replied no since the resident was not cognitively impaired nor did he have any physical deficits which would have placed him at risk prior to the incident. Follow up interview on 05/04/26 at 10:19 AM with Resident #1. Resident #1 stated the microwave incident occurred two weekends ago. Resident #1 stated he was in the employee breakroom around 11 AM, there were no staff in the breakroom. Resident #1 stated he used his personal cup and got the water himself from the breakroom and spilled the water on his hand while removing the cup from the microwave. Resident #1 stated he was not in any pain when the spill occurred. Resident #1 stated he did not tell anyone about the incident when it happened since he was not in pain. Resident #1 stated that was the only time he had used the microwave in the breakroom. Resident #1 stated it happened a long time ago and it was nothing. Resident #1 stated he knows not to use the microwave again and to ask staff for assistance next time. Interview on 05/04/26 at 1:59 PM with ADON/LVN A revealed that Hospice RN D was visiting Resident #1 on Monday 04/27/26. ADON/LVN A stated that Hospice RN D noticed that Resident #1 had a homemade style bandage on his right hand and he brought it to the attention of ADON/LVN A and the DON. ADON/LVN A stated that Hospice RN D had asked Resident #1 about the bandage and Resident #1 reported that he tried to warm up water in the microwave in the breakroom and accidentally spilled the water on his hand. Resident #1 stated that the incident occurred over the weekend but Resident #1 did not report it to anyone. ADON/LVN A stated he immediately went to assess Resident #1 since he was the facility wound care nurse. ADON/LVN A stated that Resident #1 resisted an assessment at first, Resident #1 was stating his right hand was ok. ADON/LVN A stated that the area was red without blisters. ADON/LVN A stated he called the MD for treatment orders. ADON/LVN A stated Resident #1's hand is improving and NP C was monitoring it. Interview on 05/04/26 at 2:18 PM with CNA F revealed Resident #1 was alert and oriented. CNA F stated Resident #1 is independent with his ADLs; he does everything on his own. CNA F stated she had never seen Resident #1 go into the breakroom or ask to use a microwave. Interview on 05/04/26 at 6:55 PM via telephone with LVN H revealed she worked the weekend of 04/25-04/26/26. LVN H stated that her normal shift was double weekends, 6:00 AM-10:00 PM. LVN H revealed Resident #1 was alert and oriented. LVN H stated that Resident #1 has never asked to use a microwave or been seen using a microwave. LVN H stated she had no knowledge of the incident that resulted in Resident #1's injury. LVN H stated she asked Resident #1 about his injury on 05/02/26. LVN H stated Resident #1 wrote to me using his phone that he got burned when using a microwave, that he reached into the microwave to get the water and it got on his hand. Resident #1 told LVN H that the incident occurred in the middle of the night. Review of employee schedule dated revealed LVN I worked the 10:00 PM-6:00 AM shift on 04/25-04/26/26. Interview attempted on 05/05/26 at 8:26 AM with LVN I via telephone. LVN I did not return phone call prior to investigation completion. Text message send to LVN I on 05/05/26 at 10:28 AM requesting a return phone call. Interview on 05/05/26 at 8:41 AM with the ADM revealed the facility does not have a policy on microwaves including microwaves in the employee breakroom. ADM stated we did an in service on 04/27/26 with all staff on the expectation protocol of microwave security. Interview on 05/05/26 at 8:52 AM with LVN G revealed Resident #1 was alert and oriented. LVN G stated that Resident #1 was alert and oriented. LVN G stated that Resident #1 has never asked to use the microwave. Interview on 05/05/26 at 10:10 AM via telephone with Hospice RN D revealed on Monday 04/27/26 Resident #1 was observed with a homemade style bandage on his right hand. Hospice RN I asked Resident #1 about the bandage and Resident #1 would not say what happened, Resident #1 just said hot water and he was fine. Hospice RN I stated he went to the ADON/LVN A and the DON to tell them about Resident #1's bandage so that the ADON/LVN A and DON could investigate. Review of in service dated 04/27/26 with all staff conducted by the DON regarding the topic of resident safety revealed the following: Resident Safety Notice-Microwave Security. For the resident safety, all microwaves must remain secured at all times and accessible to staff only. The storage is restricted to staff, and the lock code is for staff only and must not be shared with residents or families. All staff are expected to ensure residents do not use microwaves independently. This includes keeping microwaves secured after each use, and intervening immediately if a resident attempts to access or use one without assistance. Always check the temperature prior to serving to prevent burns or injury. Strict adherence to this protocol is required to reduce risk, prevent accidents, and maintain a safe environment for all residents.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #30 and Resident #33) of twelve residents observed for infection control. RN A failed to sanitize shared use equipment (blood pressure device and wrist cuff) before and after resident use with Resident #30 and Resident #33 on 07/30/2025. This failure could place residents at risk for spread of infection through cross-contamination.Findings included:Review of Resident #33's Face Sheet dated 07/30/2025 revealed she was a [AGE] year-old female admitted from an acute care hospital. Relevant diagnoses included acute cerebrovascular insufficiency (inadequate blood flow to the brain), vascular dementia (impaired cognitive function related to impaired blood flow to the brain), depression (mood disorder), and seizures (sudden, uncontrolled electrical disturbance in the brain). Review of Resident #33's Quarterly MDS dated [DATE] revealed she had a severe cognitive impairment with a BIMS score of 03. She used a walker and wheelchair for mobility and had no impairments to her upper and lower extremity. Resident #33 required setup or clean up assistance for eating, shower/bathing, and personal hygiene. Review of Resident #30's Face Sheet dated 07/30/2025 revealed she was an [AGE] year-old female admitted from an acute care hospital. Relevant diagnoses included dementia (decline in mental abilities), psychotic disorder (group of mental illnesses involving hallucinations and/or delusions), traumatic brain injury (external force that causes damage to the brain), schizoaffective disorder (mental health condition characterized by a combination of schizophrenia and a mood disorder), major depressive disorder (mental illness characterized by persistent sadness and loss of interest in activities), and altered mental status (change in a person's level of consciousness or cognitive function). Review of Resident #30's Quarterly MDS dated [DATE] revealed she was cognitively intact with a BIMS score of 13. She used a wheelchair for mobility and had no impairments to her upper and lower extremity. Resident #30 required supervision with toileting, shower/bathing, and personal hygiene. In observation of RN A on 07/30/2025 at 8:55 AM, she obtained Resident #33's vitals with the blood pressure device and wrist cuff and placed it on her right wrist. RN V then provided Resident #33 with her medications. RN A failed to sanitize the blood pressure device and wrist cuff prior to obtaining Resident #33's vitals. RN V then moved on to Resident #30 and obtained her vitals with the same blood pressure device and wrist cuff and placed it on her right wrist. RN V then provided Resident #30 with her medications. RN V failed to sanitize the blood pressure device and wrist cuff before and after obtaining Resident #30's vitals. In interview with RN A on 07/30/2025 at 9:39 AM, she stated she did not sanitize the blood pressure device and wrist cuff prior to Resident #30 because she only sanitizes the [blood pressure device and wrist cuff] every two people. When asked if the facility trained her to do this, she stated not really. When asked what can occur if shared use equipment was not sanitized between every resident use, she stated infection control issues. Interview with ADON B on 07/31/2025 at 10:14 AM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Interview with the DON on 07/31/2025 at 10:28 AM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Interview with the Administrator on 07/31/2025 at 2:02 PM revealed her expectations were for any shared use equipment to be sanitized before and after resident use for infection control reasons. Record review of facility policy Standard Precautions, undated, provided by the DON on 07/31/2025 at 10:35 AM revealed Standard precautions are based upon the principle that all blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions are intended to be applied to the care of all persons in all healthcare settings, regardless of suspected or confirmed presence of an infectious agent. Record review of facility policy, Fundamentals of Infection Control Precautions, rev. 2019, reflected 6. Resident care equipment and articles . 3. Non-invasive resident care equipment is cleaned daily or as needed between use .

Based on interview and records review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of six residents reviewed for pain medication. LVN A failed to administer Resident #1 pain medicine for a complaint of pain intensity level 4 (moderate pain) out of 10 on 01/04/25; pain intensity level 4 (moderate pain) out of 10 on 01/05/25; pain intensity 5 (moderate pain) out of 10 on 01/06/25; pain intensity 5 (moderate pain) out of 10 on 01/07/25; pain intensity 7 (severe pain) out of 10 on 01/10/25, and a pain intensity 6 (moderate pain) out of 10 on 01/10/25 (intensity levels are interpreted as 0: no pain; 1 - 3: mild discomfort; 4 - 6: moderate pain; 7 - 10: Severe discomfort/pain). This failure placed residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life. Findings included: A record review of Resident #1's incomplete Admission MDS assessment dated [DATE] revealed a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses of Rhabdomyolysis (a condition that causes muscles to break down); Hereditary and idiopathic neuropathy (nerve damage in the peripheral nervous system (PNS) where the cause cannot be determined); and Spondylolysis, Cervical Region (a painful spine condition. It is a bony defect in the neck area [the first seven irregular bones in the spine]). The Admission MDS assessment did not reflect a BIMS summary score or that a staff assessment for mental status was conducted. Section J - Health Conditions of the Admission MDS assessment was not completed and did not indicate if Resident #1 had pain or was hurting, pain frequency, pain effect on sleep, pain interference with ADLs, or pain intensity. Section V - Care Area Assessment (CAA) Summary in the Admission MDS assessment did not trigger care areas for care planning. A record review of Resident #1's Care Plan Conference, dated 01/06/25, indicated focus, goals and interventions were reviewed and included discharge plan for Resident #1 to return home; Full Code; Risk for falls; UTI and antibiotics; actual wound to coccyx; and Resident #1's preferences. A baseline care plan was not available for review in the chart. A record review of Resident #1's order summary report printed 01/18/25 indicated: Start date 01/03/25: Tylenol Oral Tablet 325 mg. Give 2 tablets by mouth every 4 hours as needed for pain mild to moderate. Start date 01/03/25: Gabapentin (a drug that affects chemicals and nerves in the body that are involved in the cause of some types of pain) 100 mg Oral Capsule. Give 2 capsules by mouth three times a day for nerve pain. Start date 01/12/25: X-Ray Left Knee. One time only for left knee pain and swelling. Record review of a written statement dated 01/15/25 at 7:22 PM, RN C wrote when he worked on Sunday, 01/12/24 Resident #1's family members informed him that Resident #1 was complaining of pain to the left knee. RN C assessed the site and note it was swollen. Resident #1 rated the pain a 7 out of 10. RN C stated he administered Tylenol 325 mg, 2 tablets, called the physician, and an x-ray of the knee was ordered. Effective Date: 01/04/25 12:35 PM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 4. Effective Date: 01/05/25 11:00 AM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 4. Effective Date: 01/06/25 7:43 AM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 5. Effective Date: 01/07/25 10:42 AM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 5. Effective Date: 01/10/25 1:49 PM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 7. Effective Date: 01/10/25 9:29 PM Type: Nursing Note Author: LVN A Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 6. Effective Date: 01/12/25 12:56 AM Type: MAR - Administration Note Author: RN E Note Text: Tylenol Oral Tablet 325 mg. Give 2 tablet by mouth every 4 hours as needed for pain mild to moderate pain. Effective Date: 01/12/25 1:27 AM Type: MAR - Administration Note Author: RN E Note Text: Tylenol Oral Tablet 325 mg. Give 2 tablet by mouth every 4 hours as needed for pain mild to moderate pain. PRN administration was Effective. Follow-up pain scale was 0 (zero). Effective Date: 01/12/25 7:23 PM Type: MAR - Administration Note Author: RN C Note Text: Tylenol Oral Tablet 325 mg. Give 2 tablet by mouth every 4 hours as needed for pain mild to moderate pain. Pain at the left knee Effective Date: 01/12/25 8:55 PM Type: MAR - Administration Note Author: RN C Note Text: Tylenol Oral Tablet 325 mg. Give 2 tablet by mouth every 4 hours as needed for pain mild to moderate pain. PRN administration was Effective. Follow-up pain scale was 0 (zero). Effective Date: 01/12/25 9:17 PM Type: Nursing Progress Note Author: RN C Note Text: [Resident #1] Complained of pain 7 out of 10 and swelling of the left knee. [Attending Physician] ordered x-ray of left knee. Effective Date: 01/12/25 9:30 PM Type: Nursing Note Author: RN C Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 7. Effective Date: 01/13/25 4:24 AM Type: Nursing Note Author: RN E Note Text: Skilled Nurse Note Resident states/appears in pain. Pain rating at 3. Effective Date: 01/13/25 8:29 AM Type: Nursing Progress Note Author: ADON Note Text: X-ray tech present at facility to do left knee x-ray will await results. Review of Resident #1's January 2025 MAR reflected RN E administered Tylenol 325 mg, 2 tablets, on 01/12/25 at 12:56 AM for an unknown level of pain. RN C administered Tylenol 325 mg, 2 tablets on 01/12/25 at 7:23 PM for a pain level of 7 (severe) out of 10 to the left knee and swelling. There were no other entries on the MAR that indicated Tylenol was administered from 01/03/25 through 01/11/25. During an interview on 01/18/25 at 12:11 PM, LVN A said that she worked 6A - 2P shifts. LVN A said when she was scheduled, or picked up extra shifts, she was assigned as Resident #1's nurse. LVN A said that Resident #1 was a new admission and resided at the facility for less than 3 weeks. LVN A said that Resident #1 was alert and oriented to self, surroundings, was occasionally confused and needed prompts or cues about the date or time of day. LVN A said that Resident #1 could voice and make her wants and needs known. LVN A said Resident #1 required 2-persons to assist with toileting and transferring. LVN A said that Resident #1 was wheelchair bound and required the mechanical lift for transfers. LVN A said that Resident #1 never complained about pain or requested pain medication. During a phone interview on 01/19/25 at 4:26 PM, RN E said that she worked 10P - 6A shifts. RN E said that when she was scheduled, she was assigned as Resident #1's nurse. RN E said that Resident #1 did not often complain about pain. RN E said when she worked on 01/11/25, Resident #1 said that she was hurting behind her knees. RN E said that she did not recall the pain level before she administered the Tylenol. RN E said that Resident #1's knee(s) were not swollen when asked if she checked and noticed any swelling, redness, or felt any warmth behind Resident #1's knees at the time she complained of pain. RN E said when she followed up with Resident #1 around 1:30 AM (01/12/25), the Tylenol was effective because [Resident #1] said she was okay. During a phone interview on 01/19/25 at 4:53 PM, LVN A stated that Resident #1 received a routine pain medication, and she would assess Resident #1's pain level prior to administering routine medications. LVN A identified the routine pain medication as Gabapentin that was given for nerve pain. LVN A said that Resident #1 would indicate her pain was generalized. LVN A said that she did not administer PRN Tylenol to Resident #1 because the Gabapentin relieved any pain Resident #1 had. LVN A acknowledged that there were medication aides who administered routine medications to Resident #1 and stated that LVN A administered medications on the weekend. LVN A could not speak to why she stated she administered routine medications to Resident #1 during the weekday or to why she did not assess the severity and the impacts of the pain on Resident #1. LVN A denied performing or suggesting coping strategies or non-pharmacological pain management techniques to assist Resident #1 with pain relief. Review of the facility's policy Pain Management, Assessment Scale revised May 25, 2016, indicated complaints of pain will be assessed accordingly by the nurse and effectively managed through prescribed medications, comfort measures, and all available resources of the facility. Procedure 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. 2. Perform comfort measures to promote relaxation. 5. Apply heat or cold as ordered to minimize or relieve pain. 6. Help resident into a comfortable position and use pillows to splint or support painful areas, as appropriate, to reduce muscle tension or spasm and to redistribute pressure on body part. 7. Ask resident to help establish goals and develop plan for pain control. 8. Instruct resident in use of relaxation techniques. 9. Have the resident to rate pain on a scale of one to ten with one being the least pain and ten being the worst pain experienced. The nurse may use the pain rating scale when assessing effectiveness of medications and assessing for pain intensity. Utilize the Pain Assessment Tool in documenting the resident's complaint of pain. 10. Assist the resident in maintaining a pain management and rest schedule, exercise program and medication regimen. 11. Encourage self-care activities. 12. Talk with the resident about pain and assess for pain relief after interventions. 13. Monitor for effectiveness of pain interventions. 14. The care plan team will routinely assess the effectiveness of pain management interventions. Appropriate care plans will be maintained for the management of the resident's pain.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to ensure LVN A provided physician ordered wound care for Resident #1 on 01/04/25 - 01/07/25. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life. Findings included: Record Review of Resident 1's quarterly MDS assessment revealed he was an [AGE] year-old male, admitted to the facility on [DATE]. Resident's MDS revealed he had a BIMS score of 9 indicating his cognition was moderately impaired. His diagnoses included heart failure, peripheral vascular disease (a chronic condition that reduces blood flow to the arms, legs, and organs), end-stage renal disease, malnutrition, and traumatic amputation of most toes. Record Review of Resident #1's Care Plans reflected, 11/29/24 The resident had a pressure ulcer of the left heel. Facility interventions included: Document on pressure ulcer of the left heel, amount of drainage, peri-wound area, pain, edema, and circumference measurements. Evaluate wound for: size, depth, margins: peri-wound skin. Document progress in wound healing on an ongoing basis. Notify physician as indicated. There was no care plan for the right heel. Record Review of Resident #1's Order Summary Report, dated January 2025, reflected: 1. Cleanse wound to left heel with normal saline, pat dry, apply betadine, and cover with a gauze roll (kerlix), and secure with tape (paper) once daily and as needed for wound care. 2. Cleanse wound to right heel with normal saline, pat dry, apply collagen powder and calcium alginate, cover gauze roll (kerlix), and secure with tape (paper) once daily one time a day for wound care. 3. May have pressure relieving mattress every shift. Review of Resident #1's Wound Evaluation and Management Summary reflected: 01/01/25 1. Stage 4 Pressure Wound of the Right Heel: 1.5 x 0.5 x Not Measurable Centimeters with black necrotic (dead) tissue. Wound progress: Exacerbated (worsened) 2. Unstageable Wound of the Left Heel: 0.9 x 0.8 x Not Measurable Centimeters with black necrotic tissue. Wound progress: Improved 01/08/25 1. Stage 4 Pressure Wound of the Right Heel: 1 x 0.5 x Not Measurable centimeters with black necrotic tissue. Wound progress: Improved 2. Unstageable Wound of the Left Heel: 0.8 x 0.8 x Not Measurable Centimeters with black necrotic tissue. Wound progress: Improved Record review of Resident #1's electronic treatment administration record reflected LVN A documented the ordered wound care was completed on 01/04/25-01/07/25. An observation and interview on 01/07/24 at 9:50 AM with Resident #1 and his family member revealed he was lying in bed. He was awake, alert, oriented. His feet were uncovered and lying flat on the regular mattress . Neither foot had a dressing. He had multiple missing toes with black sutures extending out of the skin. The family member said the heel wounds were healing and the sutures were put in August 2024. LVN A entered the room and raised each foot. Each heel had a necrotic circular area. LVN A said the heels were supposed to be off-loaded, but the resident refused the boots to off-load them. LVN A said the sutures were dissolvable. An interview on 01/07/24 at 2:35 PM with LVN A revealed she did the wound care for Resident #1 on 01/04/25 - 01/07/25. She said she did not do the ordered wound care on his feet but signed that she did. She said that she put skin prep/betadine on the heels and left them uncovered. She said the heel wounds had been resolved. She said she did not know if the resident was supposed to have a pressure relieving mattress. LVN A said she did not know what the plan was for the sutures but was told by the ADON that they were dissolvable. She said she was not the wound care nurse. LVN A said the risk to the resident for not completing the ordered wound care and signing it as done was infection. An interview on 01/07/24 at 3:05 PM with the ADON revealed she was also the wound care nurse. She said she looked at the wounds for Resident #1 on Monday, Wednesday, and Friday. She said she was not able to look at them on Monday because she did not work. She said the staff nurses did their own wound care. The ADON said the heel wounds were still supposed to be treated as ordered and the heel wounds were not resolved. She said the Wound Care Physician went to the facility weekly and was scheduled to arrive on 01/08/25. The ADON said she did not know if the resident was supposed to be on a pressure relieving mattress. The ADON said the facility needed to contact Resident #1's surgeon about the sutures because they had not dissolved, and she did not know why. The ADON said she did not realize Resident #1's wounds were not treated as ordered on 01/04/25-01/07/25. The ADON said the resident was at risk for a decline in his wounds if his treatments were not completed as ordered. The ADON said the Wound Care Physician did not look at surgical wounds. An interview on 01/08/25 at 1:00 PM with the DON revealed Resident #1 was going to get an air mattress. She said the staff nurses were responsible for doing the wound care and was told LVN A did not administer the ordered treatment for his heel wounds. She said she was not aware of any other residents who did not receive their ordered treatment. She said the sutures on his toes was from his surgery before he admitted to the facility. The DON said the resident still had the sutures because she was told they were dissolvable. The DON said the facility was contacting his surgeon who was out of state. The DON said the nurses were trained how to document in the electronic treatment administration record. The DON said she checked the orders every morning to ensure nurses were documenting correctly. She said if the resident did not receive the ordered wound care, he could develop infection. She said if a nurse documented a treatment was completed when it was not, then the resident was at risk for a missed treatment. The DON said she and the nurses were responsible for ensuring wound care was completed. Record review of the facility policy, Pressure Injury: Prevention, Assessment and Treatment revised 08/12/16, reflected: Procedure: 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury and infection . 2. Early prevention and/or treatment is essential upon initial nursing assessment of the condition of the skin on admission and whenever a change in skin status occurs. .follow any orders as directed by the physician . Sign off on treatment sheet any treatment completed .

Based on interview and record review, the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for one (Resident #1) of three residents reviewed for nursing services. The facility failed to ensure LVN A did not falsely document that she provided physician ordered wound care for Resident #1 on 01/04/25 - 01/07/25. This failure could place residents at risk for not receiving ordered wound care. Findings included: Record Review of Resident 1's quarterly MDS assessment revealed he was an [AGE] year-old male, admitted to the facility on [DATE]. Resident's MDS revealed he had a BIMS score of 9 indicating his cognition was moderately impaired. His diagnoses included heart failure, peripheral vascular disease (a chronic condition that reduces blood flow to the arms, legs, and organs), end-stage renal disease, malnutrition, and traumatic amputation of most toes. Record Review of Resident #1's Order Summary Report, dated January 2025, reflected: 1. Cleanse wound to left heel with normal saline, pat dry, apply betadine, and cover with a gauze roll (kerlix), and secure with tape (paper) once daily and as needed for wound care. 2. Cleanse wound to right heel with normal saline, pat dry, apply collagen powder and calcium alginate, cover gauze roll (kerlix), and secure with tape (paper) once daily one time a day for wound care. 3. May have pressure relieving mattress every shift. Record review of Resident #1's electronic treatment administration record reflected LVN A documented the ordered wound care was completed on 01/04/25-01/07/25. An observation and interview on 01/07/24 at 9:50 AM with Resident #1 and his family member revealed he was lying in bed. He was awake, alert, oriented. His feet were uncovered and lying flat on the regular mattress. Neither foot had a dressing. He had multiple missing toes with black sutures extending out of the skin. The family member said the heel wounds were healing and the sutures were put in August 2024. LVN A entered the room and raised each foot. Each heel had a necrotic circular area. LVN A said the heels were supposed to be off-loaded, but the resident refused the boots to off-load them. LVN A said the sutures were dissolvable. An interview on 01/07/24 at 2:35 PM with LVN A revealed she did the wound care for Resident #1 on 01/04/25 - 01/07/25. She said she did not do the ordered wound care on his feet but signed that she did. She said that she put skin prep/betadine on the heels and left them uncovered. She said she thought the heel wounds had been resolved. She said she was not the wound care nurse. LVN A said the resident was at risk for infection if the staff documented that wound care was completed but failed to complete it. An interview on 01/07/24 at 3:05 PM with the ADON revealed she was also the wound care nurse. She said she looked at the wounds for Resident #1 on Monday, Wednesday, and Friday. She said she was not able to look at them on Monday because she did not work. She said the staff nurses did their own wound care. The ADON said the heel wounds were still supposed to be treated as ordered and the heel wounds were not resolved. She said the Wound Care Physician went to the facility weekly and was scheduled to arrive on 01/08/25. The ADON said she did not realize Resident #1's wounds were not treated as ordered on 01/04/25-01/07/25. The ADON said the resident was at risk for a decline in his wounds if his treatments were not completed as ordered. An interview on 01/08/25 at 1:00 PM with the DON revealed staff nurses were responsible for doing the wound care and was told LVN A did not administer the ordered treatment for Resident #1's heel wounds. She said she was not aware of any other residents who did not receive their ordered treatment. The DON said the nurses were trained how to document in the electronic treatment administration record. The DON said she checked the orders every morning to ensure nurses were documenting correctly. She said if the resident did not receive the ordered wound care, he could develop infection. She said if a nurse documented a treatment was completed when it was not, then the resident was at risk for a missed treatment. The DON said she and the nurses were responsible for ensuring wound care was completed. Record review of the facility policy, Job Description Charge Nurse, dated 2014, reflected: .Timely and accurate documentation of resident's charts . Record review of the facility policy, Dressing Change Checklist, not dated, reflected: .Documents procedure per facility policy.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of three residents (Resident #1) observed for infection control. The facility failed to ensure the ADON wore the appropriate PPE while measuring and assessing foot wounds for Resident #1. These failures could place residents at risk of transmission of multidrug-resistant organisms. Findings included: Record Review of Resident 1's quarterly MDS assessment revealed he was an [AGE] year-old male, admitted to the facility on [DATE]. Resident's MDS revealed he had a BIMS score of 9 indicating his cognition was moderately impaired. His diagnoses included heart failure, peripheral vascular disease (a chronic condition that reduces blood flow to the arms, legs, and organs), end-stage renal disease, malnutrition, and traumatic amputation of most toes. Record Review of Resident #1's Care Plans reflected, 11/29/24 The resident had a pressure ulcer of the left heel. Facility interventions included: Document on pressure ulcer of the left heel, amt of drainage, peri-wound area, pain, edema, and circumference measurements. Evaluate wound for: size, depth, margins: peri-wound skin. Document progress in wound healing on an ongoing basis. Notify physician as indicated. There was not a care plan for the right heel. Record Review of Resident #1's Order Summary Report, dated January 2025, reflected: 1. Cleanse wound to left heel with normal saline, pat dry, apply betadine, and cover with a gauze roll (kerlix), and secure with tape (paper) once daily and as needed for wound care. 2. Cleanse wound to right heel with normal saline, pat dry, apply collagen powder and calcium alginate, cover gauze roll (kerlix), and secure with tape (paper) once daily one time a day for wound care. 3. May have pressure relieving mattress every shift. Review of Resident #1's Wound Evaluation and Management Summary reflected: 01/01/25 1. Stage 4 Pressure Wound of the Right Heel: 1.5 x 0.5 x Not Measurable Centimeters with black necrotic (dead) tissue. Wound progress: Exacerbated (worsened) 2. Unstageable Wound of the Left Heel: 0.9 x 0.8 x Not Measurable Centimeters with black necrotic tissue. Wound progress: Improved 01/08/25 1. Stage 4 Pressure Wound of the Right Heel: 1 x 0.5 x Not Measurable centimeters with black necrotic tissue. Wound progress: Improved 2. Unstageable Wound of the Left Heel: 0.8 x 0.8 x Not Measurable Centimeters with black necrotic tissue. Wound progress: Improved Record review of Resident #1's electronic treatment administration record reflected LVN A documented the ordered wound care was completed on 01/04/25-01/07/25. An observation and interview on 01/07/24 at 9:50 AM with Resident #1 and his family member revealed he was lying in bed. He was awake, alert, oriented. His feet were uncovered and lying flat on the regular mattress. Neither foot had a dressing. He had multiple missing toes with black sutures extending out of the skin. LVN A entered the room, put on gloves, and raised each foot . Each heel had a necrotic circular area. LVN A said the heels were supposed to be off-loaded, but the resident refused the boots to off-load them. LVN A said the sutures were dissolvable. An observation and interview on 01/07/25 at 4:05 PM with the ADON revealed she entered Resident #1's room. The resident had a sign on his door showing that he was on enhanced barrier precautions. The ADON entered the resident's room and donned gloves. The ADON did not put on a gown. The ADON proceeded to undress each foot wound and measure/assess them. While the ADON measured/assessed the wounds on his heels, her scrubs touched the bed. The ADON said she was supposed to wear a gown and gloves for a resident on enhanced barrier precautions to prevent the spread of infection. She said she forgot to wear a gown that time. An interview on 01/08/25 at 1:00 PM with the DON revealed Resident #1 was on enhanced barrier precautions. The DON said for measuring and assessing the resident's wounds, a gown and gloves were required. The DON said failure to wear the appropriate PPE could lead to the spread of infection. Record review of the facility policy, Infection Control Plan: Overview updated March 2024, reflected: .Gowns and protective apparel 1. Gowns and protective apparel are worn to provide barrier protection and reduce the opportunity for transmission of microorganisms in the LTCF [long term care facility]. Gowns are worn to prevent contamination of clothing and to protect the skin of personnel from blood and body fluid exposures. Gowns that are selected for use in the facility will be impermeable to liquids. 2. Gowns are also worn by personnel during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from residents or items in their environment to other residents or environments; when gowns are worn for this purpose, they are removed before the personnel leave the resident's environment . -

Based on observations, interviews, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #4) reviewed for physical environment. The facility failed to ensure the call light was within reach for Resident #4. This could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: 1. Record review of Resident #4's Quarterly MDS Assessment, dated 10/16/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMs score was 6 indicating his cognitive status was severely impaired. He had no behaviors. He required substantial/maximal assistance (Helper does more than half the effort) with transfers and toileting. His diagnoses included non-Alzheimer's dementia and seizures. Record review of Resident #4's Care Plan, dated 10/20/23, reflected the resident was at risk for falls. Facility interventions included: Make sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. An observation and interview on 01/07/25 at 10:11 AM with Resident #4 revealed he was lying in bed. His call light was not visible. The resident said it was behind the dresser and he could not reach it. He said he did not press the call light and that staff checked on him. An interview on 01/07/25 at 10:15 AM with CNA B revealed he was in the hallway. CNA B entered Resident #4's room. CNA B looked for the call light. He grabbed it from behind the dresser and put it within the resident's reach. CNA B said it was important for Resident #4 have his call light in case he needed to use it to call staff. CNA B said he checked daily to make sure the resident's call light was within reach. An interview on 01/07/25 at 2:10 PM with RN C revealed she did not know why Resident #4 did not have access to his call light. RN C said the aides and nurses were responsible for making sure the resident had their call light within reach to contact staff. She said she made rounds every 2 hours to make sure residents had their call lights. An interview on 01/07/25 at 2:35 PM with the Administrator revealed Resident #4 lived in the Memory Care Unit and would move his call light . She said she did not know why the behavior was not care planned. An interview on 01/08/25 at 12:55 PM with the DON revealed she did not know why Resident #4 did not have access to his call light. She said staff were responsible for making sure residents had their call lights to contact staff. The DON said she had not identified it as an issue with the resident before. She said the facility was going to in-service staff to make sure residents had access to their call lights. Record review of the facility's policy titled, Resident Rights, not dated, reflected: The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and the environment was free from accident hazards for one (Resident #2) of four residents reviewed for supervision. Inside the facility the courtyard could not be viewed due to the blinds being closed and there was no camera monitoring of the courtyard. The facility failed to adequately supervise Resident #2. On 08/17/24 RN B was making rounds around 6:40 AM and Resident #2's roommate reported her missing. RN B stated he and staff searched the facility for Resident #2. He stated the Administrator, police, and ADON were notified. Resident #2 was able to exit the dining room and enter the courtyard. The alarms to the doors had been removed (08/09/24 by the Maintenance Supervisor) prior to the incident. Once Resident #2 was in the courtyard, the resident was locked into the courtyard as demonstrated by the surveyor observation. This courtyard and the locking of the doors can be considered an environmental hazard as Resident #2 was trapped. Resident #2 was found by staff around 8:50 AM on the ground by her wheelchair in the courtyard by the dining room and male secure unit; and she complained of pain to both knees. An Immediate Jeopardy (IJ) was identified on 09/04/24 at 5:30PM. The IJ template was provided to the facility on [DATE] at 5:52PM and signed by the Administrator. While the IJ was removed on 09/05/24 the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This failure placed residents at risk for not being adequately supervised and the potential for serious injury and/or death. Findings included: Record review of Resident #2's Quarterly MDS assessment, dated 08/21/24 revealed she was a [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses included hypertension, renal insufficiency (poor function of the kidneys that may be due to a reduction in blood-flow to the kidneys caused by renal artery disease), urinary tract infection, hyperlipemia (too many lipids (fats) in her blood), Non-Alzheimer's Dementia, anxiety disorder, depression, and schizophrenia. Her BIMS score was 8 out of 15, which revealed she was moderately cognitively impaired. Her behavior section revealed wandering presence and frequency occurred one to three days. Her functional status revealed she used a walker and wheelchair. She required setup or clean-up assistance with eating, sit to stand, transferring, walk 10 feet, walk 50 feet with two turns, and walk 150 feet. She required supervision or touching assistance with bathing, dressing, and personal hygiene. Review of Resident #2's Care Plan, dated 08/12/24 and revised 08/17/24, reflected Resident #2 was at-risk for elopement as evidenced by cognitive impairment. Her goal was to remain safe within the facility unless accompanied by staff or other authorized person. Her interventions were assess/record/report to MD risk factors for potential elopement such as wandering, repeated requests to leave facility, statements such as I'm leaving and I'm going home. Attempts to leave the facility, elopement attempts from previous facility, home, or hospital. Supervise closely and make regular compliance rounds whenever resident was in room. Determine the reason the resident was attempting to elope. If resident was exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, and etc. Review of Resident #2's Elopement Risk, dated 08/17/24, reflected she was a high risk of elopement. Review of the facility's Provider Investigation Report, dated 08/22/24, reflected on 08/17/24 at 6:50 AM, the facility conducted a search throughout the facility, called 911, and continued searching for Resident #2. Resident #2 was found on the ground by her wheelchair in the courtyard by the dining room and men's secure unit. EMS was on-site, Resident #2 was at baseline and refused to be sent to the hospital for further evaluation. A head-to-toe evaluation was completed and no injury was noted at the time of the assessment. Resident #2 complained of pain to both knees and the physician was notified. Neuro assessment and skin assessments were completed. The Administrator followed up with Resident #2 to ensure her safety and well-being in the facility and spoke with the RP. Resident #2 initially refused to go to the hospital but was sent to the ER per family request. Lab results from the hospital revealed she had a UTI. The facility conducted an elopement drill and would complete three elopement drills per week for the next four weeks. The facility staff were educated on elopement prevention and response policy and emphasized on checking courtyards during searches. Staff were educated on the importance rounding during shift change and two hour rounding. An abuse and neglect in-service was completed. Elopement risk assessments were completed. Resident #2's care plan was updated. Elopement assessments were completed with doctor's orders. Resident #2 was placed in the female secure unit. Resident will be assessed for elopement risk after completion of UTI medication. Observation on 09/03/24 at 1:05 PM revealed the Administrator and Surveyor exited one of the doors in the dining room to enter the male secure unit courtyard. Once the door was opened the alarm sounded. When the door closed the alarm shut off. There were windows with closed blinds facing the courtyard. The layout of the courtyard was in between the male secure unit and the main dining room. There was a sidewalk in the middle of the courtyard. There were air conditioning units on both sides of the courtyard. Once in the courtyard the Surveyor and Administrator were unable to re-enter the facility. The Administrator and Surveyor were not visible from inside the facility once outside in the courtyard. There were no cameras in the courtyard. Not having cameras in the courtyard also contributed to the area being a hazard. The Administrator had to use her phone to call staff to open the door from inside the facility. Any staff or resident using the main dining room could enter the courtyard. There were no residents by the doors. However, there were vending machines next to the doors that residents access throughout the day. Interview with the Administrator on 09/03/24 at 1:09 PM revealed Resident #2 had moments of confusion. She stated Resident #2 was a new admission and had not had any previous elopements while at the facility. Resident #2 went missing around 6:47 am on 08/17/24. She stated Resident #2 got turned around and exited the door in the dining room near the vending machine. She stated the door did not have an alarm and was unlocked. She stated the door could be pushed open into the male secure unit courtyard and once outside the dining room door locked when closed. She stated Resident #2 fell out of her wheelchair (unknown how she fell out of her wheelchair) and was found around 8:50 AM in between two air conditioning units. She stated the temperature outside was in the 80s (Fahrenheit). She stated Resident #2 was assessed by the nurse and did not sustain any injuries. She stated Resident #2 complained of pain to her knees. She stated the physician was notified. The Administrator stated Resident #2 refused to go the hospital but the RP agreed to have her sent to the hospital. The Administrator stated Resident #2 received an X-ray at the hospital and no fractures were noted. She stated Resident #2 was not previously on the female secure unit but was moved to the female secure unit after the elopment She stated an alarm was placed on the doors after the incident happened. She stated staff were in-serviced regarding elopement. She stated Resident #2 was moved to the female secure unit at the facility. She stated staff completed elopement drills. Interview with the Maintenance Supervisor on 09/04/24 at 10:30 AM revealed there was not an alarm on both doors in the dining room near the male secure unit courtyard. He state the alarms on the dining room doors facing the male secure unit courtyard were removed on 08/09/24 and replaced on 08/26/24. He stated the alarms on the door were removed because HHSC Life Safety informed the facility the wrong alarms were on the doors. He stated there was no alarm on the doors when Resident #2 was missing. Observation of Resident #2 on 09/04/24 at 1:20 PM revealed she was sitting in her wheelchair in the female secure unit. She was clean, well-groomed, and appropriately dressed. She was free from any odors. She displayed no obvious signs or symptoms of distress. There were no concerning marks or bruises noted on her person. There were no noted concerns regarding her appearance. During an attempted interview with Resident #2 on 09/04 at 1:20 PM, it was noted that Resident #2 was pleasantly confused and was unable to participate in a reliable interview due to cognitive impairment. However, she reported that she had bruising and was in pain after the incident. Review of the facility's policy title, Elopement Prevention, dated January 2023, reflected, every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. An Immediate Jeopardy (IJ) was identified on 09/04/24 at 5:30PM. The IJ template was provided to the facility on [DATE] at 5:52PM and signed by Administrator. A Plan of Removal was requested at that time. The facility's Plan of Removal was accepted on 09/05/24 at 2:09 PM and reflected the following: The facility failed to ensure Resident #2 was free from accident hazards. The facility failed to ensure Resident #2 could enter and exit the facility from the male secure unit courtyard. All residents in the main building have the potential to be affected by this alleged deficient practice. Interventions: As of 9/4/2024 Resident #2 resided on the facility's female secured unit. As of 9/5/2024 Door #1 (located near the courtyard gate) has been locked by maintenance and will remain locked at all times since it is not an exit door or door of egress. Door #2 in the dining room (designated as the 2nd exit door for the courtyard) has had mag locks installed by our fire safety contractor and will remain locked at all times but will disengage when the fire alarm system is activated. The Medical Director was notified by the Administrator of this plan on 9/4/2024. An Ad Hoc QAPI meeting was held on 9/4/2024. In-services: All staff will be in-serviced by 9/5/2024 by the Admin/designee regarding the following and all staff not in-serviced by 9/5/2024 will not be allowed to work their assigned position until completion of these in-services. All new hires, PRN, and agency staff will be in-services prior to the start of their assignment: This will be ongoing. Admin and ADON were in-serviced by Compliance Nurse. Abuse and Neglect All staff must respond immediately when the door alarms are triggered and intervene as appropriate. Elopement Prevention and Response Monitoring: The Admin/Maintenance and/or designee will monitor all doors functioning, including the dining room door and alarms 5 times per week. Monitoring began 9/4/2024 and will continue x 4 weeks. Any issues identified will be addressed immediately. Monitoring: Record review of facility in-service training reports dated 09/04/24 revealed facility staff from the 6:00 AM - 2:00 PM, 2:00 PM - 10:00 PM, and 10:00 PM -6:00 AM weekday and weekend shifts and management were in-serviced regarding elopement prevention and response, elopement Risk and protection, elopement risk and prevention, if a door alarm was triggered, staff must respond immediately to assess the situation, intervene and redirect residents as appropriate, door alarm response, and abuse/neglect policy. Interviews with the Administrator, ADON, Staffing Coordinator, LVN A, RN B, LVN C, CNA D, and CNA E on 09/06/24 were between 12:00 PM and 5:18 PM revealed staff from all shifts and various disciplines were in-serviced regarding elopement prevention and response, elopement Risk and protection, elopement risk and prevention, if a door alarm was triggered, staff must respond immediately to assess the situation, intervene and redirect residents as appropriate, door alarm response, and abuse/neglect policy. Staff stated they were aware there was a keypad placed on one of the doors in the dining room facing the male secure unit courtyard. Staff stated they were aware the courtyard was for the residents located on the male secure unit with supervision. They stated they understood what to do and where able to demonstrate competency by responding to drills. Observation on 09/05/24 at 4:15 pm of both doors in the dining room near the male secure unit courtyard revealed one door was permanently sealed and the other door had a keypad installed. The keypad was for staff to access the male secure unit courtyard. The courtyard could not be accessed without a key code, and once outside in the courtyard the staff could use a key code to re-enter the facility through the male secure unit. The alarm was triggered and staff from various disciplines ran to the dining room to respond to the door alarm. A code could be used to stop the alarm. Interview with RN A on 09/06/24 at 4:32 PM revealed he was informed by Resident #2's roommate that she was not in her room. He stated Resident #2 went missing around 6:40 AM and was found around 8:50 AM. He stated Resident #2 was found on the ground in the male secure unit courtyard in between two air conditioning units. He stated there were no alarms on the doors in the dining room facing the male secure unit courtyard. He stated Resident #2's wheelchair was next to her. He stated Resident #2 appeared to be confused. He stated he assessed Resident #2 and she did not sustain any injuries. He stated Resident #2 complained of pain to both of her knees. He stated she had a history of knee pain. He stated Resident #2 was placed on the female secure unit due to her elopement. He stated Resident #2 refused to go to the hospital. He stated RP requested Resident #2 be sent to the hospital. Interview with the Administrator on 09/06/24 at 5:18 pm revealed she supervised her staff to ensure policies/procedures were being followed by monitoring, re-educating staff, rounding, and spot checking. She stated she checked the staff's work and followed up with them. She stated during morning meetings, stand down meetings, and other meetings throughout the day accomplishments were discussed. She stated the IJ occurred because Resident #2 exited out of the door to the male secure unit courtyard and was not able to re-enter through the door. She stated the IJ would have been prevented had the door alarms not been removed. She stated the lock with a keypad on one door and permanently locking the other door would prevent the incident from reoccurring. She stated staff were in-serviced regarding frequently monitoring the doors to see if the alarms went off, seeing if staff responded to alarms, elopement, abuse, and neglect. The Administrator was notified the IJ was removed on 09/05/24, however the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #1) of four residents reviewed for environment. The facility failed to ensure Resident #1's walls in his room were in good repair. The facility also failed to ensure Resident #1's air conditioning unit was properly installed in his room. The failures could place residents at risk for a diminished quality of life due to the lack of a homelike environment. Findings included: Record review of Resident #1's Quarterly MDS assessment, dated 08/24/24 revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included hypertension, hip fracture, aphasia (a disorder that affects how you communicate), cerebrovascular accident (an interruption in the flow of blood to cells in the brain), Non-Alzheimer's Dementia, traumatic brain injury, malnutrition, and psychotic disorder. His BIMS score was 0 out of 15, which revealed he was severely cognitively impaired. Observation on 09/03/24 at 11:50 AM of Resident #1's room revealed there was a hole in the corner of the wall above the base baseboard located near the right side of the room. There was a gap above the upper right side of the air conditioner. The outside of the facility was visible from the gap. Resident #1 appeared to be confused and did not answer the surveyor's questions. Review of the maintenance log titled, Task Export Report, undated, revealed there were no repairs made to the gap above the air conditioner or the hole in the corner of the wall above the baseboard. Interview with CNA F on 09/03/24 at 11:59 am revealed he did not know there was a gap above the air conditioner and a hole in the wall above the base boards on the right side of the room. He stated he would inform the nurse and Maintenance Supervisor if repairs were needed in a resident's room. He stated the Maintenance Supervisor was responsible for making repairs at the facility. He stated the gap above the air conditioner and the hole in the wall did not create a home like environment for the resident. Interview with the Maintenance Supervisor on 09/04/24 at 10:30 AM revealed he was responsible for facility repairs. He stated he made rounds throughout the facility at least four times a day. He stated the facility had a program called Champion Rounds (staff are assigned rooms at the facility to check on resident concerns). He stated staff would complete a form regarding any maintenance concerns. He stated his primary focus during rounding at the facility was the exterior. He stated he did not know there was a gap above the air conditioner and a hole in the corner of the wall in Resident #1's room. He stated the gap above the air conditioner needed to be sealed. He stated sheet rock and spackle was needed to repair the hole in the corner of the wall. He stated there were no risk to Resident #1. He stated the gap above the air conditioner and the hole in the corner of the wall did not affect Resident #1's home like environment. Interview with the Administrator on 09/06/24 at 5:18 PM revealed she was not aware there was a gap above the air conditioner and hole in the corner the wall in Resident #1's room. She stated the Maintenance Supervisor made daily rounds at the facility. She stated the Maintenance Supervisor was actively making repairs throughout the facility. Record review of the facility policy titled Preventative Maintenance/Work-Order Request, dated 2003, revealed The facility will repair or replace damaged/broken equipment or building amenities as needed.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 8 residents (Resident #30) reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #30 on 6/4/24 during lunch service when LVN A had a witnessed, verbal altercation with Resident #30. The altercation occurred in the presence of other residents. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #30's Admission Record revealed he was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #30's Quarterly MDS assessment dated [DATE] reflected he had moderately impaired cognition, used a wheelchair for mobility and required partial to moderate assistance with eating. The MDS Assessment reflected his diagnoses included: hypertension (high blood pressure), non-Alzheimer's dementia (changes in the brain that can cause forgetfulness, limited social skills, impaired thinking, irritability, and extreme mood swings). Record review of Resident #30's Care Plan reflected the following entries: An entry dated 3/10/22 and revised on 2/23/24 reflected: Focus: [Resident #30] has impaired cognitive function and impaired thought processes r/t Neurological symptoms, Short and Long term memory loss . Interventions: . Ask yes/no questions in order to determine the resident's needs . Cue, reorient and supervise as needed . Use task segmentation to support short term memory deficits. Break tasks into one step at a time. An entry dated 3/10/22 and revised on 2/23/24 reflected: Focus: I have an ADL self-care performance deficit r/t CVA .Interventions: . EATING: I am able to feed self with set-up assistance . Encourage me to participate to the fullest extent possible with each interaction . When assisting, observe for any changes in my ability to participate in my care and report any changes in ADL function . During an observation on 6/4/24 at 1:22 AM, Resident #30 was observed in his room, sitting in a wheelchair. He was well-dressed and groomed and was holding a toothbrush and toothpaste. He denied any concerns or complaints about his care at the facility. During an observation in the dining room on 6/4/24 at 12:31 PM, Resident #30 was observed sitting at a table by himself eating lunch. There were approximately six residents still eating their lunch. LVN A was observed several feet away from Resident #30 at another tab le attending to other residents. Resident #30 called out to LVN A stating he wanted a coffee refill. (This Surveyor G was standing at a table situated between Resident #30 and LVN A talking to Residents #14 and #56). LVN A stated, He normally gets it himself;, he's being lazy today. LVN A was speaking loudly enough to be heard by Resident #30. Resident #30 stated, She's being mean to me! LVN A stated, That's what he does when he doesn't want to get it himself. Resident #30 appeared angry and yelled out, I'm reporting you to the State! LVN A replied loudly, I'm reporting myself to the State right now! This Surveyor G approached Resident #30 and asked him whether he typically refilled his own coffee and he replied, no. He motioned toward the coffee container which was situated on a bar across the room and stated he did not like to because it was a little high for him. LVN A, still standing a few tables away, stated, Oh you big liar, he can do it himself. The DON entered the dining area and was waved down by Resident #30. Resident #30 asked him to get him some more coffee. The DON took his cup, refilled his coffee, retrieved extra sugar for him then left the dining area. It was unclear whether the DON had heard any of the verbal exchange. After the DON left the area, LVN A stated, you can do it, I've seen you do it, you tell stories to everyone. I'll remember that tomorrow. Resident #30 turned his attention to drinking his coffee and appeared to ignore LVN A's remark. LVN A continue to assist other residents and pick up tray. ADON B entered the dining room and also began to remove trays. Resident #30 left the dining room with no further verbal exchange. During an interview on 6/4/24 at 12:59 PM, LVN A was asked what she meant when she said to Resident #30 'I'll remember that tomorrow'. She stated, I said that because he'll get his own coffee tomorrow, like there are times he'll have other residents push him to his room, I've had to ask him to stop doing that before another resident gets hurt. This is his behavior. He gets his own coffee himself all the time, but when a manager or someone walks in, he acts like that. When asked if she felt it was appropriate to call him a liar across the dining room, LVN A denied saying it. When this Surveyor G read her quote to her, LVN A stated she only did it once because he does that all the time, he comes in the dining room and demands, 'where's my food?', I'll tell him to come and sit and be patient and he'll get angry. When asked if she routinely cared for Resident #30 and if his behaviors had ben care planned, LVN A stated he did not reside on her hall, and she mainly interacted with him in the dining room or the hallway. She stated she would normally interact with him and joke around in the hallway but in the dining room he acts like 'Bring it to me!' He demands it immediately only when someone else walked in. LVN A stated she had received training on Abuse and Neglect the day before. She stated she did not consider the incident to be verbal abuse because, Technically he was lying because he said he never does it and he does it all the time, when someone's around, he acts like that. When asked if she felt it was appropriate to treat someone like that who had those types of behaviors, LVN A stated, no and stated she normally did not react when he did it. She stated she would normally say, go get your coffee and he would go, but then he would start complaining. She stated he would cut her off whenever she tried to talk to him just as he would when she would ask him not to have residents push his chair. She stated she would ask him to stop, and he would start yelling if she said something he did not want to hear. She stated she knew there was a risk of escalating Resident 30's behavior but sometimes he got under her skin, and she knew she should not let him get to her. LVN A stated the risk of altercations with other residents present was that it could escalate other resident's behaviors. She stated, All we're trying to do is to get him to do more for himself when he doesn't want to. She stated her comment of I'll remember this tomorrow meant he's going to start with 'get me my coffee or I'll get the State'. She stated the comment was not a threat to the resident. During an interview on 6/4/24 at 1:16 PM with the Administrator, DON and Area Director of Operations, the Administrator stated he had been made aware by LVN A that she had a disagreement with Resident #30 and had been removed from the floor. The Administrator stated he was familiar with Resident #30, and he would stop him in the dining room and ask for coffee. He stated Resident #30 would ask him for additional refills before finishing his current one. The DON stated he began working at the facility the previous week and was often in the dining room. He stated Resident #30 would cross the dining room to get his attention or that of another staff member. This Surveyor G reported the events witnessed in the dining room during lunch observations. The Administrator stated verbal altercations and arguing with residents could cause psychological issues for the resident. The DON stated altercations could lead other residents' behaviors and be perceived as aggression. The Administrator stated LVN A would be suspended pending an investigation and a report would be called into the State. He stated the ADONs and DON would assess Resident #30. During an observation and interview on 6/4/24 at 2:28 PM, Resident #30 was observed being wheeled into his room by facility staff who told him they would be right back to assist him. Resident #30 stated he was doing fine. Resident #30 stated LVN A was the only staff member who made him angry. He denied ever complaining about her in the past. He stated he did get his own coffee at times but did not want to that day because he was afraid that he would spill it. He stated he saw LVN A getting coffee for other people all the time and she made him angry that day at lunch. He stated he believed LVN A had an attitude. He denied any other complaints and stated he was glad the situation had been reported. An observation and interview on 6/4/24 at 2:57 PM revealed Resident #56 and Resident #14 were sitting in their room. Both residents stated they were not bothered by the altercation in the dining room between Resident #30 and LVN A and neither could recall ever seeing any staff being rude to residents. Resident #56 stated he had previously seen Resident #30 be rude to LVN A. During an interview on 6/5/24 at 8:19 AM, CNA D stated she worked on Resident #30's hall. She stated she had not seen Resident #30 ever pour his own coffee but did not often work in the dining room during meals. She stated he would ask her to get coffee for him at times. CNA D stated Resident #30 was usually friendly but, depending on his mood, would occasionally yell or speak abruptly at staff. She stated she had never seen him have any altercations or complaints with staff members. During an interview on 6/5/24 at 8:38 AM, Resident #39 stated he had been in the dining room during lunch on 6/4/24. When asked if he had noticed any altercations there, he replied, They guy with the coffee? Yeah. He stated he had never noticed, and staff get into altercations or be rude with anyone before and was not bothered by it. He stated Resident #30 just gets mad sometimes. An observation and interview on 6/5/24 at 9:07 AM revealed Resident #30 was self-propelling in the hallway in his wheelchair, smiled and said hello. Resident #30 asked this Surveyor G if I was there yesterday and he was reminded I had spoken with him in his room and dining room. Resident #30 laughed and stated, Oh yeah!. He stated he was doing just fine today. During an interview on 6/5/24 at 9:21 AM, ADON C stated she had been working at the facility for about 2 months. She described Resident #30 as very polite to her, alert and oriented, could definitely make his needs known. She stated he knew what he wanted and liked such as not wanting to get up early in the morning, he would definitely let the nurse know about it. She stated she did not recall seeing him in any altercations with staff. She stated it was in his nature to say something like, hey move! if someone was in his way but nothing volatile. ADON C stated she had seen him in the dining room in passing and he would sit at his own table and feed himself. She stated she had seen him go and retrieve his own coffee and did not recall him having any difficulty with it. ADON C stated she had previously seen him interact with LVN A and it was usually laughing and joking, never bickering, or having cross words. ADON C stated she did not believe his behaviors warranted any special care plans other than the general behavior monitoring for changes that would go along with medications or cognitive issues. She stated he was generally a laid-back guy. ADON C stated she spoke with Resident #30 in the afternoon on 6/4/24 and he told her he was upset about the altercation. She stated he made some small-talk afterward and told her he was doing okay. She stated he had never mentioned anything like it happening before. ADON C stated the facility had just completed in-servicing related to abuse, neglect, and misappropriation the week before. She stated, had she witnessed the situation, she would have asked LVN A to leave, assisted the resident with his needs and report the situation to the Administrator immediately. ADON C stated they had ongoing conversations with the staff regarding burnout and they were always encouraged to ask for help, step away for some air, and ask managers for help if they felt themselves getting upset. She stated the risk of verbal abuse or altercations with residents was escalation of behaviors. An observation on 6/5/24 at 12:38 PM revealed Resident #30 was sitting in the dining room eating lunch. When asked how he was doing, he lifted his coffee cup, smiled and replied, good. During an interview on 6/5/24 at 12:48 PM, ADON B stated she conducted in-service training in the facility and had just conducted training related to Abuse and Neglect on 5/30/24. She stated the in-service included a review of verbal, physical and mental abuse, as well as misappropriation. She stated examples of each type were discussed and the importance of calling the administrator immediately for any suspected occurrences. When asked what was meant by 'mental abuse', ADON B described it as generally messing with them and gave the example of, if you know a resident hates red and you're constantly showing them red things, doing things that could trigger them or cause them to become upset. She described verbal abuse as degrading a resident like calling them by a name when you know they asked to be called by another. She stated calling a resident a 'liar' would be considered verbal abuse because you were attacking their character. ADON B stated she had not heard anything when she entered the dining room during lunch on 6/4/24 and was coming to assist the residents who were finishing their meals. ADON B stated she was occasionally asked by Resident #30 for coffee when she rounded through the dining room during breakfast, and she did not recall ever seeing him pour his own. She stated he would yell out at her in the hallway at times just to say hello. ADON B stated she did not recall Resident #30 ever getting into altercations with staff or other residents. She stated, when Resident #30 wanted something, it was part of his demeanor to say I want it now but she did not feel that warranted a special care plan. She stated they just got him what he needed, and he was fine. The Corporate Compliance Nurse joined the interview and stated managers were trained about staff burnout and the importance of paying attention to the staff for indications of burnout. She stated staff were constantly reminded to reach out to managers if they were feeling overwhelmed and needed a break. ADON B stated she was constantly on the floor checking to see if the staff needed any assistance and they all knew to call her in the evening and on weekends as well. The Corporate Compliance Nurse stated the facility also provided additional ongoing computer-based training to staff that touched on burnout, abuse, and other topics. She stated the courses were a requirement and she would pull a transcript for LVN A showing the trainings she had completed. ADON B stated her expectation was that if a resident requested a cup of coffee, regardless of their behaviors, they should be provided with it as just good customer service. She stated if a staff member felt a resident was getting 'under their skin', they should step away to cool off or report to their manager for assistance. She stated the risks of verbal or mental abuse included psychological harm, fear, depression, and escalation of behaviors. She stated the risks to residents witnessing staff to resident altercations included fear of staff and increased behaviors themselves. During an interview on 6/5/24 at 1:20 PM, LVN E stated she regularly cared for Resident #30. She stated he was receiving medications for anxiety and sometimes had periods of confusion making it difficult to tell if he was joking or not. She stated he sometimes had verbal exchanges with other residents, including his roommate, but it was never more than just bickering. LVN E stated she had previously never heard of him having any altercations with staff members. She stated she had not observed him in the dining because she usually worked the 2 PM to 10 PM shift and was assigned to another dining room at dinner. LVN E stated she was made aware had had been in an altercation and was told to monitor him for any changes. She stated she had not noted anything out of the ordinary for him. She stated the risk to residents involved in altercations with staff was it was demeaning to the resident;, they may feel less important and have a decrease in dignity. She stated the risk to residents witnessing staff to resident altercations was they might be taken aback and feel uncomfortable around staff. An observation and interview on 6/6/24 at 12:55 PM revealed Resident #30 was sitting in his room watching television. He stated things were going well and had improved in the dining room. He expressed his appreciation that people had listened to him and denied any concerns. During a telephone interview on 6/6/24 at 12:58 PM, LVN F stated he was working the day shift on 6/4/24 and taking care of Resident #30. He stated he had been informed the resident had been in an altercation and monitored him for any distress. LVN F stated he checked on Resident #30 and he did not show any concerns or distress. He stated the resident had a visit from a family member and they left the unit to visit. LVN F stated he had never seen Resident #30have any altercations with staff. He stated he could definitely demand what he wanted. He stated if was never acceptable to argue with him, just smile and get it, that's his personality. LVN F stated he was usually assigned to a different dining room during meals so he rarely saw Resident #30 in the dining room but, when he did, the resident would occasionally stop him and ask for things like extra sugar. LVN F described verbal abuse as as cussing at residents, exchanging words or being argumentative with residents. He stated the risk to residents included mental distress and depression. He stated the risk to resident bystanders during a staff to resident altercation included fear of the situation and fear of asking the staff for assistance because they may be abused. In an interview on 6/6/24 at 1:20 PM, ADON C stated they were still monitoring Resident #30 for any adverse effects. She stated a psychiatric nurse had met with Resident #30 on 6/4/24 and had no immediate concerns. During an interview on 6/6/24 at 1:36 PM, the DON stated LVN A continued to be suspended. He stated they had initiated in-service training for all staff related to abuse, resident rights, interacting with residents and customer service. The DON stated they had a psychological consultation completed for Resident #30 on 6/4/24. He stated he continues to check on Resident #30 and staff monitored him every shift and in the dining room. He stated he felt the risk for residents was they may become fearful to ask for help. During an interview with the Administrator on 6/6/24 at 1:49 PM, he stated he had been investigating the incident and LVN A would not be returning to the facility. He stated their investigation determines she had been properly trained and she still acted the way she acted. The Administrator stated the DON and ADONs continued to follow-up with Resident #30 and he had spoken with him as well. He stated safe surveys were conducted with residents and no other complaints had been reported. The Administrator stated he expected the staff to reach out to management if they felt stressed, take a break or walk away. He stated verbal abuse placed residents at risk for suffering anxiety and make them fearful of asking for help. During an interview on 6/6/24 at 2:12 PM, the Social Worker described verbal abuse as screaming at a resident, calling them by different names, or being verbally demeaning. She stated she had not received any complaints from residents or family members regarding abuse and had never received any complaints regarding LVN A. The Social Worker stated she had conducted safe surveys with facility residents as part of the abuse investigation and had not received any complaints or concerns from the residents. The Social Worker stated the risks to residents involved in verbal altercations with staff included they could become fearful of retaliation, experience an escalation in behaviors and sustain psychosocial harm. She stated the risk for other residents who may witness staff to resident altercations was that may become fearful and think, that can happen to me. Record review of the facility's in-service dated 5/30/24 conducted by ADON B reflected the staff were trained on the facility's Abuse/Neglect policy and procedure. The In Service Training Attendance Roster reflect the training had been attended by LVN A. Record review of the facility's policy and procedure titled, Abuse/Neglect dated Revised 3/29/18 reflected the following: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart . Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Definitions: 1. Abuse: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .3. Verbal Abuse: Any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, or within their hearing distance, regardless of their age, ability to comprehend, or disability .Procedure: A. The facility will conduct criminal background checks of all personnel in accordance with Texas Health and Safety Code, Chapter 250 .C. Prevention: The facility will provide the residents, families, and staff an environment free from abuse and neglect .

Based on interview and record review, the facility failed to transmit resident assessments within the required time frame for 3 of 3 discharged residents (Resident #1, #3, #59) reviewed for data encoding and transmission to CMS that: The facility failed to ensure the resident's assessments were encoded and transmitted timely. Resident #1 ARD was due on 5/3/2024 according to the resident's individual ARD- Assessment Reference Date. Resident #3 ARD was due on 5/3/2024 according to the resident's individual ARD- Assessment Reference Date. Resident #59 ARD was due on 5/2/2024 according to the resident's individual ARD- Assessment Reference Date. This failure placed residents at risk for not having their MDS Assessments transmitted in a timely manner. The findings included: Record review of Resident #1's face sheet revealed the resident original admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's admitting diagnoses included Metabolic Encephalopathy- (Degeneration of brain function), contracture- (a shortening or distortion of muscular or connective tissue) of right knee, contracture of left knee, chronic diastolic (congestive) heart failure. Record review of Resident #1's EMR revealed the resident's last quarterly MDS dated [DATE] MDS with ARD date of 05/03/2024 was not encoded and transmitted as of 06/10/2024. Record review of Resident #3's face sheet revealed the resident original admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3's admitting diagnoses included essential hypertension, anxiety disorder, glaucoma with increased episcleral venous pressure. Record review of Resident #3's EMR revealed the resident's last quarterly MDS dated [DATE]. MDS next ARD date of 05/03/2024 was not encoded and transmitted as of 06/10/2024. Record review of Resident #59's face sheet revealed the resident admitted to the facility on [DATE]. Resident #59's admitting diagnosis included unspecified dementia, unspecified severity, without disturbance, psychotic disturbance, mood disturbance and anxiety. Record review of Resident #59's EMR revealed the resident's last quarterly MDS dated [DATE]. MDS next ARD date of 05/02/2024 was not encoded and transmitted as of 06/10/2024. Interview on 06/06/24 at 02:42 PM with MDS coordinator indicated she as the only MDS coordinator at this time and she took over the position about a month ago. The MDS coordinator revealed there are some MDS that have been completed but not sent CMS. The MDS coordinator revealed she follows the facilities MDS Policy for the scheduling of assessments. The MDS coordinator revealed the corporate office sends staff to the facility to assist and sign the MDS for transmittal. The MDS coordinator revealed the importance was to provide a picture of the care for the resident. The MDS coordinator stated the new Director of Nursing was not, yet MDS trained. Interview on 06/06/2024 at 3:00pm with the administrator revealed understanding of the importance of transmitting the MDS assessments in a timely manner. The facility's policy for MDS assessment data accuracy 2.2021 revealed Purpose/Policy 7. The OBRA schedule and if applicable the Medicare PPS assessment schedule must be followed for setting of the Assessment Reference Date (ARD) and completion of the MDS assessment. Please refer to CMS's RAI 3.0 Version Manual for the scheduling of assessments. CMS's RAI-Resident Assessment Instrument Version 3.0 Manual. Chapter 5: Submission and Correction of the MDS Assessments 5.2 Timeliness Criteria In accordance with the requirements at 42 CFR S483.20(f)(1), (f)(2), and (f)(3), long-term care facilities participating in the Medicare and Medicaid programs must meet the following conditions: o Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (i.e., enter the information into the facility MDS software). The encoding requirements are as follows: - For a Quarterly, Significant Correction to Prior Quarterly, Discharge, or PPS assessment, encoding must occur within 7 days after the MDS Completion Date (Z0500B + 7 days).

Based on observation and interview, and record review, the facility failed to provide adequate supervision and ensure the resident environment remains free of accident hazards as is possible for 2 of 2 (male unit and female unit) secure units reviewed for accidents and hazards. 1. The facility failed to ensure the emergency exit door was locked. Resident #1 was able to exit from the back door and then fell outside while she ran from staff from the secure unit. Resident #1 subsequently had a serious injury to the forehead which resulted in her having three stitches. 2. The facility failed to have a monitoring system for residents who wanted to go outside in the courtyard from the dining room exit door to the outside smoke area in the secured unit. These failures could place residents at risk of accidents, injury, or being left outside exposed to physical environment elements. Findings included: 1. Record Review of face sheet dated 01/12/2024 revealed Resident #1 was an [AGE] year-old female admitted on [DATE]. Her diagnoses included: dementia (impaired ability to remember, think, or make decisions that interferes with doing every day activities), agitation, anxiety disorder (persistent and excessive worry that interferes with daily activities), hypertension (high blood pressure is when the pressure in your blood vessels is too high 140/90 mmHG or higher) chronic pain(long standing pain that persists beyond the usual recovery period), and epilepsy (a brain condition that causes recurring seizures). Record review of Resident #1's MDS assessment dated [DATE] revealed Resident #1 had no BIMS score noted which indicated severe cognitive impairment. Record review of behavior section of the MDS assessment revealed a score of 1 for physical behavioral symptoms directed toward others (hitting, kicking, etc.) and verbal behavioral symptoms directed toward others (screaming, etc.) which indicted this behavior occurred 1 to 3 days. Record review of wandering section of the MDS assessment revealed a score of 0 which meant no behavior exhibited. Record review of health condition section of MDS assessment revealed no falls noted. Record review of Resident's #1's care plan dated 01/12/24 reflected: Resident resides in the Secure Care Unit, related to diagnosis of dementia (or related diagnosis) and risk for elopement. Disoriented to place Goal: Resident will not have feelings of isolation and will feel safe and secure in the care received while on the Secure Care Unit. Interventions: Admit to Secure Care unit per MD orders. Record review of Resident#1's incident report dated 01/16/24 at 10:45 AM was completed by LVN T revealed: The resident was walking in the hallway and went out the back emergency door and fell . The resident is confused and could not answer. She only said, 'you got me.' The incident report reflected a head to toe assessment was performed, and the resident was noted to have a laceration that required first aide. The resident was not taken to the hospital. The incident report reflected LVN A and CNA J were witnesses. The incident report's post incident section reflected: no injuries observed post incident. It also reflected the physician and responsible party were notified. Record review of the fall assessment sheet dated 01/16/24 at 11:00 AM, completed by LVN T, revealed Resident #1's blood pressure was 132/74 and pulse was 80. Record review of fall assessment sheet revealed no injuries. Record review of Resident #1's progress notes was completed by ADON M, dated 01/16/24 reflected, Resident #1 was transferred to a hospital on 01/16/2024 at 11:00 AM related to fall with laceration to forehead. Interview on 04/10/24 at 8:27 AM with Resident #1s family member (Family Member #1) revealed staff (unknown) reported to her that Resident #1 was running away from staff and trying to go out the back door. Family Member #1 revealed staff reported she fell and hit her head and was bleeding. Family Member #1 revealed Resident #1 had to get three stitches. Family Member #1 revealed Resident #1 did not return to the facility. Interview on 04/10/24 at 10:15 AM with Maintenance revealed Resident #1 went out the back emergency door. He stated the alarm sounded when the door was opened. Interview on 04/10/24 at 10:45 AM with Resident #1's family member (Family Member #2) revealed staff (unknown) reported to her that Resident #1 was running from staff and tripped going out the back door and had a cut to her forehead. Family Member #2 revealed Resident #1 cannot run at all and used a walker. Family Member #2 revealed Resident #1 had to get three stitches to the forehead. Interview on 04/10/24 at 1:30 PM with CNA J revealed she did not recall Resident#1. Interview on 04/10/24 at 1:55 PM with LVN A revealed Resident #1 had fallen on the concrete outside, and she was bleeding. LVN A revealed the paramedics picked her up. Interview on 04/10/24 at 2:20 PM with LVN L revealed she saw Resident #1 outside on the ground from another resident's room. LVN L revealed the paramedics came and took her to the hospital. LVN L revealed she did not recall anything else from that incident. Interview on 04/10/24 at 2:58 PM with ADON A revealed she was not the ADON on duty at the time of incident. ADON A revealed Resident #1 tried to get out of the secure unit back door. ADON A revealed Resident #1 fell and had a laceration to her forehead and was transferred to the hospital. Interview on 04/10/24 at 3:12 PM with the DON revealed Resident #1 tried to get out the backdoor and ran away from staff. Resident#1 fell , and the paramedics were called. The DON revealed the family took Resident#1 out of the facility. The DON revealed she called the hospital to check on patient and no information was given. Interview and record review at 04/10/24 at 3:55 PM with the Administrator revealed she did not report Resident #1's incident because it was a witnessed fall. The Administrator revealed the facility was not aware Resident #1 had to get stitches. 2. Observation on 04/10/24 at 8:47 AM of the male secure unit revealed no visible staff when entering the secure unit and dining room area. Observation on 04/10/24 at 9:00 AM revealed the dining room door going to the courtyard was unlocked and opened with no alarm sound. Observation of the courtyard revealed it is fenced in. Observation of the dining room door to enter back into the facility did not alarm or lock. Interview on 04/10/24 at 9:16 AM with LVN J revealed residents went in and out the door to smoke. LVN J revealed resident were supervised during smoke breaks always. Interview on 04/10/24 at 10:15 AM with Maintenance revealed the male secure unit dining room door had never had an alarm or locking mechanism since he had been at the facility the last 2 years. Interview on 04/10/24 at 2:10 PM with CNA R revealed residents went in and out the door to smoke. CNA R revealed residents could go outside when the weather was bad, like when it was raining or when it was too hot, and could get hurt. Interview on 04/10/24 at 2:20 PM with LVN L revealed residents in the male secure unit went in and out the door. LVN L revealed this could be a security issue, and it was possible for someone to jump the fence and come into the facility. LVN L revealed a resident could be left outside. Interview on 04/10/24 at 3:12 PM with the DON revealed the dining room door that led to the courtyard/smoke area had always been unlocked and unalarmed. The DON revealed the door has always been this way. The DON revealed residents could get outside and be exposed to the elements. Interview on 04/10/24 at 3:55 PM with the Administrator revealed the dining room door that led to the courtyard/smoke area had always been unlocked. The Administrator revealed corporate was contacted about the door not having a locking mechanism or alarm system. The Administrator revealed the facility's corporate reported the secure fence made the unit secured. The Administrator revealed residents could be unattended and exposed to inclement weather. Record review of facility's current, undated Secure Care Program Admission Criteria and Process policy reflected the following: The goal of the Secure Care Program is to meet the individual needs of residents living with Dementia. The Secure Care Program will provide a safe environment .The resident must score 10 or greater on the elopement risk assessment. An attempt was made to contact LVN T via telephone, but the attempt was unsuccessful. The Administrator and DON were asked to provide the contact information for ADON M, but the contact information was not provided prior to exit.

Based on observation, interview, and record review the facility failed to properly secure medications in a locked compartment for 4 of 5 medication carts (Halls 100, 200, 300 hall nursing carts, and Medication Aide cart) and 1 of 1 treatment cart reviewed for drug storage. LVN A left 4 medication carts and 1 treatment cart unlocked and unattended in the hallway near the 300 Hall nursing station for an unknown amount of time . These failures placed residents at risk for unauthorized access to the medication cart and consumption of harmful medications. Findings include: In an observation during initial tour of the facility on 03/12/24 at 4:08 AM, 4 medication carts and one treatment cart were observed lined up surrounding a corner nurses' station on the 300 Hall . No staff were observed in the area and no residents were observed in the hallways. An observation on 03/12/24 at 5:04 AM at the 300 Hall nurses' station revealed there were 4 medication carts and 1 treatment cart situated around the nurses' station. All 5 carts were unlocked. During an observation and interview on 03/12/24 at 5:26 AM at the 300 Hall nurses' station, LVN B stated he had been responsible for all the carts there during the 10:00 PM to 6:00 AM shift. He stated he was covering the 100, 200, and 300 halls that evening. The carts were used for those halls and included nurses and medication aide carts as well as a treatment cart. He stated he had counted the carts with the previous shift with no concerns. He stated he was accustomed to managing the carts overnight and typically carried one set of keys for one cart on his person and locked all the other keys into that cart. He stated the carts should be locked at all times. LVN B stated he could not explain why he had walked away leaving them all unlocked and must have become side-tracked while organizing and stocking the contents. He stated managing so many carts was not usually a problem for him but he had become busy during the night. He was unable to say how long he was away from the carts while they were unlocked. LVN B stated the risks for leaving the carts unlocked included residents could gain access to items such as medications and scissors which could cause injury or illness. In an interview on 03/12/24 at 11:47 AM, the DON stated she had been made aware by LVN B that the medication carts and treatment cart had been left unlocked and unattended that morning. She stated the carts had been checked and they found nothing to be missing. The DON stated all nursing staff were responsible for ensuring their carts were locked and secure at all times. She stated she and the ADONs had already initiated in-service training with all nurses and medication aides. The DON stated medication and treatment carts should always be locked when not in use and risks included unauthorized access to medications by residents. During an interview with the Administrator on 03/12/24 at 12:51 PM, she stated she had been made aware there were unlocked medication carts in the hallway that morning and the DON had initiated in-services. She stated all nursing staff were responsible for ensuring the medication carts were locked and secured at all times. She stated risks included unauthorized access to medications by residents. Record review of the facility's policy and procedure titled, Medication Carts, dated 2003 reflected: 1. The medication carts shall be maintained by the facility. 2. The carts are to be locked when not in use or under the direct supervision of the designated nurse . 4. Carts must be secured

Based on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for one (Men's Secured Unit) of two (Men's Secured Unit and Women's Secured Unit) resident secured units reviewed for sufficient staff. The facility failed to have sufficient staff available to provide resident care and supervision for the men's secured unit on the 10:00PM to 6:00AM shift beginning on 03/11/24 and ending on 03/12/24. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: Observation of the Women's Secured Unit on 03/12/24 at 4:10AM revealed the two staff members who were assigned to work on the separate secured units, CNA H and LVN C, were both physically present on the Women's Secured Unit. Observation of the Men's Secured Unit on 03/12/24 at 4:15AM revealed there were no staff members present on the Men's Secured Unit. It appeared as though all the residents on the Men's Secured Unit were in their rooms; no residents were observed wandering the halls and no call lights had been activated. During an interview with LVN C on 03/12/24 at 4:10AM, she stated that she and CNA H were the only staff members who were assigned to work on the separate men and women's secured units. LVN C stated the facility was currently running short on staff. She said the facility typically staffed 2 Nurses and 5 CNAs on the 10:00PM-6:00AM shift; however, on the current shift, the facility only had 2 Nurses and 3 CNAs on duty. LVN C stated she notified the appropriate parties that there had been call-ins for the current shift, but no coverage was found. She stated because of this, at the time of the surveyors' entrance into the building, there were no staff members present on the Men's Secured Unit. LVN C said typically, she and CNA H would switch off so there was always coverage on both units, but she was busy completing documentation which kept her from being on the men's side of the secured unit. During an interview with the Administrator on 03/12/24 at 12:52PM, she stated the facility typically staffed the 10:00PM-6:00AM shift with 2 Nurses and 4-5 CNAs. She stated on the most recent 10:00PM-6:00AM shift in which the surveyors entered the facility, none of the direct care staff present advised that there was a call-in on the secured unit, leaving them short staffed. She stated she was not aware that the Men's Secured Unit was left unsupervised; the expectation was for both the men and women's secured units to be supervised at all times. She stated the risk of a secured unit being left unsupervised was the potential for accidents and negative outcomes. Review of the facility's Employee Punch Report, dated 03/12/24, revealed on the 10:00PM to 6:00AM shift (03/11/24 to 03/12/24), there were 2 Nurses and 3 CNAs who worked the shift. During an interview with the Administrator on 03/12/24 at 2:20PM, she stated the facility did not have any written policies or procedures related to staffing levels or staffing of the secured units.

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of (Halls 500 and 600) six halls and 3 (Residents #1, #2, and #3) of 9 residents reviewed for safe environment in that, 1. The facility failed to provide hot water on Halls 500 and 600 2. The facility failed to provide linens free from stains and holes for Residents #1, #2, and #3. These failures could place residents at risk for a diminished quality of life due to an unhomelike and uncomfortable environment. Findings included: During an interview on 03/12/24 at 6:29 AM, ADON A stated she was the Unit Manager over the 500 Hall and 600 Hall which were secured units. She stated she had not received any complaints related to the facility linens or water temperatures. She stated she had seen a few towels with stains but they did not really look bad. In an observation on 03/12/24 at 7:09 AM, in room [ROOM NUMBER] which was occupied by Resident #1, the resident was out of the room, her bed was unmade, there were multiple yellow stains on the fitted sheet along the left side and middle of her bed. The largest yellow stain was along the outer edge of the sheet and appeared to be approximately 8 inches by 6 inches. There were smaller yellow stains closer to the foot of the bed. A black stain was observed near the head of the bed that was approximately 2 inches in diameter. Her pillow was observed on her nightstand, her pillowcase was observed to have large yellow stains on it. The water in her bathroom was checked, the hot water handle was used and allowed to run for 2 minutes (timed using stopwatch app on phone), the water remained cold to touch. The other handle was checked the same way and no difference in water temperature was felt . When a thermometer was used to test the temperature of the hot water, it did not rise above 60 degrees F. In an observation on 03/12/24 at 7:16 AM, in room [ROOM NUMBER]B which was occupied by Resident #2, the resident was out of the room. Her bed was made, two holes were observed in her bedspread that appeared to be approximately 2 inches in diameter. The bed was situated against the far wall in the room near a window. The holes could be seen upon entering the room. The water in her bathroom was checked, the hot water handle was used and allowed to run for 2 minutes, the water remained cold to touch. The other handle was checked the same way and no difference in water temperature was felt When the hot water was tested with a thermometer, it did not rise above 60 degrees F. During an interview with LVN D on 03/12/24 at 7:25 AM, he stated he had worked at the facility for about a month. He stated he reported the lack of hot water in the employee bathroom about a month ago and it had since been fixed. LVN D stated he was unaware of the lack of hot water in the resident's rooms. When shown the bedspread in room [ROOM NUMBER], LVN D stated he had not noticed it before, and it was not appropriate. LVN D was then shown the stained linens in room [ROOM NUMBER] and he began stripping the bed. He stated that was inappropriate as well. He stated he was unable to tell if the linens were fresh and stained or soiled. LVN D stated having stains or holes in linens could make the residents feel bad and as though they were not important. During another interview with ADON A on 03/12/24 at 7:30 AM, when asked whether she had ever seen stains on the residents' linens, she stated she had seen some on the towels and washcloths. When asked whether she felt those were appropriate to give to the residents, she replied, They're not super dark, more like light yellow stains. She stated the residents might not feel good about it. During an interview and observation in the shower room on the 600 hall on 03/12/24 at 7:35 AM, the hot water was checked and allowed to run for 2 minutes using each handle. The water felt cold to touch and no difference was felt using either handle. When the hot water was checked with a thermometer by this surveyor, it registered at 60 degrees. LVN D was nearby and stated he recalled reporting that around the same time as reporting the employee bathroom to ADON A about a month prior. He stated the residents were taken down the 400 Hall for showers. He stated he had not reported it again since. In an interview on 03/12/24 at 7:40 AM, CNA E stated she rotated around the building and was assisting on the secured units. She stated she was aware the 500 and 600 halls had no hot water. She stated she knew the issue had already been reported and she believed they were waiting for a part to be installed. She denied hearing complaints from residents. She stated they used other shower rooms for bathing and used wipes for cleaning the residents. CNA E stated linens with holes or stains should be bagged separately and reported to housekeeping so they could order replacements. She denied seeing any on the 600 Hall that morning. During an observation and interview on 03/12/24 at 7:45 AM, Resident #3 was observed on the 600 Hall, in her room in bed. She was resting on two pillows. The bottom pillow had no pillowcase, the top pillowcase was a dingy off-white color and had several small black spots along the left side. Resident #3 stated she had asked for new pillowcases a few days ago, mine are grungy. She was unable to recall who she spoke with. She stated the water in her bathroom had been cold for a while. She stated it was bothersome when she washed her hands or face, but showers were not a problem because she went to another hall for those. Resident #3 denied complaining to staff about the water temperature. During an interview on 03/12/24 at 8:05 AM on the 500 hall, CNA G stated she rotated shifts and halls. She stated there was no hot water on the 500 and 600 halls. She stated she was not sure how long the hot water had been out and stated, I think they are trying to fix it. She stated she had not heard any residents complain and took them to another hall for showers. CNA G stated she occasionally found linen stained. She stated she had not used stained linen on resident beds and returned any stained linen she found to the laundry department. CNA G stated she would not use stained or torn linens for the residents because it would not look or feel good to have linen looking like that. During an interview and observation on 03/12/24 at 8:13 AM, the DON was asked about the lack of hot water on the secured units (500 and 600 Halls). She stated, We've had these complaints before, they're not running the water long enough. The DON was asked to demonstrate and was observed running the water in the shower room in the 600 Hall shower room. The DON was observed running the water with her hand in the stream but made no mention of the temperature The DON stated, if the staff knew the water was running cold, they should have reported it to maintenance so he could check the pilot light. The DON stated staff had been taking residents to another hall to shower as long as she had been there and she stated they preferred to use the shower room on the 400 Hall. She stated she believed they used the other shower room because it was larger and not because of the water temperature. She stated anyone could make a report to maintenance and she would look into the issue. During an interview on 03/12/24 at 8:25 AM, the Administrator stated she had just heard about the lack of hot water from the DON and was contacting maintenance. She said she was unaware there was no hot water on the secured units. She stated any staff member could contact maintenance. The Administrator stated the facility used a program called, Maintenance Care and any member of the management team could access it. She stated the employees should report any issues to their managers and they could enter the information. The Administrator stated the facility recently had plumbing work done and would pull the documentation. On 03/12/24 at 9:00 AM, attempts to interview Residents #1 and #2 was unsuccessful due to poor cognition. During a follow-up interview on 03/12/24 at 9:48 AM, the Administrator stated the water temperatures were to be checked weekly and she had believed the problems had been addressed. She stated she had been unaware there were still any issues with the water. The Administrator stated she expected worn or stained linens to be thrown out and reported to the housekeeping department. She stated she had not received any complaints related to the condition of the linens and expected the housekeeping department to monitor the condition of the linen. She stated risks included resident dissatisfaction. In an interview on 03/12/24 at 10:05 AM, the Maintenance Supervisor stated a new mixing valve had been placed in February and he had been testing the water weekly ever since. He stated the valve replacement was done to correct the hot water issues that had affected the 500 and 600 halls. He stated he last checked the temperature that morning after hearing there was a problem and found the temperature to be low. He stated he had made the necessary adjustments and the hot water was functioning again. The Maintenance Director stated he had previously informed the nursing staff of the changes and that it might require periodic adjustments. He stated he had not received any recent complaints about the water temperatures. A follow-up interview with ADON A on 03/12/24 at 10:21 AM, revealed she was aware there were previous complaints about the water temperatures and knew there had been some plumbing work done. She stated she had assumed the problem had been resolved because she had not received any further complaints. An observation on 03/12/24 at 10:30 AM, revealed the hot water had been restored within the 500 and 600 halls. In an interview on 03/12/24 at 11:23 AM, the Housekeeping Supervisor stated he occasionally found linens with stains or holes and his laundry staff tried to remove them from circulation whenever they found them. He stated he expected nursing staff to bag them separately as they found them and let them know so that new linen could be ordered. The Housekeeping supervisor stated he had no issues ordering new linens when needed. He stated he did not believe the facility had a written policy related to stained or torn linens. The Housekeeping Supervisor stated maintaining linens in good condition was important for the facility because no one wanted to sleep on bad linens. He stated residents could develop skin problems from laying directly on mattresses due to holes in the linens. In an interview and record review with the Administrator and Maintenance Supervisor on 03/12/24 at 12:51 PM, the Administrator provided a Service Report dated 2/16/24 that reflected the following description of work: .Picked up material from shop and arrived on site, checked in with customer and found that the valve was positioned so that the valve could not be rebuilt easily. Left for parts to take it out and repair it, came back and made the repair and set the valve in the green zone but told the customer to keep an eye on it and adjust as needed . The Administrator provided an invoice dated 2/26/24 that reflected the valve repair. Temperature logs were also provided which reflected the water temperatures on the 500 Hall was 99 degrees F on 2/27/24 and 3/3/24. The water temperatures on the 600 Halls were 100 degrees F on 2/27/24 and 101.5 degrees on 3/3/24. The Maintenance Supervisor stated he had informed all staff working on the affected units when the repairs had been completed and had advised them to let him know if other adjustments were needed. He stated he had not received any complaints since that time. A request was made for any facility policies related to water temperatures and linens. No facility policy was provided related to water temperatures. The facility policy titles, Linens dated 2018 reflected the following: 1. Resident linens must be clean and dry and changed regularly .7. Collect and remove soiled linens immediately. Soiled linens will be transported to the laundry processing area in a covered laundry hamper

Based on observation, interview and record review the facility failed to incorporate the recommendations from the PASRR report for 1 of 2 resident (Resident #1) reviewed for PASRR services. The facility did not submit a request for approval for Resident #1's CMWC in the LTC Online Portal within 20 business days after the date of the IDT meeting. NFs have 20 business days from the IDT meeting to enter a request for NF Specialized Services. This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life. Findings included: Record review of Resident #1's face sheet, dated 01/30/2024, indicated Resident #1 was a [AGE] year old male, admitted on [DATE], Medicaid PASRR therapies listed as a payer source with diagnoses including quadriplegia , which is a symptom of paralysis that affects all a person's limbs and body from the neck down, degenerative disease of nervous system, seizures, muscle spasms, abnormal weight loss, protein-calorie malnutrition, vitamin deficiencies, metabolic encephalopathy , a problem in the brain caused by a chemical imbalance in the blood, hypercholesterolemia (high cholesterol), contractures of the left knee and right knee, lack of coordination, muscle weakness, multiple fractures of left ribs, secondary hypertension (secondary high blood pressure), Type 2 diabetes, anemia, which is a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells, allergic rhinitis, which is inflammation of the inside of the nose caused by an allergen, intellectual disabilities, hypothyroidism (underactive thyroid), which happens when the thyroid gland doesn't make enough thyroid hormone, aphasia which is loss of ability to understand or express speech, caused by brain damage, dysphagia which is difficulty swallowing, oropharyngeal phase of swallowing which involves transferring a food bolus posteriorly to the epiglottis (a flap of tissue that sits beneath the tongue at the back of the throat) and then to the upper esophageal sphincter, the high-pressure zone located in between the pharynx (throat) and the cervical esophagus (behind the trachea), neck fracture of left femur, dysarthria (difficulty speaking) and anarthria (loss of speaking), cognitive communication and traumatic subdural hemorrhage, which is bleeding in the area between the brain and skill without loss of consciousness, cognitive communication deficit, and conversion disorder with seizures or convulsions, sequela which is a pathological condition resulting from a disease, injury, therapy, or other trauma . PASRR Level 1 Screening assessment dated [DATE] indicated Resident #1 had an intellectual disability. Further review indicated the facility was able and willing to serve Resident #1; therefore, Resident #1 was admitted . Record review of Resident #1's PCSP dated 07/07/2022 indicated Resident #1 had an IDT meeting for specialized services review on 07/06/2022. The IDT form indicated the IDT members recommended Resident #1 receive a Customized Manual Wheelchair . Record review of Resident #1's care plan updated on 08/29/2022 indicated Resident #1 had a chronic health condition and comorbid conditions that affected physical functioning with the goal to maintain quality of life. Record review of Resident #1's care plan updated on 01/01/2024 indicated Resident #1 had a positive PASRR status related to intellectual disability and used a wheelchair for mobility. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 was severely cognitively impaired, totally dependent upon staff for ADL s and used a wheelchair for mobility. Review of PASRR compliance call report for June 2022 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following: *IDT meeting was held on 07/06/2022, *PCSP was created on 07/07/2022, *IDT date plus 30 days was on 08/06/2022 Further review of the spreadsheet indicated services needed were a Customized Manual Wheelchair. Record Review of the PASSR Assessment revealed that the DLN was submitted to the LTC Online Portal by the previous MDS Coordinator on 08/06/2022, which was more than 20 days after the IDT Meeting on 07/06/2022. The Status of the PASSR Assessment was set to Pending Denial on 08/08/2022. The PASSR Assessment received a system-generated Denial on 08/22/2022. Due to the PASSR Assessment receiving a system-generated Denial the service request for the CMWC was denied manually. On 11/07/2022, the facility resubmitted a DLN for the service request for the CMWC for Resident #1. The Status of the PASSR Assessment tab was set to Pending Denial on 11/07/2022. The LTC Online Portal sent the facility an alert requesting more information. The PASSR Assessment received a system-generated Denial on 11/21/2022. Due to the PASSR Assessment receiving a system-generated Denial on 11/21/2022, the request of the CMWC was manually Denied. The facility failed to follow-up with the alerts sent by the LTC Online Portal requesting more information from the facility and the service request resulted in another denial. On 06/30/2023, the facility submitted a new NFSS request with a DLN and the PASSR Assessment was set to Pending Denial on 07/03/2023. On 07/03/2023, the facility made corrections and uploaded the CMWC/DME Signature page, and the Assessment was approved on 07/06/2023. The CMWC Request Tab was approved on 07/07/2023 . Resident #1 received the CMWC on 07/24/2023. In an interview with the facility's DON on 01/29/2024 at 10:34 AM, she stated that she has been employed at the facility since 02/06/2023. The DON stated that she was not directly involved with the situation involving Resident #1 and his CMWC. In a telephone Interview on 01/29/2024 at 12:35 PM, Resident #1's RP stated that she did not have any concerns regarding his care at the facility. She stated that Resident #1 has not expressed to her any concerns regarding his care at the facility. RP stated that Resident #1 did not mention anything to her about needing his CMWC after the IDT Meeting. In an interview with the facility's ADM on 01/29/2024 at 1:07 PM, she stated that her hire date was 06/19/2023. The ADM stated that the prior Administration at the facility which included the Administrator, DON and MDS/PASSR Coordinator were involved with the IDT Meeting and the request for specialized services for Resident #1 to obtain a CMWC. She stated that the prior Administration did not this was all before her start date of employment at the facility and she had no insight and no additional information. In an interview with the facility's Social Worker on 01/29/2024 at 1:48 p.m., she stated that she has been employed at the facility since 03/14/2023. Social Worker reported that she does not have any information regarding the CMWC for Resident #1 because the IDT Meeting was held prior to her employment. The Social Worker stated that Resident #1 has not filed any Grievances regarding being in discomfort or pain. The Social Worker reported that Resident #1 has not mentioned anything to her regarding his CMWC. In an interview with the facility's MDS/PASRR Coordinator on 01/29/2024 at 2:07 p.m., she stated the facility was unable to confirm a request for the wheelchair was ever sent for Resident #1. She stated that she was unable to provide more information because the previous MDS/PASRR Coordinator was no longer employed at the facility. She reported that her hire date was 9/01/2023. Observation of Resident #1 on 01/29/2024 at 3:15 PM in his room. Resident #1 is verbal but was unable to be interviewed. Record review of the facility's policy titled PASRR Level 1 Screen Policy and Procedure last revised on 03/06/2019, revealed It is the policy of Creative Solutions in Healthcare facilities to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via SimpleLTC (software simplifies regulatory compliance, reimbursement optimization and quality measurement for post-acute care healthcare) timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to pre-screen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible The NF must convene an IDT meeting after the LIDDA submits the PE and within 14 days after admitting the individual. The IDT will determine which specialized services the resident will receive. After the IDT meeting, the NF must submit the information from the IDT meeting on the LTC Online Portal. Record review of the facility's undated policy entitled Comprehensive Care Planning revealed no information about submitting requests for specialized services.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of six residents (Resident #25) observed for infection control. CNA P failed to perform hand hygiene during while providing incontinence care to Resident # 25. This failure could place the residents at risk for infection. Findings include: Observation on 04/12/23 at 12:20 PM revealed CNA P providing incontinent care to Resident #25. The resident was observed sitting on the bedside with brief on the thigh and pants pulled to the floor, the brief was noticeably wet. CNA P informed Resident #25 not to stand because his pants were wet, and she wanted to change him. Then CNA P stated she did not have wipes and asked the charge nurse who was on the hallway to get her a bag of wipes. CNA P completed hand hygiene and gloved and when the charge nurse brought the wipes CNA P removed the dirty brief from the resident and placed it in the trash bag and then removed the wet pants and placed in another trash bag. CAN P then told Resident #25 to stand up, and with the wipes CNA P cleaned Resident #25's bottom area. After CNA P cleaned the resident, without any form of hand hygiene or change of gloves CNA P applied the clean brief then proceeded to assisting the resident putting on his clean pants and shirt. Then CNA P proceeded to the shower room with trash and dirty linen and washed hands. In an interview on 04/12/23 at 12:32 PM with CNA she stated she had completed hand hygiene before care and after care, but she did not complete hand hygiene during care after she had cleaned the resident because she forgot. CNA P stated she was supposed to complete hand hygiene because her hands were contaminated after cleaning the resident. CNA P stated hand hygiene was completed to prevent the spread of infection. CNA P stated she received an in-service on infection control last week In an interview on 04/13/23 at 11:03 AM with the DON revealed during incontinent care CNA P was to complete hand hygiene before, in between after cleaning the resident and after when CNA P was done providing care. The DON stated it was necessary for the staff to complete hand hygiene in-between care to prevent cross contamination and prevent the spread on infection. Review of the facility policy undated and titled Hand Hygiene reflected Hand hygiene continue to be the primary means of preventing the transmission of infection. When to perform hand hygiene .Before and after assisting a resident with toileting. Record Review of the CDC Guidelines regarding Hand Hygiene in Healthcare Settings, dated 04/28/23, stated Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, contaminated surfaces, and immediately after glove removal.

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of two treatment carts reviewed. The facility failed to ensure one facility treatment carts were locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings include: In an observation on 12/21/22 at 2:30 PM revealed the facility treatment cart was unlocked and unattended. Treatment cart was positioned posterior to the nursing station with drawers facing out, in the Lobby. All drawers of the treatments cart could be opened, and supplies were easily accessible. No staff were observed within eyesight of the treatment cart. Resident #1 was observed near the treatment cart in his wheelchair. Record review of face sheet undated, revealed resident #1 is a [AGE] year old male who was admitted to the facility on [DATE]. Resident #1 was diagnosed with unspecified intellectual disabilities, [CONDITION(S)], and unspecified Dementia. Record review of MDS assessment dated [DATE] revealed Resident#1 refused to participate in the BIMS. In an interview on 12/21/22 at 3:00 PM with LVN A, stated the treatment cart was supposed to be behind the nurse's station. LVN A, stated the treatment cart was left unlocked because the wound care doctor left with the key on Tuesday. LVN A stated the vendor was supposed to come out this week and make another key. LVN A, stated he was not sure why the treatment cart was left in the hallway. LVN A, stated if a resident needed wound care and nursing staff forgot to put the treatment cart back. LVN A, stated the treatment cart should always be locked to prevent residents from getting into it. LVN A stated residents could be confused and could take the medications. LVN A, stated Resident #1 does wander up and down the hallway. During an observation on 12/21/22 at 3:10 PM of the treatment cart, findings included: *Diclofenac sodium gel (Temporarily relieves minor to moderate aches and pains caused by arthritis) *Nystatin topical powder (Used to treat fungal (or yeast) infections that affect the skin, mouth, and intestinal tract.). *Ammonium [MEDICATION(S)] lotion (Used to treat dry, scaly skin conditions. *Ciclopirox gel 0.77%* (Used to treat fungal skin infections such as athlete's foot, jock itch, and ringworm) *Triamcinolone [MEDICATION(S)] cream (Used to treat a variety of skin conditions such as [CONDITION(S)], [CONDITION(S)], allergies, rash). *Dakin's solution (Used to prevent and treat skin and tissue infections that could result from cuts, scrapes and pressure sores) *Povidone iodine 10%Solution (Topical antiseptic to aid in the prevention of infection) In an interview on 12/21/22 at 3:18 PM with LVN B, revealed the treatment cart should be locked when not being used. LVN B, stated the treatment cart should be parked in the nurses station and brought out when it is being used. In an interview on 12/21/22 at 3:30 PM with the DON, revealed the treatment cart should always be locked. She said unlocked treatment carts are a risk to residents if they should get into them. She said her expectation is for staff to follow the facility policy and ensure treatment carts are locked when not in use or supervised nurse. She said unlocked treatment carts may be a harm to residents if they get into creams or treatment utensils stored in the carts. DON stated treatment cart was the nursing staff responsibility to secure. She stated the Medication Administration Procedures Policy refers to medication carts however the facility expects treatment carts are subject to the same policy. A record review of the policy titled, Storage of Medication dated 2001 and revised on April 2007 revealed , The nursing staff shall be responsible for maintaining medication storage . A record review of the policy titled, Security of Medication Cart dated 2001 and revised on April 2007 revealed 4. Medication cart must be securely locked at all times when out of the nurses view.5. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room.

Based on observation, interview, and record review, the facility failed to ensure that a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections to the extent possible for 2 residents (Resident #4 and Resident #5) of 3 residents reviewed for urinary catheters. Nursing staff failed to secure the urinary catheter tubing for Resident #4 and Resident #5. This failure could place residents at risk for urethral tears, dislodgment of the catheter and/or infection. Findings included: 1. Review of Resident #4's undated electronic Admission Record revealed the resident was a [AGE] year-old male who initially admitted to the facility 03/16/22 and readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's active electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's quarterly MDS assessment dated [DATE] revealed the resident's BIMS was 7 indicating severely impaired cognition. The MDS assessment reflected the resident utilized an indwelling urinary catheter and additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's current care plan initiated 04/07/22 revealed the urinary catheter was addressed and goals included remaining free from catheter related trauma and signs/symptoms of infection. Interventions included monitoring for signs/symptoms of infection and/or leakage. The care plan did not address anchoring or securing the catheter. Observation with CNA B, on 10/27/22 at 10:11 a.m., revealed Resident #4 was awake in bed with an indwelling urinary catheter in place. The catheter tubing was folded inside the resident's pant leg. CNA B removed the resident's pants, and the catheter tubing was not anchored or secured to the resident in any manner. 2. Review of Resident #5's undated electronic Admission Record revealed the resident was a [AGE] year-old male who initially admitted to the facility 04/13/21 and readmitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's active electronic physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's quarterly MDS assessment dated [DATE] revealed the resident's BIMS was 5 indicating severely impaired cognition. The MDS assessment reflected the resident utilized an indwelling urinary catheter to include suprapubic catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder). Review of Resident #5's current care plan initiated 02/11/22 revealed the urinary catheter was addressed and goals included remaining free of catheter related infection. Interventions included monitoring for signs/symptoms of infection. The care plan did not address anchoring or securing the catheter. Observation with LVN C, on 10/27/22 at 10:27 a.m., revealed Resident #5 was awake in bed with a suprapubic catheter in place. The catheter tubing was twisted, positioned under the resident's left leg, and not anchored or secured to the resident in any manner. Interview with LVN C on 10/27/22 at 10:31 a.m., she stated she was responsible for ensuring leg straps were in place for residents with indwelling urinary catheters. She stated she was the charge nurse assigned to Resident #4 and Resident #5. She further stated she did not know if Resident #5 had a leg strap in place and she guessed she had forgotten to check and apply the leg strap for Resident #4. LVN C stated a leg strap should be in place to prevent pulling and dislodgement of the catheter. Interview with the DON on 10/28/22 at 12:50 p.m., she stated it was important to have a leg-straps in place to prevent catheters for being pulled out, to keep the tubing straight and to prevent infections. Review of the facility's policy/procedure entitled Catheter Care, Urinary revised September 2014 revealed, Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh.)

Based on interview and record review, the facility failed to ensure comprehensive assessments were completed within 14 calendar days after admission as required for three (Resident #1, #2 and #3) of three residents reviewed for comprehensive assessments. 1. Resident #1 admitted to the facility on [DATE] and did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. 2. Resident #2 admitted to the facility on [DATE] and did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. 3. Resident #3 admitted to the facility on [DATE] and did not have a completed admission/comprehensive MDS assessment within 14 days following admission to the facility. This failure could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: 1. Review of Resident #1's undated admission record revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's MDS assessment summary screen in the EHR on 10/28/22 revealed the resident's admission/comprehensive MDS assessment was still in progress with an ARD date of 10/25/22. 2. Review of Resident #2's undated admission record revealed the resident was a [AGE] year-old female who admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS assessment summary screen in the EHR on 10/28/22 revealed the resident's admission/comprehensive MDS assessment was still in progress with an ARD date of 10/16/22. 3. Review of Resident #3's undated admission record revealed the resident was a [AGE] year-old male who admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's MDS assessment summary screen in the EHR on 10/28/22 revealed the resident's admission/comprehensive MDS assessment was still in progress with an ARD date of 10/20/22. Interview with the MDS Coordinator on 10/28/22 at 11:25 a.m., she stated she was responsible for completing all MDS assessments. She stated the MDS assessments for Residents #1, #2 and #3 were still in progress because she thought she had completed Resident #1's assessment and had not gotten around to completing Resident #2's assessment. She stated Resident #3's assessment was 8 days overdue because it needed to be signed by the RN and she did not know why it had not been signed. Interview with the MDS Coordinator on 10/28/22 at 11:34 a.m., she stated she had worked at the facility for two months. She stated it was important for resident's MDS assessments to be completed within 14 days of admission because nursing staff needed to know how to care for the residents. She stated not completing MDS assessments timely could cause a resident's needs to not be met. Interview on 10/28/22 at 11:49 a.m. RN A stated she was the Corporate MDS Specialist. She stated it was her responsibility to sign MDS assessments because the DON was not RUG certified. She stated she had not signed Resident #3's MDS assessment because she had gotten behind. She stated it was important for MDS assessments to be completed timely because it was a regulation and could affect resident care needs if the MDS assessment was completed later than the 21-day care plan completion requirement. Interview with the DON on 10/28/22 at 12:50 p.m., she stated it was important for MDS assessments to be completed timely because resident care needs could be overlooked or omitted. She stated she was not involved in the MDS assessment completion process. Interview on 10/28/22 at 1:21 p.m., the MDS Coordinator stated the facility did not have a policy/procedure related to MDS assessments. She stated the facility followed the CMS RAI Manual. She provided pages 2-16, 2-17 and 2-18 from the CMS RAI version 3.0 manual related to required time frames for completing MDS assessments. Review of the RAI manual source provided by the MDS coordinator reflected admission comprehensive MDS assessments should be completed no later than the 14th calendar day of the resident's admission.

Based on interview and record review, the facility failed to ensure residents could exercise their rights without interference, coercion, discrimination, or reprisal from the facility for one (Resident #1) of one resident reviewed for resident rights. The facility failed to allow Resident #1 personal privacy and privacy with visitors and phone calls and placed him on on-on-one supervision without significant explanation. This failure resulted in Resident #1 experiencing increased emotional distress and decreased quality of life by feeling like his home and feeling of security were in jeopardy and had the potential to affect residents with a decreased quality of life and hostile living environment. Findings included: Resident #1's quarterly MDS Resident assessment from his prior stay at the facility dated [DATE] revealed he was a [AGE] year-old male initially admitted to the facility on [DATE]. He had no cognitive delays and had clear speech, vision and hearing. He had no short- or long-term memory problems and only mood related issue was difficulty sleeping. The MDS Assessment reflected Resident #1 had verbal behavioral symptoms directed towards others but the behaviors did not put residents at risk for illness/injury, did not interfere with resident care, did not interfere with social activities, did not intrude on the privacy of others and the behavior did not disrupt care or the living environment. His functional status included the need for extensive physical assistance of one to two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #1 had range of motion impairment on both sides of his upper and lower extremities and used a wheelchair for mobility and could self-propel. Resident #1's active [DIAGNOSES REDACTED]. He was in frequent pain which made it hard to sleep. He received anti-depressant medication only. The MDS Assessment reflected the resident did have active discharge planning to return to the community. There was no MDS assessment available from his re-admission on [DATE]. Resident #1 received an immediate discharge letter dated [DATE] that reflected the safety of individuals in the facility was endangered due to aggressive behavior with residents, resident family members, staff to include verbal threats to cause physical harm to residents and a staff member. He was notified of his right to appeal the discharge and was given the option to be discharged to the location of his choice. The facility did not have documented evidence that Resident #1 was harmful or had the potential to be dangerous to other residents in the facility when the immediate discharge was initiated. Resident #1 went to the hospital for acute catheter care and was not allowed back to the facility. Resident #1 appealed the facility discharge with the assistance of the local Ombudsman. Review of Resident #1's Fair Hearing order dated [DATE] reflected Resident #1's facility-initiated discharge was reversed due to the facility not being present for the hearing held on [DATE]. The facility was ordered to immediately re-admit Resident #1 upon receipt of the order if he chose to return; however, they refused. Review of Resident #1's admission documents reflected he re-admitted to the facility on [DATE]. Review of Physician Telephone Orders dated [DATE] reflected Resident to be on 1:1 for aggressive behaviors. Interview with Resident #1 on [DATE] at 3:59 PM revealed, They brought me back here so they could get their license renewed and then they are gonna give me the boot. They already have a plan in action. He said the facility was using the physician as the way to discharge him. He said if the physician discharges him from service, then there is no recourse for him for being able to stay at the facility. He said he came back to the facility on [DATE]st or 2nd, 2019 . Prior to his re-admission, the ADM, DON and SW came to the facility where he was living and said the Medical Director (MD) was going to accept him under his care. Resident #1 said he got his hopes up thinking that everything was fine because there was a new set of nursing management and administrator. They were asking him if he had ever assaulted anyone or if he had made any threats. He stated they provided a document they wanted him to sign, and upon initial reading, he thought the paper read like he would have continuous supervision while in the nursing home. He said he thought this was the level of supervision that all residents got when they lived in a nursing home. He said he asked them what the continuous supervision meant but they did not explain anything related to one on one supervision. He stated, Not once was that (one-on-one supervision) mentioned. Resident #1 said the day after this conversation he readmitted back to the facility. He said no care plan was made until two weeks later and the admission paperwork was not done until very recently. He said presently, the facility was kicking him out. He said the facility had started monitoring him about a week into his stay. He said one day he was in his room on the phone with his attorney and out of nowhere, a female staff member came in and sat in his roommate's empty Geri chair by the door with a tablet and paper. He said she did not knock or introduce herself but started writing things down. He said he was upset and confronted her but she would not respond to him. He said he left the room in his wheelchair and she followed him everywhere he went. He said he tried to video tape her on his phone but she was ducking and dodging. He said he had not seen her before. He said since then, there was someone following him everywhere he went and wanted to know his every move. If he smoked they documented, if he slept, they documented. He said, This is an invasion of privacy! He said the first night it happened, he called the police but the ADM told him and the police that Resident #1 had signed up for it because of the paper he signed. Resident #1 stated, But that was not the agreement ever, I never once agreed to this, because I guarantee one thing, I would have never signed up for this. He said a lot of the staff felt uncomfortable with the continuous monitoring when he had private time with his girlfriend. He said when his girlfriend was in his room, he would pull the privacy curtain, but the staff member would either sit there and listen or stand at the door and listen. Further interview with Resident #1 revealed he met with the MD about three days after he returned to the facility. He stated the MD said he was going to be his doctor. Resident #1 said he was in bed one night and an x-ray tech showed up close to midnight and wanted to do an x-ray. He said he did not refuse, but he wanted to know why it was being done because he did not want [MEDICAL CONDITION] passing through him unnecessarily and no one had forewarned him he was getting and x-ray. As a result, he declined the x-ray until he could get more information. Three days after that, he was called back into a meeting with the MD who told him (Resident #1) he was dropping him as a patient because Resident #1 not go through with the x-ray and did not trust the MD. Resident #1 said, I told him I am not accepting anything he is throwing at me medically and I have a right to know why he was ordering procedures. I told him trust is not given, it is earned, I don't know you from Adam and you can have the simple respect for me to respect my wishes. He said he was only seen medically by the MD one time. He said when the MD dropped him, he told Resident #1 he had only ten days to find another doctor. A week later, the ADM delivered a letter to him from the MD that reflected he was not going to be his doctor anymore. Resident #1 said, The letter did not say at all why he dropped me. It only states I have 30 days to find a doctor or I am out of here. He said he called the local Ombudsman and informed her and gave her a copy. She told him the facility was using the doctor to get rid of him because there was no repercussion and he could not file appeal. He said the facility brought him back to stop the state and federal fines they were accruing and to get their licensed renewed. He said he talked to another physician that saw his roommate and told him he was in severe need of a doctor. Resident #1 said that physician said he would be willing to take him as a patient and for him to make the request known up front and he would look at it. Resident #1 said he did make the request known to the facility management but they said it would not be feasible because the physician has a medical practice with a doctor that did not want to work with him from the past and there would be a conflict of interest. Resident #1 said, I have been put through the ringer since I have been here. Resident #1 stated when he lived at the facility prior, he enjoyed seeing a counselor, but when the facility tried to discharge him and they went to the fair hearing, the facility used what he said in his sessions against him. He said he did not trust that would not happen again. He said his sessions were supposed to be confidential and the facility used them against him. Resident #1 was unaware of his being able to get off one-on-one was dependent on his requiring psychiatric services. Review of an Agreement made between Resident #1 and the facility prior to his readmission, dated [DATE], reflected , (Resident #1), (the Medical Director (MD)) is willing to accept you as a resident of (facility name) only if the following stipulations are met: (a) I will initially be under constant staff supervision during the time that I will be a resident of (facility name) (b) I will agree to supervision with visitation of any/all outside entities in a public area (c) I will not be allowed to verbally, emotionally or physically abuse any staff members and/or residents while I am a resident of (facility name). If these stipulations are agreeable to you, (Resident #1), (MD) will be our physician of record during the time you are a resident at (facility name). (MD) will have the right to change/amend any/all stipulations at any tine (sic) during your stay. If you violate any/all of these stipulations then (MD) and the staff at (facility name) have the right and responsibility to discharge you from (facility name) in accordance with current Regulatory Guidelines. (ADM name) Administrator (facility) Resident #1 then hand wrote underneath Facility will follow the guidelines from DADS as far as [AGE]-hour pass; Facility will try and put plugs in the room computer . The agreement was signed by resident only. Interview with the local Ombudsman on [DATE] at 8:23 AM revealed that she talked to the ADM before Resident #1 was readmitted about Resident #1 waiting for the ADM to accept him back into the facility after he won his fair hearing and inappropriate discharge. She said she talked to the ADM about Resident #1's rights being violated by the agreement the ADM wanted the resident to sign requiring him to agree to continuous supervision. She said Resident #1 wanted to move back to the facility so he acquiesced to the agreement he would be continuously supervised. She said Resident #1 believed the facility only accepted him back because they were trying to clear their citations and fines accrued with C[CONDITION] and HHSC when they were cited for inappropriately discharging him. She said now that he had come back to the facility, they had him on one-on-one supervision and she had observed staff sitting in the room watching him. She said there was a nurse who sat in the room and listened to him. She said she had talked to the facility and they told her they could do that if a resident was in danger. The Ombudsman said she told the ADM, DON and clinical nurse that Resident #1 was a strong-minded person, but what they were doing was considered profiling. She told them they were violating his rights if they were going to continue the one-on-one monitoring. She said Resident #1 felt his rights were being violated as well and thought the facility was retaliating against him for challenging his previous discharge from the facility and winning his fair hearing. Interview with the ADM and DON on [DATE] at 10:30 AM revealed the facility had accepted Resident #1 back to the facility at the end of [DATE]. The ADM said he had been the ADM at the facility for about three months and the new DON had been there for about a month. He said when they started their employment, they were getting bits and pieces of information about what was going on with the outstanding deficiencies related to Resident #1's inappropriate discharge. The ADM said they were new and did not want to take hearsay as evidence of how they should view the situation. He said when the penalties for the plan of correction for the deficiencies related to Resident #1 started accruing, corporate called him and told him that the facility was going to need to take him back. The medical director (MD) agreed to take Resident #1 as a patient. Prior to Resident #1 returning to the facility, corporate told the ADM they wanted Resident #1 to agree to have one-on-one supervision when he admitted back into the facility. The ADM said he did not want to start off his relationship with Resident #1 in an adversarial role so corporate let him have the latitude to implement one-on-one or not. The ADM said he then talked with the DON and they opted not to initiate the one-on-one when Resident #1 admitted to the facility. The ADM said corporate felt the one on one supervision was necessary because of Resident #1's past behaviors such as being verbally abusive and taking pictures of other residents. The ADM said he agreed to allow Resident #1 back into the facility and had him sign a paper that said he would agree to one-on-one supervision. The ADM then said when Resident #1 admitted , initially he was not on continuous monitoring, and everything was okay for about a week. Then he said there were issues with his bowel management program and asked the DON to explain. The DON said Resident #1 had an old physician's orders [REDACTED]. She said she could not verify where the order came from and it could have been fabricated for all I know. She said her nurses are not trained to digitally stimulate the rectum like that and stimulating the vagus nerve for that long can cause harm, including a potentially fatal effect, such as a drop in his blood pressure. She said the nurses would put the blood pressure cuff on him and when they would do the digital stimulation, he would start sweating profusely. She stated it was making the nurses uncomfortable because they did not want to harm him and it was out of their scope of practice. The DON also alleged she thought Resident #1 received possible sexual stimulation from the bowel program but she never talked to him about it or was able to provide any incident reports or nursing documentation to reflect it. She said the MD ordered a KUB, which was an x-ray to see if Resident #1 had any bowel impactions in his stomach, but he refused the screening. The MD then ordered a suppository and laxative which Resident #1 refused as well. She said after that, the MD met with Resident #1 and explained that the nurses would no longer use the digital stimulation. The DON stated Resident #1 became upset about this. The ADM said Resident #1 and MD had words, then the MD issued the resident a 30-day notice that he would not be his doctor because he would not agree to his treatment plan. The ADM also said around this time, Resident #1 began cursing at the nurses and calling them [***] es for refusing to do his bowel program. The Administrator stated because of this behavior he decided to initiate 15 minutes check on Resident #1, per the agreement Resident #1 had sign prior to his readmission. He said the agreement reflected that the ADM had the right to initiate 1:1 at any time. He said when the MD gave Resident #1 the 30-day notice, Resident #1 then agreed to discontinuing the digital stimulation bowel program. The DON said since that meeting Resident #1 received the suppository and had his routine bowel movements without the 20-minute digital stimulation and had been compliant with the program. The ADM then proceeded to state the facility's online electronic health charting database had recently been hacked by [REDACTED]s and was being held for a ransom, so the facility was not able to access any clinical documents for Resident #1. He then pulled out a red folder sitting on his desk and said he was keeping a file on Resident #1 and showed the discharge letter from the MD and the letter he had Resident #1. He said when Resident #1 found out the MD was discharging him, he called the police later that night and the police came out. The ADM then showed the police the letter Resident #1 agreed to. The ADM stated Resident #1 was saying out loud while the police were leaving the facility that if the CNA monitoring him got close to him, he was going to punch her. The ADM asked the police officer to come back and asked Resident #1 to repeat that statement, which he did. The police then told Resident #1 if he chose to do that, he would be taking a ride with him in his police car. Resident #1 stopped and wheeled away according to the ADM. Review of the MD's handwritten notes after a care plan conference dated [DATE] reflected the meeting was held due to Resident #1's noncompliance with the recommended treatment. Present were Resident #1, ADM, DON and ADON. MD documented in his note that after the meeting, Resident #1 became argumentative, verbally aggressive and disrespectful. He stated Resident #1 was not in agreement with the plan of care recommended. Resident #1 said he wanted to continue his bowel regime which consisted of digital rectal stimulation for removal of stool. MD stated he felt that when that procedure was performed, it seemed to cause sexual stimulation and possible ejaculation per nursing staff. That treatment was stopped and a program of laxatives was effective. He noted Resident #1 was being treated with [MEDICATION NAME] as well which he stated was given for pain and helped with constipation. MD wrote he ordered x-ray of the abdomen, but patient refused. He also ordered a psychiatric consult, but patient refused. He wrote, Absent a psychiatric evaluation, I suspect that this patient suffers from a mental disorder which if not appropriately treated, could be dangerous to himself, other patients and staff. For those reasons, I informed him verbally that our physician/patient relation will be terminated pending written notification. Review of the Physician's Discharge Letter from MD dated [DATE] reflected he would no longer be able to treat Resident #1 as a patient and the termination of their patient physician relationship would be effective in 30 days from the date of the letter. The physician did not give a reason for discharging the resident from his care. Interview with the DON on [DATE] at 11:52 AM revealed she was really trying to work with Resident #1. She stated he had come to her a number of times frustrated and she would go, buy him a soda, and he would sit and talk with her. She said when he talked with her, he was calm and rational, just like any other person. She said he did not want to be in long term care and she did not think he should be in long term care because he was a young, independent person who worked in the community before he became disabled. She stated, How would we feel if something like that happened to us? Interview with the RCN on [DATE] at 1:08 PM revealed the facility did agree to accept Resident #1 back because corporate realized the C[CONDITION] and state penalties needed to be resolved. She said the MD reluctantly agreed to be his attending physician but had since given Resident #1 a termination of services letter. She said that the facility did have Resident #1 sign a paper prior to coming back to the facility that said he agreed to constant supervision based on his history of aggression and a previous incident with Resident #2 during his last stay. She said though, due to his history of aggressive behavior and him starting to be verbally aggressive to the nurses since he had been back, the facility decided to implement the constant supervision agreement. She said they had to look at if it was a violation of his rights and every day she had a standing three o'clock phone call with the ADM where they discussed whether or not it continued to be appropriate . She said that the facility had not initiated a facility discharge to the resident and she did not plan on doing one at this time. She said the plan of correction the facility agreed to said she and the RVP must approve any facility-initiated discharges and she was not there yet with Resident #1. She voiced understanding that the physician's 30 days expired on [DATE] and the facility could issue an emergency discharge to Resident #1 at that time because he would no longer have a doctor; however, she said she was and would continue to do everything in her power to try and locate a physician who would oversee his care until they could help Resident #1 find a placement in the community or at an assisted living. She said she was going to try and work with the MD to see if he would extend his oversight of Resident #1 until the facility could find him an agreeable place to live in the community. The RCN was asked if all residents who admitted with a behavioral history had to have one on one supervision. She said she had seen it done with residents before at facilities when there was a potential threat the resident may harm or hurt themselves or other residents/staff at the facility. She said Resident #1 could be a potential threat because she had heard he had a criminal history but she did not verify it because if she did it could have been considered profiling. Interview with CNA A on [DATE] at 2:56 PM revealed she had been one of the staff who did 1:1 supervision of Resident #1, but she did not know exactly was she what supposed to monitor for. She said she supervised all his movements, like what he did during the day. She said she supervised him the day prior ([DATE]) on her 12-hour shift from 6:00 AM to 6:00 PM. She said she had to document whether he was sleeping, calm, on the phone or having behaviors. She said she watched him while he was in his room and when he went to smoke as well. She said she had not observed him have any behaviors and he was not rude to her. CNA A said no one explained to her why he was on 1:1 supervision. Interview with LVN B on [DATE] at 4:40 PM revealed she was the charge nurse for Resident #1 on the 2PM-10PM shift. She said he yelled at nurses, but not at CNAs or residents. She said he did yell at her once since his re-admission because he wanted his bowel care done. She said she went to his room and was explaining to him what she was going to do, but he would not let her finish. He told her if she did not do what he asked, he was going to record her on his phone. She stated she left and returned with the morning nurse and he started using profanity at LVN B. The morning nurse then told LVN B that she was late to do Resident #1's bowel program and was not able to get it done on her shift (6:00 AM-2:00 PM). LVN B stated when she went in to do it, Resident #1 was upset about having to wait and did not want her to explain the procedure and just wanted the bowel care done then. She left the room to give him space when he grabbed his phone. LVN B stated the morning nurse ended up going in and finishing the bowel program. LVN B said that was the only incident she had with him. She said she worked with him Monday thru Friday on 2:00 PM-10:00 PM shift. She said Resident #1 recently started leaving the facility more often and had told her he was going to be leaving more because he did not want to get in trouble. She said, He only started doing that when they started putting one on one with him. She said the first day they started 1:1 supervision with Resident #1, they had a CNA monitoring him who had never worked with him before. She said Resident #1 was upset being followed around by her and said she was a dumb dog, that he could not have privacy and that the facility was harassing him. LVN B said, I think I need more training on behavior management .I feel like (Resident #1) is a different kind of person. No one has told me what kinds of interventions to do with him specifically. LVN B said Resident #1 had voiced to her that he was angry someone was always watching him. LVN B said he told her he could not have his privacy and was being harassed and that was why he started cursing the CNA. LVN B said, I can tell he is frustrated. They have to sit in his room on a chair. They just watch him. LVN B said Resident #1 did called her a [***] when there was the issue with him getting his bowel program late. LVN B said she did not know how long the constant supervision was supposed to go on and it had been two weeks so far. 4Interview with the ADM, RNC and DON on [DATE] at 2:24 PM revealed when Resident #1's behavior falls in line and he did not act out towards staff or residents, the 1:1 supervision would go away . The DON said the MD addressed his behavior and the 1:1 supervision was physician driven. The ADM stated for the one-on-one supervision to be removed they would have to monitor Resident #1 for three to five days and see if his behavior got better, then they would go to 15 minutes or 30 minutes, then they would continue to review the situation to see if they could take him off monitoring. The ADM said, I want him to not curse, threaten staff or threaten physical harm. The ADM, RNC, and DON admitted there was not a care plan or a plan in writing that discussed the 1:1 monitoring, the behavior that caused it to be used, and how the monitoring would be titrated. They said they could not access any clinical notes in the electronic database due to the hacking. The RNC said they could update and revise the care plan to reflect what exact behaviors were identified as causing the 1:1 and how the supervision would be titrated. The ADM said he would train the staff who were watching him on what exact behavior(s) they were monitoring. The RNC said Resident #1 was out on pass but when he came back to the facility, it would be a good time for them to sit down with him and review the titration possibility of the constant supervision and make sure he was in agreement. She said staff would be in-serviced on what to observe for related to cursing, being inappropriate to staff, quick jerky movements in his wheelchair and how to halt the action appropriately. Interview with DON on [DATE] at 6:05 PM revealed she could not locate any of the behavior monitoring sheets for Resident #1 since the one-on-one had been implemented. She said the CNAs were supposed to turn them into the charge nurses at the end of the shift but she had just looked for them and no one knew where they were. Additionally, she said she did not have access to any current incident reports related to Resident #1. DON said she had not seen him display any aggression toward other residents. Interview with the ADON on [DATE] at 6:08 PM revealed she had not seen Resident #1 have any behavioral issues since his readmission. She said there was only one instance where two nurses reported he displayed verbal aggression related to his bowel program. The ADON said that had since been resolved. The ADON said they were still monitoring him for verbal aggression towards staff and that was why he remained on 1:1 supervision. The ADON stated, I don't see other residents scared of him. She said she was not scared of him and stated He's actually sweet. I haven't had any issues. The ADON did not give a direct response when asked if she felt if Resident #1 having constant 1:1 supervision was a violation of his rights or privacy. She said in the beginning, after he was readmitted , he displayed verbal aggression, but did not presently and it had been about two weeks since he had displayed verbal aggression. The ADON said no resident had voiced any concerns about him. She said she was not part of the decision to put him on constant supervision. She said ,He knows what he needs to do to come off of it and he has met that criteria. Interview with the SW on [DATE] at 6:27 PM revealed in all her interactions with Resident #1, he had been kind and had displayed nothing but respect to her. Review of the list of residents with behaviors provided by the DON on [DATE] showed she printed out all residents receiving psychiatric medications. She said all those resident listed got psychiatric services, some got psychotherapy and none had behaviors directed towards staff. The list of residents she provided on psychiatric meds totaled 71. Per the DON, none of them were on a behavior management program, behavioral contract or 1:1 supervision. An interview with Resident #1 on [DATE] at 7:29 PM revealed having a staff member invade his privacy and follow him around 24 hours a day while at the facility made him and his loved ones feel like they were in prison to have their every privacy violated both in conversation and in deed. He said his every move had been documented. If he ate, slept, watched tv, pooped, farted, spent time with his family, girlfriend, etc. it was documented. He said every little thing had been documented and spied on by this ridiculous one on one surveillance. He said, Do you know what it's like to have someone stare at you while you sleep, eat, do a bowel program, or spend time with my girlfriend? He said, I am not a monkey in a zoo, nor am I [AGE] year old needing a chaperone. He said his loved ones felt the same way. He said, Not to mention violating attorney client privilege with his lawyer or their hired goons spying to tell the ADM every time he called and reported them. He said he should not have to leave the facility to get privacy with his loved ones or to avoid being harassed regularly with all the knit-picking. Attempted interview with MD on [DATE] at 11:48 AM was unsuccessful. A message was left requesting he return call for an interview related to Resident #1's discharge from his care. An interview with the ADM on [DATE] at 11:32 AM revealed Resident #1 remained on 1:1 supervision. The ADM did not respond when he was asked if Resident #1 had displayed behaviors since [DATE]. The ADM said that Resident #1 had to stay on 1:1 supervision per the MD's order until he was discharged from his services on [DATE]. He said the MD said the only way Resident #1 could come off 1:1 supervision was by agreeing to psychiatric services . On [DATE], the ADM faxed additional information he was unable to obtain on [DATE] and included the following: Physician's telephone order clarification for Resident #1 dated [DATE] that revealed Order clarification-Resident to be placed on 1:1 for aggressive behaviors until (doctor) services are discontinued on [DATE] or evaluation for psychiatric services completed; and 1:1 behavior monitoring sheets that reflected Resident #1 did not have any negative behavioral issues observed. Review of the Resident Rights provided in the admission packet and provided to Resident #1 upon admission reflected, .D. Healthcare Information and Decisions .(3) Resident has the right to refuse treatment after the possible consequences of refusing the treatment are fully explained and the resident/responsible party acknowledges he/she clearly understands the consequences of refusing treatment .; .L. Privacy and Confidentiality Resident has the right to personal privacy and to confidentiality of his/her personal and clinical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetin

Based on interview and record review, the facility failed to ensure residents could exercise their rights without interference, coercion, discrimination, or reprisal from the facility for one (Resident #1) of one resident reviewed for resident rights. The facility placed Resident #1 on continuous one on one (1:1) supervision without justification when he readmitted to the facility after winning his appeal against an inappropriate discharge by the facility. The facility failed to inform Resident #1 why he was placed on 1:1 supervision, how long the supervision was to last, and what steps were to be taken to remove that level of supervision. This failure resulted in Resident #1 experiencing increased emotional distress and decreased quality of life by feeling like his home and feeling of security were in jeopardy and had the potential to affect residents with a decreased quality of life and hostile living environment. Findings included: Resident #1's quarterly MDS Resident assessment from his prior stay at the facility dated [DATE] revealed he was a [AGE] year-old male initially admitted to the facility on [DATE]. He had no cognitive delays and had clear speech, vision and hearing. He had no short- or long-term memory problems and only mood related issue was difficulty sleeping. The MDS Assessment reflected Resident #1 had verbal behavioral symptoms directed towards others but the behaviors did not put residents at risk for illness/injury, did not interfere with resident care, did not interfere with social activities, did not intrude on the privacy of others and the behavior did not disrupt care or the living environment. His functional status included the need for extensive physical assistance of one to two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #1 had range of motion impairment on both sides of his upper and lower extremities and used a wheelchair for mobility and could self-propel. Resident #1's active [DIAGNOSES REDACTED]. He was in frequent pain which made it hard to sleep. He received anti-depressant medication only. The MDS Assessment reflected the resident did have active discharge planning to return to the community. There was no MDS assessment available from his re-admission on [DATE]. Resident #1 received an immediate discharge letter dated [DATE] that reflected the safety of individuals in the facility was endangered due to aggressive behavior with residents, resident family members, staff to include verbal threats to cause physical harm to residents and a staff member. He was notified of his right to appeal the discharge and was given the option to be discharged to the location of his choice. The facility did not have documented evidence that Resident #1 was harmful or had the potential to be dangerous to other residents in the facility when the immediate discharge was initiated. Resident #1 went to the hospital for acute catheter care and was not allowed back to the facility. Resident #1 appealed the facility discharge with the assistance of the local Ombudsman. Review of Resident #1's Fair Hearing order dated [DATE] reflected Resident #1's facility-initiated discharge was reversed due to the facility not being present for the hearing held on [DATE]. The facility was ordered to immediately re-admit Resident #1 upon receipt of the order if he chose to return; however, they refused. Review of Resident #1's admission documents reflected he re-admitted to the facility on [DATE]. Review of Physician Telephone Orders dated [DATE] reflected Resident to be on 1:1 for aggressive behaviors. Interview with Resident #1 on [DATE] at 3:59 PM revealed, They brought me back here so they could get their license renewed and then they are gonna give me the boot. They already have a plan in action. He said the facility was using the physician as the way to discharge him. He said if the physician discharges him from service, then there is no recourse for him for being able to stay at the facility. He said he came back to the facility on [DATE]st or 2nd, 2019 . Prior to his re-admission, the ADM, DON and SW came to the facility where he was living and said the Medical Director (MD) was going to accept him under his care. Resident #1 said he got his hopes up thinking that everything was fine because there was a new set of nursing management and administrator. They were asking him if he had ever assaulted anyone or if he had made any threats. He stated they provided a document they wanted him to sign, and upon initial reading, he thought the paper read like he would have continuous supervision while in the nursing home. He said he thought this was the level of supervision that all residents got when they lived in a nursing home. He said he asked them what the continuous supervision meant but they did not explain anything related to one on one supervision. He stated, Not once was that (one-on-one supervision) mentioned. Resident #1 said the day after this conversation he readmitted back to the facility. He said no care plan was made until two weeks later and the admission paperwork was not done until very recently. He said presently, the facility was kicking him out. He said the facility had started monitoring him about a week into his stay. He said one day he was in his room on the phone with his attorney and out of nowhere, a female staff member came in and sat in his roommate's empty Geri chair by the door with a tablet and paper. He said she did not knock or introduce herself but started writing things down. He said he was upset and confronted her but she would not respond to him. He said he left the room in his wheelchair and she followed him everywhere he went. He said he tried to video tape her on his phone but she was ducking and dodging. He said he had not seen her before. He said since then, there was someone following him everywhere he went and wanted to know his every move. If he smoked they documented, if he slept, they documented. He said, This is an invasion of privacy! He said the first night it happened, he called the police but the ADM told him and the police that Resident #1 had signed up for it because of the paper he signed. Resident #1 stated, But that was not the agreement ever, I never once agreed to this, because I guarantee one thing, I would have never signed up for this. He said a lot of the staff felt uncomfortable with the continuous monitoring when he had private time with his girlfriend. He said when his girlfriend was in his room, he would pull the privacy curtain, but the staff member would either sit there and listen or stand at the door and listen. Further interview with Resident #1 revealed he met with the MD about three days after he returned to the facility. He stated the MD said he was going to be his doctor. Resident #1 said he was in bed one night and an x-ray tech showed up close to midnight and wanted to do an x-ray. He said he did not refuse, but he wanted to know why it was being done because he did not want [MEDICAL CONDITION] passing through him unnecessarily and no one had forewarned him he was getting and x-ray. As a result, he declined the x-ray until he could get more information. Three days after that, he was called back into a meeting with the MD who told him (Resident #1) he was dropping him as a patient because Resident #1 not go through with the x-ray and did not trust the MD. Resident #1 said, I told him I am not accepting anything he is throwing at me medically and I have a right to know why he was ordering procedures. I told him trust is not given, it is earned, I don't know you from Adam and you can have the simple respect for me to respect my wishes. He said he was only seen medically by the MD one time. He said when the MD dropped him, he told Resident #1 he had only ten days to find another doctor. A week later, the ADM delivered a letter to him from the MD that reflected he was not going to be his doctor anymore. Resident #1 said, The letter did not say at all why he dropped me. It only states I have 30 days to find a doctor or I am out of here. He said he called the local Ombudsman and informed her and gave her a copy. She told him the facility was using the doctor to get rid of him because there was no repercussion and he could not file appeal. He said the facility brought him back to stop the state and federal fines they were accruing and to get their licensed renewed. He said he talked to another physician that saw his roommate and told him he was in severe need of a doctor. Resident #1 said that physician said he would be willing to take him as a patient and for him to make the request known up front and he would look at it. Resident #1 said he did make the request known to the facility management but they said it would not be feasible because the physician has a medical practice with a doctor that did not want to work with him from the past and there would be a conflict of interest. Resident #1 said, I have been put through the ringer since I have been here. Resident #1 stated when he lived at the facility prior, he enjoyed seeing a counselor, but when the facility tried to discharge him and they went to the fair hearing, the facility used what he said in his sessions against him. He said he did not trust that would not happen again. He said his sessions were supposed to be confidential and the facility used them against him. Resident #1 was unaware of his being able to get off one-on-one was dependent on his requiring psychiatric services. Review of an Agreement made between Resident #1 and the facility prior to his readmission, dated [DATE], reflected , (Resident #1), (the Medical Director (MD)) is willing to accept you as a resident of (facility name) only if the following stipulations are met: (a) I will initially be under constant staff supervision during the time that I will be a resident of (facility name) (b) I will agree to supervision with visitation of any/all outside entities in a public area (c) I will not be allowed to verbally, emotionally or physically abuse any staff members and/or residents while I am a resident of (facility name). If these stipulations are agreeable to you, (Resident #1), (MD) will be our physician of record during the time you are a resident at (facility name). (MD) will have the right to change/amend any/all stipulations at any tine (sic) during your stay. If you violate any/all of these stipulations then (MD) and the staff at (facility name) have the right and responsibility to discharge you from (facility name) in accordance with current Regulatory Guidelines. (ADM name) Administrator (facility) Resident #1 then hand wrote underneath Facility will follow the guidelines from DADS as far as [AGE]-hour pass; Facility will try and put plugs in the room computer . The agreement was signed by resident only. Interview with the local Ombudsman on [DATE] at 8:23 AM revealed that she talked to the ADM before Resident #1 was readmitted about Resident #1 waiting for the ADM to accept him back into the facility after he won his fair hearing and inappropriate discharge. She said she talked to the ADM about Resident #1's rights being violated by the agreement the ADM wanted the resident to sign requiring him to agree to continuous supervision. She said Resident #1 wanted to move back to the facility so he acquiesced to the agreement he would be continuously supervised. She said Resident #1 believed the facility only accepted him back because they were trying to clear their citations and fines accrued with C[CONDITION] and HHSC when they were cited for inappropriately discharging him. She said now that he had come back to the facility, they had him on one-on-one supervision and she had observed staff sitting in the room watching him. She said there was a nurse who sat in the room and listened to him. She said she had talked to the facility and they told her they could do that if a resident was in danger. The Ombudsman said she told the ADM, DON and clinical nurse that Resident #1 was a strong-minded person, but what they were doing was considered profiling. She told them they were violating his rights if they were going to continue the one-on-one monitoring. She said Resident #1 felt his rights were being violated as well and thought the facility was retaliating against him for challenging his previous discharge from the facility and winning his fair hearing. Interview with the ADM and DON on [DATE] at 10:30 AM revealed the facility had accepted Resident #1 back to the facility at the end of [DATE]. The ADM said he had been the ADM at the facility for about three months and the new DON had been there for about a month. He said when they started their employment, they were getting bits and pieces of information about what was going on with the outstanding deficiencies related to Resident #1's inappropriate discharge. The ADM said they were new and did not want to take hearsay as evidence of how they should view the situation. He said when the penalties for the plan of correction for the deficiencies related to Resident #1 started accruing, corporate called him and told him that the facility was going to need to take him back. The medical director (MD) agreed to take Resident #1 as a patient. Prior to Resident #1 returning to the facility, corporate told the ADM they wanted Resident #1 to agree to have one-on-one supervision when he admitted back into the facility. The ADM said he did not want to start off his relationship with Resident #1 in an adversarial role so corporate let him have the latitude to implement one-on-one or not. The ADM said he then talked with the DON and they opted not to initiate the one-on-one when Resident #1 admitted to the facility. The ADM said corporate felt the one on one supervision was necessary because of Resident #1's past behaviors such as being verbally abusive and taking pictures of other residents. The ADM said he agreed to allow Resident #1 back into the facility and had him sign a paper that said he would agree to one-on-one supervision. The ADM then said when Resident #1 admitted , initially he was not on continuous monitoring, and everything was okay for about a week. Then he said there were issues with his bowel management program and asked the DON to explain. The DON said Resident #1 had an old physician's orders [REDACTED]. She said she could not verify where the order came from and it could have been fabricated for all I know. She said her nurses are not trained to digitally stimulate the rectum like that and stimulating the vagus nerve for that long can cause harm, including a potentially fatal effect, such as a drop in his blood pressure. She said the nurses would put the blood pressure cuff on him and when they would do the digital stimulation, he would start sweating profusely. She stated it was making the nurses uncomfortable because they did not want to harm him and it was out of their scope of practice. The DON also alleged she thought Resident #1 received possible sexual stimulation from the bowel program but she never talked to him about it or was able to provide any incident reports or nursing documentation to reflect it. She said the MD ordered a KUB, which was an x-ray to see if Resident #1 had any bowel impactions in his stomach, but he refused the screening. The MD then ordered a suppository and laxative which Resident #1 refused as well. She said after that, the MD met with Resident #1 and explained that the nurses would no longer use the digital stimulation. The DON stated Resident #1 became upset about this. The ADM said Resident #1 and MD had words, then the MD issued the resident a 30-day notice that he would not be his doctor because he would not agree to his treatment plan. The ADM also said around this time, Resident #1 began cursing at the nurses and calling them [***] es for refusing to do his bowel program. The Administrator stated because of this behavior he decided to initiate 15 minutes check on Resident #1, per the agreement Resident #1 had sign prior to his readmission. He said the agreement reflected that the ADM had the right to initiate 1:1 at any time. He said when the MD gave Resident #1 the 30-day notice, Resident #1 then agreed to discontinuing the digital stimulation bowel program. The DON said since that meeting Resident #1 received the suppository and had his routine bowel movements without the 20-minute digital stimulation and had been compliant with the program. The ADM then proceeded to state the facility's online electronic health charting database had recently been hacked by [REDACTED]s and was being held for a ransom, so the facility was not able to access any clinical documents for Resident #1. He then pulled out a red folder sitting on his desk and said he was keeping a file on Resident #1 and showed the discharge letter from the MD and the letter he had Resident #1. He said when Resident #1 found out the MD was discharging him, he called the police later that night and the police came out. The ADM then showed the police the letter Resident #1 agreed to. The ADM stated Resident #1 was saying out loud while the police were leaving the facility that if the CNA monitoring him got close to him, he was going to punch her. The ADM asked the police officer to come back and asked Resident #1 to repeat that statement, which he did. The police then told Resident #1 if he chose to do that, he would be taking a ride with him in his police car. Resident #1 stopped and wheeled away according to the ADM. Review of the MD's handwritten notes after a care plan conference dated [DATE] reflected the meeting was held due to Resident #1's noncompliance with the recommended treatment. Present were Resident #1, ADM, DON and ADON. MD documented in his note that after the meeting, Resident #1 became argumentative, verbally aggressive and disrespectful. He stated Resident #1 was not in agreement with the plan of care recommended. Resident #1 said he wanted to continue his bowel regime which consisted of digital rectal stimulation for removal of stool. MD stated he felt that when that procedure was performed, it seemed to cause sexual stimulation and possible ejaculation per nursing staff. That treatment was stopped and a program of laxatives was effective. He noted Resident #1 was being treated with [MEDICATION NAME] as well which he stated was given for pain and helped with constipation. MD wrote he ordered x-ray of the abdomen, but patient refused. He also ordered a psychiatric consult, but patient refused. He wrote, Absent a psychiatric evaluation, I suspect that this patient suffers from a mental disorder which if not appropriately treated, could be dangerous to himself, other patients and staff. For those reasons, I informed him verbally that our physician/patient relation will be terminated pending written notification. Review of the Physician's Discharge Letter from MD dated [DATE] reflected he would no longer be able to treat Resident #1 as a patient and the termination of their patient physician relationship would be effective in 30 days from the date of the letter. The physician did not give a reason for discharging the resident from his care. Interview with the DON on [DATE] at 11:52 AM revealed she was really trying to work with Resident #1. She stated he had come to her a number of times frustrated and she would go, buy him a soda, and he would sit and talk with her. She said when he talked with her, he was calm and rational, just like any other person. She said he did not want to be in long term care and she did not think he should be in long term care because he was a young, independent person who worked in the community before he became disabled. She stated, How would we feel if something like that happened to us? Interview with the RCN on [DATE] at 1:08 PM revealed the facility did agree to accept Resident #1 back because corporate realized the C[CONDITION] and state penalties needed to be resolved. She said the MD reluctantly agreed to be his attending physician but had since given Resident #1 a termination of services letter. She said that the facility did have Resident #1 sign a paper prior to coming back to the facility that said he agreed to constant supervision based on his history of aggression and a previous incident with Resident #2 during his last stay. RNC stated Resident #2 alleged Resident #1 had run into her wheelchair three times with his electric wheelchair during his previous stay at the facility. RNC said she questioned some of the validity of what Resident #2 was saying anyway because before Resident #2 lived at the facility, She lived at an assisted living and was kicked out for making crack in her room. She said both Resident #1 and Resident #2 were currently at the facility, both smokers, but lived on different halls. The RNC denied any altercations between the two residents since Resident #1's return to the facility. She said though, due to his history of aggressive behavior and him starting to be verbally aggressive to the nurses since he had been back, the facility decided to implement the constant supervision agreement. She said they had to look at if it was a violation of his rights and every day she had a standing three o'clock phone call with the ADM where they discussed whether or not it continued to be appropriate . She said that the facility had not initiated a facility discharge to the resident and she did not plan on doing one at this time. She said the plan of correction the facility agreed to said she and the RVP must approve any facility-initiated discharges and she was not there yet with Resident #1. She voiced understanding that the physician's 30 days expired on [DATE] and the facility could issue an emergency discharge to Resident #1 at that time because he would no longer have a doctor; however, she said she was and would continue to do everything in her power to try and locate a physician who would oversee his care until they could help Resident #1 find a placement in the community or at an assisted living. She said she was going to try and work with the MD to see if he would extend his oversight of Resident #1 until the facility could find him an agreeable place to live in the community. The RCN was asked if all residents who admitted with a behavioral history had to have one on one supervision. She said she had seen it done with residents before at facilities when there was a potential threat the resident may harm or hurt themselves or other residents/staff at the facility. She said Resident #1 could be a potential threat because she had heard he had a criminal history but she did not verify it because if she did it could have been considered profiling. Interview with CNA A on [DATE] at 2:56 PM revealed she had been one of the staff who did 1:1 supervision of Resident #1, but she did not know exactly was she what supposed to monitor for. She said she supervised all his movements, like what he did during the day. She said she supervised him the day prior ([DATE]) on her 12-hour shift from 6:00 AM to 6:00 PM. She said she had to document whether he was sleeping, calm, on the phone or having behaviors. She said she watched him while he was in his room and when he went to smoke as well. She said she had not observed him have any behaviors and he was not rude to her. CNA A said no one explained to her why he was on 1:1 supervision. Interview with LVN B on [DATE] at 4:40 PM revealed she was the charge nurse for Resident #1 on the 2PM-10PM shift. She said he yelled at nurses, but not at CNAs or residents. She said he did yell at her once since his re-admission because he wanted his bowel care done. She said she went to his room and was explaining to him what she was going to do, but he would not let her finish. He told her if she did not do what he asked, he was going to record her on his phone. She stated she left and returned with the morning nurse and he started using profanity at LVN B. The morning nurse then told LVN B that she was late to do Resident #1's bowel program and was not able to get it done on her shift (6:00 AM-2:00 PM). LVN B stated when she went in to do it, Resident #1 was upset about having to wait and did not want her to explain the procedure and just wanted the bowel care done then. She left the room to give him space when he grabbed his phone. LVN B stated the morning nurse ended up going in and finishing the bowel program. LVN B said that was the only incident she had with him. She said she worked with him Monday thru Friday on 2:00 PM-10:00 PM shift. She said Resident #1 recently started leaving the facility more often and had told her he was going to be leaving more because he did not want to get in trouble. She said, He only started doing that when they started putting one on one with him. She said the first day they started 1:1 supervision with Resident #1, they had a CNA monitoring him who had never worked with him before. She said Resident #1 was upset being followed around by her and said she was a dumb dog, that he could not have privacy and that the facility was harassing him. LVN B said, I think I need more training on behavior management .I feel like (Resident #1) is a different kind of person. No one has told me what kinds of interventions to do with him specifically. LVN B said Resident #1 had voiced to her that he was angry someone was always watching him. LVN B said he told her he could not have his privacy and was being harassed and that was why he started cursing the CNA. LVN B said, I can tell he is frustrated. They have to sit in his room on a chair. They just watch him. LVN B said Resident #1 did called her a [***] when there was the issue with him getting his bowel program late. LVN B said she did not know how long the constant supervision was supposed to go on and it had been two weeks so far. Interview with Resident #2 on [DATE] at 5:22 PM revealed she was the resident who had an altercation with Resident #1 during his last stay at the facility. She stated Resident #1 called her a name and they exchanged words and he cursed at her. She then went to leave the dining room and she said Resident #1 jerked his electric wheelchair joystick and hit her wheelchair as she went by him. She said he did it one time and it hit the side rim of the wheel and did not hurt her. She said that was the extent of it. She said she was not afraid of Resident #1, he could not move his legs and he was not a physically imposing person. She said when he readmitted to the facility, he said hello to her and vice versa. She said presently, he was not mean, rude or disrespectful to her and she felt safe and did not feel like he was going to do anything bad. She said since Resident #1 had come back, he had been put on constant supervision. She said she asked him how it made him feel, and he said it felt awful and that the facility was trying to wear him down to get him to leave. She said he told her he felt worn down and tired. She said no one should be treated like that and the facility should not be using old behaviors or incidents against him. She said, This is our home and who in their right mind wants someone watching you all the time. She said she never felt he would hurt another resident; it was just a bunch of hot air. She said she never told the facility that she was scared or frightened of him. She said if you looked at him, he was not physically intimidating, Yes, he can try to say things to threaten staff, but he has no follow through, it's just talk. Interview with the ADM, RNC and DON on [DATE] at 2:24 PM revealed when Resident #1's behavior falls in line and he did not act out towards staff or residents, the 1:1 supervision would go away . The DON said the MD addressed his behavior and the 1:1 supervision was physician driven. The ADM stated for the one-on-one supervision to be removed they would have to monitor Resident #1 for three to five days and see if his behavior got better, then they would go to 15 minutes or 30 minutes, then they would continue to review the situation to see if they could take him off monitoring. The ADM said, I want him to not curse, threaten staff or threaten physical harm. The ADM, RNC, and DON admitted there was not a care plan or a plan in writing that discussed the 1:1 monitoring, the behavior that caused it to be used, and how the monitoring would be titrated. They said they could not access any clinical notes in the electronic database due to the hacking. The RNC said they could update and revise the care plan to reflect what exact behaviors were identified as causing the 1:1 and how the supervision would be titrated. The ADM said he would train the staff who were watching him on what exact behavior(s) they were monitoring. The RNC said Resident #1 was out on pass but when he came back to the facility, it would be a good time for them to sit down with him and review the titration possibility of the constant supervision and make sure he was in agreement. She said staff would be in-serviced on what to observe for related to cursing, being inappropriate to staff, quick jerky movements in his wheelchair and how to halt the action appropriately. Interview with the SW on [DATE] at 2:46PM revealed she had completed the directed in-service mandated as a result of the facility's plan of correction from the inappropriate discharge of Resident #1 related to behavior management techniques and the CAR technique. Then the RNC said the facility was actually not using the technique identified in the directed in-service training because it was over the staffs' head and too advanced . The RNC stated the SW was not the only one responsible for implementing the CAR technique and it was for everyone to implement. Review of the [DATE] directed in-service reflected the requirements were to address dealing with difficult residents' behaviors, managing behavioral and psychological symptoms and how to supervise the staff, and the social worker's role in managing behavior and implementation of C.A.R. (Calm, Aware, Respectful) approach and implementation of the Cohen-Mansfield Agitation Inventory. (Note: The Cohen-Mansfield Agitation inventory Form was a seven-point rating scale for assessing the frequency with which people show certain behaviors. There were 29 descriptors that should be rated from ,[DATE] and are tracked for a two-week time frame) The directed in-service reflected the facility social worker would be responsible for the completion of the form when residents demonstrated difficult and/or aggressive behaviors. Then that information would be addressed with the IDT and during the ADM's daily stand up meeting starting [DATE]. Interview with DON on [DATE] at 6:05 PM revealed she could not locate any of the behavior monitoring sheets for Resident #1 since the one-on-one had been implemented. She said the CNAs were supposed to turn them into the charge nurses at the end of the shift but she had just looked for them and no one knew where they were. Additionally, she said she did not have access to any current incident reports related to Resident #1. DON said she had not seen him display any aggression toward other residents. Interview with the ADON on [DATE] at 6:08 PM revealed she had not seen Resident #1 have any behavioral issues since his readmission. She said there was only one instance where two nurses reported he displayed verbal aggression related to his bowel program. The ADON said that had since been resolved. The ADON said they were still monitoring him for verbal aggression towards staff and that was why he remained on 1:1 supervision. The ADON stated, I don't see other residents scared of him. She said she was not scared of him and stated He's actually sweet. I haven't had any issues. The ADON did not give a direct response when asked if she felt if Resident #1 having constant 1:1 supervision was a violation of

Based on interview and record review, the facility failed to permit the resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs cannot be met in the facility; and the facility failed to ensure the physician completed a discharge summary for one (Resident #1) of one resident reviewed for facility initiated discharges. 1. The facility failed to allow Resident #1 to remain in the facility and initiated a 30-day discharge, then an immediate discharge even after the resident appealed the discharge without documenting the danger the failure to transfer or discharge would pose. This resulted in Resident #1 experiencing stress, loss of morale, sleepness nights, skipping meals and headaches. 2. The facility did not have documented evidence that Resident #1 was harmful or had the potential to be dangerous to other residents in the facility when an immediate discharge was initiated. 3. Resident #1's physician failed to complete a discharge summary that could be sent with the resident to his new placement. This failure could result in residents experiencing psychosocial harm due to inappropriate and unplanned discharges, being discharged without appropriate reasons and documentation communicated to help with the transition of care. Findings included: Resident #1's quarterly MDS Resident assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He had no cognitive delays and had clear speech, vision and hearing. He had no short- or long-term memory problems and only mood related issue with difficulty sleeping. The MDS Assessment reflected Resident #1 had verbal behavioral symptoms directed towards others but the behaviors did not put residents at risk for illness/injury, did not interfere with resident care, did not interfere with social activities, did not intrude on the privacy of others and the behavior did not disrupt care or the living environment. He did have rejection of care during the assessment period for 1 to 3 days. His behaviors were noted to be the same as behaviors from the last MDS review. His functional status included the need for extensive physical assistance of one to two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #1 had range of motion impairment on both sides of his upper and lower extremities and used a wheelchair for mobility and could self-propel. Resident #1's active [DIAGNOSES REDACTED]. He was in frequent pain which made it hard to sleep. He received anti-depressant medication only. The MDS Assessment reflected the resident did had active discharge planning to return to the community. Review of Resident #1's care plan initiated 11/08/18 and last updated on 03/27/19 did not reflect discharge planning. A problem onset dated 03/27/19 reflected, I am accusatory towards staff at times; Approaches-provide redirection addressing specific accusation, encourage positive and appropriate interaction with others and provide emotional support in a calm manner, aside that accusations do not intrude upon rights of other residents, social worker to visit as needed, and document each episode and include interventions and outcomes. The care plan had a behavioral revision on 03/27/19 which stated, Behaviors: (Resident #1) has demonstrated verbally abusive behavior and hostility towards others. He continues to yell and curses staff. He is very disruptive, belligerent and disturbs the other residents. Approaches- Psychiatric consult as indicated, monitor and document observed behavior and attempted interventions, provide positive feedback for good behavior, can be verbally abusive and threatening towards staff members when upset-allow time to calm down and re-approach at a later time. At the time of the care plan revision on 03/27/19, the facility had already issued Resident #1 a 30-day discharge notice and subsequent immediate discharge notice, both dated 03/26/19. Resident #1's care plan did not reflect the resident was being discharged due to behavioral issues. Additionally, the care plan did not document any behavioral issues related to Resident #1 until after they gave him a discharge notice. Review of nursing progress notes from 01/02/19-03/27/19 revealed no incidents or issues related to resident harm or safety or threats of harm to staff. The three progress notes that addressed maladaptive behaviors included: - 01/21/19: Resident #1 had complaints about his PRN pain mediation and the parameters of its administration. Resident became loud and argumentative and threatened to report the nurse when it was not given as requested. - 03/04/19: Resident #1 needed his Foley irrigated but the nurse could not get the Foley apart. Resident felt it was because the tube was leaking and his leg band felt soaked, however nurse did not agree. Resident #1 got agitated and started cussing, saying it was leaking from somewhere and the nurse was calling him a liar. Another nurse was brought in and resident wanted catheter tubing changed but the nurses could not find another tube to replace it with in the supply room. He became agitated and cussed, threatening their license and told them he was going to call the state and to exit his room. - 03/11/19: Nurse told by social worker that Resident #1 made a compliant to her in reference to another resident on his unit that yells out. ADM and SW visited the resident and offered another room which he declined because he felt he had been there first and should not have to move, to which the administrator asked him if he was aware of the type of facility it was. Resident began yelling at administrator saying they should do something about the yelling resident and asked them to leave his room. Review of a grievance dated 03/22/19 from Resident #1 revealed he reported that he was tired of a resident on his hall yelling and screaming all night. He stated that morning at 3AM the other resident was placed by his door and when Resident #1 told him to be quiet, the other resident said he was going to hit him. Resident #1 said this was not the first time the resident was yelling outside his door. Review of the care plan conference meeting summary dated 03/26/19 revealed Resident #1, his girlfriend and his mother (by phone) attended the meeting, along with the previous ADM and DON, the current SW and ADON. No physician was present for the meeting. The summary of the discussion included concerns about the resident's care, including various grievances he had and an issue with another resident on his hall who was yelling. He was documented to be concerned about the timeliness of getting a urine analysis after multiple requests when he felt he had a UTI. He was concerned that he had been having chronic UTIs resulting in multiple rounds of antibiotics. He also reported he had a wound on his elbow that he had told the facility about but nothing was being done to address it. During the meeting, the nurse said she would send a referral to the wound doctor for him to be seen that week. At that point, the SW documented that ADM explained to the resident that if he was so unsatisfied with his care and his stay, he had the option to move out to a place that could meet his needs. Facility stated we could not meet his needs, a 30-day discharge would be issued. At that point, Resident #1 was noted to say, Let's get the boxing gloves and we can go outside to the administrator. Then the issue with Resident #1's hall neighbor screaming was briefly addressed by the administrator and he reminded the resident it was a nursing home. Then Resident #1 said he was tired of the other resident yelling out and did not want it to get physical between them. Review of the 30-day facility-initiated discharge letter dated 03/26/19 reflected Resident #1 was issued a discharge notice because of verbal threats towards administrator, creating a hostile environment within the facility, being non-compliant with care and verbal abuse towards staff and other residents. The effective date of discharge was 04/24/19. The 30-day notice informed Resident #1 of his right to appeal the discharge and the right to be discharged to a location of his choice. Review of the immediate discharge letter dated 03/26/19 reflected Resident #1 was issued a new and revised discharge notice because safety of individuals in the facility was endangered due to aggressive behavior with residents, resident family members, staff to include verbal threats to cause physical harm to residents and a staff member. The effective date of discharge was revised to immediate. He was notified of his right to appeal the discharge and was given the option to be discharged to the location of his choice. Interview with Resident #1 on 08/23/19 at 2:58 PM revealed he was back at the hospital due to a urinary tract infection. He said he had won his discharge appeal against the facility on 06/17/19, but they were not letting him admit back because they claimed there was no doctor that would accept him there. He said he chose the medical director that previous week of (MONTH) 19th, 2019; but had heard nothing back from him or the facility on if the medical director accepted him. Resident #1 said prior to the care plan meeting on 03/26/19, he had been feeling like he had a urinary tract infection for three weeks but the nurses were not following through on getting him a urine analysis. He said he had severe bladder spasms and urine leakage and had been paralyzed for [AGE] years so he knew his body and signs and symptoms of a UTI. He said the nurses refused to follow up. He felt the facility was mad at him because he had been elected vice president of the resident council and was vocal in advocating for the residents' right in the facility. Resident #1 said on the day of his discharge notice from the facility, he was in his room doing his bowel program when the previous DON came in suddenly and told him she was going to meet with him. He said she was ugly and abusive and wanted the meeting right then because his mother had been calling the facility asking why they were not following up on his UTI concerns. He said after he finished his bowel program, he went to meet with the DON, and he found out it was not just her, but also the ADM, ADON and SW. He wanted a witness so he got his girlfriend to attend in person, and his mother to participate via phone. Resident #1 said as soon as they closed the door, the ADM and DON started screaming at him at the top of their lungs because they did not like that his family had insinuated they were not taking care of him. Resident #1 said he was making waves as the resident council vice president. He said they did not like that he was being proactive in his care and others' care. He said, After the screaming match, it pushed me to where I said if you want to scream at me, we can take this outside. At that point, he said the ADM and DON said he was threatening them. Resident #1 admitted that his tone did get up a little, but it was because I wanted my voice to be heard. At that point, he ended the meeting and within ten minutes I had a discharge notice in my hand. Resident #1 said the reason the facility gave him for his discharge was because he was a threat to residents, staff and family members. Resident #1 denied threatening anyone, he said he felt the facility was making it up just to get rid of him. He said he met with the Ombudsman who went and talked to the ADM and DON and then the ADM came back with an immediate discharge notice the next day. He said he had been feeling worse, his urine looked black and he felt so sick, he was blacking out and he felt blisters forming on his back were getting septic. He asked LVN C to send him to the hospital to be evaluated but she said that she'd already been notified I was being discharged so it was not their problem. He said he called 911 himself and was transferred to the hospital where he was placed on high potency antibiotic therapy for a UTI. He said the facility was contacted for him to go back from the hospital after he had filed his appeal, but they said he could not come back. He felt the facility illegally dumped him at the hospital. As a result, he had to choose another facility which was pure hell due to the poor care he received there. Further interview with Resident #1 revealed he was unaware Physician B had dropped him as a patient until the appeal hearing in (MONTH) 2019, and he was shown the doctor's discharge letter by the Ombudsman. He said there was never an issue with Physician B, only with his PA because she came in one time and told him she was going to take him off his pain medications cold turkey ([MEDICATION NAME] and Tylenol with [MEDICATION NAME]). He said that was not what he and Physician B had agreed on and the PA got upset. He asked her to leave the room. After that, he had a visit from Physician B about the incident and he explained himself. He said the doctor said he would take care of it and Resident #1 would deal with him directly going forward. He re-iterated there was never an issue with Physician B until the facility discharged him. Resident #1 said he still wanted to go back to the facility presently because it was close to his girlfriend, pastor, friends and family members, which made it easier for those to visit him who did not have cars. He said because the facility did not honor the appeal decision, he had to move to a facility in another county, which forced him to change insurance carriers, which affected the services he had been waiting on with his former insurance related to community placement. He said the facility, screwed me out of where I was staying and everything I had been waiting on for eight months .they put my family through hell, me through hell, with the expenses of moving and the hospital stays. Resident #1 also said the inappropriate discharge and refusal to take him back after he won the appeal had caused him a lot of stress, a lot of sleepless nights because of the position they had forced him in. He said he did not see his family as much anymore because of the location, he did not eat at times and he got headaches since the discharge had happened. He said his girlfriend had been in tears because he cannot see her as much. He felt he was starting to lose morale and felt there was not enough protection for resident as far as advocacy. He said had it not been for the hospital, he would currently be homeless on the streets and he had no other place to go right when the hospital would eventually have to discharge him. Interview with the previous ADM A on 08/23/19 at 2:08PM revealed he knew Resident #1 had appealed the discharge and had won it, but he felt it was only because he was unable to be present on the phone (ADM), so the resident won the appeal by default. He stated he had since called the appeal court and a new revision date for a new appeal hearing was set for 09/03/19. ADM A said he had gone out of his way to help Resident #1 obtain certain things out of his own pocket, such as special gloves, a new pair of shoes, an expensive hairdryer, a special electrical socket for his computer, but he did not feel Resident #1 appreciated any of it. He stated, I have done everything I could to be nice. He is a tyrant! He treats residents bad, people bad, running through the hallways cursing, threatening to beat me up, crazy, he is very manipulative. He said, The guy is not only ungrateful, he's just flat out mean. When he left, the building got really quiet and peaceful, we were like thank god. ADM A said when Resident #1 won his discharge appeal, there were no doctors contracted with the facility willing to take him back. ADM A said at the care plan meeting on 03/26/19, Resident #1 was going off on him and the DON because he was not seeing what they were trying to do out of their own pocket to pay for things. ADM said Resident #1 said he would take me outside and something like fight me. ADM A said he was not scared for himself, but what the resident could do to harm the other residents, because even though he was a paraplegic, he still had use of his arms. As a result, the ADM said, No. We are not going to do this, this is over. It wasn't for me. After the care plan meeting on 03/26/19, ADM A issued Resident #1 a 30-day discharge letter. When he went to deliver it to him, ADM A said the paper fell on the floor and he was going to pick it up for Resident #1, when he said to ADM A something like I don't need your (f******) help. After that interaction, ADM A said he went back and reviewed the CMS regulations with the DON and changed the 30-day notice to an immediate discharge notice. That night, ADM A said Resident #1 called 911 and transferred himself to the hospital due to a catheter issue. ADM A said he knew Resident #1 wanted to come back to the facility from the hospital, but there was no doctor to take him on. He said, We would have probably had no choice to take him back if he had a doctor. Interview with ADON D on 08/23/19 at 11:15 AM revealed she was the only nursing management still at the facility who knew of Resident #1. She said he was not a danger to himself and could not say if he was a danger to others. She said he got into an argument with another resident who was causing rifts between him and his girlfriend (who was the daughter of another resident). However, that did not escalate into anything and the two still were around each other after that incident because they were smokers. She said the resident who he got into the verbal argument with told her about it and admitted they were both cursing at each other. She said it happened at the beginning of 2019 and the resident did not mention being scared of him. She said the only other incident she could remember was a resident's family member told him to turn down his portable speaker in the dining room and it started from there. ADON D could not elaborate on the incident because she was out of the loop. She said in regards to the staff, Resident #1 had PRN [MEDICATION NAME] for pain management and there were times he had issues with the time it was being administered by the nurses and would confront them and at times become upset if they were unwilling to administer it. He also felt his catheter should be changed more than the order prescribed, so he would have conflict with the nurses over that. She said the facility had the care plan meeting on 03/26/19 because they wanted to meet his needs. She said during the meeting, he got verbally aggressive with her and the other staff, but particularly with the administrator and he offered to take him outside and kick his ass and that was when ADM A stopped the meeting. She said Physician B had already given Resident #1 a discharge notice when that meeting occurred and he was not present. ADON D said Resident #1 would not have been able to come out of his wheelchair to harm ADM A and had never threatened the staff with harm before. After the meeting, the ADM ended up issuing Resident #1 an immediate discharge notice that same day. ADON D said there were no residents in the facility who had been harmed by Resident #1 or who said they were afraid of the resident. She said no residents avoided him and he was active in the facility resident community life. She said Resident #1 was exactly the same personality and behavior wise as when he initially admitted . She said he ended up transferring to the hospital because of a catheter issue and then to a different nursing facility but had been back in the hospital as of recent. And within the past two weeks, the hospital called the facility with a court order for him to come back to the facility, and the facility declined to re-admit him. She acknowledged he appealed his discharge and won it, but there were currently no doctors that would take him on at the facility due to his history of non-compliance and aggressive behavior. Interview with Physician B's physician assistant (PA) on 08/23/19 at 2:43PM revealed Resident #1 had been on their case load for about a two week time span in (MONTH) 2019 and they inherited him because he had fired his previous physician because he was unhappy with the management of his suprapubic catheter. She said she met with him only one time for about ten minutes and she informed him of her role and the inability to provide narcotic pain medications and that typically they would refer him out to a specialist to manage his chronic pain. She noted at that point, Resident #1 became verbally aggressive and said he would take her license and call the State. She said she let him vent then went to facility management and told them about it. She said she talked to Physician B and told him about the incident and that he might be a better fit to see Resident #1. The PA said she knew Resident #1 was angry about the pain medication, and that he most likely would not act on his threat, but she did not want to set herself up for an adversarial relationship with him in the future, so she preferred Physician B be the one to see him on a routine basis and she would be available for emergencies and standby only. She said when Resident #1 went to the hospital and wanted to come back, I think if he would have come back in that 30-days, I think we would have had to see him. I was not asked by the facility to continue watching him after he went to hospital during the 30-day time frame. Interview with Physician B on 08/23/19 at 5:38 PM revealed he had concerns with the pain medication Resident #1 was receiving and said he had to comply with DEA guidelines for controlled substance prescriptions. As a result, he had to talk to the resident about other methods to control his pain, with which the resident was in agreement. Physician B said he heard about Resident #1 threatening staff through the nurses at the facility and through an incident with his P[NAME] Physician B said Resident #1 was never directly mean or verbally abusive to him, but he did not want to take the chance on him being so. He said he decided to discharge him from his service. He said he did not have to legally give the resident a reason he discharged him from service. He wrote Resident #1 a 30-day Physician discharge notice but by the time he was at the facility to deliver it, Resident #1 had already transferred to the hospital. He said he gave his notice to ADM A, so he did not give the letter to the resident. He said he told ADM A to tell Resident #1 that if he wanted to come back from the hospital, he would have continued seeing him until the 30 days were up. Physician B was asked if he completed a physician's discharge summary and stated he did not because the resident basically discharged himself. Review of Resident #1's clinical progress notes revealed no visits from his new attending physician when he was placed on his caseload for two weeks in (MONTH) 2019, Physician B, when he was placed on his patient caseload. On 08/23/19 and 08/26/19, ADM C was asked multiple times to provide any physician visits from Physician B for Resident #1. On 08/26/19 at 1:00PM, ADM C stated the facility could not locate any consults and did not have documented evidence Resident #1 was seen by his new attending physician, Physician B. Review of Resident #1's Physician's 30-day discharge from services notice dated 03/19/19 (three days after he transferred to the hospital for catheter pain) reflected he was being discharged from Physician B's medical practice and he would be available for the next 30 days. Physician B did not give a reason he was discontinuing his medical services to Resident #1. Review of Resident #1's clinical record revealed no transfer order to the hospital on [DATE] or subsequent physician's discharge order from the facility, no active discharge plan, and no physician's discharge summary. Reviw of Resident #1's face sheet record from the new nursing facility he had to chose while at the hospital, reflected an admission date of [DATE]. Interview with LVN C on 08/26/19 at 11:30 AM revealed she was the charge nurse on duty 03/27/19 when Resident #1 went to the hospital. She said his Foley was leaking so he irrigated it but about 20-30 minutes later, he came back and told her he was in too much pain said he wanted his Foley catheter changed or to be sent out to the hospital. She said she assessed him and medicated him with PRN pain medication and called Physician B who was okay with sending him out. Resident #1 said he wanted his Foley catheter changed but the facility only had a 20 French, not a 22 French, which is what the resident was used to. She asked him if he wanted to wait until the next day when the 22 French came in and he said a 20 was too small and to send him out so he could get a 22. LVN D said, I can say, he was in pain. He was shivering, sweating so much and his facial expressions and this was after I'd given him pain medication. She said he couldn't wait until the next day so she scheduled transportation and they said less than 30 minutes they would be in the building. She notified Resident #1 and he said okay, but then said it was too long to wait and to call 911. He ended up calling 911 who arrived and transported him to the hospital. Regarding his behaviors while a resident at the facility, LVN D said Resident #1 would curse at her when she did not do what he wanted or as fast as he wanted it done. He wanted to be the priority. She said at those times, he would eventually calm down after awhile, go out for a smoke break and be okay. Other times, he could be mad the whole shift, it just depended. She said she never knew of him to say he was going to hurt anyone, including staff or residents. Interview with the SW on 08/23/19 at 4:47 PM revealed Resident #1 was given a 30-day discharge notice by the facility, then an immediate discharge notice a day later. She said the discharge was because of his threat to the ADM and some other residents were saying things; however, the SW did not have any specific information regarding what they were saying. She said there were some safe surveys she had done that talked about him and the ADM would have them. She said in the care plan meeting on 03/26/19, the ADM and DON said they were going to give him a discharge notice. She said that was not the point of the meeting though, the meeting had been called to discuss his care and constant UTIs and then it turned into him saying things to the Administrator about going outside and getting boxing gloves. The SW said she did not think Resident #1 physically would have been able to harm the administrator. She said he went to the hospital on his own accord. In her personal interactions with Resident #1, the SW said she never felt scared of him. She said she never saw him be mean or threatening to any residents. She said she knew of the incident with the PA who came out of the room crying and she said Resident #1 told her he was going to have her license regarding some issue with pain medicine and she was saying she would quit and she was visibly upset. SW said the PA did not want to see him and for Physician B to see him. She said, As far as I know, there were no issues with (Physician B). SW also stated she did not know why the medical director would not accept Resident #1 as a patient. Interview with the local Ombudsman on 08/23/19 at 6:24 PM revealed she was notified by Resident #1 and the facility on 03/26/19 that a 30-day discharge notice had been given. She said she visited with the resident the next day and advised Resident #1 of his right to appeal the 30-day discharge and he chose to appeal. She said by the end of that day, Resident #1 notified her that he needed to go to the hospital due to a catheter issue, but the facility would not send him. She re-educated him on his right to go to the hospital if he felt like he needed to go. She said, Little did I know they would not allow him to come back to the facility when he went to the hospital and they didn't allow him to come back. The ombudsman said after filing the appeal to the 30-day discharge, she found out later that the facility had gone back and issued him an immediate discharge. She said the resident won his discharge appeal case but was left with no other choice than to choose another facility to move to because the facility was not agreeing to take him back. She said Resident #1 was a self-determined person and he exercised his rights to self-determination. She said since he had to move to another facility, it was further away and in another county, so it made it harder for him to see his girlfriend and family members, as well as changed his insurance provider, which has caused more barriers for him moving eventually into assisted living or his own apartment. During an interview with the current administrator (ADM E) and C-RN on 08/26/19 at 11:27AM, they were asked to provide the safe surveys the social worker referenced were written about Resident #1 and incident reports related to his behavior and refusals to see a psychiatrist for an evaluation, The ADM stated she did not have any of the requested items. C-RN said were no safe surveys completed that indicated other residents in the facility were fearful of Resident #1. Review of a letter provided by ADM [NAME] on 08/26/19 at 1:15PM reflected one was from a current resident and one was from a resident's daughter. The letter from the current resident was dated 04/01/19 after Resident #1 was transferred to the hospital and indicated Resident #1 called her a lying whore in the dining room during lunch when he was there with his girlfriend. She asked him and his girlfriend what he meant and neither would answer. She denied being fearful of him and denied negative psychological effects. The other letter from another resident's family member was dated 03/28/19 after Resident #1 was transferred to the hospital and indicated the family member had prior issues with Resident #1 turning his music down during lunch time because her mother was anxious due to her diagnosis. She noted Resident #1 would begrudgingly turn the music down, but the same issue would occur the next day. Around 12/26/18, she stated the dining room was already noisy and he began playing his music loudly. In aggravation, she raised her voice to him and asked him to turn it down. He yelled and she yelled and it became a hostile situation and both of them made the atmosphere for the other residents uncomfortable. The family member acknowledged her behavior was not appropriate. Interview with the MD on 08/26/19 at 10:21 AM revealed he never met Resident #1 but had heard about him through the grapevine and he did not want to take him on as a patient for liability reasons, including potential legal issues and hearing he was aggressive towards individuals. He said the resident had called him on his cell phone since he was discharged to see if he would take him as a patient but the medical director never returned his phone call to confirm if he would take him or not. He said that in his view, not calling the resident was an indication he would not be taking him on his caseload. He said the things he had heard about the resident were hearsay and he could not confirm if they were actually true or not. He felt he did not want to take the risk of having him as a patient in the case the resident was readmitted and ended up harming another resident or staff, then the facility would be in a lot of trouble with the state for not protecting the individuals in the facility. MD was not able to point to any specific incidents where the resident was harmful to residents or staff, but he felt the threat was there. He said he treated about 30 residents in the facility. He said he was not required to oversee the care of a resident when an attending discharged them from their care or was unable to meet the resident's needs. Review of the facility's Transfer or Discharge Documentation policy revised (MONTH) (YEAR) reflected, Policy Interpretation and Implementation: .2. If a resident e

Based on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for [REDACTED]. The facility failed to establish and follow a policy to allow Resident #1 to return to the facility after a hospitalization when he had appealed his discharge from the facility. This resulted in Resident #1 experiencing stress, loss of morale, sleepness nights, skipping meals and headaches. This failure could result in residents experiencing psychosocial harm due to inappropriate and unplanned discharges, being discharged without appropriate reasons and documentation communicated to help with the transition of care. This failure could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process. Findings included: Resident #1's quarterly MDS Resident assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He had no cognitive delays and had clear speech, vision and hearing. He had no short- or long-term memory problems and only mood related issue with difficulty sleeping. The MDS Assessment reflected Resident #1 had verbal behavioral symptoms directed towards others but the behaviors did not put residents at risk for illness/injury, did not interfere with resident care, did not interfere with social activities, did not intrude on the privacy of others and the behavior did not disrupt care or the living environment. He did have rejection of care during the assessment period for 1 to 3 days. His behaviors were noted to be the same as behaviors from the last MDS review. His functional status included the need for extensive physical assistance of one to two staff for bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #1 had range of motion impairment on both sides of his upper and lower extremities and used a wheelchair for mobility and could self-propel. Resident #1's active [DIAGNOSES REDACTED]. He was in frequent pain which made it hard to sleep. He received anti-depressant medication only. The MDS Assessment reflected the resident did have active discharge planning to return to the community. Review of the 30-day facility-initiated discharge letter dated 03/26/19 reflected Resident #1 was issued a discharge notice because of verbal threats towards administrator, creating a hostile environment within the facility, being non-compliant with care and verbal abuse towards staff and other residents. The effective date of discharge was 04/24/19. The 30-day notice informed Resident #1 of his right to appeal the discharge and the right to be discharged to a location of his choice. Review of the immediate discharge letter dated 03/26/19 reflected Resident #1 was issued a new and revised discharge notice because safety of individuals in the facility was endangered due to aggressive behavior with residents, resident family members, staff to include verbal threats to cause physical harm to residents and a staff member. The effective date of discharge was revised to immediate. He was notified of his right to appeal the discharge and was given the option to be discharged to the location of his choice. Review of Resident #1's Fair Hearing order dated 06/21/19 reflected Resident #1's discharge was reversed due to the facility not being present for the hearing held on 06/03/19. The facility was ordered to immediately re-admit Resident #1 upon receipt of the order if he chose to return. Interview with Resident #1 on 08/23/19 at 2:58 PM revealed he had won his discharge appeal to the facility on [DATE], but the facility was not letting him re-admit because they claimed there was no doctor that would accept him there. He said he chose the medical director that past week of (MONTH) 19th, 2019, but had heard nothing back from him or the facility on if the Medical Director accepted him. He said he was unaware Physician B had dropped him as a doctor until the appeal hearing in (MONTH) 2019, and he was shown the doctor's discharge letter by the Ombudsman. He said there was never an issue with Physician B, only with his PA because she came in one time and told him she was going to take him off his pain medications cold turkey ([MEDICATION NAME] and Tylenol with [MEDICATION NAME]). Resident #1 said he still wanted to go back to the facility presently because it was close to his girlfriend, pastor, friends and family members, which made it easier for those to visit him who did not have cars. He said because the facility did not honor the appeal decision, he had to move to a facility in another county, which forced him to change insurance carriers, which affected the services he had been waiting on with his former insurance related to community placement. He said the facility, screwed me out of where I was staying and everything I had been waiting on for eight months .they put my family through hell, me through hell, with the expenses of moving and the hospital stays. Resident #1 also said the inappropriate discharge and refusal to take him back after he won the appeal had caused him a lot of stress, a lot of sleepless nights because of the position they had forced him in. He said he did not see his family as much anymore because of the location, he did not eat at times and he got headaches since the discharge had happened. He said his girlfriend had been in tears because he cannot see her as much. He felt he was starting to lose morale and felt there was not enough protection for resident as far as advocacy. He said had it not been for the hospital, he would currently be homeless on the streets and he had no other place to go right when the hospital would eventually have to discharge him. Interview with the previous ADM A on 08/23/19 at 2:08 PM revealed he knew Resident #1 had appealed the discharge and had won it, but he felt it was only because he was unable to be present on the phone (ADM), so the resident won the appeal by default. ADM A said when Resident #1 won his discharge appeal, ADM A knew Resident #1 wanted to come back to the facility from the hospital, but there was no doctor to take him on. He said, We would have probably had no choice to take him back if he had a doctor. Interview with ADON D on 08/23/19 at 11:15 AM revealed she acknowledged Resident #1 appealed his discharge and won it, but there were currently no doctors that would take him on at the facility due to his history of non-compliance and aggressive behavior. Interview with Physician B's physician assistant (PA) on 08/23/19 at 2:43PM revealed Resident #1 had been on their case load for about two weeks in (MONTH) 2019 and they inherited him because he had fired his previous physician because he was unhappy with the management of his suprapubic catheter. She said she met with him only one time for about ten minutes when she informed him of her role and the inability to provide narcotic pain medications and that typically they would refer him out to a specialist to manage his chronic pain. She noted at that point, Resident #1 became verbally aggressive and said he would take her license and call the stated. She said she let him vent then went to facility management and told them about it. She said she talked to Physician B and told him about the incident and that he might be a better fit to see Resident #1. The PA said she knew Resident #1 was angry about the pain medication, and that he most likely would not act on his threat, but she did not want to set herself up for an adversarial relationship with him in the future, so she preferred Physician B be the one to see him on a routine basis and she would be available for emergencies and standby only. She said when Resident #1 went to the hospital and wanted to come back, I think if he would have come back in that 30 days, I think we would have had to see him. I was not asked by the facility to continue watching him after he went to hospital during 30-day time frame. Interview with Physician B on 08/23/19 at 5:38 PM revealed he had concerns with the pain medication Resident #1 was receiving and said he had to comply with DEA guidelines for controlled substance prescriptions. As a result, he had to talk to the resident about other methods to control his pain, with which the resident was in agreement. Physician B said he heard about Resident #1 threatening staff through the nurses at the facility and through an incident with his P[NAME] Physician B said Resident #1 was never directly mean or verbally abusive to him, but he did not want to take the chance on him being so. He said he decided to discharge him from his service. He said he did not have to legally give the resident a reason he discharged him from service. He wrote Resident #1 a 30-day Physician discharge notice but by the time he was at the facility to deliver it, Resident #1 has already transferred to the hospital. He said he gave his notice to ADM A, so he did not give the letter to the resident. He said he told ADM A to tell Resident #1 that if he wanted to come back from the hospital, he would have continued seeing him until those 30 days were up. Physician B was asked if he completed a physician's discharge summary and stated he did not because the resident basically discharged himself. Review of Resident #1's Physician's 30-day discharge from services notice dated 03/19/19 (three days after he transferred to the hospital for catheter pain) reflected he was being discharged from Physician B's medical practice and he would be available for the next 30 days. Physician B did not give a reason he was discontinuing his medical services to Resident #1. Reviw of Resident #1's face sheet record from the new nursing facility he had to chose while at the hospital, reflected an admission date of [DATE]. Interview with LVN C on 08/26/19 at 11:30 AM revealed she was the charge nurse on duty 03/27/19 when Resident #1 went to the hospital. She said his Foley was leaking so he irrigated it but about 20-30 minutes later, he came back and told her he was in too much pain said he wanted his Foley catheter changed or to be sent out to the hospital. She said she assessed him and medicated him with PRN pain medication and called Physician B who was okay with sending him out. Resident #1 said he wanted his Foley catheter changed but the facility only had a 20 French, not a 22 French, which is what the resident was used to. She asked him if he wanted to wait until the next day when the 22 French came in and he said a 20 was too small and to send him out so he could get a 22. LVN D said, I can say, he was in pain. He was shivering, sweating so much and his facial expressions and this was after I'd given him pain medication. She said he couldn't wait until the next day so she scheduled transportation and they said less than 30 minutes they would be in the building. She notified Resident #1 and he said okay, but then said it was too long to wait and to call 911. He ended up calling 911 who arrived and transported him to the hospital. Regarding his behaviors while a resident at the facility, LVN D said Resident #1 would curse at her when she did not do what he wanted or as fast as he wanted it done. He wanted to be the priority. She said at those times, he would eventually calm down after awhile, go out for a smoke break and be okay. Other times, he could be mad the whole shift, it just depended. She said she never knew of him to say he was going to hurt anyone, including staff or residents. Interview with the SW on 08/23/19 at 4:47 PM revealed Resident #1 was given a 30-day discharge notice by the facility, then an immediate discharge notice a day later. She said he went to the hospital on his own accord. In her personal interactions with Resident #1, the SW said she never felt scared of him. She said she never saw him be mean or threatening to any residents. SW said the PA did not want to see him due to a negative interaction where he threatened her license related to his pain medication prescriptions and for Physician B to see him. She said, As far as I know, there were no issues with (Physician B) prior to the resident's transfer to the hospital. SW also stated she did not know why the medical director would not accept Resident #1 as a patient when no other doctors wanted to take him. Interview with the local Ombudsman on 08/23/19 at 6:24 PM revealed she was notified by Resident #1 and the facility on 03/26/19 that a 30-day discharge notice had been given. She said she visited with the resident the next day and advised Resident #1 of his right to appeal the 30-day discharge and he chose to appeal. She said by the end of that day, Resident #1 notified the facility that he needed to go to the hospital due to a catheter issue, but the facility would not send him. She re-educated him on his right to go to the hospital if he felt like he needed to go. She said, Little did I know they would not allow him to come back to the facility when he went to the hospital and they didn't allow him to come back. The ombudsman said after filing the appeal for the 30-day discharge, she found out later that the facility had gone back and issued him an immediate discharge. She said the resident won his discharge appeal case but was left with no other choice than to choose another facility to move to because the facility was not agreeing to take him back. She said Resident #1 was a self-determined person and he exercised his rights to self-determination. She said since he had to move to another facility, it was further away and in another county, so it made it harder for him to see his girlfriend and family members, as well as changed his insurance provider, which has caused more barriers for him moving eventually into assisted living or his own apartment. Fair and Fraud Hearings Handbook, retrieved 08/30/19 from https://hhs.texas.gov/book/export/html/4340, reflected: 1810 Responsibility of the Agency Representative for Implementing Decisions Revision 10-3; Effective (MONTH) 21, 2010 When the hearings officer reverses the agency action on appeal, the agency representative is required to implement the order and enter implementation data in the TIERS, Hearings and Appeals, Decision Implementation module. .2410 General Revision 14-5; Effective (MONTH) 10, 2014 Although program staff may disagree with the hearings officer's decision, they must carry out the fair hearing decision once it has been made. However, program staff have 20 calendar days from the date of the decision to ask for an exception to the fair hearing decision. The exception process exists to make sure both program staff and hearings officers consistently apply applicable policy. When a hearings officer issues a fair hearing decision, staff must carry out the decision within the implementation time frames, including restoring benefits to which the appellant is entitled. The agency representative has 10 days from the date the decision was issued to implement the hearing decision. If additional information is needed, the agency representative will contact the appellant and pend the implementation process. Once the additional information is received, the agency representative has three business days to complete the implementation. The agency representative implements the hearing decision and enters the implementation information in the TIERS Hearings and Appeals, Decision Implementation module, including delays. (For more information on delays, see Item 1723, Delays in Issuing a Decision - 1 TAC §357.23(a)(3).) Review of the facility's policy titled, Admission Criteria revised (MONTH) (YEAR), reflected, .1. The objective of our admission criteria policy are to: a. provide uniform criteria for admitting residents to the facility .12. The Administrator, through the Admission Department, shall assure that the resident and the facility follow all applicable admission policies. Review of the facility's Transfer or Discharge Documentation policy revised (MONTH) (YEAR) reflected, Policy Interpretation and Implementation: .2. If a resident exercised his or her right to appeal a transfer or discharge notice, he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility; 3. If the resident is transferred or discharged despite his or her pending appeal, the danger that failure to transfer or discharge would pose will be documented; .

Based on observation, interview, and record review, the facility failed to ensure prevention and development of and provide care and services to pressure ulcers for six (Resident #27, #24, #17, #26, #13, and #5) of 31 residents reviewed for pressure ulcers. 1. Resident #27 was not assessed or positioned to prevent the development of a pressure ulcer. On 10/20/11, after surveyor intervention, a deep tissue injury pressure ulcer was identified on the resident right heel. 2. Resident #24 was not assessed or provide positioning devices to prevent the development of a pressure ulcer. On 10/20/11, after surveyor intervention, a Stage 2 pressure ulcer was identified on the resident's right lateral ankle. 3. Resident #17 was not assessed or treated for [REDACTED]. Resident #17 had developed two pressure ulcers on 10/20/11. 4. Resident #26 developed multiple pressure ulcers on both feet due to ill fitting shoes. 5. Resident #13 had long fingernails and had moist white macerated skin on the palms of her severely contracted hands. 6. Resident #5 a resident with a [DIAGNOSES REDACTED]. These failures regarding pressure sores resulted in Residents #5, #13, #17, #24, #26 and #27 developing and the delay of treatment for [REDACTED]. These failures could affect the 98 residents who were identified by the facility as having pressure ulcers and/or receiving preventive skin care. Findings included: 1. Observation on 10/20/11 at 5:15 PM revealed Resident #27 was in bed on her back. Treatment Nurse C, the facility's treatment nurse, removed the cover off Resident #27's lower legs. The resident's lower legs were positioned with her heels together. The resident's right heel was pressed into her left heel. When Treatment Nurse C separated the resident's legs, the resident groaned loudly with pain. Observation of her right heel at that time revealed a round area approximately 2 inches in diameter. The skin in this area was mushy-looking with a pink color more intense than the surrounding tissue where the resident's right heel had indented into her left heel. Treatment Nurse C then repositioned the resident's legs exactly the same way they were before with the heels pressed against one another. Treatment Nurse C left the room in order to return with Resident #27's pain medication. During an interview on 10/20/11 at 5:29 PM, Treatment Nurse C stated she was unaware of Resident #27's mushy heel "until now." A review of Resident #27's skin records entitled "Skin Grid-Other Skin Problems" dated 09/23/11 and provided by Treatment Nurse C and the DON revealed four pages addressing skin problems consisting of: a bruise on her left inner thigh, a bruise on her left hand, an abrasion on her abdomen and a skin tear on her left upper arm. These documents reflected there was reassessment of the above four skin problems on 10/05/11 and 10/18/11. There was no mention of any skin impairment on Resident #27's heels. On 10/21/11 at 9:30 AM, Resident #27 refused to allow the surveyor to look at her skin and heels. The resident said it would be too painful. LVN M gave Resident #27 pain medication at approximately 10:15 AM. At 12:30 PM, Resident #27 would only allow the surveyor to look under the covers. Her heels were separated at that time and off the bed. The right heel had a small area on the bottom and inside wall, which was slightly purplish in color. This area was pink on 10/20/11. The resident refused to have her heel touched or measured. She stated, "It was done the day before." At 5:30 PM on the same day, Resident #27 again refused to allow the surveyor to look at her heels or the skin on her back. The resident did allow the surveyor to look under the covers. At that time, both heels were lying directly on the mattress (no off-loading). Review of Resident #27's MDS assessment dated [DATE] revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment characterized Resident #27 as cognitively impaired, requiring extensive assistance of two persons to dress, for personal hygiene/bathing, as incontinent of bowel and bladder, and was bedridden. Resident #27's Care Plan dated 07/30/10 and updated October 2011 included some of the following approaches: "Skin assessment by licensed nurse weekly. Skin observation by caregivers daily. Report findings to charge nurse immediately...." During an interview with CNA BB on 10/21/11 at 2:30 PM, she was asked if Residents #27 had any skin issues or breakdown? She replied she was not aware of any and added she, "takes care of them every day and makes sure to keep their shoulders, elbows, knees, and heels off the bed." CNA II stated in an interview on 10/21/11 at 2:40 PM when asked the same question, she, "was not aware of any skin problem on either resident." During their interviews, CNA BB and CNA II were both asked if they saw a skin issue, what would they do? Both CNAs answered they would tell their Charge Nurse. Review of literature retrieved on 10/27/11 at <http://www.nlm.nih.gov/medlineplus/tutorials/[MEDICATION NAME]/dm 2.pdf> revealed the National Institute of Health's warning that "if a person sits or lies in one position for a long time, the pressure on the skin could cut off the oxygen to the skin. If the pressure is not stopped the area of skin starts to die. Pressure ulcers are most likely to happen in areas where your skin and bone are close such as ... heels. Pressure ulcers may be treated by removing pressure from the affected area...." Review of Patient Education regarding pressure ulcers retrieved on 10/27/11 (<http://www.stoppain.org/pressure ulcers/common/pdf/BIMC_patient.pdf>) revealed that "patients who are unable to get out of bed or spend most of the day in a wheel chair are at high risk of getting a pressure ulcer. A suspected deep tissue injury needs to be examined by a doctor or wound specialist as it can quickly become a Stage III or Stage IV pressure ulcer. "The publication defined a deep tissue injury as "a purple or maroon area of damaged tissue under intact skin; it looks like a deep bruise." 2. Review of Resident #24's MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further reflected the resident was severely impaired cognitively and was totally dependent on staff for bed mobility, transfers, eating, dressing, personal hygiene and bathing. The resident was assessed at risk of developing pressure ulcer and had one healed Stage 2 pressure ulcer. Interview with CNA AA on 10/21/11 at 12:50 PM revealed on 10/20/11 she noticed scratches on Resident #24's right upper thigh and had told LVN M. CNA AA stated she had worked with Resident #24 for three days and helped get the resident dressed. CNA AA stated that all she had noticed on 10/20/11 was the scratches. CNA AA stated she knew to look for any abnormal skin issues during the care of a resident. Interview with CNA BB on 10/21/11 at 12:55 PM revealed she cared for Resident #24 on 10/18/11 and had not noticed any skin issues when the resident was showered and dressed. Interview with LVN M on 10/21/11 at 1:05 PM revealed she received a skin tear report on another resident from the night shift nurse but nothing else. She stated an aide had reported Resident #24 had a scratch on the right inguinal area and she had looked at the area and noted it to be dry, so there was no treatment needed. She stated the facility practice was to follow up on and observe the area for 72 hours. LVN M then stated she remembered some one mentioned Resident #24's ankle was a concern, but she had not checked it yet. Interview with LVN M on 10/21/11 at 2:20 PM revealed she understood the pressure area to Resident #24's right lateral ankle was found 10/20/11 PM when the facility completed surveyors' recommendation to do skin assessments for all residents with high risk of pressure ulcers. She further stated she had gotten an order for [REDACTED]." Interview with Treatment Nurse C on 10/21/11 at 2:25 PM revealed she had put a dressing on Resident #24's ankle last night. She stated the right lateral ankle was a prior healed pressure ulcer. She stated she had assessed the ankle on 10/17/11 and it was not opened, was scarred and not red. Treatment Nurse C stated on the evening of 10/20/11, skin checks were done and the area on the right lateral ankle was found. She stated she had gotten an order from Resident #24's doctor's PA for TAO and foam dressing to protect it until the doctor could assess the area. She stated she expected the doctor to come today or tomorrow. Treatment Nurse C stated there was usually a pillow under the leg to off load (reduce/prevent pressure). On 10/21/11 at 2:55 PM, Resident #24 was on his back in bed and his right leg naturally reclined to the right with his right lateral ankle directly touching the surface of the bed. His right lateral ankle had a dressing. The resident was observed to frequently move his right leg, causing the right lateral side of his leg and ankle to rub against the bed. Treatment Nurse C removed the dressing from Resident #24's right lateral ankle to reveal a Stage 2 pressure ulcer approximately one centimeter in length and width. During the observation, Treatment Nurse C had some difficulty and made a concentrated effort to position the leg/ankle so the area could be viewed. During an interview with Treatment Nurse C on 10/21/11 at 4:00 PM, Resident #24's skin assessment/treatment sheets for at least the last three months were requested. She brought one sheet labeled "Weekly Skin Assessment" with dates of 10/10/11 and 10/17/11 on it. She also brought two sheets labeled "Skin Grid/Pressure/Stasis/Diabetic Only" dated 05/13/11 through 08/14/11. There were no sheets provided, which covered the time from 08/14/11 through 10/10/11. No explanation was given for the dates missing. Review of Resident #24's care plan dated 06/07/11 revealed the resident was at risk for skin breakdown related in part to fragile skin. Approaches listed to prevent skin breakdown included: Assist with repositioning as needed, using padding between pressure areas; Monitor for skin breakdown, report to doctor; Provide pressure-relieving and positioning devices as needed; Assess skin weekly and record findings; Turn and reposition every 2 hours; Prevent shearing forces and friction during transfers; and Keep bed free of wrinkles, crumbs, and other sources of pressure Review of Resident #24's Weekly Skin assessment dated [DATE] revealed the right lateral ankle on the diagram was circled with a notation, "raised discolored." The assessment was completed by Treatment Nurse C. Review of Resident #24's Weekly Skin assessment dated [DATE] revealed the right lateral ankle on the diagram was circled with a notation, "old wound, discolored, area closed." The assessment was completed by Treatment Nurse C. Resident #24's doctor's orders dated 10/20/11 reflected an order to cleanse right ankle with normal saline, pat dry, apply TAO and cover with foam dressing daily. 3. The MDS assessment dated [DATE] reflected Resident #17, an [AGE] year-old female, was admitted on [DATE] and had [DIAGNOSES REDACTED]. The MDS assessment reflected the resident was cognitively impaired and had an altered mental status. The MDS assessment further reflected Resident #17 was dependent on one staff to perform all her ADLs, transfers and mobility. Resident #17 had limited range of motion in the upper and lower portions of her body. The MDS assessment reflected Resident #17 was always incontinent of bowel and bladder and was at risk for developing pressure ulcers but had no pressure ulcers at the time of the assessment. Resident #17's care plan dated 02/13/09 and updated June 2011 s reflected it addressed the resident's self care deficits and reflected the resident was dependent on one person to perform the resident's ADLs. The care plan also addressed the resident's high risk for alteration in skin integrity related to incontinence. Interventions included scheduled Braden Assessments for early identification of risk factors and interventions, daily skin checks by CNAs, weekly skin checks by licensed staff, provision of peri-care after each incontinent episode, use of disposable briefs to decrease contact of moisture to skin, monitoring of labs per physician's orders [REDACTED]. An interview conducted with LVN D on 10/17/11 at approximately 11:30 AM, during the initial tour of the facility, revealed Resident #17 had a Stage II pressure ulcer on her sacrum. An interview conducted with CNA K on 10/19/11 at approximately 4:45 PM revealed the CNA put cream on the "sore" on Resident #17's bottom each time he performed the resident's incontinent care. An interview Treatment Nurse C on 10/19/11 at approximately 4:55 PM revealed she was not aware Resident #17 had a pressure ulcer on her sacrum. CNA K stated he had told the charge nurse (RN I) nurse about the pressure ulcer on Resident #17's "bottom" at the end of last week (10/11/11). An observation of Resident #17 on 10/20/11 at approximately 9:13 AM as CNA V provided incontinent care for Resident #17, revealed the resident had two pressure areas, one on each buttock slightly to the side of Resident #17's sacrum. During the incontinent care, Resident #17 was positioned on her left side, facing the wall. LVN D stood between Resident #17 and the wall with the resident facing the LVN. LVN D informed CNA V she (LVN D) was watching the CNA perform Resident #17's incontinent care, because today was the resident's scheduled skin assessment. At that time, Resident #17 was exposed from her waist to her knees. The surveyor informed LVN D Resident #17 had not one but two pressure ulcers. The center of the pressure ulcer on Resident #17's left buttock was covered with white slough and was un-stageable. No odor or undermining of the wound edges was noted. The wound edges were pink. The center of the pressure ulcer on Resident #17's right buttock was dark red. No odor or undermining of the wound edges was noted. The wound edges were red. After CNA V cleaned the skin barrier cream from Resident #17's buttocks, LVN D walked around the bed and looked at the area of Resident #17's skin CNA V had exposed. LVN D returned to the far side of Resident #17's bed and observed CNA V as the CNA applied skin barrier protectant cream over the resident's buttocks, including the pressure ulcers, with both front-to-back and back-to-front motions. LVN D left the room as soon as she had assisted CNA V to turn the resident onto her back. LVN D did not observe any area of Resident #17's skin other than the area of Resident #17's back and thighs exposed by CNA V for incontinent care. An observation of Resident #17 on 10/20/11 at approximately 10:00 AM as Treatment Nurse C provided wound care for the resident's pressure ulcers revealed the pressure ulcer on Resident #17 left buttock measured 2 cm X 1 cm. Treatment Nurse C identified the white slough in the center of the pressure ulcer as being eschar and determined the pressure ulcer was unstageable. The Stage II pressure area on Resident #17's right buttock measured 2.75 cm X 1 cm. The treatment nurse said she would call Resident #17's physician for wound care orders. During an interview conducted at that time, Treatment Nurse C said she had not assessed Resident #17's pressure ulcer when she was informed about it on 10/19/11.. The treatment nurse stated she had reviewed the nurse's notes for the day CNA K said he discovered Resident #17's wound. The treatment nurse stated the notes reflected there was a skin tear, not a pressure ulcer on Resident #17's buttocks. Treatment Nurse C stated for that reason the pressure ulcer was not reported to her and the CNAs had continued applying skin barrier cream to Resident #17's buttocks. When the surveyor asked Treatment Nurse C if applying skin barrier protectant cream was the appropriate treatment for [REDACTED]." An interview with Treatment Nurse C on 10/20/11 at approximately 12:15 PM revealed Resident #17's physician had given orders for daily wound care. The treatment nurse stated Resident #17's pressure ulcers were to be cleaned with normal saline daily, patted dry and covered with Calcium Alginate and a foam dressing. A review of the facility's document entitled "Departmental Notes" revealed on 10/11/11 at 10:48 PM, RN I documented, "CENA (sic) called this nurse and stated pt has a sore on her buttock. upon assessment, pt observed with non bleeding skin tear 1.5 X 0.3 cm to coccyx area... [MEDICATION NAME] to open area on coccyx q shift until healed ... DON notified at 8:15 PM." (sic) A review of the facility's document entitled "Weekly Skin Assessment" revealed Resident #17's most recent skin assessment, prior to 10/20/11 was performed on 09/30/11. On 10/21/11, LVN D documented Resident #17 had two open areas on her buttocks. A review of the facility's document entitled "Skin Grid/Pressure/Stasis/Diabetic Only" reflected on 10/20/11 Resident #17 had a 2 cm X 1 cm unstageable pressure ulcer on her left buttock. The treatment nurse documented Resident #17's unstageable pressure ulcer had eschar. (However the surveyor identified it was slough, not escar and discussed the difference with the treatment nurse) The same document reflected Resident #17 had a 1 cm round Stage II pressure ulcer on her right buttock. The treatment nurse documented Resident #17's pressure ulcers had no odor, drainage, tunneling or undermining. A review of Resident #17's physician's telephone orders revealed: A) 10/11/11 physician's orders [REDACTED]." B) 10/20/11 physician's orders [REDACTED]." 4. The MDS assessment dated [DATE] reflected Resident #26, a [AGE] year-old female, was admitted originally on 05/19/10 and readmitted on [DATE] and had the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident was cognitively impaired and exhibited inattention, altered levels of consciousness, and psychomotor [MEDICAL CONDITION]. The same MDS assessment reflected Resident #26 was always incontinent of bowel and bladder and was totally dependent on one person to perform all the resident's ADLs. The MDS assessment reflected the resident was at risk for developing pressure ulcers but had no pressure ulcers at the time of the assessment. A record review of Resident #26's care plans revealed a care plan, dated 02/26/09 and last updated 10/11 to address the resident's high risk for impaired skin integrity. Interventions included scheduled Braden Assessments for early identification of risk factors and interventions, daily skin checks by CNAs, weekly skin checks by licensed staff, use of disposable briefs to decrease moisture contact to the resident's skin, incontinent care with moisture barrier applied after each incontinent episode turning and repositioning every two hours and as needed, use of pillows and padding to prevent skin-to-skin contact, nutritional assessments, monitoring of the resident's labs and use of a pressure reducing mattress. An observation of Resident #26 on 10/20/11 at approximately 7:20 PM as RN I performed a skin assessment for the resident revealed the resident had pressure ulcers on both feet. RN I performed a head-to-toe skin assessment. During the skin assessment RN I removed Resident #26's socks and discovered the resident had multiple pressure ulcers, several of them with open areas, on both of her feet. RN I revealed the pressure ulcers were "just from her shoes." RN I started to put Resident #26's socks back on without assessing the pressure ulcers. The surveyor request RN I complete a current assessment and measurements of the the pressure ulcers on Resident #26's feet. Observations of the wounds on Resident #26's left foot revealed: A) 0.6 CM round pink pressure ulcer with a small hard black area in the center on the top of the resident's second toe. B) 0.7 X 0.6 cm pink pressure ulcer with a small hard black area in the center on the top of the resident's third toe. C) 1.0 cm X 1.0 cm pink pressure ulcer with a 0.5 cm X 0.2 cm open pink area in the center on the inner aspect (arch) of the resident's left foot midway between the resident's large toe and heel. D) 1.5 cm X 1.0 cm reddened pressure ulcer on the outer aspect of the sole of the resident's foot. Observations of the pressure ulcers on Resident #26's right foot revealed: A) 1.0 cm X 1.0 cm reddened pressure ulcer on the top of the resident's second toe. B) 1.0 X 0.7 cm pink pressure ulcer that was hard to the touch on the resident's right heel. C) 3.0 cm X 3.0 cm reddened pressure ulcer with a 1.5 x 1 cm open pink area in the center on the inner aspect (arch) of the resident's right foot midway between the resident's large toe and heel. RN I measured each of the pressure ulcers by placing a paper tape measure directly on the ulcer. RN I used the same tape measure to measure all seven pressure ulcers. An interview conducted at the same time with RN I revealed the RN was not aware she should have used a clean paper measuring tape for each pressure ulcer if she touched the ulcer with the tape. RN I was not aware she should measure the entire pressure ulcer, not just the blackened scabbed or open areas. A record review of the facility's documents entitled "Weekly Skin Assessment" revealed on 10/06/11 and 10/13/11 RN I documented Resident #26 had no areas of skin impairment. A record review of the facility's documents entitled "Departmental Notes" revealed: A) On 10/21/11 at approximately 10:17 AM LVN D wrote she addressed the fit of Resident #26's shoes with one of the resident's family members. The note reflected the family member stated, "Well they just put the wrong shoes on her. She is to wear the oxford ones. The slip on ones are for if she runs out only." The note reflected because Resident #26's daughter did not want to take the ill-fitting shoes home the shoes were bagged and placed in the resident's closet. B) On 10/12/11 at approximately 2:50 PM the treatment nurse wrote she had assessed several small areas on Resident #26's bilateral feet. The treatment nurse's note reflected Resident #26 had a blister on her left toe measuring 0.75 x 0.75, inner left foot abrasion .25 x .25, a callous on heel 2 cm (centimeters) X 1.75 cm, Medial lateral foot callous .75 x .5 with a small blood blister next to it, dry calloused heel lateral foot. The treatment nurse's note reflected " Rt foot 1.5 x 1.5 inner foot, right foot second toe 1.5 x 1.5 abrasion." "Nursing informed to keep shoes off and to be treated with skin prep daily." A record review of Resident #26's physician's telephone orders revealed a 10/21/11 physician's orders [REDACTED]. Use only bootee. Apply skin prep to all areas on feet until healed q (every) shift." 5. Resident #13 was a [AGE] year-old female whose 08/24/11 quarterly assessment MDS assessment reflected a 07/20/07 admitted . [DIAGNOSES REDACTED]. A record review of Resident #13's 08/24/11 MDS assessment revealed the resident was severely impaired cognitively and exhibited inattention and psychomotor [MEDICAL CONDITION]. The same MDS assessment reflected Resident #13 was incontinent bladder and was totally dependent on facility to provide her bed mobility, transfers and ADLs. Resident #13's 08/24/11 MDS assessment reflected the resident had limited range of motion on both sides in her upper and lower extremities. The same MDS assessment reflected Resident #13 was at risk for skin impairment but currently had no pressure ulcers. A record review of Resident #13's care plans, last reviewed in August 2011, revealed care plans were in place to address the residents: A) High risk for altered skin integrity due to contractures, [MEDICAL CONDITIONS] and [MEDICAL CONDITION] Disorder. Interventions included scheduled Braden Assessments for early identification of risk factors and interventions, Daily skin checks by CNAs, weekly skin checks by licensed staff, turning and repositioning every two hours and as needed, use of pillows and padding to prevent skin-to-skin contact, nutritional assessments and floating the resident's heel while in bed using pillows. B) Limitation of range of motion and contractures of upper extremities (hands) and lower extremities (feet). Interventions included performance of PROM (Passive Range of Motion) to all the resident's extremities during provision of care, use of a soft folded cloth in Resident #13's hands for hygiene and to prevent skin to skin contact, Resident #13's hands were to be monitored for skin integrity, were to be cleansed in warm water daily and to be dried thoroughly, Resident #13 was to be turned and re-positioned every two hours and as needed with pillows utilized to maintain the resident's alignment. On 10/20/11 at approximately 8:00 PM the surveyor observed RN I as the RN attempted to conduct a skin check of the inside of Resident #13's contracted hands. RN I removed rolled disposable wipes from Resident #13's hands. The RN stated the pieces of blue material that had been in Resident #13's hands all week were the coverings to inflatable hand splints the facility had tried to use to reduce the resident's contractures. RN I stated the blue splint covers had been removed and sent to the laundry to be cleaned. RN I attempted to straighten Resident #13's fingers in order to assess the skin on the inside of the resident's hands. RN I and the surveyor observed Resident #13's fingernails were long and extended well beyond the end of the resident's fingers. Resident #13's fingernails were curled in at the tips and the corners of the tips of the resident's fingernails were sharp. No odor was noted. The palms and inner aspects of the fingers on Resident #13's hands were not assessed because RN I was not able to open the resident's hands very wide and because the lighting in the resident's room was too low. RN I and the surveyor observed the middle finger on Resident #13's right hand was torn and bleeding. RN I stated she needed to have the treatment nurse check Resident #13's hands and nails. On 10/20/11 at approximately 8:15 PM the surveyor informed the DON and the treatment nurse about Resident #13's hands and long fingernails. The treatment nurse revealed she would assess Resident #13's hands. The treatment nurse stated because Resident #13 had the [DIAGNOSES REDACTED].#13's nails. On 10/21/11 at approximately 10:00 AM the surveyor observed LVN D as the LVN performed a skin check of Resident #13's hands. Resident #13's fingernails were still long. The nail on Resident #13's right hand was still torn with dried red blood under and around the nail. There was a layer of moist white macerated skin on both of Resident #13's palms and the inner aspects of the resident's fingers. An interview with the treatment nurse on 10/21/11 at approximately 11:55 AM revealed the treatment nurse had not assessed the skin on the inside of Resident #13's contracted hands. A record review of the facility's document entitled "Weekly Skin Assessment" revealed on 10/07/11 and 10/14/11 Resident #13 had no areas of skin impairment. The same document reflected on 10/20/11 Resident #13 had multiple dry areas on her scalp and the resident's right middle fingernail was bleeding. A record review of the facility's document entitled "Departmental Notes" reflected: A) On 10/21/11 at 12:41 PM, the treatment nurse documented she clipped Resident #13's fingernails. "Middle finger on right hand noted to have fallen off. Red dried blood noted. Cleansed with NS (normal saline) and TAO (Triple Antibiotic Ointment) applied. B) On 10/21/11 at 12:51 PM, the treatment nurse documented she had attempted to assess Resident #13's palms but was unable to open the resident's hands at that time. A review of Resident #13's physician's telephone orders revealed a 10/21/11 telephone order to "cleanse middle finger on Rt (right) hand c (with) NS, pat dry, apply TAO daily and monitor for S/S (signs and symptoms) infection." 6. On 10/21/11 at 9:30 AM, while Resident #5 was being weighed, the surveyor noticed a large red area on his right heel. LVN M was in the room assisting with obtaining his weight. The surveyor showed LVN M the red area on Resident #5's heel. LVN M replied, "His skin assessment is due tonight." When the surveyor was convinced LVN M was not going to do a skin assessment, the surveyor notified Treatment Nurse C at 12:00 PM of the red area on the heel. At 12:30 PM that day, Treatment Nurse C went to assess and measure the reddened heel area at the surveyors request. The color was observed to be red, measuring 4.35 cm X 3.5 cm. It was determined to be a Stage I Pressure Ulcer per Treatment Nurse C who stated she would treat it with "A skin prep and off load it with a pillow." When asked if she planned to notify the physician she paused and said, "Oh, yes." Resident #5 was admitted to the facility on [DATE] and re-admitted on [DATE] with the following [DIAGNOSES REDACTED]. There was no Care Plan for Prevention of Skin breakdown/Pressure Ulcers. The surveyor had Resident #5 weighed for evidence of continued monthly weight loss from his weight record dated January 2011 to October 2011. The last Dietary Consult was 08/11/11. An interview with the DON on 10/21/11 at 11:30 AM revealed she has had in-services in the past year with nurses regarding prevention of pressure ulcers to include: turning and repositioning residents, off-loading pressure areas, pressure reduction devices, early signs of skin breakdown and monitoring bony prominences. She stated nurse aides have had perineal care training and nurses monitor the CNAs to ensure the provision was correct. The DON further stated she was in the process of developing a competency evaluation program for nurses. She admitted that perineal care has been a "struggle" and that more training was to have begun this week. She stated she felt there was a miscommunication between RN I and Treatment Nurse C regarding the pressure ulcers on Resident #17's buttocks. RN I did not report the ulcers and the nurse and CNAs were treating them themselves. She stated she did not know why the pressure ulcers on the other residents had not been discovered during the regular weekly skin assessments for all residents. An interview with the ADM on 10/20/11 at 3:00 PM revealed he was aware that observations by the surveyors had revealed improper skin assessments by some facility nurses and thus identified weaknesses on some nurses' assessment abilities. He stated he asked Treatment Nurse C daily regarding the number of residents with skin breakdown. He stated he will be doing some additional analysis as it appeared the DON and Treatment Nurse C had failed to monitor the situation. During an interview with CNA BB on 10/21/11 at 2:30 PM, she was asked if Residents #5 had any skin issues or break

Based on observation, interview and record review, it was determined the facility failed to ensure two of thirteen residents (Residents #17 and #27) with contractures, who had entered the facility without limited range of motion, did not experience reduction in range of motion unless the resident's clinical condition demonstrated a reduction in range of motion was unavoidable. 1) Resident #17 developed painful, limited range of motion in both of her hands after admission to the facility. 2) Resident #27 developed painful, limited range of motion in both of her hips after admission to the facility causing her heels to push into each other resulting in painful pressure issues. The resident required PRN pain medication along with scheduled pain medication and had trouble sleeping and the pain limited her activities. This failure could affect the 65 residents, who were bedbound or spent most of their time in a chair by causing increased pain and discomfort, loss of functional ability and decreased quality of life. Findings included: 1. Resident #17 was an [AGE] year-old female whose 09/02/11 quarterly MDS assessment reflected a 04/11/11 admitted . The same document reflected [DIAGNOSES REDACTED]. The MDS assessment further reflected the resident was cognitively impaired and had an altered mental status. The same MDS assessment reflected Resident #17 was dependent on one staff to assist with all her ADLs, transfers and mobility. Resident #17's MDS assessment reflected the resident had limited range of motion in the upper and lower portions of her body. A review of Resident #17's 02/01/10 annual MDS assessment and the resident's 07/28/10 MDS assessment revealed Resident #17 had no limitation of her range of motion in either her upper or lower extremities. A review of Resident #17's care plans revealed: A) A 02/13/09 care plan to address Resident #17's self care deficits, last updated June 2011, which reflected the resident was dependent on one person to assist with the resident's ADLs. B) A 10/21/11 care plan to address the resident's contractures. Interventions included monitoring for increased pain and stiffness, keeping contracted areas clean and dry, providing PROM and not forcing contractured areas. An interview conducted on 10/19/11 at approximately 9:55 AM with CNA V revealed whether the CNA provided a resident with passive range of motion exercises (PROM) depended on the resident. CNA V stated if a resident was bedfast, she learned about the resident to see if the resident needed or could do PROM. During the same interview, CNA V revealed when she did PROM for a resident, the exercise took between ten and twenty-five minutes. CNA V stated because the warm water in the shower relaxed the residents, she (the CNA) sometimes did PROM for a resident while the resident was taking a shower. CNA V demonstrated the way she moved the residents' arms, hands, legs and feet when she did PROM. CNA V stated she sometimes provided PROM to residents' backs by giving them a relaxing back massage. An observation of Resident #17 on 10/19/11 at approximately 4:45 PM revealed the resident was seated in her Geri-chair at the foot of her bed. Resident #17 had hand rolls (rolled and taped disposable wipes) in each of her hands. During an interview conducted at the same time, CNA K revealed he did not provide PROM for Resident #17, because the nurses had not told him the resident needed PROM. An observation of Resident #17 on 10/20/11 at approximately 9:15 AM as CNA V checked the resident's skin revealed the resident's hands were contracted. The CNA removed the hand rolls from both of Resident #17's hands without difficulty. CNA V asked Resident #17 to open her hands. Resident #17 did not open her hands or show any other acknowledgement of the CNA's request. CNA V was able to open Resident #17's right hand and to extend the resident's fingers. CNA V had difficulty opening Resident #17's left hand. CNA V was not able to extend Resident #17's fingers at all. Resident #17's skin on her hands, which was under the hand rolls was pink and dry. When CNA V released Resident #17's hands, the resident's fingers immediately curled inward back into the same contracted position. An interview was conducted on 10/20/11 at approximately 9:40 AM with CNA G. The CNA revealed she provided PROM for her residents each time she did incontinent care or repositioned them. CNA G stated when she did PROM, she moved the residents' fingers, hands, arms, legs and feet. An interview was conducted on 10/20/11 at approximately 10:10 AM with LVN D. The LVN stated the CNAs were expected to do PROM for each bedfast resident every time the CNAs performed the resident's incontinent care. An interview was conducted on 10/20/11 at approximately 3:15 PM with the Director of Therapy. The Director of Therapy stated if a therapist ordered PROM to be done by the Restorative Aide (RA), the therapist trained the RA on how the PROM was to be done for the resident. The Director of Therapy stated the way the RA performed ROM was customized for the individual resident's assessed needs. The Director of Therapy said she did not know how the CNAs were trained to do PROM for the residents. The Director of Therapy stated she would check on the therapy and restorative interventions for Resident #17. Resident #17 was observed on 10/20/11 at approximately 3:50 PM as PT U assessed the resident's ROM. The resident did not have contractures in her legs. The surveyor observed PT U was able to easily move, straighten and bend Resident #17's legs. PT U stated Resident #17's contractures were in the resident's arms and hands. PT U reviewed Resident #17's physician's telephone orders dated 10/11/11, which ordered PT to evaluate the resident for hand contractures. PT U said he would inform the Director of Therapy so the appropriate therapist (Occupational Therapist) would evaluate Resident #17's hand and arm contractures. On 10/20/11 at approximately 4:00 PM, the Director of Therapy provided the surveyor with a document entitled "Initial Treatment Plan for Rehabilitation" dated 06/01/11. The Director of Therapy said it was the only documentation regarding Resident #17 she was able to find. The Director of Therapy stated she could not find any documentation regarding the August 2011 orders for Occupational Therapy to address Resident #17's hand contractures. Review of the 06/01/11 "Initial Treatment Plan for Rehabilitation" revealed Resident #17's right upper arm and left upper arm strength and ROM were within functional limits. Review of a therapy one-time screening, dated 08/18/09 revealed, "Pt holds left hand at times but able to open fully. " Review of the facility's document entitled "Interdisciplinary Therapy Screening Tool" dated 08/06/10 revealed Resident #17's ROM was within functional limits and no therapy evaluations were needed. Review of the facility's document entitled, "Departmental Notes" revealed: A) A 08/03/11 nurses' note written at 9:24 PM reflected Resident #17 was referred to occupational therapy for hand intervention. B) A 08/09/11 nurses' note written at 1:25 PM reflected "Moans when ROM attempted." "Left hand contracted." C) A 10/11/11 nurses' note written at 10:48 PM reflected, "Family also requested for towel rolls in pt's hands (contractures)." "Pt to be referred to PT in AM for increase contractures in hands." 2. Review of Resident #27's MDS assessment dated [DATE] revealed portions of the MDS assessment had been left blank. The MDS assessment reflected the resident was never depressed and never had trouble with sleep. The MDS assessment reflected Resident #27 was totally dependent on staff for ADLs except for eating, which required set-up help and supervision. The MDS assessment further reflected she was incontinent of bowel and bladder. The MDS assessment also reflected her ROM showed limitation on both arms and legs, she was able to balance for a surface to surface transfer when stabilized with assistance and she used a wheelchair for mobility. The MDS assessment reflected the resident was on scheduled pain medication but did not receive PRN pain medication and the resident denied the presence of pain. Review of Resident #27's MDS assessment dated [DATE] revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident felt depressed 2-6 days out of the week and frequently had trouble sleeping. The MDS assessment reflected Resident #27 was cognitively impaired, required extensive assistance of two persons to dress, for personal hygiene/bathing, was incontinent of bowel and bladder, and was bedridden. The MDS assessment reflected she had no impairment on her upper extremities for ROM, but had ROM impairment in both legs. The MDS assessment reflected the resident no longer had the wheelchair for mobility and had none checked on the assessment. The MDS assessment in regards to the resident's ability to balance for transfer reflected the activity did not occur. The MDS assessment reflected Resident #27 had pain frequently, which made it hard to sleep and limited her daily activities and she received PRN pain medication along with her scheduled pain medication. Review of Resident #27's care plans revealed there was no care plan, which addressed her contractures. Observation on 10/20/11 at 5:15 PM revealed Resident #27 was in bed on her back. During skin observation with the facility's treatment nurse at that time, Treatment Nurse C removed the cover from Resident #27's lower legs. The resident's lower legs were positioned with her heels together. The resident's right heel was pressed into her left heel. When Treatment Nurse C separated the resident's legs, the resident groaned loudly with pain. Observation of her hips, legs and feet revealed the resident had no movement of her hip joints and her legs were close together. When her legs were spread slightly apart to keep her heels from touching each other, Resident #27 groaned loudly with pain. The resident was unable to move her hips and/or legs. On 10/21/11 at 9:30 AM, Resident #27 refused to allow the surveyor to look at her skin and heels. The resident said it would be too painful. LVN M gave Resident #27 pain medication at approximately 10:15 AM. At 12:30 PM, Resident #27 would only allow the surveyor to look under the covers. Her legs were separated at that time with a pad, which had been rolled like a log and placed between the resident's legs. The resident complained at that time, 10:15 AM, again at 12:30 PM and again at 5:00 PM, repeatedly saying separating her legs hurt. During an interview with CNA BB on 10/21/11 at 2:30 PM, she was asked if Resident #27 had any issues? She replied she was not aware of any problems. CNA BB stated she took care of Resident #27 every day and made sure to keep the resident's shoulders, elbows, knees, and heels from coming in direct contact with the bed. In an interview on 10/21/11 at 2:40 PM, CNA II was also asked if Resident #27 had any issues. CNA II responded she was not aware of any skin problems or issues with Resident #27. During their interviews, CNA BB and CNA II were asked if they saw a problem or issue with a resident, what would they do? Both CNAs answered they would tell their Charge Nurse. An interview with the DON on 10/21/11 at 11:30 AM revealed she had in-services in the past year with nurses regarding prevention of contractures to include: turning and repositioning residents, and the use of splints to prevent skin breakdown due to joint contractures. The DON further stated she was in the process of developing a competency evaluation program for nurses. The DON further stated she has instituted in-services by the PT department for all CNAs regarding ROM exercises for the prevention of contractures. An interview with the ADM on 10/20/11 at 3:00 PM revealed he was aware observations by the surveyors had identified weaknesses in some nurses' assessment abilities. The ADM additionally stated he had had some concerns regarding the range of motion (ROM) program. He stated he talked to the past Director of Rehabilitation about the ROM program and he thought the program was occurring, even though there was now a new director. He stated the transition from the Restorative Nursing program to the CNAs obviously was "broken." The ADM stated the facility PT department would be looking at every resident with contractures and the care plans would document the interventions. The PT department had already begun in-services for all CNAs regarding how to perform ROM exercises. He stated the administration would follow up by quizzing the CNAs. Review of in-services dated 10/20/11 revealed the topic was Contracture Prevention, and it was presented by the Physical Therapy department. The objectives were to minimize joint contractures, prevent disuse atrophy, prevent skin breakdown and address any need for therapy. A total of 28 CNAs from the three shifts had attended the in-service that day. Return demonstrations were conducted, per the documentation. The surveyor was presented with a copy of the "Texas Nurse Aide Candidate Handbook," which was identified as the source for the in-service. During an interview conducted with the DON on 10/20/11 at approximately 5:45 PM, the DON stated she was not able to find a policy/procedure for nursing staff providing ROM for the residents. The CMS form 672, Resident Census and Conditions of Residents, dated 10/17/11 and signed by the DON reflected there were 65 residents, who were bedfast or sat in a chair most of the time.

Based on observation, interview and record review, it was determined the facility failed to provide one (Resident #13) of five residents, admitted to the facility with diminished range of motion with the appropriate treatment and services to prevent further decrease in range of motion. Resident #13 had functional limitation per a range of motion assessment in her upper extremities in June 2011. The resident's Occupational Therapy was discontinued on 07/02/11. In August 2011, the resident was assessed with [REDACTED]. The carrots/splints to be applied to both hands to improve the contractures were lost before October 2011. Resident #13's arms could not be moved from her chest when a chest x-ray had been ordered. This failure could affect the 65 residents who were bedbound or spent most of their time in a chair by causing increased discomfort, pain, loss of functional ability and decreased quality of life. Findings included: Resident #13, a [AGE] year-old female, was admitted on [DATE] according to the MDS assessment dated [DATE] and had [DIAGNOSES REDACTED]. The MDS assessment reflected the resident was severely impaired cognitively and exhibited inattention and psychomotor [MEDICAL CONDITION]. The same MDS assessment reflected Resident #13 was incontinent of bladder and was totally dependent on facility staff to provide her bed mobility, transfers and ADLs. Resident #13's MDS assessment reflected the resident had limited ROM in both arms and both legs. Review of Resident #13's care plans, last reviewed in August 2011, revealed the following problems were addressed: A) Impaired ability to communicate due to cognitive deficiencies and [MEDICAL CONDITION]. Interventions included use of short simple phrases and allowing Resident #13 time to respond; use of touch, facial expressions, eye contact, tone of voice and posture to communicate. B) Self care deficit, which included oral care, dressing, eating, bathing and grooming. Interventions included oral care twice a day and assistance of one to two people for bathing and dressing. Resident #13's needs were to be anticipated and met by staff daily. C) Limitation of range of motion and contractures of upper extremities (hands) and lower extremities (feet). Interventions included performance on Passive Range of Motion (PROM) to all the resident's extremities during provision of care, use of a soft folded cloth in Resident #13's hands for hygiene and to prevent skin to skin contact. Resident #13's hands were to be monitored for skin integrity, cleansed in warm water daily and to be dried thoroughly. Resident #13 was to be turned and re-positioned every two hours and as needed with pillows utilized to maintain the resident's alignment. Review of the care plan dated 10/21/11, which addressed Resident #13's contractures revealed interventions included monitoring the resident for increased pain and stiffness, keeping the resident's contracted areas clean and dry and providing PROM. Observation of Resident #13 on 10/17/11 at approximately 3:20 PM revealed her hands and arms were contracted. Pieces of blue material showed on either side of the resident's contracted hands. Resident #13's fingers were tightly curled into the palms of her hands. Resident #13 had a splint on her left arm, and she was holding a teddy bear in the crook of arm under the splint. Resident #13's legs were elevated on a pillow. The resident's feet turned inward and down. CNA G was observed on 10/18/11 at approximately 9:00 AM as she provided incontinent care for Resident #13. CNA G was not able to hold the resident's legs very far apart as she cleaned the resident during the incontinent care. CNA G was also providing PROM for the resident. The CNA was able to fully extend the resident's legs but she was unable to flex the resident's feet. Resident #13 kept her arms held tightly against her chest. LVN D was present during the observation of CNA G providing incontinent care for Resident #13. At that time, LVN D was interviewed. When LVN D was asked about the use of hand splints for the resident, the LVN told the surveyor Resident #13's family would not allow any hand splints, other than the pieces of blue cloth in the resident's hands, the left arm splint and the teddy bear. LVN D stated the therapists had provided Resident #13 with inflatable "carrot" hand splints, but the family removed them every time they came to visit the resident. LVN D said the carrots were now lost. LVN D added the family also would not keep the pillows positioned between Resident #13's legs and feet. LVN D stated when she addressed the need for the splints and the pillows, the family insisted it would be done their way or Resident #13 would be removed from the facility. An observation of Resident #13 on 10/18/11 at approximately 6:10 PM, as RN I assisted a radiology technician with Resident #13's chest x-ray revealed the RN and technician were not able to raise Resident #13's arms away from her chest. Observation of Resident #13's hands on 10/21/11 at approximately 10:00 AM during LVN D's skin assessment revealed the resident's fingers were curled tightly into her palms and were extremely difficult to move. An interview was conducted with Resident #13's family member on 10/19/11 at 9:30 AM. The family member told the surveyor Resident #13 had contractures in her upper and lower extremities when she was admitted to the facility. The family member stated he/she did not know whether the resident's contractures had gotten worse since she was admitted . An interview conducted with CNA G on 10/20/11 at approximately 9:40 AM revealed the CNA provided PROM for Resident #13 each time she did incontinent care or repositioned her. CNA G stated when she did PROM, she moved the resident's fingers, hands, arms, legs and feet. CNA G stated the blue material in Resident #13's hands was the cover for the inflatable hands splints ("carrots") the facility used to try to use reduce the resident's hand contractures. CNA G stated Resident #13's family member had not liked the "carrots" and kept removing them. CNA G said the carrots were now lost. An interview conducted on 10/20/11 at approximately 3:15 PM with the Director of Therapy revealed if a therapist ordered PROM to be done by the RA, the therapist trained the RA on how the PROM was to be done for that particular resident. The Director of Therapy stated the way the RA performed ROM was according to the individual resident's assessed needs. The Director of Therapy said she did not know how the CNAs were trained to do PROM. The Director of Therapy stated she would check on the therapy and restorative interventions for Resident #13. On 10/20/11 at approximately 4:00 PM, the Director of Therapy provided the surveyor with Resident #13's "Updated Treatment Plan for Rehabilitation" dated 06/17/11. The Director of Therapy told the surveyor it was the only documentation regarding Resident #13 she was able to find. The Director of Therapy stated she could not find any documentation regarding why the orders were written to discontinue Resident #13's Occupational Therapy when the updated treatment plan reflected if the resident did not have therapy, she was at greater risk to develop contractures. Review of Resident #13's Updated Treatment Plan for Rehabilitation dated 06/17/11 revealed the range of motion in the resident's upper extremities was within functional limits but the resident's strength was less than poor. The plan further reflected: A) Short-term functional goals were to have Resident #13: 1) tolerate the carrot splint for two hours without distress 2) tolerate PROM of her hands to reduce contractures 3) the therapist was to educate the staff on inflatable carrot placement in both hands with the resident tolerating 8 hours in the right hand. B) Resident #13 was at greater risk to develop contractures without therapy. Resident #13's physician's telephone orders dated 07/02/11 reflected "Discharge from Occupational Therapy at this time." The facility's "Nursing Rehabilitative/Restorative Care Program" reflected nursing staff would "don/doff" the carrot splints to both of Resident #13's hands to reduce contractures with the goal of the resident wearing the carrot splints in both hands for four hours a day. The same document reflected staff would perform PROM to both hands to within functional limits as Resident #13 tolerated it with the goal the resident would maintain PROM of both hands to within functional limits. An interview conducted with CNA V on 10/19/11 at approximately 9:55 AM revealed whether she provided PROM for a resident depended on the resident. CNA V stated if a resident was bedfast, she learned about the resident and could tell if he/she needed or could do PROM. CNA V said PROM for a resident took between ten and twenty-five minutes. CNA V added the warm water in the shower relaxed the residents, and she (CNA V) sometimes did PROM for a resident while the resident was taking a shower. CNA V demonstrated the way she moved the residents' arms, hands, legs and feet when she did PROM. CNA V revealed she sometimes did PROM to residents' backs by giving them a relaxing back massage. An interview conducted with CNA K on 10/19/11 at approximately 4:45 PM revealed the CNA only did PROM when it was assigned by the nurses.. CNA K stated he was afraid he would hurt someone by doing PROM if it was not ordered. An interview was conducted with RA E on 10/20/11 at approximately 10:05 AM. RA E told the surveyor when she finished with her ordered PROM treatments with residents or they were discontinued, the nursing staff was responsible for providing PROM for the residents. RA E said she did not know how often nursing staff were expected to provide PROM for residents. An interview with LVN D on 10/20/11 at approximately 10:10 AM revealed the CNAs were expected to provide PROM for each bedfast resident every time the CNAs performed the resident's incontinent care. During an interview with the ADM on 10/20/11 at 3:00 PM, he revealed he had had some concerns regarding the facility's ROM program. He stated he talked to the past Director of Rehabilitation about the ROM program, and he thought the program was occurring, even though there was now a new director. He stated the transition from the Restorative Nursing program to the CNAs obviously was "broken." The ADM stated the facility PT department would be looking at every resident with contractures and the care plans would document the interventions. The PT department had already begun in-services for all CNAs regarding how to perform ROM exercises. He stated the administration would follow up by quizzing the CNAs. During an interview conducted with the DON on 10/20/11 at approximately 5:45 PM, the DON said she was not able to find a policy/procedure for nursing staff providing ROM for the residents. An interview with the DON on 10/21/11 at 11:30 AM revealed she had in-services in the past year with nurses regarding prevention of contractures to include: use of splints to prevent skin breakdown due to joint contractures and turning and repositioning residents. The DON further stated she has instituted in-services by the PT department for all CNAs regarding ROM exercises for the prevention of contractures. Review of in-services dated 10/20/11 revealed the topic was Contracture Prevention and it was presented by the Physical Therapy department. The objectives were to minimize joint contractures, prevent disuse atrophy, prevent skin breakdown and address any need for therapy. A total of 28 CNAs from the three shifts had attended the in-service that day. Return demonstrations were conducted, per the documentation. The surveyor was provided with a copy of the "Texas Nurse Aide Candidate Handbook," which was identified as the source for the in-service. The CMS form 672, Resident Census and Conditions of Residents, dated 10/17/11 and signed by the DON reflected there were 65 residents, who were bedfast or sat in a chair most of the time.

Based on observation, interview and record review, the ADM and the DON failed to effectively and efficiently manage the facility's resources to attain or maintain the highest practicable physical well-being for of six (Residents #5, #13, #17, #24, #26 and #27) of 31 residents reviewed for pressure ulcers/skin breakdown and five (Residents #4, #7, #13, #17, and #19) of 14 residents reviewed for contractures and range of motion (ROM). The ADM failed to supervise and monitor the DON to ensure the DON had implemented policies and procedures to ensure residents had timely identification of pressure sores/skin breakdown and prevention/worsening of contractures. The DON failed to implement polices and procedures for the prevention and timely identification of pressure ulcers/skin breakdown and prevention and further worsening of contractures. These failures regarding pressure sores resulted in Residents #5, #13, #17, #24, #26 and #27 developing and delay of treatment for [REDACTED]. These failures regarding contractures and range of motion resulted in Residents #4, #7, #13, #17 and #19 developing contractures of joints, which caused pain, limited mobility and function, and a decreased quality of life. These failures could affect the 98 residents who were identified by the facility as having pressure ulcers and/or receiving preventive skin care. Findings included: Resident #13 was a [AGE] year-old female whose 08/24/11 quarterly assessment MDS assessment reflected a 07/20/07 admitted . [DIAGNOSES REDACTED]. A record review of Resident #13's 08/24/11 MDS assessment revealed the resident was severely impaired cognitively and exhibited inattention and psychomotor [MEDICAL CONDITION]. The same MDS assessment reflected Resident #13 was incontinent of bladder and was totally dependent on facility to provide her bed mobility, transfers and ADLs. Resident #13's 08/24/11 MDS assessment reflected the resident had limited range of motion on both sides in her upper and lower extremities. A record review of Resident #13's care plans, last reviewed in August 2011, revealed care plans were in place to address the residents: A) Impaired ability to communicate due to cognitive deficiencies and [MEDICAL CONDITION]. Interventions included use of short simple phrases and allowing Resident #13 time to respond and use of touch, facial expressions, eye contact, tone of voice and posture to communicate. B) Self care deficit which included oral care, dressing, eating, bathing and grooming. Interventions included oral care twice a day and assistance of one to two people for bathing and dressing. Resident #13's needs were to be anticipated and met by staff daily. C) Limitation of range of motion and contractures of upper extremities (hands) and lower extremities (feet). Interventions included performance of PROM to all the resident's extremities during provision of care, use of a soft folded cloth in Resident #13's hands for hygiene and to prevent skin to skin contact, Resident #13's hands were to be monitored for skin integrity, were to be cleansed in warm water daily and to be dried thoroughly, Resident #13 was to be turned and re-positioned every two hours and as needed with pillows utilized to maintain the resident's alignment. A record review of the 10/21/11 care plan to address Resident #13's contractures revealed interventions included monitoring for increased pain and stiffness, keeping the resident's contracted areas clean and dry and providing PROM. An observation of Resident #13 on 10/17/11 at approximately 3:20 PM revealed the resident's hands and arms were contracted. There were pieces of blue material showing on either side of the resident's contracted hands. Resident #13's fingers were tightly curled into the palms of her hands. Resident #13 had a splint on her left and a teddy bear was located in the crook of the resident's arm under the splint. Resident #13's legs were elevated on a pillow. The resident's feet were turned inward and down. An observation of Resident #13 on 10/18/11 at approximately 9:00 AM as CNA G provided incontinent care for the resident revealed the CNA was able to fully extend the resident's legs but was unable to flex her feet. Resident #13 kept her arms held tightly against her chest. CNA G was not able to separate Resident #13's legs very wide to provide the resident's incontinent care. During an interview with LVN D conducted at the same time the LVN revealed Resident #13's family would not allow any hand splints, other than the pieces of blue cloth in the resident's hands, the left arm splint and the teddy bear. The LVN stated the therapists had provided Resident #13 with inflatable "carrot" hand splints but the family removed them every time they came into the room. LVN D said the carrots were now lost. LVN D revealed the family also would not keep the pillows positioned between Resident #13's legs and between the resident ' s feet. LVN D stated when she addressed the need for the splints and the pillows, the family insisted it would be done their way or Resident #13 would be removed from the facility. An observation of Resident #13 on 10/18/11 at approximately 6:10 PM, as RN I assisted a radiology technician with Resident #13's lateral chest x-ray revealed the RN and technician were not able to raise Resident #13's arms away from her chest. An observation of Resident #13's hands on 10/21/11 at approximately 10:00 AM as LVN D assessed the resident's skin revealed Resident #13's fingers were curled tightly into her palms and were extremely difficult to move. An interview conducted with Resident #13's family member on 10/19/11 at 9:30 AM revealed Resident #13 had contractures in her upper and lower extremities when she was admitted to the facility. The family member stated he/she did not know whether the resident's contractures had worsened since she was admitted . An interview conducted with CNA V 10/19/11 at approximately 9:55 AM revealed whether she provided a resident with passive range of motion exercises) PROM or did not, depended on the resident. CNA V stated if a resident was bedfast, she learned about the resident and could tell if he/she needed or could do PROM. CNA V revealed when she did PROM for a resident the exercise took between ten and twenty-five minutes. CNA V stated because the warm water in the shower relaxed the residents, she (CNA) sometimes did PROM for a resident while the resident was taking a shower. CNA V demonstrated the way he/she moved the residents' arms, hands, legs and feet when she did PROM. CNA V revealed she sometimes did PROM to residents' backs by giving them a relaxing back massage. An interview conducted with CNA K on 10/19/11 at approximately 4:45 PM revealed the CNA only did passive range of motion when it was assigned by the nurses. CNA K stated he was afraid he would hurt someone by doing passive range of motion if it was not ordered. An interview conducted with CNA G on 10/20/11 at approximately 9:40 AM revealed the CNA provided PROM for Resident #13 each time she did incontinent care or repositioned her. CNA G stated when she did PROM she moved the residents fingers, hands, arms, legs and feet. CNA G revealed the blue material in Resident #13's hands was the covers for the inflatable hands splints "carrot" the facility had used to try to reduce the resident's hand contractures. CNA G stated Resident #13's family member had not liked the "carrots" and kept removing them until the carrots were lost. An interview conducted with RA E on 10/20/11 at approximately 10:05 AM after her PROM treatments with residents were discontinued, the nursing staff were responsible for providing passive range of motion exercises for the resident. RA E revealed she did not know how often nursing staff were expected to provide passive range of motion for residents. An interview with LVN D on 0/20/11 at approximately 10:10 AM revealed the CNAs were expected to do passive range of motion for each bedfast residents every time the CNAs performed the resident's incontinent care. An interview with the ADM on 10/20/11 at 3:00 PM revealed he had had some concerns regarding the range of motion (ROM) program. He stated he talked to the past Director of Rehabilitation about the ROM program and he thought the program was occurring, even though there was now a new director. He stated the transition from the Restorative Nursing program to the CNAs obviously had been "broken." The ADM stated the facility PT department would be looking at every resident with contractures and the care plans will document the interventions. The PT department has already begun in-services for all CNAs regarding how to perform ROM exercises. He stated the administration will follow up by quizzing the CNAs. During a interview conducted with the DON on 10/20/11 at approximately 5:45 PM, the DON revealed she was not able to find a policy/procedure for nursing staff providing range of motion for the residents. A record review of the facility's document entitled Updated Treatment Plan for Rehabilitation dated 06/17/11 revealed the range of motion in Resident #13's upper extremities was within functional limits but the resident's strength was less than poor. A) Short-term functional goals were to have Resident #13: 1) tolerate the carrot splint for two hours without distress 2) tolerate PZROM of her hands to reduce contractures 3) the therapist was to educate the staff on inflatable carrot placement bilaterally in hands with the resident tolerating 8 hours in the right hand. B) The document reflected Resident #13 was a greater risk without to develop contractures without therapy. A record review of Resident #13's physician's telephone orders revealed a 07/02/11 order to "Discharge from Occupational Therapy at this time." A record review of the facility's document entitled " Nursing Rehabilitative/Restorative Care Program" revealed staff would don/doff carrot splints in bilateral hands to reduce contractures with the goal of Resident #13 wearing the carrot splints in both hands for four hours a day. The same document reflected staff would perform PROM of both hands to within functional limits as Resident #13 tolerated it with the goal the resident would maintain PROM of both hands to within functional limits. An interview conducted on 10/20/11 at approximately 3:15 PM with the Director of Therapy revealed if a therapist ordered PROM to be done by the restorative aide (RA), the therapist trained the RA on how the PROM was to be done. The Director of Therapy stated the way the RA performed range of motion was customized for the individual resident ' s assessed needs. The Director of Therapy revealed she did not know how the CNAs were trained to do PROM. The Director of Therapy stated she would check on the therapy and restorative interventions for Resident #13. On 10/20/11 at approximately 4:00 PM the Director of Therapy provided the surveyor with a document entitled "Updated Treatment Plan for Rehabilitation" dated 06/17/11. The Director of Therapy revealed it was the only documentation regarding Resident #13 she was able to find. The Director of Therapy stated she could not find any documentation regarding why the orders were written to discontinue Resident #13's Occupational therapy when the updated treatment plan reflected if the resident did not have therapy she was at greater risk to develop contractures. reflected the resident needed therapy. An interview with the DON on 10/21/11 at 11:30 AM revealed she has had in-services in the past year with nurses regarding prevention of pressure ulcers and contractures to include: turning and repositioning residents, off-loading pressure areas, pressure reduction devices, early signs of skin breakdown, monitoring bony prominences and use of splints to prevent skin breakdown due to joint contractures. She stated nurse aides have had perineal care training and nurses monitor the CNAs to ensure the provision was correct. The DON further stated she was in the process of developing a competency evaluation program for nurses. She admitted that perineal care has been a "struggle" and that more training was to have begun this week. She stated she felt there was a miscommunication between RN I and Treatment Nurse C regarding the pressure ulcers on Resident #17's buttocks. RN I did not report the ulcers and the nurse and CNAs were treating them themselves. She stated she did not know why the pressure ulcers on the other residents had not been discovered during the regular weekly skin assessments for all residents. The DON further stated she has instituted in-services by the PT department for all CNAs regarding ROM exercises for the prevention of contractures. An interview with the ADM on 10/20/11 at 3:00 PM revealed he was aware that observations by the surveyors had revealed improper skin assessments by some facility nurses and thus identified weaknesses on some nurses' assessment abilities. He stated he asked Treatment Nurse C daily regarding the number of residents with skin breakdown. He stated he will be doing some additional analysis as it appeared the DON and Treatment Nurse C had failed to monitor the situation. The ADM additionally stated he had had some concerns regarding the range of motion (ROM) program. He stated he talked to the past Director of Rehabilitation about the ROM program and he thought the program was occurring, even though there was now a new director. He stated the transition from the Restorative Nursing program to the CNAs obviously had been "broken." The ADM stated the facility PT department would be looking at every resident with contractures and the care plans will document the interventions. The PT department has already begun in-services for all CNAs regarding how to perform ROM exercises. He stated the administration will follow up by quizzing the CNAs. Review of in-services dated 10/20/11 revealed the topic was Contracture Prevention and it was presented by the Physical therapy department. The objectives were to minimize joint contractures, prevent disuse atrophy, prevent skin breakdown and address any need for therapy. A total of 28 CNAs from the three shifts had attended the in-service that day. Return demonstrations were conducted, per the documentation. The surveyor was presented with a copy of the "Texas Nurse Aide Candidate Handbook" which was identified as the source for the in-service. The CMS form 672, Resident Census and Conditions of Residents, dated 10/17/11 and signed by the DON reflected there were four residents with pressure ulcers and ninety-four residents receiving preventive skin care. This was also confirmed by an interview with the DON on 10/19/11 at approximately 4:30 PM.