Every finding on record at Hilltop Park Rehabilitation and Care Center

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 1 of 6 residents (Resident #3) whose records were reviewed. The facility failed to ensure Resident #3 had a Baseline Care Plan developed and implemented within 48 hours following admission to the facility. This failure could place the residents at risk of not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings includedRecord review of Resident #3's face sheet, not dated revealed a [AGE] year-old female admitted on [DATE] with diagnoses to include: Alzheimer's disease (progressive mental deterioration that can occur in middle age or old age due to degeneration of the brain), Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), acute cystitis ( inflammation of the bladder) stroke ( a medical emergency occurring when blood flow to the brain is blocked or a vessel bursts causing rapid brain cell death).Record review of Resident #3's admission MDS assessment dated [DATE] revealed the following: Resident #3 had a BIMS score of 02 which indicated the resident had severe cognitive impairment, Resident #3 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), and physical behavioral symptoms directed toward others . Resident #3 used a walker and required touch assistance and supervision to ambulate. She required partial to moderate assistance with transfers. Resident #3 was also incontinent of bowel and bladder. Resident #3 received a scheduled pain medication .Review of Resident #3's clinical record revealed a baseline care plan had not been completed within 48 hours following the resident's initial admission to the facility on [DATE]. During an Interview with the CCN on 03/16/26 at 3:00 PM, she stated the form titled Baseline care plan in the Resident's EMR was not completed. She stated that the prior DON was responsible for delegating the task, but she was unsure who was assigned to complete it for Resident #3 She stated the failure could put residents at risk for not getting needed care. During an Interview with the MDS Nurse A on 03/16/26 at 3:30 PM, she stated the form titled Baseline Care Plan in the Resident's EMR had been deleted and was not completed. She stated her name was on the deleted form , but she was not sure who deleted it or why it was not completed. She stated the failure could have put residents at risk for not getting needed care. Review of the facility's policy and procedure titled Care Plans- Baseline dated - November 14, 2023, revealed the following [in part]: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Policy Interpretation and Implementation1) To assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission.2) The interdisciplinary team will review the health care practitioner's orders and implement a baseline care plan to meet the residents immediate care needs including but not limited to:a. Initial goals based on admission orders.b. Physician orders.c. Dietary orders.d. Therapy services.e. Social services.3) The baseline care plan will be used until the staff can conduct comprehensive assessments and develop an interdisciplinary person-centered care plan.4) The resident and the representative will be provided with a copy of the baseline care plan that includes but is not limited to:a. The initial goals of the resident.b. The summary of the resident's medication and dietary instructions.c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility and,d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on interview and record review, the facility failed to ensure residents had the right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 6 residents (Resident #3 ) reviewed for antipsychotic consents. The facility failed to ensure Resident #3, or her representative signed consent for the antipsychotic medication Seroquel (quetiapine) (an antipsychotic medication used to treat mental health disorders, such as schizophrenia) prior to administering the medication, and after the dosage was increased prior to administering the new dosage ordered by physician. These failures could affect residents by placing them at risk of not being informed the risks and possible side effects of their medication to make informed decisions regarding their care. Findings included: Record review of Resident #3's electronic face sheet, not dated revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease (progressive mental deterioration that can occur in middle age or old age due to degeneration of the brain), Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), stroke ( a medical emergency occurring when blood flow to the brain is blocked or a vessel bursts causing rapid brain cell death). Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 00 which indicated the resident was unable to complete the BIMS test. Further review of the MDS Section N-Medications revealed Resident #3 was taking an antipsychotic medication. Record review of Resident #3's physician order dated 11/10/2025 revealed: Quetiapine tablet 50 mg 1 tablet to be administered daily at bedtime. Record review of Resident #3's physician order dated 11/23/2025 revealed: Quetiapine tablet 50 mg 2 tablets to be administered at bedtime. Record review of Resident #3's MAR dated November 2025 revealed Resident #3 received Seroquel (quetiapine) 50 mg 1 tablet at bedtime starting the night of 11/10/2025 - 11/22/2025, and two 50 mg tablets at bedtime starting 11/23/25 - 11/26/25. Record review of Resident #3's EMR revealed there was not a HHSC Form 3713 Consent for Antipsychotic or Neuroleptic Medication Treatment. A facility form used for consent Seroquel revealed no evidence of a signature by Resident or their representative. Further review revealed a verbal consent obtained by the prior ADON on 11/27/2025 for dosage of Quetiapine (Seroquel) 50mg at bedtime. There was no evidence that side effects were discussed with Resident #3s representative and that she acknowledged understanding of the side effects listed on the form. Record review of Resident #3's electronic medical chart revealed no evidence Resident #3, or her representative consented to or was aware of an increased dosage of Seroquel on or before 11/23/2025. Record review of an Inservice dated 03/11/2026 signed by 10 members of the nursing staff reflected All Antipsychotics must have a signature on the 3713 prior to administration. During a telephone interview on 03/12/2026 at 8:00 a.m., Resident #3's representative stated she did not give verbal consent for Quetiapine and would not have given the consent if she had been aware that the medication was not recommended for use in the elderly. During an interview on 03/12/2026 at 2:45 p.m., LVN A stated the process for giving an antipsychotic medication began with the nurse getting an order from the physician and then calling the family to get consent from the family. She stated there are two papers for them to sign, the HHSC form 3713 and a Consent for use of psychotropic medications. She stated the medication cannot be given until both of these consents are signed by the resident or resident representative. During an interview on 03/13/2026 at 1:08 p.m., with the Interim DON present, the CCN stated it was the nurse's responsibility for getting consents signed for psychoactive medications. She stated those consents should have been obtained prior to giving psychoactive medication to the resident. She stated she was not able to find a consent for Quetiapine (Seroquel) medication on Resident #3. She stated she was unaware that verbal consents were not appropriate for Quetiapine on Resident #3. She stated she could not find a consent with updated dosage for Resident #3. She verified that the consent for Seroquel on Resident #3 did not have a physical signature on the form. She stated what might have contributed to Resident #3 not having a consent on file could be that the facility had changed in Nursing administration over the past several months and them not being familiar with the consent requirements for antipsychotics. The CCN stated not obtaining consent prior to medication administration could have caused residents or their representatives to not be provided with information of the side effects of the medication or not being notified that the resident was ordered that medication. She stated DON and ADONs were responsible for monitoring that the appropriate medications had consents. She stated she had just started monitoring the consents and had conducted an in-service on consents on 3/11/2026. Record review of facility policy titled Antipsychotic Medication Use dated March, 2025 revealed: Antipsychotic medications will be prescribed at the lowest possible dosage, for the shortest period of time and are subject to gradual dose reductions and re-review. Requirements for consents: If a resident is currently on an antipsychotic or Neuroleptic medication, a consent will be obtained by the resident, or a resident's legally authorized representative providing consent to prescribe this medication, HHSC (consent) form, which is form 3713, the form 3713 either the original version or a copy, will be added to the resident's clinical record. This form is completed if the antipsychotic or Neuroleptic medication is prescribed to a resident for the first time and will be completed prior to the first dose is administered. Review of LTCR Provider letter titled Consent for Antipsychotic and Neuroleptic Medications dated May 5, 2022, accessed on 03/19/2026 at https://www.hhs.texas.gov/sites/default/files/documents/pl2022-11.pdf, revealed The prescriber of the medication, the prescriber's designee, or the NF' s medical director must complete Section I of Form 3713. HHSC cannot specify who can be the designee for the prescriber. Prescribers should consult their own board, such as the Texas Medical Board, to determine who can act as their designee. A prescriber can delegate the completion of Form 3713, Section I, if the prescriber's license permits it . The resident or the resident's legally authorized representative must sign Section II of Form 3713 (Consent for Antipsychotic or Neuroleptic Medication Treatment). The rule requires consent in writing by the resident or by a person authorized by law to consent on behalf of the resident. Verbal consent does not meet the rule requirements. NF staff cannot sign on behalf of the resident.

Based on interview and record review, the facility failed to ensure the resident's right to be free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms 1 of 6 residents (Resident #3) whose records were reviewed for chemical restraints. Resident #3 was administered Quetiapine (Seroquel), an antipsychotic, without a diagnosis for justification of use. The facility's failure could affect residents by placing them at risk for adverse reactions and negative side effects from the administration of medication that was not indicated for use to treat medical conditions and symptoms. The findings included:Record review of Resident #3's electronic face sheet dated 3/11/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's disease (progressive mental deterioration that can occur in middle age or old age due to degeneration of the brain), Vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging brain tissue), stroke ( a medical emergency occurring when blood flow to the brain is blocked or a vessel bursts causing rapid brain cell death). Review of Resident #3's Physician Order Report dated 11/01/25 to 11/30/2025 Revealed orders for Quetiapine tablet 50 mg 1 tablet to be administered daily at bedtime for vascular dementia with agitation. Record review of Resident #3's physician order dated 11/23/2025 revealed orders for: Quetiapine tablet 50 mg 2 tablets to be administered at bedtime for vascular dementia with agitation. Record review of Resident #3's MAR dated November 2025 revealed Resident #3 received Quetiapine (Seroquel) 50 mg 1 tablet at bedtime starting the night of 11/10/2025 - 11/22/2025, and two 50 mg tablets at bedtime starting 11/23/25 - 11/26/25. Record review www.drugs.co website on 3/17/2026, revealed Quetiapine (Seroquel) was an antipsychotic typically used in the treatment of schizophrenia (a chronic severe mental disorder) and bipolar disorder (a chronic disorder characterized by severe mood swings). Its stated common side effects include sedation, fatigue, weight gain, Constipation, and dry mouth. Other side effects include low blood pressure with standing, seizures, high blood sugar, tardive dyskinesia (a neurologic disorder that causes involuntary, uncontrollable, and repetitive movements which typically appears with the long term use of antipsychotics), and neuroleptic malignant syndrome u( a rare and life-threatening reaction to the use of almost any kind of antipsychotic) in older people with dementia, its use may increase the risk of death.During an interview with Interim DON on 03/17/26 at 1:00 p.m. she stated Vascular Dementia with agitation was not an appropriate diagnosis for Quetiapine. She stated the medication could cause over sedation in the elderly. During an interview with the CCN on 03/17/2026 at 1:30 p.m., she agreed Vascular Dementia with Agitation is not a proper diagnosis for the use of the antipsychotic medication Quetiapine. She stated a negative outcome to the residents could be oversedation. She stated that the Hospice nurse had obtained the order for the Quetiapine. Record review of the facility's policy for Antipsychotic Medication Use, dated as revised March 2025, revealed the following [in part]:Policy: Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician, nurse practitioner, and other staff will gather and document information to clarify the resident's behavior, mood function, medical condition, specific symptoms, and risk to the resident and others. Anti-psychotic medications should generally be used only for the following conditions diagnosis: schizophrenia, schizoaffective disorder, delusional disorder, mood disorders, psychosis, and in the absence of dementia. Antipsychotic medications will be prescribed at the lowest possible dose for the shortest period of time, and are subject to the gradual dose reduction and re -review.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen and 1 of 3 nourishment refrigerators (200/300 hall) reviewed for food services in that:The facility failed to store foods in the kitchen refrigerator and freezer that were sealed and labeled with an identifier and/or opened/expiration date for 1 of 2 refrigerator/freezers.The facility failed to store foods and drinks in a unit nourishment refrigerator that were sealed and labeled with an opened date for 1 of 2-unit refrigerators. These failures could place residents at risk for decline in nutritional health status and foodborne illness.Findings included: In an observation on 09/02/2025 at 10:50 AM, during the initial tour of the facility kitchen, revealed the following:Large walk-in fridge/freezer:1 large clear plastic zipper unsealed bag of cheese with one date, 7/25, wrote in red permanent marker. 1 large clear plastic zipper sealed bag that contained 2 smaller bags with one date of 8/5 and guacamole wrote on bag with permanent marker. In an observation on 09/03/2025 at 11:15 AM, during rounds on nourishments refrigerators, revealed the following:Small refrigerator at nurses' station for 200/300 Hall:1 opened carton of milk that expired 08/29/2025.1 plastic bottle that appeared to contain soda with no wrapper, no label, and the number 302 wrote on the lid.On a door shelf, there was a crusty brown substance as well as a brown sticky substance. 1 glass container with lid that contained leftover spaghetti with meat sauce and broccoli that was not labeled or dated.1 opened water bottle that was not labeled or dated.Inside the back panel of the fridge, there was condensation running down along with an orange rust substance from a screw. In an interview on 09/02/2025 at 11:15 AM, the DM stated foods received were dated with green marker and when they were opened, they were marked with red marker. The DM stated he does not like this method and is in the process of changing back to printing labels as this was his 3rd week working at this facility. The DM stated the bag of cheese in the refrigerator dated 7/25 should have already been discarded and that these items, once opened, were good for 7 days, with leftovers like the tub of mixed veggies on the opposite shelf were good for 2 days and were used this morning for the chicken pot pie. The DM stated his expectation was that all staff members were proactive in watching for dates and discarding anything that was out of date range. He further stated a negative outcome would be the residents becoming ill from food borne illness depending on the food product. In an interview on 09/03/2025 at 1:42 PM, [NAME] A stated it was the responsibility of all staff to check dates every shift. He further stated this was to make sure food items that have been opened more than the set number of days were discarded and not served to the residents. [NAME] A stated leftovers were only kept for 2 days and other things like the shredded cheese was kept for 7 days after opening. [NAME] A stated the red marked dates are when the item was received, and the green dates are when it was opened. [NAME] A stated the expectation was for all outdated items to be discarded, and a negative outcome could be food borne illness depending on the food in question. In an interview on 09/03/2025 at 1:55 PM, LVN B stated the night shift nurse does temperature checks on the unit fridge, all help to clean it out when needed, and housekeeping also helps making sure all dates are good. LVN B stated the expectation was no food would be left any longer than the dates on the item or thrown out by expiration. LVN B tated a negative outcome could be the resident could become ill. In an interview on 09/03/2025 at 2:00 PM, RN C stated it's the nurse's responsibility to keep up with the temperature logs, make sure all items were labeled correctly with names/dates, and when expired they were to discard of them. Stated sometimes management would come around and help when the nurses are busy. Stated the expectation was to keep the refrigerators clean and temp logs up to date. He further stated a negative outcome could be a resident or staff member becoming ill should something be expired. In an interview on09/03/2025 at 2:45 PM, the DON stated her expectation was for the night shift nurses to update the temperature log and clean out any expired foods, drinks, or anything not labeled. The DON stated a negative outcome would be, if consumed, it could cause someone to become sick. She also stated to her knowledge there has been no issues with food borne illnesses. Review of the facility policy for Food Storage, dated 10/1/2018, revised 6/1/2019, revealed [in part]:Policy: To ensure that all food served by the facility is good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines.Procedures:2. Refrigeratorsd. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of the facility policy for Refrigerators and Freezers, not dated, revealed [in part]:Policy: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.Policy Interpretation and Implementation:7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened.8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes.9. Supervisors will inspect refrigerators and freezers monthly for gasket conditions, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs.10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.

Based on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 6 medication carts (medication cart E) and 1 of 3 medication rooms (medication room B) reviewed for pharmacy services. The facility did not ensure medication carts and medication storage rooms were secured and locked. This failure could put residents at risk for drug diversions. Findings included: During an observation on 9/3/25 at 9:10 am, medication room on hall 300 was observed to be unlocked and the door open with no nurse or staff at nurses' station for approximately 10 minutes. Upon entering unlocked medication storage room, medication was observed on counter in plain sight. Medication storage refrigerator was unlocked with medications inside. During an observation on 9/3/25 at 9:12 am, medication cart E on hall 300 was observed unlocked and unattended in the hall. The nurse was removing items from the cart and walked across the hall into room [ROOM NUMBER]. She did not lock the cart. During an interview on 9/3/25 at 9:30am, LVN D stated, she forgot to close the medication room. LVN D stated they were supposed to be closed and locked. She stated she was the only one with a key and was responsible for the medications stored in that room. LVN D stated other residents could go in and take medications that could harm them. She then stated the policy on medication carts was they were supposed to be locked. She stated she did not realize she did not shut the medication cart and lock it. Medication Cart was out of her sight and should have been locked. LVN D stated a possible negative outcome could have been unauthorized person taking medications out of cart. During an interview on 9/3/25 at 1:27 pm, DON stated her expectations for the nurses regarding safety with medication rooms and carts were that they were all always kept locked and clean when unattended. She further stated a negative outcome could have been other staff or residents taking medications that did not belong to them and possibly harm them. Record review on 9/3/25 of a facility policy undated with revised date of April 2019 titled Storage of Medications revealed [in part]: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. #8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. #9. Unlocked medication carts are not left unattended #12. Only persons authorized to prepare and administer medications have access to locked medications.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for one of six (Resident #1) residents reviewed for notification of change in condition. The facility failed to ensure Resident #1's feedings were administered as ordered by the physician over a period of 8 days, from 12/22/2024 to 12/30/2024. The facility failed to notify Resident #1's attending physician of feedings being held due to nausea, vomiting and diarrhea. On 12/30/24 Resident #1 required hospitalization for hypovolemic shock, sepsis, UTI, and required emergency surgical intervention for treatment of a rectus abdominus hematoma. An Immediate Jeopardy (IJ) situation was identified on 01/29/2025 at 4:20 pm . The IJ was removed on 01/31 /2025 at 10:24 AM. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention, decline in health, serious injury, harm, impairment, or death. Findings include: Record review of Resident #1's face sheet, dated 01/03/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had relevant diagnoses which included cerebral infarct ( a condition where blood flow to the brain is interrupted, causing brain tissue to die), dysphagia (difficulty swallowing), other signs and symptoms concerning food and fluid intake, unspecified signs and symptoms involving cognitive function after stroke, speech and language deficits, hypertension ( high blood pressure), and long-term use of anticoagulants. Record review of Resident #1's Discharge MDS assessment dated [DATE], reflected she had both short-term and long-term memory problems. She was dependent for bed mobility, transfers, feeding, and maximum assistance with wheelchair mobility wheelchair for mobility. She was incontinent of both bowel and bladder and she had a feeding tube; Record review of Resident #1's Comprehensive Care Plan reflected the following, Focus: Resident has a potential fluid deficit related to tube feedings, goal - the resident will be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor, interventions - monitor and document frequency of bowel movements, monitor vital signs and report significant abnormalities to physician. Focus, G-tube feeding required due to dysphagia (feeding via a tube inserted through the abdomen surgically into the stomach due to difficulty swallowing). Interventions included: Give 150ml water every shift via gastrostomy tube to equal 450ml/24hrs, Glucerna 1.5 at 57ml/hour with 39ml/hour continuous water flush for 20 hours a day via GT = 1133 ml formula, 1700 kcals, 91gms protein, 2066ml water/24 hours (excludes med flushes), monitor/document/report PRN any signs or symptoms of aspiration, fever, shortness of breath, tube dislodgment, Infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, or dehydration. Throughout the course of the investigation, Resident # 1 was no longer at the facility and was unavailable for interview due to the decline in her condition . Record review of Resident #1's active physician orders from the nursing facility, dated 12/30/2024 reflected her attending physician as Dr W, and contained an order which stated, remove from feeding pump for 4 hours one time a day, and then reconnect to pump one time a day. The orders also stated Resident #1 was NPO (nothing by mouth). Her feeding order was give 150ml water q shift via feeding tube to equal 450ml/24hours, Glucerna 1.5 at 57ml/hour with 39ml/hour continuous water flush for 20 hours a day via g-tube to equal 1133 ml formula, 1700 kcals, 91 gm's protein, and 2066 ml water/24 hours (excludes med flushes). The order had a start date of 07/13/2023. Record review of Resident #1's active physician orders from the nursing facility, dated 12/30/2024 reflected The resident also had an order for Zofran 4 mg every 6 hours as needed for nausea and vomiting. The order had a start date of 07/13/2023. Record review of Resident's #1's MAR for the month of December 2024 revealed she did not receive Zofran 4 mg in the month of November or December until the date of 12/22/2024. Record review of Resident #1's facility nursing progress notes dated 12/22/2024 to 12/30/2024 reflected documentation in the nursing progress notes on 12/22/2024, 12/24/2024, 12/25/2024 x2, 12/27/24 2 times, and 12/30/24 showing the resident received Zofran 4 mg for nausea and vomiting. The order had a start date of 07/13/23. Record review of Resident # 1's physician progress notes authored by NP L with an encounter date 12/19/2024 reflected no evidence of nausea or vomiting and documented pharmacotherapy reviewed, patient on 23 medications. Recommendation for discontinuation of Mylanta Oral Suspension, Ondansetron (Zofran) HCL tablet, and MOM (milk of magnesia)suspension PRN medications as they have not been utilized in the past three months. Record review of Resident #1's Nursing Progress Notes, with a look-back period between 12/22/2024 - 12/30/2024, reflected no documentation related to a completed assessment or notification to a medical provider of Resident #1's continued nausea, vomiting and diarrhea nor any other concerns until 12/30/2024 when LVN A documented the primary care physician was notified. Her blood pressure was documented to be 70/46 with a pulse of 46 by LVN A. Record review of Resident #1's electronic medical record revealed no lab work had been ordered since November 2024. Her Comprehensive Metabolic Panel and Complete Blood Count were within Normal limits at that time. Throughout the course of the investigation 01/03/25 to 01/31/25), Resident # 1 was no longer at the facility and was unavailable for interview due to the decline in her condition. Record review of physician ER notes in the ER hospital records, dated 12/30/24, indicated the resident presented with nausea, diarrhea, and abdominal pain. She was diagnosed with hypovolemic shock (shock caused by major blood or fluid loss), sepsis (an extreme reaction by the body to infection) , and abdominal pain. The ER Physician stated in the note Overall, I feel the shock is multifocal, rectus sheath hematoma ( a collection of blood cause by a tear in the rectus abdominus muscle of the abdomen) with volume loses secondary to reported nausea and vomiting. Record Review of clinical chart documentation dated 12/30/24, the ER Physician stated The high probability of sudden, clinically significant deterioration in the patient's condition required the highest level of my preparedness to intervene urgently. The service I provided to this patient were to treat and/or prevent clinically significant deterioration that could result In severe disability or death. Further review of the Physician ER note, dated 12/30/25, revealed the resident required transfer to a higher level of care and hospitalization on [DATE] for hypovolemic shock, sepsis, and required emergency surgical intervention for treatment of a rectus abdominus hematoma, the resident was also found to have a UTI. Record review of the lab results, dated 12/30/24, from the ER Record revealed her Lactic Acid was 3.2 H ( normal range 0.5 to 2.2 millimoles, a condition where the level of lactic acid in the blood is elevated indicating the liver and kidneys are not are not able to metabolize lactic avid or are producing too much), WBC's 25.31 H,( blood cells that fight infection, the normal range is 4.000 to 11,000. Her urine had many bacteria, 3-4, RBC's ( red blood cells carry oxygen to cells and tissues normal range 4.2 to 5.4) Sodium was 128 L (sodium normal range between 135 - 145 an electrolyte that helps regulate water in the body , Chloride 88 L ( normal range 96 to 106 it is an elctrolye that main tains fluid volume an acid base balance in the body), Co2 32 H( normal range between 23 and 29 regulates the respiratory rate and the affinity of hemoglobin for oxygen) , BUN 33 H (normal range 6 to 24 high BUN indicates how well the kidneys are removing urea which is a waste product from the blood), Albumin 2.9 L(normal range 3.4 to 5.4 albumin helps transport fluids throughout then body). During an interview on 01/03/2025 at 8:00 AM with Resident # 1's family member, she stated the resident had been in the facility since March of 2024. She stated Resident #1 took her medication and all fluids and nourishment through a tube in her stomach. She stated Resident #1 was in ICU at that time. She stated the resident was admitted to the hospital on 12/30/24. and that was the first time the facility had let the family know how sick she was. She stated the resident was septic and severely dehydrated when she arrived at the hospital with a blood pressure of 48/28. The family member stated Resident #1's room was electronically monitored, and she could see the feeding tube was turned off intermittently from the 21st of December until the time she went to the hospital on 12/3020/24. She stated the ER physician told her there was a foul smell emitting from her gastrostomy tube at the time of her transfer to the hospital. She stated the ER staff told her the odor was so bad there was no way the facility staff could have not known about it. She stated her urine was so concentrated it was the color of tea or coffee. She stated on 12/29/24 she was told by a nurse at the facility ( she did not know her name) that Resident #1's color was ashen, and she was concerned about her. She stated the nurse stated she was trying to reach the physician. They finally notified her that they had received orders for transfer, and transferred her to the emergency roiagnom on the 30th of [DATE]. An attempt to interview the ER Physician was unsuccessful on 01/27/2025 at 2:30 PM and 4:30 PM, the purpose of the call and a call back number was left on voicemail. In interview with NP L, on 1/03/2025 at 1:00 PM, she stated she never saw or treated Resident #1 from 12/22/2024 until 12/30/2024 and she was not called by the facility or informed of her nausea, vomiting and diarrhea. In interview with Resident #1's primary care physician W, on 1/03/2025 at 1:40 PM, he stated he was not notified of a condition change in Resident #1 from 12/22/2024 until 12/30/2024, and was not informed of her nausea, vomiting and diarrhea over the course of 8 days. He stated he was notified on 12/30/2024 and he sent her to the hospital for evaluation. He stated he was never notified that her gastrostomy tube feedings were held. He stated he would have expected the nursing staff to notify him of the condition change after 24 hours with no improvement. He stated that he would have intervened sooner if he had been notified and ordered IV fluids and lab work. In a follow up interview with Primary care physician W on 1/27/2025 at 2:30 PM, he stated he did not know if early intervention would have prevented her hospitalization . He stated interventions such as fluids and labs might have prevented her hospitalization , but it was hard to say. He stated in his opinion in general, most elderly residents in nursing homes did suffer from some degree of dehydration. He stated he did not lay eyes on Resident #1 before he gave orders for her transfer to the hospital for evaluation, therefore he could not say what her condition was at the time of transfer. In an interview on 01/03/2025 at 1:30 PM CNA D stated she worked the 23rd and 24th of December. She stated on the 23rd she doesn't think Resident #1 had nausea or diarrhea during her shift from 6:00 AM until 2:00 PM when she worked. But on the 24th she had diarrhea and vomiting, but she's not sure how many times it occurred. She stated the diarrhea was runny and brownish, reddish in color and the vomit was brown. She stated she reported it to LVN A who also helped her clean Resident #1 up. In an interview on 01/03/2025, CNA E at 1:40 PM stated she took care of the resident 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, and 12/30/2024. She stated the resident vomited and had diarrhea during her 8-hour shift (6am-2pm). She stated she reported this to the charge nurse ( LVN A). She stated she remembered Resident # 1 had diarrhea and vomiting for a long time and she reported it to the nurse each time the nausea, vomiting and diarrhea occurred, because it needed to be stopped. She stated she did not remember anything unusual about the color. She also stated several residents on the 500 hall had been sick, but Resident #1 had it longer than the other residents. She stated she did not notice if Resident #1's tube feeding was connected to the pump or if the charge nurse turned the pump off on the 6:00 AM - 2:00 PM shift, because that was the nurse's responsibility. She stated she did not remember how long Resident #1 the vomiting and diarrhea had, but it was for about a week. She stated several of the staff and other residents also had the diarrhea and vomiting at the same time, but Resident #1 had it longer than anyone else. CNA E was not available for a follow up interview. She did not work again during the course of the investigation, and attempts on 01/27/2025 at 2:00 PM and 5:00 PM for a phone interview were unsuccessful. During an interview with LVN A on 01/03/2025 at 2:40 PM, she stated she worked days on 12/23/2024, 12/24/2024, 12/25/2024, 12/26/24, and 12/30/2024. She stated she sent the resident to the hospital. She stated she knew the resident had the diarrhea and vomiting for several days. She stated Dr W had standing orders for Zofran as needed every 6 hours for nausea and vomiting. She stated she heard in the change of shift report given to her by LVN C that Resident #1 vomited and had diarrhea on the night shift. She stated she immediately went down to Resident #1's room to check on her. She stated Resident #1's B/P was 70/46, and she was complaining that her stomach hurt, so she immediately called the physician. She stated Resident #1 was on her way to the hospital by 7:00 Am. She stated she had been off for a few days prior to 12/30/2024 with symptoms of vomiting and diarrhea and 12/30/2024 was her first day back at work since 12/26/2024. She stated she notified the physician on 12/30/2024. She stated she did not notify the physician or the POA of Resident # 1's condition change prior to 12/30/2024 because she didn't think about doing it. In an interview on 01/03/2025 at 3:20 PM, LVN F stated she was the charge nurse and worked 2:00 PM to 10:00 PM on 12/24/2024. She stated on 12/24 /25, LVN A told her she had unhooked her from her feeding and stopped the pump due to nausea and vomiting during the 6:00 AM to 2:00 PM shift. She stated she assessed the resident, and she asked her if she felt better. She stated the resident told her she was not nauseated, and her vital signs were within normal range, so she resumed the feeding. She stated she had never seen Resident #1 have any brown or coffee ground emesis. She stated the tube flushed very well and she never noticed an odor. In a follow up interview on 1/8/2025 at 1:41 PM, LVN A stated she did not recall that Resident #1 ever had emesis of a brownish or coffee ground color as stated by CNA D . She stated it was always the color of the tube feeding. She stated Resident #1 had physician orders for her pump to be off for 4 hours each day . She reviewed her nursing progress notes and the MAR for the month of December during the interview and stated she did turn the pump off on 12/24/24 on the 6 AM -2 PM shift and also held her medications due to nausea and vomiting. She stated she did not notify the physician on 12/24/2024. In an Interview on 01/08/25 at 3:30 PM, LVN C stated she took care of Resident #1 during the time period of 12/21/24 to 12/30/24. She stated she had turned the feeding pump off several times during that time period due to the resident's nausea, vomiting and diarrhea. She stated she did not notify the physician of the resident's condition. She stated she gave the resident Zofran for nausea through the g-tube like everyone else did. She stated, I just never thought about calling the doctor to notify him the resident was not getting better and not able to tolerate her feedings. In an interview with LVN B on 01/08/2025at 3:00 PM, she stated she worked on 12/27/2024 thru 12/29/2024. She stated she stopped Resident #1's pump, and held her medications due to nausea on 12/27/2024. She stated she did not notify the physician. She stated she did not think of notifying the physician. She stated she thought he knew because she had the Zofran ordered for nausea. Interview with the DON on 01/03/2025 at 1:15 PM, she stated she was responsible for monitoring and providing oversight for the Nursing staff of the facility. She stated she was responsible for providing in-services to the staff. She stated she was not aware of Resident #1 having had diarrhea with nausea and vomiting which continued over the course of 8 days from 12/22/2024 to 12/30/2024. She stated her expectation was that staff would notify the resident's physician, POA, or responsible party of any change of condition in a resident. She stated she would have expected a nurse to recognize the symptoms and report the changes. She stated there was a 24-hour communication book that nurses could communicate changes of condition to other shifts. She stated she had looked in the nurses' notes from 12/21/2024 - 12/30/2024 the day of transfer, and she only saw the one notification to the family which was at the time of the transfer. She stated she would have expected them to do an Interact form which should have been done to gather and communicate assessment findings . She stated the nurses were supposed to do an Interact form with a condition change which would assist in cueing the nurse to notify the physician and send them to the hospital. She stated she saw no documentation of that occurring. Review of the 24hour communication book revealed no documentation that the physician had been notified of the condition change or that feedings were held. In an interview with the Administrator on 01/06/2025 at 11:35 AM, he stated his expectations were for the nurse to have reported Resident #1's condition change to the RP and the physician. He stated it was important for facility nursing staff to notify the doctor of any change of condition that required holding of a resident's feedings and of her condition change and continued nausea and vomiting. He stated that he would have intervened sooner if he had known. In an interview with the Administrator at 9:50 AM on 1/13/25, the Administrator stated he was not aware of the situation with Resident #1 until it was brought to his attention by the surveyor. He stated he felt like it was poor nursing care. In an interview with DON on 1/13/2025 at 9:45 AM, she stated that she wanted to let me know that she had suspended LVN C on the 10:00 PM to 6:00 AM shift . She stated that the nurse should have completed an interact form and notified the physician if Resident #1 was unable to tolerate the prescribed tube feeding due to nausea and vomiting. She stated she felt like it was poor nursing care, and she suspended LVN C to investigate the circumstances. She stated she would have notified the physician if she had been the nurse during that shift. She stated she would not want her family treated in that manner. She stated the nurses that worked during that time period should have contacted the physician. She stated turning off the feeding pump could result in dehydration and malnutrition. She stated the physician, the dietician or somebody should have been contacted. She stated LVN A had also quit. She stated Dr W talked to her after talking with the surveyor and he stated that he was not notified and would have expected the nursing staff to notify him of the continued nausea and vomiting and that the feedings were held. He stated he would have intervened sooner. In an interview on 01/13/2025 at 9:15 AM, Resident # 1's POA stated Resident #1 transferred to another SNF on 01/09/2025. She stated she was still concerned with the lack of care she received from 12/22/2024 to 12/30/2024. She stated she felt they almost let her die. Record review of the facility's staffing sheets, provided by the DON, reflected: LVN A worked day shift 6:00 AM to 2:00 PM 500 hall on 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/30/24 LVN B worked 6:00 AM to 10:00 PM 500 hall on 12/27/2024, 12/28/2024, and on 12/29/2024 LVN C worked night shift 10:00 PM to 6:00 AM 500 hall on 12/24/2024, 12/25/2024, 12/26/2024, and 12/29/2024 LVN F worked evening shift on 12/25/2024, and 12/26/2024 CNA D worked 6:00 AM to 2:00 PM on 12/23/2024, 12/24/2024, 12/26/2024, and 12/30/2024 CNA E worked 6:00 AM to 2:00 PM on 12/23/2024, 12/4/2024, 12/25/2024, 12/26/2024, 12/27/2024, and 12/30/2024. Record review of the facility's policy, Change In a Resident's Condition or Status dated revised May of 2017, reflected in part: Our facility shall promptly notify the resident, his or her attending physician or Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the physician or nurse practitioner or the physician on call when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant change in the resident's physical/emotional/mental condition, a need to alter the resident's treatment significantly, refusal of medications or treatment 2 or more consecutive times, need to transfer the resident to a hospital, specific instruction to notify the physician of a change in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. Impacts more than 1 area of a resident's health, requires interdisciplinary review and/or revision to the care plan. Record review of facility's policy, titled, Enteral Tube feeding via Continuous Pump, with a revised date of 10/04/2019 reflected the following: The purpose of this procedure is to provide a guideline for the use of a pump for internal feedings. Verify the physicians order for this procedure, review the residence care plan, and provide for any special needs of the resident. Report complications such as diarrhea gastric distension, and respiratory distress promptly to the supervisor and the attending physician. Report negative consequences of tube feeding such as agitation, depression, self extubation, and infections to the supervisor and attending physician. This was determined to be an Immediate Jeopardy (IJ) on 01/29/2025 at 4:20 PM. The Administrator and Clinical Compliance Director were notified. The Administrator, DON, and the CCD were provided with the IJ template on 1/29/2025 at 4:20 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 01/30/2025 at 10:56 PM POR F580 - Notify of Changes (Injury/Decline/Room, Etc.) Resident #1 was sent to Hospital on 12/30/24. On 1/3/25 due to HHSC entrance of the facility that there was a complaint of resident #1. Facility began to review any other residents with G-tubes no other residents with a G-tube remains in the facility and/or changes in condition, that would result with any required changes of condition and physician notification. oThe Charge nurses reviewed for any other changes of condition, and none were identified on 1/3/25 by oversight from the DON. The underlying cause is the facility failed to ensure the Physician was notified when a resident experienced a change in condition. All residents could have been affected by this alleged deficient practice. oOn 1/3/2025 - Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON, (The policy was reviewed, and verbal comprehension was acknowledged via Q&A and discussion with return demonstration of Situation Background Assessment Recommendations). oIn-services were initiated by the Director of Nursing/Quality Improvement Nurse on 1/6/2025 to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract (Situation, Background, Assessment and Recommendations to enhance the communication information among team members). Completed on 1/30/2025. oOn 1/6/2025 Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed. Completed 1/6/2025 [NAME] alter the process or system failure the Stop and Watch (early warning communication tool to alert a nurse or manager if they notice something different in a person's daily care routine) was initiated, training and education started to the certified nurses' aides utilizing the alert system on 1/8/25. (Verbal instruction and application along with monitoring of use to ensure understanding and compliance of the communication system) completion date 1/30/2025. oThe SBAR/eInteract is being monitored in the clinical morning startup daily by DON/ADON/Designee. oOversight will be provided by the Administrator/DON/Designee oOn 1/6/25 LVN A resigned and then called in on 1/9, 1/10, 1/13 resignation was accepted immediately. oOn 1/13/25 LVN B resigned with resignation accepted immediately oOn 1/5/25 - LVN C was terminated. oOn 1/17/25 - LVN A, LVN B and LVN C license was referred to the Texas Board of Nursing for further review. Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition. Oversite of the testing will be managed by DON/ADON. (Initiated: 1/30/25) To ensure understanding. This test will be given to new nurses hired during orientation and yearly with competencies. Completion date 1/30/2025. oChange of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed daily in clinical start-up with oversite provided by DON/ADON/Designee. DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off, daily at morning clinical start up. This will be with the oversight of the administrator. Discrepancies will be addressed immediately with root-cause analysis and brought to QAPI with the oversite with the Medical Director monthly for six months. Administrator/DON/Designee will review and ensure that understanding comprehension of the protocol. [Facility ] Medical Director notified of IJ (01/29/2025) [Facility] Monitoring of the POR Included the following: Verification of POC. 1/31/25 at 9:30 AM with DON present. Reviewed on 01/31/2025 at 9:39 am - Completed. Reviewed 01/31/2025 at 9:43 am - Completed. Reviewed 01/31/2025 at 9:50 am. Completed. On-going 3 staff left, cannot work until in-service completed. oOn 1/06/2025 LVN A resigned and then called in on 01/9, 01/10, 01/13 resignation was accepted immediately. oOn 01/13/2025 LVN B resigned with resignation accepted immediately oOn 01/05/2025 - LVN C was terminated. oOn 1/17/2025 - LVN's A, B, and C license was referred to the Texas Board of Nursing for further review. Reviewed the employee files of Nurses A, B, and C with the documentation of the disciplinary actions taken with the DON 01/31/2025 at 9:56 am. Completed. Reviewed the inservice sheet and the employee list provided by the facility with the D atat 1/31/25 at 9:57 am. The inservice efforts are on-going required for agency and new staff before they are allowed to work All nurses employed at the facility with the exception of 2 nurses on the staff list had completed the inservices. They cannot work until completed. This information stating they should not clock in before they had received the inservice and taken the competency based test. was posted on time clock by the DON. Reviewed letter of notification of Immediate Jeopardy Signed by Medical Director on 01/20/2025. Reviewed signed document with DON. Interview Verification: , On 01/30/2025 at In interviews from 2PM 12:30 AM with LVN G, Charge Nurse (6 AM-2 PM) LVN H (6 AM-2 PM) shift, LVN F(2 PM-10 PM) shift, LVN I (2 PM-10 PM) shift, CMA FF (6 Am -6 PM) shift, LVN K, (6 AM-2PM) shift, LVN L (2 PM -10 PM) shift LVN M PRN, LVN N Agency, CNA D (6am-6pm) shift, LVN O (2 PM - 10 PM) shift, CNA Q (2 PM-10 PM) shift, Agency CNA R. (2 PM - 10 PM) shift, LVN S (6 am - 2 pm )shift, LVN T (10pm-6am) shift, . LVN GG (10 AM-6 PM), RN U (10 PM- 6 AM) shift, CNA V (10 PM -6 AM) shift, CNA X (2 PM- 6 AM) shift, LVN Z (10 PM-6 AM), CNA AA, CNA CC (10am-6pm) shift, and LVN BB (10 AM-6 PM) shft all stated a change of condition was anything that is outside of resident's normal state. They stated Information can come from a CNA, Therapy, other staff and should be reported to the charge nurse immediately, who in turn should notify the physician. They stated the eInteract (SBAR) should be used to assess the resident for a change in condition because it was very specific to conditions. They were all able to demonstrate how to fill out the e-interact form, and a provided sample. They stated it would be passed on in shift report and documented on the communication sheet for each hall and the SBAR form would stay open in the electronic medical record until the physician was notified. They stated nurses go in for morning report, with management to go over any change that has occurred or new orders on a physician. They stated the inservice was held on, 01/30/2025 for e-interac (SBAR) The Inservice was mandatory. A competency based test was given to each staff member over the information in the Inservice after the inservice . Record review of In-service, Notification of Change in Condition, conducted by CCN, Admin and DON included facility definition, purpose, process for provider notification as it related to all changes or decline in condition are required to be reported to the attending physician by utilizing the facility sanctioned communication documents. Record review of In-service titled, SBAR, conducted by Corporate Nurse, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. In interview with the Administrator on 01/31/2025 at 9:50 AM , he stated failure to report a change a change in condition to the resident's nurse could be considered neglect. He stated Immediate notification to a provider for any resident change in condition was important. He Knew what a change in condition was and was able to state signs and symptoms that would indicate a condition change such as change in LOC and the signs and symptoms his staff should be monitoring for infection such as fever, increased behaviors or confusion etc He further stated what and where his staff should be documenting any change in condition in the electronic medical record (EMR) and the other parties that should be notified in addition to the provider. He sufficiently defined abuse, neglect, and/or exploitation and the expectations of hi [TRUNCATED]

Based on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for one of six (Resident #1) residents reviewed for notification of change in condition. The facility failed to notify Resident #1's attending physician of nausea, vomiting and diarrhea which lasted from 12/22/2024 to 12/30/2024 without improvement. An Immediate Jeopardy (IJ) situation was identified on 01/29/2025 at 4:21 pm . The IJ was removed on 01/31 /2025 at 10:24 AM. The facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of a delay in medical intervention, decline in health, serious injury, harm, impairment, or death. Findings include: Record review of Resident #1's face sheet, dated 01/03/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had relevant diagnoses which included cerebral infarct ( a condition where blood flow to the brain is interrupted, causing brain tissue to die), dysphagia (difficulty swallowing), other signs and symptoms concerning food and fluid intake, unspecified signs and symptoms involving cognitive function after stroke, speech and language deficits, hypertension ( high blood pressure), and long-term use of anticoagulants. Record review of Resident #1's Discharge MDS assessment dated [DATE], reflected she had both short-term and long-term memory problems. She was dependent for bed mobility, transfers, feeding, and maximum assistance with wheelchair mobility wheelchair for mobility. She was incontinent of both bowel and bladder and she had a feeding tube; Record review of Resident #1's Comprehensive Care Plan reflected the following, Focus: Resident has a potential fluid deficit related to tube feedings, goal - the resident will be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor, interventions - monitor and document frequency of bowel movements, monitor vital signs and report significant abnormalities to physician. Focus, G-tube feeding required due to dysphagia (feeding via a tube inserted through the abdomen surgically into the stomach due to difficulty swallowing). Interventions included: Give 150ml water every shift via gastrostomy tube to equal 450ml/24hrs, Glucerna 1.5 at 57ml/hour with 39ml/hour continuous water flush for 20 hours a day via GT = 1133 ml formula, 1700 kcals, 91gms protein, 2066ml water/24 hours (excludes med flushes), monitor/document/report PRN any signs or symptoms of aspiration, fever, shortness of breath, tube dislodgment, Infection at tube site, self-extubating, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, or dehydration. Record review of Resident #1's active physician orders from the nursing facility, dated 12/30/2024 reflected The resident also had an order for Zofran 4 mg every 6 hours as needed for nausea and vomiting. The order had a start date of 07/13/2023. Record review of Resident's #1's MAR for the month of December 2024 revealed she did not receive Zofran 4 mg in the month of November or December until the date of 12/22/2024. Record review of Resident #1's facility nursing progress notes dated 12/22/2024 to 12/30/2024 reflected documentation in the nursing progress notes on 12/22/2024, 12/24/2024, 12/25/2024 x2, 12/27/24 2 times, and 12/30/24 showing the resident received Zofran 4 mg for nausea and vomiting. The order had a start date of 07/13/23. Record review of Resident # 1's physician progress notes authored by NP L with an encounter date 12/19/2024 reflected no evidence of nausea or vomiting and documented pharmacotherapy reviewed, patient on 23 medications. Recommendation for discontinuation of Mylanta Oral Suspension, Ondansetron (Zofran) HCL tablet, and MOM (milk of magnesia)suspension PRN medications as they have not been utilized in the past three months. Record review of Resident #1's Nursing Progress Notes, with a look-back period between 12/22/2024 - 12/30/2024, reflected no documentation related to a completed assessment or notification to a medical provider of Resident #1's continued nausea, vomiting and diarrhea nor any other concerns until 12/30/2024 when LVN A documented the primary care physician was notified. Her blood pressure was documented to be 70/46 with a pulse of 46 by LVN A. Record review of Resident #1's electronic medical record revealed no lab work had been ordered since November 2024. Her Comprehensive Metabolic Panel and Complete Blood Count were within Normal limits at that time. Throughout the course of the investigation 01/03/25 to 01/31/25), Resident # 1 was no longer at the facility and was unavailable for interview due to the decline in her condition. Record review of physician ER notes in the ER hospital records, dated 12/30/25, indicated the resident presented with nausea, diarrhea, and abdominal pain. She was diagnosed with hypovolemic shock (shock caused by major blood or fluid loss), sepsis (an extreme reaction by the body to infection) , and abdominal pain. The ER Physician stated in the note Overall, I feel the shock is multifocal, rectus sheath hematoma ( a collection of blood cause by a tear in the rectus abdominus muscle of the abdomen) with volume loses secondary to reported nausea and vomiting. Record Review of clinical chart documentation dated 12/30/24, the ER Physician stated The high probability of sudden, clinically significant deterioration in the patient's condition required the highest level of my preparedness to intervene urgently. The service I provided to this patient were to treat and/or prevent clinically significant deterioration that could result In severe disability or death. Further review of the Physician ER note, dated 12/30/24, revealed the resident required transfer to a higher level of care and hospitalization on [DATE] for hypovolemic shock, sepsis, and required emergency surgical intervention for treatment of a rectus abdominus hematoma, the resident was also found to have a UTI. Record review of the lab results, dated 12/30/24, from the ER Record revealed her Lactic Acid was 3.2 H ( normal range 0.5 to 2.2 millimolesa condition where the level of lactic acid in the blood is elevated indicating the liver and kidneys are not are not able to metabolize lactic avid or are producing too much), WBC's 25.31 H,( blood cells that fight infection, the normal range is 4.000 to 11,000. Her urine had many bacteria, 3-4, RBC's ( red blood cells carry oxygen to cells and tissues normal range 4.2 to 5.4) Sodium was 128 L (sodium normal range between 135 - 145 an electrolyte that helps regulate water in the body , Chloride 88 L ( normal range 96 to 106 it is an elctrolye that main tains fluid volume an acid base balance in the body), Co2 32 H( normal range between 23 and 29 regulates the respiratory rate and the affinity of hemoglobin for oxygen) , BUN 33 H (normal range 6 to 24 high BUN indicates how well the kidneys are removing urea which is a waste product from the blood), Albumin 2.9 L(normal range 3.4 to 5.4 albumin helps transport fluids throughout then body). During an interview on 01/03/2025 at 8:00 AM with Resident # 1's family member, she stated the resident had been in the facility since March of 2024. She stated Resident #1 took her medication and all fluids and nourishment through a tube in her stomach. She stated Resident #1 was in ICU at that time. She stated the resident was admitted to the hospital on 12/30/24. and that was the first time the facility had let the family know how sick she was. She stated the resident was septic and severely dehydrated when she arrived at the hospital with a blood pressure of 48/28. The family member stated Resident #1's room was electronically monitored, and she could see the feeding tube was turned off intermittently from the 21st of December until the time she went to the hospital on 12/30/24. She stated the ER physician told her there was a foul smell emitting from her gastrostomy tube at the time of her transfer to the hospital. She stated the ER staff told her the odor was so bad there was no way the facility staff could have not known about it. She stated her urine was so concentrated it was the color of tea or coffee. She stated on 12/29/24 she was told by a nurse at the facility ( she did not know her name) that Resident #1's color was ashen, and she was concerned about her. She stated the nurse stated she was trying to reach the physician. They finally notified her that they had received orders for transfer, and transferred her to the emergency roiagnom on the 30th of [DATE]. An attempt to interview the ER Physician was unsuccessful on 01/27/2025 at 2:30 PM and 4:30 PM, the purpose of the call and a call back number was left on voicemail. In interview with NP L, on 1/03/2025 at 1:00 PM, she stated she never saw or treated Resident #1 from 12/22/2024 until 12/30/2024 and she was not called by the facility or informed of her nausea, vomiting and diarrhea. In interview with Resident #1's primary care physician W, on 1/03/2025 at 1:40 PM, he stated he was not notified of a condition change in Resident #1 from 12/22/2024 until 12/30/2024, and was not informed of her nausea, vomiting and diarrhea over the course of 8 days. He stated he was notified on 12/30/2024 and he sent her to the hospital for evaluation. He stated he was never notified that her gastrostomy tube feedings were held. He stated he would have expected the nursing staff to notify him of the condition change after 24 hours with no improvement. He stated that he would have intervened sooner if he had been notified and ordered IV fluids and lab work. In a follow up interview with Primary care physician W on 1/27/2025 at 2:30 PM, he stated he did not know if early intervention would have prevented her hospitalization . He stated interventions such as fluids and labs might have prevented her hospitalization , but it was hard to say. He stated in his opinion in general, most elderly residents in nursing homes did suffer from some degree of dehydration. He stated he did not lay eyes on Resident #1 before he gave orders for her transfer to the hospital for evaluation, therefore he could not say what her condition was at the time of transfer. In an interview on 01/03/2025 at 1:30 PM CNA D stated she worked the 23rd and 24th of December. She stated on the 23rd she doesn't think Resident #1 had nausea or diarrhea during her shift from 6:00 AM until 2:00 PM when she worked. But on the 24th she had diarrhea and vomiting, but she's not sure how many times it occurred. She stated the diarrhea was runny and brownish, reddish in color and the vomit was brown. She stated she reported it to LVN A who also helped her clean Resident #1 up. In an interview on 01/03/2025, CNA E at 1:40 PM stated she took care of the resident 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/27/2024, and 12/30/2024. She stated the resident vomited and had diarrhea during her 8-hour shift (6am-2pm). She stated she reported this to the charge nurse ( LVN A). She stated she remembered Resident # 1 had diarrhea and vomiting for a long time and she reported it to the nurse each time the nausea, vomiting and diarrhea occurred, because it needed to be stopped. She stated she did not remember anything unusual about the color. She also stated several residents on the 500 hall had been sick, but Resident #1 had it longer than the other residents. She stated she did not notice if Resident #1's tube feeding was connected to the pump or if the charge nurse turned the pump off on the 6:00 AM - 2:00 PM shift, because that was the nurse's responsibility. She stated she did not remember how long Resident #1 the vomiting and diarrhea had, but it was for about a week. She stated several of the staff and other residents also had the diarrhea and vomiting at the same time, but Resident #1 had it longer than anyone else. CNA E was not available for a follow up interview. She did not work again during the course of the investigation, and attempts on 01/27/2025 at 2:00 PM and 5:00 PM for a phone interview were unsuccessful. During an interview with LVN A on 01/03/2025 at 2:40 PM, she stated she worked days on 12/23/2024, 12/24/2024, 12/25/2024, 12/26/24, and 12/30/2024. She stated she sent the resident to the hospital. She stated she knew the resident had the diarrhea and vomiting for several days. She stated Dr W had standing orders for Zofran as needed every 6 hours for nausea and vomiting. She stated she heard in the change of shift report given to her by LVN C that Resident #1 vomited and had diarrhea on the night shift. She stated she immediately went down to Resident #1's room to check on her. She stated Resident #1's B/P was 70/46, and she was complaining that her stomach hurt, so she immediately called the physician. She stated Resident #1 was on her way to the hospital by 7:00 Am. She stated she had been off for a few days prior to 12/30/2024 with symptoms of vomiting and diarrhea and 12/30/2024 was her first day back at work since 12/26/2024. She stated she notified the physician on 12/30/2024. She stated she did not notify the physician or the POA of Resident # 1's condition change prior to 12/30/2024 because she didn't think about doing it. In an interview on 01/03/2025 at 3:20 PM, LVN F stated she was the charge nurse and worked 2:00 PM to 10:00 PM on 12/24/2024. She stated on 12/24 /25, LVN A told her she had unhooked her from her feeding and stopped the pump due to nausea and vomiting during the 6:00 AM to 2:00 PM shift. She stated she assessed the resident, and she asked her if she felt better. She stated the resident told her she was not nauseated, and her vital signs were within normal range, so she resumed the feeding. She stated she had never seen Resident #1 have any brown or coffee ground emesis. She stated the tube flushed very well and she never noticed an odor. In a follow up interview on 1/8/2025 at 1:41 PM, LVN A stated she did not recall that Resident #1 ever had emesis of a brownish or coffee ground color as stated by CNA D . She stated it was always the color of the tube feeding. She stated Resident #1 had physician orders for her pump to be off for 4 hours each day . She reviewed her nursing progress notes and the MAR for the month of December during the interview and stated she did turn the pump off on 12/24/24 on the 6 AM -2 PM shift and also held her medications due to nausea and vomiting. She stated she did not notify the physician on 12/24/2024. In an Interview on 01/08/25 at 3:30 PM1/8/ , LVN C stated she took care of Resident #1 during the time period of 12/21/24 to 12/30/24. She stated she had turned the feeding pump off several times during that time period due to the resident's nausea, vomiting and diarrhea. She stated she did not notify the physician of the resident's condition. She stated she gave the resident Zofran for nausea through the g-tube like everyone else did. She stated, I just never thought about calling the doctor to notify him the resident was not getting better. In an interview with LVN B on 01/08/2025at 3:00 PM, she stated she worked on 12/27/2024 thru 12/29/2024. She stated she stopped Resident #1's pump, and held her medications due to nausea on 12/27/2024. She stated she did not notify the physician. She stated she did not think of notifying the physician. She stated she thought he knew because she had the Zofran ordered for nausea. Interview with the DON on 01/03/2025 at 1:15 PM, she stated she was responsible for monitoring and providing oversight for the Nursing staff of the facility. She stated she was responsible for providing in-services to the staff. She stated she was not aware of Resident #1 having had diarrhea with nausea and vomiting which continued over the course of 8 days from 12/22/2024 to 12/30/2024. She stated her expectation was that staff would notify the resident's physician, POA, or responsible party of any change of condition in a resident. She stated she would have expected a nurse to recognize the symptoms and report the changes. She stated there was a 24-hour communication book that nurses could communicate changes of condition to other shifts. She stated she had looked in the nurses' notes from 12/21/2024 - 12/30/2024 the day of transfer, and she only saw the one notification to the family which was at the time of the transfer. She stated she would have expected them to do an Interact form which should have been done to gather and communicate assessment findings . She stated the nurses were supposed to do an Interact form with a condition change which would assist in cueing the nurse to notify the physician and send them to the hospital. She stated she saw no documentation of that occurring. Review of the 24hour communication book revealed no documentation that the physician had been notified of the condition change or that feedings were held. In an interview with the Administrator on 01/06/2025 at 11:35 AM, he stated his expectations were for the nurse to have reported Resident #1's condition change to the RP and the physician. He stated it was important for facility nursing staff to notify the doctor of any change of condition that required holding of a resident's feedings and of her condition change and continued nausea and vomiting. He stated that he would have intervened sooner if he had known. In an interview with the Administrator at 9:50 AM on 1/13/25, the Administrator stated he was not aware of the situation with Resident #1 until it was brought to his attention by the surveyor. He stated he felt like it was poor nursing care. In an interview with DON on 1/13/2025 at 9:45 AM, she stated that she wanted to let me know that she had suspended LVN C on the 10:00 PM to 6:00 AM shift . She stated that the nurse should have completed an interact form and notified the physician if Resident #1 was unable to tolerate the prescribed tube feeding due to nausea and vomiting. She stated she felt like it was poor nursing care, and she suspended LVN C to investigate the circumstances. She stated she would have notified the physician if she had been the nurse during that shift. She stated she would not want her family treated in that manner. She stated the nurses that worked during that time period should have contacted the physician. She stated turning off the feeding pump could result in dehydration and malnutrition. She stated the physician, the dietician or somebody should have been contacted. She stated LVN A had also quit. She stated Dr W talked to her after talking with the surveyor and he stated that he was not notified and would have expected the nursing staff to notify him of the continued nausea and vomiting and that the feedings were held. He stated he would have intervened sooner. In an interview on 01/13/2025 at 9:15 AM, Resident # 1's POA stated Resident #1 transferred to another SNF on 01/09/2025. She stated she was still concerned with the lack of care she received from 12/22/2024 to 12/30/2024. She stated she felt they almost let her die. Record review of the facility's staffing sheets, provided by the DON, reflected: LVN A worked day shift 6:00 AM to 2:00 PM 500 hall on 12/23/2024, 12/24/2024, 12/25/2024, 12/26/2024, 12/30/24 LVN B worked 6:00 AM to 10:00 PM 500 hall on 12/27/2024, 12/28/2024, and on 12/29/2024 LVN C worked night shift 10:00 PM to 6:00 AM 500 hall on 12/24/2024, 12/25/2024, 12/26/2024, and 12/29/2024 LVN F worked evening shift on 12/25/2024, and 12/26/2024 CNA D worked 6:00 AM to 2:00 PM on 12/23/2024, 12/24/2024, 12/26/2024, and 12/30/2024 CNA E worked 6:00 AM to 2:00 PM on 12/23/2024, 12/4/2024, 12/25/2024, 12/26/2024, 12/27/2024, and 12/30/2024. Record review of the facility's policy, Change In a Resident's Condition or Status dated revised May of 2017, reflected in part: Our facility shall promptly notify the resident, his or her attending physician or Nurse Practitioner and the resident representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the physician or nurse practitioner or the physician on call when there has been an accident or incident involving the resident, discovery of injuries of an unknown source, adverse reaction to medication, significant change in the resident's physical/emotional/mental condition, a need to alter the resident's treatment significantly, refusal of medications or treatment 2 or more consecutive times, need to transfer the resident to a hospital, specific instruction to notify the physician of a change in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. Impacts more than 1 area of a resident's health, requires interdisciplinary review and/or revision to the care plan. This was determined to be an Immediate Jeopardy (IJ) on 01/29/2025 at 4:20 PM. The Administrator and Clinical Compliance Director were notified. The Administrator, DON, and the CCD were provided with the IJ template on 01/29/2025 at 4:20 PM and a POR was requested. The following Plan of Removal submitted by the facility was accepted on 01/30/2025 at 10:56 PM POR F580 - Notify of Changes (Injury/Decline/Room, Etc.) Resident #1 was sent to Hospital on 12/30/24. On 1/3/25 due to HHSC entrance of the facility that there was a complaint of resident #1. Facility began to review any other residents with G-tubes no other residents with a G-tube remains in the facility and/or changes in condition, that would result with any required changes of condition and physician notification. oThe Charge nurses reviewed for any other changes of condition, and none were identified on 1/3/25 by oversight from the DON. The underlying cause is the facility failed to ensure the Physician was notified when a resident experienced a change in condition. All residents could have been affected by this alleged deficient practice. oOn 1/3/2025 - Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON, (The policy was reviewed, and verbal comprehension was acknowledged via Q&A and discussion with return demonstration of Situation Background Assessment Recommendations). oIn-services were initiated by the Director of Nursing/Quality Improvement Nurse on 1/6/2025 to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract (Situation, Background, Assessment and Recommendations to enhance the communication information among team members). Completed on 1/30/2025. oOn 1/6/2025 Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed. Completed 1/6/2025 [NAME] alter the process or system failure the Stop and Watch (early warning communication tool to alert a nurse or manager if they notice something different in a person's daily care routine) was initiated, training and education started to the certified nurses' aides utilizing the alert system on 1/8/25. (Verbal instruction and application along with monitoring of use to ensure understanding and compliance of the communication system) completion date 1/30/2025. oThe SBAR/eInteract is being monitored in the clinical morning startup daily by DON/ADON/Designee. oOversight will be provided by the Administrator/DON/Designee oOn 1/6/25 LVN A resigned and then called in on 1/9, 1/10, 1/13 resignation was accepted immediately. oOn 1/13/25 LVN B resigned with resignation accepted immediately oOn 1/5/25 - LVN C was terminated. oOn 1/17/25 - LVN A, LVN B and LVN C license was referred to the Texas Board of Nursing for further review. Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition. Oversite of the testing will be managed by DON/ADON. (Initiated: 1/30/25) To ensure understanding. This test will be given to new nurses hired during orientation and yearly with competencies. Completion date 1/30/2025. oChange of condition will be reported from shift to shift up to nurse management by utilizing the SBAR/eInteract process and 24-hour report tool and reviewed daily in clinical start-up with oversite provided by DON/ADON/Designee. DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off, daily at morning clinical start up. This will be with the oversight of the administrator. Discrepancies will be addressed immediately with root-cause analysis and brought to QAPI with the oversite with the Medical Director monthly for six months. Administrator/DON/Designee will review and ensure that understanding comprehension of the protocol. [Facility ] Medical Director notified of IJ (01/29/2025) [Facility] Monitoring of the POR Included the following: Verification of POC. 1/31/25 at 9:30 AM with DON present. Reviewed on 01/31/2025 at 9:39 am - Completed. Reviewed 01/31/2025 at 9:43 am - Completed. Reviewed 01/31/2025 at 9:50 am. Completed. On-going 3 staff left, cannot work until in-service completed. oOn 1/06/2025 LVN A resigned and then called in on 01/9, 01/10, 01/13 resignation was accepted immediately. oOn 01/13/2025 LVN B resigned with resignation accepted immediately oOn 01/05/2025 - LVN C was terminated. oOn 1/17/2025 - LVN's A, B, and C license was referred to the Texas Board of Nursing for further review. Reviewed the employee files of Nurses A, B, and C with the documentation of the disciplinary actions taken with the DON 01/31/2025 at 9:56 am. Completed. Reviewed the inservice sheet and the employee list provided by the facility with the D atat 1/31/25 at 9:57 am. The inservice efforts are on-going required for agency and new staff before they are allowed to work All nurses employed at the facility with the exception of 2 nurses on the staff list had completed the inservices. They cannot work until completed. This information stating they should not clock in before they had received the inservice and taken the competency based test. was posted on time clock by the DON. Reviewed letter of notification of Immediate Jeopardy Signed by Medical Director on 01/20/2025. Reviewed signed document with DON. Interview Verification: , On 01/30/2025 at In interviews from 2PM 12:30 AM with LVN G, Charge Nurse (6 AM-2 PM) LVN H (6 AM-2 PM) shift, LVN F(2 PM-10 PM) shift, LVN I (2 PM-10 PM) shift, CMA FF (6 Am -6 PM) shift, LVN K, (6 AM-2PM) shift, LVN L (2 PM -10 PM) shift LVN M PRN, LVN N Agency, CNA D (6am-6pm) shift, LVN O (2 PM - 10 PM) shift, CNA Q (2 PM-10 PM) shift, Agency CNA R. (2 PM - 10 PM) shift, LVN S (6 am - 2 pm )shift, LVN T (10pm-6am) shift, . LVN GG (10 AM-6 PM), RN U (10 PM- 6 AM) shift, CNA V (10 PM -6 AM) shift, CNA X (2 PM- 6 AM) shift, LVN Z (10 PM-6 AM), CNA AA, CNA CC (10am-6pm) shift, and LVN BB (10 AM-6 PM) shft all stated a change of condition was anything that is outside of resident's normal state. They stated Information can come from a CNA, Therapy, other staff and should be reported to the charge nurse immediately, who in turn should notify the physician. They stated the eInteract (SBAR) should be used to assess the resident for a change in condition because it was very specific to conditions. They were all able to demonstrate how to fill out the e-interact form, and a provided sample. They stated it would be passed on in shift report and documented on the communication sheet for each hall and the SBAR form would stay open in the electronic medical record until the physician was notified. They stated nurses go in for morning report, with management to go over any change that has occurred or new orders on a physician. They stated the inservice was held on, 01/30/2025 for e-interac (SBAR) The Inservice was mandatory. A competency based test was given to each staff member over the information in the Inservice after the inservice . Record review of In-service, Notification of Change in Condition, conducted by CCN, Admin and DON included facility definition, purpose, process for provider notification as it related to all changes or decline in condition are required to be reported to the attending physician by utilizing the facility sanctioned communication documents. Record review of In-service titled, SBAR, conducted by Corporate Nurse, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included. In interview with the Administrator on 01/31/2025 at 9:50 AM , he stated failure to report a change a change in condition to the resident's nurse could be considered neglect. He stated Immediate notification to a provider for any resident change in condition was important. He Knew what a change in condition was and was able to state signs and symptoms that would indicate a condition change such as change in LOC and the signs and symptoms his staff should be monitoring for infection such as fever, increased behaviors or confusion etc He further stated what and where his staff should be documenting any change in condition in the electronic medical record (EMR) and the other parties that should be notified in addition to the provider. He sufficiently defined abuse, neglect, and/or exploitation and the expectations of his staff to report any observed, reported, or suspected abuse, neglect, and/or exploitation to him immediately. In interview with the DON on 01/31/2024 at 10:00 AM, she sufficiently explained the importance of immediate notification to a provider for any resident change in condition in order to prevent further decline in health status. She sufficiently stated what would constitute a change in condition and the signs and symptoms her staff should be monitoring for infection. She further stated what and where her staff should be documenting any change in condition in the electronic medical record (EMR) and the other parties that should be notified in addition to the provider. She further stated all nurses were in-serviced and knowledgeable on facility's SBAR document and will utilize it for any change in condition. The Administrator, DON, ADO, and Corporate Nurse was informed the Immediate Jeopardy was removed on 01/31/2025 at 10:24 AM. The facility remained out of compliance at a severity level of actual harm with the potential for more than minimal harm that is not immediate and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems

Based on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident #2 and Resident #7) reviewed for infection control (incontinent Care). 1. The facility failed to ensure CNA J washed or sanitized her hands before and during incontinent care for Resident #2. 2. The facility failed to ensure CNA D washed or sanitized her hands before and during incontinent care for Resident #7 This deficient practice placed residents at risk for cross contamination and/or acquiring an infection. Findings include: 1. Review of Resident 2's Significant Change in Status MDS assessment dated [DATE] revealed Resident #2 was an [AGE] year-old female originally admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired with a BIMS score of 2. Resident #2 required maximum assistance with the staff providing over one half of the support of toileting. Resident #2 was always incontinent of bladder and occasionally incontinent of bowel. Review of Resident #2' s Face sheet included the following diagnoses: dementia with behavioral disturbance, urinary tract infection with an onset date of 01/08/2025, diarrhea with an onset date of 01/06/2025 Review of the Care Plan dated revised on 01/04/2025 for Resident #2 revealed the following focus: resident has bowel and bladder incontinence and interventions: check every 2 hours and wash and dry peri area as necessary for incontinent episodes. Report and document for signs and symptoms of UTI pain, burning, blood-tinged urine, deepening of urine color or foul-smelling urine. During an observation and interview on 01/07/2025 at 1:15 PM, CNA J provided incontinent care to Resident #2. CNA J entered Resident #2's room, but did not wash her hands before applying gloves. She donned a gown which was due to the resident requiring contact precautions. The gown was improperly donned . The front of the gown hanging down off of her shoulders in the front and not tied in the back leaving her upper back and the backs of her legs exposed. She used one pair of gloves throughout the entire procedure while cleaning the front and the back of Resident #2's perineum. She removed the urine soiled brief and placed a clean brief on the resident, wearing the same gloves that she used to clean the resident's perineal area. She then removed the gloves and saw there was no hand sanitizer in the room. She stated she just realized the resident's room did not have a sink to wash her hands. She then shrugged her shoulders and disposed of the gloves and soiled linen in the trash and left the room. She stated she had an in-service on infection control during her orientation and was competency checked. She stated she had been employed at the facility for 2 months. When asked if she would have done anything differently during the procedure she replied I'm not worried about itand walked away. 2. Review of Resident #7's quarterly MDS dated [DATE] revealed Resident #7 was a [AGE] year-old female originally admitted to the facility on [DATE]. Her cognitive skills for daily decision making were moderately impaired with a BIMS score of 11. Resident #2 required maximum assistance with the staff providing over one half of the support of toileting. Resident #2 was always incontinent of bladder and bowel. Review of Resident #7s Face sheet included the following diagnoses: Muscle wasting and atrophy, Huntington's Disease ( a progressive inherited neurologic disease that causes involuntary body movements, memory problems and damages the brain cells), and hypertension (high blood pressure). Review of the Care Plan dated revised on 08/22/2024 for Resident #7 revealed the following focus: resident has bowel and bladder incontinence and interventions: check every 2 hours and wash and dry peri area as necessary for incontinent episodes. Report and document for signs and symptoms of UTI pain, burning, blood-tinged urine, deepening of urine color or foul-smelling urine. During an observation on 01/07/2025 at 1:45 PM, CNA D provided incontinent care to Resident #7 using the proper technique for cleaning the perineal area. CNA D did not remove and change her gloves, and sanitize her hands before touching the clean brief after she removed, and disposed of the urine soiled brief. She washed her hand before leaving the room. In an interview at 1:50 PM on 01/07/2025, CNA D stated she did not sanitize her hands and change her gloves before touching the clean brief that she applied to Resident #7 . She stated the failure to sanitize and change gloves could result in the spread of infection. She stated the reason she made a mistake was because she was so nervous. 3. During an interview on 01/07/2025 at 2:30 PM, the DON stated she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when performing incontinent care, and that all staff had been trained on this procedure. She stated she did not know why CNAs J and D failed to perform hand hygiene at the appropriate time. She stated all staff had been instructed on hand washing and infection control. She stated she did competency checks on all CNAs yearly and CNAs J and D had passed a competency check. She revealed that she would do additional in-service training with staff regarding Infection Control and Incontinent Care. She stated the failure to perform hand hygiene during resident care placed the residents at risk for infection. During an interview on 02/07/2025 at 2:25 PM , CNA D stated she normally washed her hands after completing incontinent care and changed her gloves when moving from a dirty area to the clean area. She stated that she was just nervous and didn't remember with the surveyor watching. She stated that she had been trained and checked off on incontinent care by the ADON. Review of the facility's policy titled Perineal Care, revised October 2010, revealed the following elements in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .Steps in the procedure . 2. Wash and dry your hands thoroughly. 6. Put on gloves. 9. Remove gloves and discard into designated container. 10. Wash and dry hands thoroughly. 14. Wash and dry hands thoroughly . Review of the facility's policy titled Handwashing/Hand Hygiene dated December 22, 2023, revealed the following elements in part: The facility considers hand hygiene the primary means to prevent the spread of infection. Use an alcohol-based hand rub containing at least 65 % alcohol, or alternatively soap and water: before going from a contaminated body site to a clean site, after contact with a resident's intact skin, after removing gloves.e.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 2 resident nourishment rooms, in that: 1. Knife blades and serving utensils were stored on a rack and suspended in the air with their sanitized food surfaces exposed to contaminants in the air. 2. Appliances and equipment were soiled with grease and food. 3. A cardboard case with diced potatoes was stored on the floor in the walk-in freezer. 4. The ice scoop was placed on top of the ice inside the ice machine. 5. The dishwasher recorded the water temperature and sanitizer level for the low temperature dish machine on the daily dish machine log prior to running the dish machine for two meals on 8/20/24. 6. The refrigerator-freezer in the secured unit resident nourishment room was observed on 8/20/24. The refrigerator did not have an interior thermometer and resident food was not dated. The freezer compartment door gasket was loose. These failures placed the residents at risk for foodborne illness and a decline in health status. The findings included: Observations on 8/20/24 at 7:04 AM during the initial tour of the facility kitchen revealed the following: - Knives with their blades on a magnetic strip and serving utensils (whisk, spoons, scoops, tongs) were hanging from a metal frame above the food preparation counter in the middle of the room. The sanitized food surface of the utensils were exposed to potential contaminants in the air from the ceiling air duct vent near the frame. - A Cambro warmer cart was plugged into an electrical outlet and used to keep food warm. The top exterior surface was greasy and sticky to touch. - A manual can opener was mounted to the end of a stainless steel counter. The food contact surface was soiled with a dried red colored substance. - The deep fryer unit contained dark colored cooking oil; the fryer baskets were in holders and had fried food and breading crumbs stuck to them; fried food crumbs were on interior surface of the deep fryer unit. - The walk-in freezer unit had a cardboard box containing diced potatoes stored directly on the floor of the walk-in freezer; a large plastic resealable bag containing what appeared to be boneless/skinless chicken breasts was not labeled/dated. - The ice scoop was inside the ice machine and was laying on top of the ice. A holder for the ice scoop was on a counter to the side of the ice machine. During an interview and record review on 8/20/24 at 7:42 AM, Dishwasher A stated the dish machine was a low temperature machine with sanitizer. He stated the water temperature and sanitizer were checked every meal 3 times daily. He stated he would check the water temperature and sanitizer level before starting to wash dishes after breakfast that morning. Dishwasher A stated the water temperature and sanitizer were documented on a daily dish machine log. A dish machine log was not observed in the dish machine room. Dishwasher A stated it was kept in a notebook binder in a cabinet in the kitchen. Dishwasher A walked to a cabinet, located outside the Dietary Manager's office, and he opened the doors and pulled out a red notebook binder used for the dish machine log. The form was dated August 2024 and documented the dish machine water temperature and chlorine sanitizer daily. The water temperature was documented at 120 degrees F and the chlorine sanitizer was documented at 100 ppm for 8/20/24 at 8:00 AM and 8/20/24 at 12:00 PM. Dishwasher A stated he had not yet run the dish machine and had not checked the water temperature and chlorine sanitizer today, but he would after breakfast and after lunch. He stated he wrote down the water temperature and sanitizer ppm in advance because he would get busy later and might forget to write down the temperatures and sanitizer levels. Observation on 8/20/24 at 4:57 PM revealed the Memory Care Nourishment Room had a residential style refrigerator/freezer unit. The gasket around the top freezer compartment door was loose and hanging down. There were small icicles hanging down from the top interior surface of the freezer. The lower refrigerator compartment did not have a thermometer dial and a thermometer was not located inside the refrigerator. The refrigerator compartment contained undated food containers with residents' names. During an observation and interview on 8/20/24 at 5:05 PM, LVN B entered the Memory Care Nourishment Room. She opened the top freezer compartment and saw the loose gasket. The LVN stated she would write a note in the Maintenance book regarding the freezer gasket being loose. She looked for a thermometer inside the refrigerator and did not find one. She opened the top freezer compartment and stated there were two thermometers in the freezer and one needed to be in the refrigerator. She removed one thermometer from the freezer compartment and placed it inside the refrigerator. The LVN stated there needed to be a cleaning schedule for the refrigerator. She proceeded to remove and throw away a few food items. In an interview on 8/21/24 at 4:40 PM, the Dietary Manager stated she had a family situation the prior day (8/20/24) and was not able to be at work. The findings from the initial tour of the kitchen on 8/20/24 were discussed with the Dietary Manager. She stated she would need to do inservice training with the dietary staff. She stated she would provide policies and procedures for kitchen sanitation and the low temperature dish machine operation. She stated the nourishment room refrigerator was the responsibility of the housekeeping department. In an interview on 8/22/24 at 9:56 AM, the Registered Dietician Consultant stated inservice training would be done with the dishwashers regarding temperatures. She stated the utensils were being removed from the halo utensil rack above the island shelf unit and going into bins. The Registered Dietician Consultant stated she had been at the facility the night before the survey (8/19/24) and everything was just fine in the kitchen. In an interview on 8/22/24 at 10:46 AM, the Registered Dietician Consultant provided copies of the policy and procedure for kitchen sanitation and cleaning. She stated the nursing department was responsible for the nourishment room and they may have a policy and procedure for refrigerators and resident food storage. In an interview on 8/22/24 at 11:19 AM, the ADON for the secure unit stated she would look for a policy and procedure for maintaining temperatures in the refrigerator in the nourishment room. She stated the nursing staff monitored the thermometer. The ADON stated she had the gasket on the freezer compartment door repaired in the secured unit. Review of the facility's policy and procedure for Foods Brought by Family/Visitors, dated as revised July 2017, reflected [in part]: Policy Statement Food brought to the facility by visitors and family is permitted . Policy Interpretation and Implementation . 4. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Perishable foods must be stored in containers with lids in a refrigerator. Containers will be labeled with the use by date (usually 3 days after the food was prepared or purchased). Review of the facility's policy and procedure for Refrigerators and Freezers, dated as revised December 2014, reflected [in part]: Policy Statement This facility will ensure safe refrigeration and freezer maintenance, temperatures, and sanitation, and will observe food expiration dates. Policy Interpretation and Implementation 1. Acceptable temperature ranges are 35 degrees F to 40 degrees F for refrigerators and less than 0 (zero) degrees for freezers 7. All food shall be appropriately dated Use by dates will be completed with expiration dates on all prepared food in refrigerators . 9. Supervisors will inspect refrigerators and freezer monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed . The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 20 residents (Residents #26 and #61) reviewed for comprehensive care plans. 1. Resident #26 had orders for the antipsychotic medication Seroquel and the mood stabilizing medication Nuedexta. The medications were not included in the resident's comprehensive care plan. 2. Resident #61 received an order dated 6/11/24 to be admitted to hospice care services with a diagnosis of Alzheimer's disease. A significant change MDS assessment dated [DATE] was completed due to the resident being admitted to hospice care services. The resident's comprehensive care plan did not address the hospice care services. These failures placed the residents at risk for not receiving necessary care and services to meet their individual needs and to promote a feeling of wellbeing during daily life within their living environment. The findings included: 1. Review of Resident #26's Admission Record, dated 8/21/2024, reflected an [AGE] year-old male initially admitted to the facility on [DATE]. The resident's diagnoses included: unspecified dementia; anxiety disorder; major depressive disorder, recurrent; bipolar disorder (a mental health condition that causes extreme mood swings); psychotic disorder with delusions; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); insomnia; post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event with symptoms including flashbacks, nightmares, or severe anxiety); and delusional disorder. Review of Resident #26's active medication orders reflected the following: - Nuedexta Oral Capsule 20-10 mg - give 1 capsule by mouth two times a day related to pseudobulbar affect, with an order date of 7/10/24. - Seroquel Tablet - give 200 mg by mouth in the morning for psychotic disorder with delusions, with an order date of 8/15/24. - Seroquel Tablet - give 200 mg by mouth at bedtime for psychotic disorder with delusions, with an order date of 8/15/24. Review of Resident #26's Quarterly MDS Assessment, dated 8/07/24, reflected the resident had received antipsychotic medication. Review of Resident #26's comprehensive care plan, dated 6/18/24, reflected it addressed the use of psychotropic medication, with the approach to administer psychotropic medications as ordered by the physician. The care plan did not specify the antipsychotic medication of Seroquel or the indication for use. The comprehensive care plan did not address mood state, mental health services, and the administration of Nuedexta for mood stabilization. In an interview on 8/22/24 at 4:07 PM, the ADON for the secure unit stated Resident #26 had received psychiatric/mental health services since he was admitted to the facility during 2014. She stated the resident had a lot of anger when he first came and was doing much better now. The ADON stated he had been seen by the psychiatrist and the nurse practitioner. She stated Resident #26 had received counseling services, and now was mostly seen for evaluation of medication and medication management by the psychiatric practitioner. During an interview and record review on 8/22/24 at 5:33 PM, MDS Coordinator #1 reviewed Resident 26's care plan dated 6/18/24 and stated usually she would be a lot more specific and would include the category of antipsychotic medication and the indication for use. She stated the resident's care plan was done by a traveling nurse for the company and was completed before she started employment in the facility on 5/20/24. 2. Review of Resident #61's Admission Record, dated 8/21/2024, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident's diagnoses included: Alzheimer's disease; anxiety; depressive disorder; insomnia; and pain. Review of Resident #61's active physician orders reflected an order dated 6/11/24 to admit to hospice with the diagnosis of Alzheimer's disease. Review of Resident #61's Significant Change of Condition MDS Assessment, dated 6/23/24, reflected the resident received hospice care. Review of Resident #61's comprehensive care plan, dated 7/19/24, reflected it addressed his terminal condition related to Alzheimer's disease. The care plan did not address the resident's admission to hospice care services. In an interview and record review on 8/22/24 at 12:48 PM, the ADON stated if a resident was receiving hospice care services it should be included in the care plan. She reviewed Resident #61's care plan and stated she did not see a care plan for Hospice services. The ADON stated the Hospice nurse's attendance during the care plan conference would be documented in the progress notes. The ADON reviewed Resident #26's progress notes and stated she did not find documented evidence of the care plan conference in the progress notes. Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered, dated as revised December 2016, reflected the following [in part]: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed for each resident. Policy Interpretation and Implementation 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 3. The IDT includes: f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident. 8. The comprehensive person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 (Resident #18) of 8 residents reviewed for infection control, in that: On 08/20/2024 at 07:36 AM the facility failed to ensure nurse put on proper personal protective equipment for resident on isolation precautions including gown, gloves, and mask while providing care to resident. Facility also failed to ensure that staff used proper hand hygiene. This failure could affect residents and place them at risk for cross contamination and infections. The findings included: Record review of Resident #18's Face Sheet dated, 08/20/2024, indicated a [AGE] year-old female admitted to the facility initially on 06/06/2024. Her diagnoses included: Enterocolitis due to clostridium difficile (stomach cramping and diarrhea due to a germ), Parkinson's Disease (nervous system disease), dehydration (not enough water and fluids in body). Record review of Resident #18's active physician orders dated included an order dated 8/11/2024 at 1:48 PM which stated: Isolation precautions for 3 months (84 days) for Sepsis, C-Diff (clostridium difficile). Record review of Resident #18's comprehensive person-centered care plan reflected a initiated date of 06/06/2024 reflected Focus: Resident #18 is on isolation - strict single room strict contact isolation related to C. Diff (clostridium difficile). Goal: Will remain in isolation until no longer contagious to others. Interventions: provide proper protective equipment. During an observation on 08/20/2024 at 07:36 AM of Resident #18's room who had Isolation Precautions sign noted on door and donning station outside room. Station to remove personal protective equipment noted inside room. LVN C was in Resident # 18 room giving medications. LVN C does not have on PPE on. LVN C exited room, walked to gel hand sanitizing station. In an interview with LVN C on 8/20/2024 at 7:39 AM regarding isolation precaution posting, LVN C stated she (Resident #18) was on isolation precautions for C-Diff (clostridium difficile), she takes vancomycin and I forgot to put on my gown and stuff. When asked about hand hygiene regarding C-Diff (clostridium difficile), LVN C then stated that she would go back into room after talking and wash her hands soap and water. LVN C further stated that you must wash your hands with soap and water because hand gel was not effective on C-Diff (clostridium difficile). In an interview on 08/20/2024 at 11:38 AM with ADON, who stated regarding residents with diagnosis of C-Diff (clostridium difficile) with C-Diff (clostridium difficile) you have to use soap and water for hand hygiene, you can't use alcohol gel. The proper PPE was gown and gloves, you can wear goggles if you want. It's contact isolation. It is effective every time you go in the room. ADON further stated when not following proper contact precautions infection transmitted to myself or throughout the building. In an interview on 8/20/2024 at 12:05 PM regarding expectation for infection control and residents with C-Diff (clostridium difficile), DON stated Residents would be on Isolation precautions, I think they should use all of those precautions which include, a gown, gloves and mask. DON further stated they need to use soap and water for hand hygiene. DON stated that an adverse outcome of not following proper infection control it could contaminate others. In an interview on 08/22/24 at 11:54 AM with Director of Operations regarding expectation of infection control specifically regarding isolation precautions and C-Diff (clostridium difficile). Director of Operations stated my expectation is to wear proper PPE and follow policy. When asked by regarding expectation of hand hygiene regarding resident with C-diff (clostridium difficile), Director of Operations stated to follow proper hand washing techniques. Director of Operations further stated, I can't really speculate on that. Regarding possible negative outcome for not following proper policy and procedure regarding infection control technique. Record review of the facility policy and procedure for Implementation of Standard of Transmission-Based Precautions reflected the following [in-part]: 2. Contact Precautions: are used with a known infection that is spread by direct or indirect contact with the resident or the resident's environment. Record review of the facility policy Infection Prevent and Control Program revealed the following [in-part]: Policy Statement: 2. The elements of the infection prevention and control program consist of coordination/oversight .outbreak management, prevention of infection. 6. Outbreak Management: (3) preventing spread to other residents; 7. Prevention of Infection: (6) implementing appropriate isolation precautions when necessary; and (7) following established general disease-specific guidelines such as those of the Centers for Disease Control (CDC) Review of website https://www.cdc.gov/c-diff/hcp/clinical-guidance on 3/8/24, reflected the following: Isolate and initiate contact precautions for suspected or confirmed Clostridioides (formerly known as Clostridium) difficile infection (CDI).

Based on observation, interview, and record review, the facility failed to obtain informed consents for bed rails, prior to installation, for 1 (Resident (R#49) of 8 residents reviewed for bed rails, in that: The facility did not have consent or orders for the use of bed rails for Resident #49. This failure could put residents at risk for injuries or entrapment. The findings included: Record review of R#49's Admission Record, dated 8/20/2024, revealed R#49 was a [AGE] year-old female who was admitted to the facility on [DATE]. R#49's diagnoses included Acute Respiratory Failure, Lack of Coordination, Muscle wasting, Muscle Weakness, Unspecified Dementia, and History of falling. Review of the Physician's Orders for R#49 dated 08/20/2024 reflected there was no orders for the use of bed rails. Record review of R#49's electronic health record from 02/14/2024 through 08/20/2024 reflected no informed consent for the use of bed rails. Record review of R#49's care plan last revised 08/19/2024 revealed: no record regarding use of bed rails. Record review of Incident and Accident Tracking logs for 06/01/2024 through 08/20/2024 revealed Resident #49 has falls dated: 7/2/2024, 7/10/2024, 7/11/2024 and 7/23/2024. In an observation on 08/20/2024 at 08:15 AM revealed R#49's bed rails up on both sides of the bed. Resident was in dining hall. In an observation on 8/22/2024 at 09:30 AM Resident #49 was in room, up in recliner and side rails were up on head of bed. Resident was not interviewable. In an interview on 08/22/2024 at 8:55 AM ADON said Resident #49 had poor safety awareness. In an interview on 08/22/2024 at 11:22 AM with DON, said Resident # 49 had no side rail assessment found. DON said her expectations were that an assessment for side rails would be done and they should be done quarterly for each resident. DON said the negative outcome could be entrapment for a resident. In a record review of Facility Policy for Proper Use of Side Rails dated 1/16/2024 reflected: (Level II) Under: Purpose in part: the safe use of rails. Under General Guidelines reflected in part: 3. Upon admission, readmission, with quarterly or significant change therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: A. Bed Mobility C. Risk of entrapment from the use of side rails 4. Consent for use of side rail will be obtained from Resident or legal representative, after presenting potential benefits and risks using the Informed Consent for use of bed rails. 10. The resident will be checked at least every shift for safety and proper functioning of the side rail use.

Based on observation, interview and record review, the facility failed to coordinate the assessment for one of four residents (Resident #74) with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR evaluations. The facility did not identify Resident #74 as having a mental illness with a with diagnoses of Paranoid schizophrenia, bipolar disorder and dementia that would require a PASRR 1012 form or a new PL1 form to initiate a PASSR evaluation by the local intellectual and developmental disability authorities. This failure could affect residents with mental illness who may not be evaluated for PASRR services and place them at risk of not receiving services needed for care and treatment. The findings included: Review of Resident #74s Face Sheet and Orders dated 08/21/2024 reflected she a was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #74's diagnoses included: dementia with behavioral disturbance (impaired though processes that affect the ability to function independently) onset date 07/03/2023, mood disturbance (altered mood) onset date 11/30/2023, paranoid schizophrenia ( a mental disorder that causes suspicion, fear and distrust of others accompanied by a belief in things that are not real) onset date 07/03/2023, and bipolar disorder ( an alteration in mood that is characterized by extreme and inappropriate highs and lows) onset date 07/03/2023. Review of Resident #74's active Physician Orders dated 08/21/2024, reflected an order for Lamictal (a mood stabilizer) 50 mg by mouth at bedtime for a diagnosis of bipolar disorder, and Seroquel 25 mg at bedtime (an antipsychotic medication) for paranoid schizophrenia. Review of Resident 74's Quarterly Minimum Data Set (MDS dated [DATE], reflected Resident #74 could usually understand others and was usually understood by others; had a moderate cognitive impairment with a BIMS (Brief Interview for Mental Status) score of 6 severe cognitive impairment. No mood or behavior concerns were documented. Review of Resident #74's Care Plan dated revised 07/11/2024 reflected the following: Focus: The resident uses psychotropic medications - Seroquel for diagnosis of Paranoid Schizophrenia Goal: The resident will be/remain free of drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through review date. Review of Resident #74's PASRR Level One Screening Form dated 07/03/2023 completed by the transferring facility reflected Resident #74 had no diagnosis of mental illness, intellectual disability, or developmental disability. Review of Resident #74's PL 1 form dated 7/3/24 which was viewed in Resident 74's electronic records and the long-term care portal. These records reflected there was not a 1012 form or a new PL1 completed. An interview on 08/21/2024 at 6:10 PM with MDS Coordinator #1 who stated that the resident #74 should have a yes for mental illness documented on his PL1 form in section C. She stated she had forty years' experience as an MDS Coordinator but had just been at this facility for about three months. She stated she and MDS Coordinator #2 were both hired at the same time. She stated she asked MDS Nurse Coordinator #2 to complete a Form 1012 or a new PL1 for Resident #74 but did not check to ensure to that it was done correctly. Stated she had been given the responsibility of monitoring the forms for accuracy. She stated she had been in the process of doing an audit to check diagnoses on all residents. In an interview on 08/21/24 at 6:16 PM, MDS Coordinator #2 stated she completed a 1012 form and had the physician sign it, but she did not check to see that a New PL1 should have been completed instead. In an interview on 8/21/24 at 2:30 PM the Regional Clinical Reimbursement Specialist stated she reviewed Simple LTC, diagnosis and dates of onset and PL1 dated 7/3/23. She said Section C on the PL1 was not coded correctly for Mental Illness and stated the Schizophrenia diagnosis dated 7/3/23 and Bipolar diagnosis dated 07/03/23 would make Resident #74 positive for Mental Illness. She also stated the administrator, or the DON should monitor to see that diagnosis are monitored for changes that would affect PASRR eligibility. She stated the failure occurred because of the prior MDS Nurses failing to monitor diagnosis routinely. Review of the facilities policy and procedures titled: Preadmission screening for MI dated 04/26//2016 reflected the following in part: The intent of the management group is to meet and abide by all state and federal regulations that pertain to resident preadmission and screening resident review rules (PASRR). The intent of the guideline is to identify residents with Mental Illness Intellectual Disability or Developmental Disability. And to ensure they are properly placed, whether in the community or in a Nursing facility and to ensure they receive the services they require for their MI or ID/DD The social worker or designee will input the PL1 into the long-term care portal. If the PE is positive the social worker or designee will notify the LIDDA or LMHA within two calendar days to schedule the IDT and initiate the PE process.

Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing (RN, LVN and CNA) staff directly responsible for resident care per shift daily. The daily nursing staffing information was posted on 08/20/2024 and 08/22/2024 but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs. The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual time worked per each shift daily. The findings included: In an observation on 08/20/2024 at 9:45 a.m. revealed the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an observation on 08/22/2024 at 10:00 a.m. revealed the facility's daily nursing posting failed to indicate the actual hours worked for each direct care staffing type. In an interview on 08/22/2024 at 3:00 pm the DON who stated she was not aware that the actual hours worked by licensed and unlicensed staff had to be posted until today when it was brought to her attention. She further stated the staffing was done daily by her ADON. In an interview on 08/22/2024 at 3:30 pm the ADON who stated she was responsible for the staffing and daily staffing posting and has never put the actual hours worked by licensed and unlicensed on the posting. In an interview on 08/22/2024 at 4:10 PM, the Administrator who stated his expectation was to follow policy and that the policy was not followed due to the total numbers of actual hours worked for RN's, LVN's and CNA's, and the census at beginning of each shift were not on the posting. He further stated that they would modify the form to include the requirement. Record review of the facility's policy Posting Direct Care Daily Staffing Numbers, dated 2001, reviewed July 2016 reflected the following [in part]: I. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, a d LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted 50133

Based on observation, interview and record review the facility failed to maintain clinical records that were complete and accurate for 1 of 3 (Resident #1) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing documentation related to wound treatments. The facility did not maintain accurate and current shower records. The facility did not maintain accurate and current bladder records. This failure could place residents at risk for inaccurate records. The findings were: Record review of Resident #1's face sheet dated 05/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #'1s Admission MDS dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section H- Bowel and bladder reflected resident was occasionally incontinent with bladder. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Record review of Resident #1's May 2024 TAR revealed the following wound care orders that were not completed on May 7, 2024: 1) Clean left lower abdominal fold with n/s, pat dry with gauze, cover with dry dressing one time a day. Start date of 05/05/2024. 2) Clean RLE with N/S, pat dry with gauze, place xero-form dressing over wound bed, and wrap with bandage one time a day. Start date 05/05/2024. 3) Clean coccyx with n/s, pat dry with gauze, lay anti-sept cream and collagen. Cover with bordered dressing one time a day. Start date 05/05/2024. Record review of Resident #1's daily Skilled Nursing Evaluation, dated 05/04/2024 revealed the following: Urostomy intact. Resident is always incontinent (no episodes of continent voiding). Record review of Resident #1's electronic record dated May 2024 did not show showers scheduled in their point of care. Record review of the facility's paper shower sheets for May 2024 revealed that Resident #1 was scheduled for showers on Tuesday, Thursday, and Saturday. Record review of the facility's individual paper shower sheets for May 2024, revealed that Resident #1 did have showers completed on the opposite days that were given on Monday, Wednesday, and Fridays. Interview on 05/22/2024 at 2:45 PM, The Wound Care Nurse stated that she did complete Resident #1's Wound Care on 05/07/2024, once she returned from wound care at 2:30 PM. She said that she had forgotten to document it in the electronic treatment record. She said this failure could result in inaccurate documentation. Interview on 05/22/2024 at 3:00 PM, the DON stated that upon her review there was electronic documentation reflecting the resident's showers being completed. She said that it should have been scheduled in the point of care records for the CNA's, but somehow it got missed. She said that it was scheduled on the paper sheets for Tuesday, Thursdays, and Saturdays, but that the resident was not there on those days due to dialysis. She said that they just did it on the other days and the CNA's put in on paper but did not ever document it electronically or notify her that it was not triggering or scheduled on their electronic documentation records. She said that the resident was occasionally incontinent but was never always incontinent. She stated that the Daily Skilled Evaluation from 05/04/2024 was inaccurate and not documented correctly. She stated that Resident #1 received wound care every day, and that the 05/07/2024 documentation that showed it was missed was inaccurate and incomplete documentation. She said that all nursing staff has been trained on documentation and following orders. She revealed that she was responsible for ensuring that documentation was entered and that she will be working with staff on this. She revealed this failure could result in inaccurate documentation. A record review of the facility's policy titled; Charting and Documentation dated 07/2017 revealed the following: All services provided to the resident, progress toward the care plan goals, or any changes in the residence medical, physical, functional, or psychosocial condition, shall be documented in the residence medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on interview and record review, the facility failed to develop and implement a base line care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of the resident's admission for 1 of 2 residents (Resident #1) whose records were reviewed in that: 1. Resident #1 did not have a Baseline Care Plan developed and implemented or reviewed by an RN following admission to the facility on [DATE]. This failure could place the residents at risk for not receiving care and services required to meet their individual needs from the date and time they were admitted to the facility. The findings included: Record review of Resident #1's face sheet dated 05/22/2024 revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #1's Admission MDS assessment dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Review of Resident #1's clinical record revealed a baseline care plan had not been completed within 48 hours following the resident's initial admission to the facility on [DATE]. In an Interview with the DON on 05/22/2024 at 3:00 PM, she stated the form titled Baseline care plan in the Resident's EMR's were not completed. She stated that she was responsible for delegating the task, but she was unsure who was assigned to complete it for Resident #1. She stated the failure could put residents at risk for not getting needed care. Review of the facility's policy and procedure titled Care Plans- Baseline dated - November 14,2023, revealed the following [in part]: Policy Statement A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. Policy Interpretation and Implementation 1) To assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the residence admission. 2) The interdisciplinary team will review the health care practitioner's orders and implement a baseline care plan to meet the residents immediate care needs including but not limited to: a. Initial goals based on admission orders. b. Physician orders. c. Dietary orders. d. Therapy services. e. Social services. 3) The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. 4) The resident and the representative will be provided a copy of the baseline care plan that includes but is not limited to: a. The initial goals of the resident. b. The summary of the residence medication and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility and, d. Any updated information based on the details of the comprehensive care plan, as necessary.

Based on interview and record review the facility failed to have assessments that accurately reflect the status of 1 of 2 residents (Resident #1) reviewed for resident assessments. Resident #1's Admission MDS assessment did not reflect her skin integrity issues, treatments and impairment in lower extremities accurately. This failure puts residents at risk of a decreased quality of care and not having their individualized needs met or communicated accurately to staff. Findings include: Record review of Resident #1's face sheet dated 05/22/2024, revealed a [AGE] year-old female admitted on [DATE] with the following diagnoses: Sepsis (infection in the bloodstream), cellulitis of right lower limb (bacterial skin infection on the right leg) and local infection of the skin and tissue. Record review of Resident #1's Admission MDS assessment dated [DATE] revealed the following: Section C- Cognitive patterns reflected the following: BIMS score of 13 which indicated the resident was cognitively intact. Section GG- Functional Abilities and Goals: Resident did not have an impairment with her lower extremities. Section M- Skin Conditions reflected the following skin conditions: Resident #1 had an Unstageable - Slough and/or eschar pressure wound that was present upon admission. Resident #1 did not have moisture associated skin damage. Resident #1 did not have treatments that reflected pressure reducing devices for chair. Record review of Resident #1's Initial skin assessment, dated 05/03/2024 revealed the following: Site 1) Lymphedema wound on the right, lower calf. Site 2) Stage 3 Pressure Wound Sacrum, full thickness. Site 3) Candidiasis rash of the abdomen, apply antifungal. Record review of Resident #1's Skilled Evaluation dated, dated 05/05/2024 revealed the resident had Lower extremity ROM: Impairment on both sides. Record review of Resident #1's treatment record for May 2024 revealed the following order: May have pressure reducing device in wheelchair as tolerated. Monitor for placement every shift -Start Date- 05/03/2024. Record review of Resident #1's May 2024 TAR revealed the following wound care orders: 1) Clean left lower abdominal fold with n/s, pat dry with gauze, cover with dry dressing one time a day. Start date of 05/05/2024. 2) Clean RLE with N/S, pat dry with gauze, place xero-form dressing over wound bed, and wrap with bandage one time a day. Start date 05/05/2024. 3) Clean coccyx with n/s, pat dry with gauze, lay anti-sept cream and collagen. Cover with bordered dressing one time a day. Start date 05/05/2024. Interview with the Wound Care Nurse on 05/22/2024 at 2:49 PM, revealed that Resident #1 did not have an unstageable pressure ulcer. She revealed that based on her observations since admission the resident had the following skin integrity issues: Stage 3 pressure ulcer on her sacrum, a lymphademic wound on her right lower extremity and a candidiasis rash of the abdomen that was moisture associated. She revealed that the resident was using a pressure reducing device while in her chair. She stated that the resident did have an impairment in her lower extremities. Interview with the DON on 05/22/2024 at 3:00 PM, revealed that she delegated the wound care to the Wound Care Nurse and that she had received all of her training. She revealed that the wound care interview and observations were correct for Resident #1. She stated that Resident #1 did not have an unstageable pressure ulcer while in the facility. She revealed that Resident #1 had a pressure reducing device while in her chair. She revealed that she had signed off on Section Z of the MDS assessment for completion, but she had not completed the MDS. She stated that the MDS nurse that had completed the MDS was unavailable for an interview since she was no longer employed by the facility. She stated that they were opening the MDS assessment and correcting the inaccuracies to reflect an accurate depiction of Resident #1. She said that the MDS nurse's failure could cause issues with the careplan, but not the resident's care, since they were already completing that. Record review of the facility's policy and procedure covering Accuracy of Assessments was requested on 05/22/2024.

Based on observation, interview, and record review the facility failed to ensure that the daily nurse staffing information, including the facility name, current date, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides, and the resident census, was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors for 1 of 1 facility. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census. Findings included: Observation on 05/22/2024 at 8:45 AM, revealed the daily staffing pattern was posted on the wall by the copier room and the DON's office, however the date was for 05/16/2024. During an interview with the DON on 05/22/2024 at 9:00 AM, She stated, that the staffing had not been updated or posted and that the last posting was for 05/16/2024. She stated that she was responsible for putting the staffing sheets out. She said that it had not been posted outside of the door, but it was in a binder book. She stated that someone had been removing that and the schedule, so they put it in a binder that was supposed to have been located at the front desk. She further stated, the failure could cause confusion on staffing and resident care issues. During an interview with the ADON on 05/22/2024 at 10:00 AM, she stated that the staffing sheets were being placed in a binder book and that it was supposed to have been kept at the front desk. She said that anyone can request or view the staffing sheets. She stated that it was not posted. She stated that employee time schedule was also taken over the weekend and she had to come up and reprint it. A copy of the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers dated July 2016 revealed the following: Policy Statement: Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residence. Policy interpretation and implementation. 1) Within two hours the beginning of each shift, the number of licensed nurses (RN's LPN's and LVN's) and the number of unlicensed nursing personnel (CNA's) directly responsible for resident care it will be posted in a prominent location accessible to residence and 2visitors and in a clear and readable format. 2) Directly responsible for resident care means that individuals are responsible for resident's total care or some aspect of the residence care including, but not limited to, assisting with activities of daily living (ADL's) performing gastrointestinal feeds, giving medication, supervising care given by CNA's, and performing nursing assessments to admit residents or notifying physicians of change of condition.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (Resident #'s 1, 3 and 5) reviewed for respiratory care. The facility failed to ensure Residents #1, #3, and #5's nebulizer mask was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include 1. Record review of Resident #1's face sheet, dated 02/01/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included dislocation of right hip, muscle wasting, cognitive communication deficit, dysphagia (swallowing difficulty), cough, asthma (inflammatory disease of the airways of the lungs). Record review of Resident #1's MDS Quarterly Assessment, dated 1/22/24, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Record review of Resident #1's Care Plan, dated 01/25/24, revealed the resident had an impaired respiratory status, her nebulizer therapy should administer as ordered by MD. Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer three times a day for shortness of breath for 5 days. Start date 1/31/24. In an interview and observation on 02/01/24 at 9:40 a.m., Resident #1 was sitting in her wheelchair drawing, observed nebulizer cup and mask sitting on dresser not bagged. Resident #1 stated she had her last treatment last night, could not recall time. Resident #1 stated she never seen nurse bag the nebulizer cup and mask, stated it was just always placed on desk. 2. Record review of Resident #3's face sheet, dated 02/01/24, revealed a [AGE] year-old male who was admitted on [DATE] and readmitted on [DATE]. Resident #3 had diagnosis which included acute respiratory failure (inadequate gas exchange), hypoxia (the body is deprived of adequate oxygen supply), shortness of breath. Record review of Resident #3's MDS Quarterly Assessment, dated 01/10/24 revealed a BIMs score of 15, which indicated the resident was cognitively intact. Record review of Resident #3's Care Plan, dated 01/15/24, revealed the resident received Oxygen therapy for ineffective gas exchange. Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer three times a day for shortness of breath for 5 days. Start date 1/31/24. In an interview and observation on 2/1/24 at 10:20 a.m., Resident #3 was sitting in wheelchair visiting with a friend. Nebulizer was observed sitting on the nightstand, cup and mask not bagged. Resident #3 stated he had received his last treatment early this morning at 7:00 a.m Resident #3 stated that the staff never has bagged nebulizer cup and mask while not in use. 3.Record review of Resident #5's face sheet, dated 2/1/24, revealed a [AGE] year-old male, who was admitted on [DATE]. Resident #5 had diagnosis which included, Acute upper respiratory infection. Record review of Resident #5's MDS Quarterly Assessment, dated 01/18/24 revealed a BIMs score of 99, which indicated the resident is severely cognitively impaired. Non interview able. Record review of Resident #5's Care Plan dated 10/14/23, revealed the resident receives Ipratropium-Albuterol Sulfate Nebulization Solution, 3 milliliter inhales orally vis nebulizer every 4 hours for shortness of breath, and wheezing. Start date 10/16/23. Observation on 2/1/24 at 11:10 a.m., Resident #5 was sleeping in bed, observed Nebulizer on nightstand, cup and mask lying on floor next to nightstand not bagged. In an interview with the ADON on 02/01/23 at 4:00 PM, she revealed it was the policy and procedure for the floor nurse after administering treatment to wash nebulizer cup and mask after each use and place cup and mask in plastic bag. ADON stated the failure to store nebulizer cup and mask properly could result in infection control issues. Record review of the facility's policy Infection Control Considerations Related to Medication Nebulizer/Continuous Aerosol, dated November 2011, revealed in part: 1) Store circuit and nasal canula or mask in plastic bag between uses. 2) Change disposable parts (set-up) every seven (7) days and label with date.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed, by failing to ensure: Facility staff cleaned or sanitized their hands during meal services when three nursing staff members (LVN1, CNA2 and CNA3) failed to sanitize hands between serving plates to residents in the dining room. LVN1 was observed placing ice in a drinking glass and then placing the ice scoop into the ice bucket, burying the scoop up to the handle. This failure by the facility places all residents at risk of acquiring a foodborne illness. Findings included: Observation on 07/11/2023 from 12:05 PM to 12:15 PM, revealed three nursing staff members, LVN1, CNA2 and CNA3, serving residents their meals without sanitizing between residents plates, instead they would place plates in front of residents, return back to the serving line and grab another resident's plate. At no time were they observe washing their hands prior to or during the meal. Observed LVN1 taking ice from a clear, square plastic container with an ice scoop and then burying the ice scoop back into the container up to the handle. In an interview on 07/12/2023 at 01:40 PM the DON said she was aware of staff not using hand sanitizer the previous day and had already in-serviced staff on hand sanitizing during meal service. She said she did not know why her staff would put the ice scoop into the ice when not removing ice from the bucket. The DON said residents could get sick from contaminated food. In an interview on 07/12/2-23 at 02:30 PM CNA3 said she just didn't think about using hand sanitizer between serving residents their lunch and knew she should have. In an interview on 07/12/2023 at 02:39 PM LVN1 said she was nervous with the state being in the building and did not want to mess anything up. LVN1 said residents could get sick if she spread an illness between them. In an interview on 07/13/2023 at 3:10 PM, the ADM said he was aware of what happened that day in the facility and the facility in-serviced their staff about proper use of hand sanitizing during meals. The ADM declined to offer a resident outcome. Record review of a document titled Hand Antiseptic, undated, revealed the following: Policy: Hand antiseptic or antimicrobial gel used by staff will be limited to situations that involve no direct contact with food by the bare hands. Hand antiseptic may be applied between washing hands as long as hands are not visibly soiled. Procedure 3. Hand antiseptic use should be limited to situations where direct contact of food with bare hands does not occur. 41944

Based on observation, interview, and record review, the facility failed to ensure: 1) all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, were reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency) for four (Residents #6, #16, #21, and #22) of 13 residents reviewed for abuse/neglect; and 2) there was no evidence the alleged violations were thoroughly investigated for two (Residents #21 and #16) of 13 residents reviewed for abuse/neglect and residents were protected from the potential of further abuse/neglect during the investigations. 1) Resident #16 was discovered with bruises on both of her forearms and left lower leg. She told LVN R she was scared of the big man who put her in her wheelchair. LVN R described the bruises on the resident's forearms as fingerprints. Written statements were not obtained from other persons involved such as staff from prior shifts, the phlebotomist and other residents. Residents were not protected from the potential of further abuse/neglect when the alleged suspects, CNAs S and N, were reassigned to another hall and were not suspended. 2) Bruises were first discovered on Resident #21 on 05/10/11. New bruises were identified on 05/12/11 and 05/13/11. The bruises were not reported to the Abuse Coordinator/ADM A until 05/16/11 (3-6 days later). The alleged suspects, CNAs N and O, were reassigned to provide care in other halls leaving residents unprotected from the potential of further abuse/neglect. The Abuse Coordinator did not inservice staff on reporting bruises of unknown origin, until 05/19/11 (three days after he was made aware). 3) Resident #22 suffered an unwitnessed fall on 06/04/11 resulting in a laceration on her right temple and left wrist and complaining of head pain. The facility failed to report the incident to the State agency within 24 hours of the incident. 4) Resident #6 slipped and fell in the shower, resulting in a bruise to her right buttock. ADM A was not immediately notified of the incident and the State agency was not notified within 24 hours of the incident. An Immediate Jeopardy (IJ) was identified on 06/03/11. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the Plan of Removal. These failures could affect the facility's 73 residents, including Residents #6, #16, #21, and #22, and placed them at risk for abuse/neglect and mistreatment resulting in residents being fearful of staff providing care, loss of pride and quality of life, resulting in depression and a poor quality of life. Findings included: 1) Resident #16's MDS assessment, dated 01/07/11, reflected the resident had inattention and disorganized thinking. Resident #16 required limited assistance with transfers and dressing and extensive assistance with bathing. Care plans dated April 2010 reflected Resident #16 had cognitive loss, impaired visual function and a potential for violent behavior. According to the May 2011 consolidated physician's orders [REDACTED]. Review of the laboratory report book revealed Resident #16 had a PT test drawn on 05/12/11. According to the nurse's notes, dated 05/13/11 at 4:50 p.m., Resident #16 came to LVN R and told her she was scared. The notes reflected LVN R asked Resident #16 why, and the resident stated, "that big man just came at me et (and) just got me up et put me. 'She indicated the w/c.' I stayed with resident through most of supper, she calmed but remained scared of the CNA." Nurse's notes, dated 05/13/11 at 8:30 p.m., reflected CNA N called LVN R into the shower room to check Resident #16's skin. The notes reflected, "Resident (#16) has bruise to top LFA (left forearm) 7.8 x 3.8 cm, a bruise to top RFA (right forearm) 5.2 x 3 cm and a bruise to LLE (left lower extremity) 5 x 2.9 cm, (former) DON notified, noted Dr. ___ (Medical Director BB), ___ (family member)." Review of Resident #16's Skin Assessment, dated 05/13/11, revealed no documentation of bruises on her forearms. The assessment reflected a bruise on Resident #16's left hand, which measured 2.5 x 2.5 cm in size. Resident #16's Skin Assessment also reflected, "Blood draw site done 05/12/11." The facility's investigation report, dated 05/16/11, reflected CNA N reported bruises on Resident #16, which she found during a routine shower. The report reflected Resident #16 had been "fearful during the afternoon and told (LVN R) and (former social worker) she was scared, 'that big man just came at me and just got me up...." When interviewed by (former social worker) Resident replied she was just scared, not hurt, 'he got me up real quick.' (Resident #16) was very fearful, holding her arms and rocking back and forth." The report reflected, "bruise to left forearm 7.8 cm x 3.8 cm, bruise to right forearm 5.2 cm x 3.0 cm, and bruise to left lower anterior leg 5 x 2.9 cm." The investigation report reflected two CNAs, CNA S and CNA N, were on duty on 05/13/11 on the Secured Unit, Hall 200. The report reflected both CNAs were reassigned to another part of the building after the bruises were found on Resident #16, and after Resident #16 expressed fear to LVN R that afternoon. The report reflected inservices were conducted on safe transfers and abuse/neglect. The only statements included in the facility's investigation report were from CNA S, CNA N, the former social worker, and LVN R. On 05/31/11 at about 10:30 a.m. during initial rounds on the Secured Unit, LVN Q described Resident #16 as being very confused, incontinent of bowel and bladder and requiring moderate assistance with her activities of daily living. LVN Q stated Resident #16 had a light bruise on her lower leg. Observation on 06/01/11 at 9:00 a.m. of Resident #16 revealed she was sitting in the wheelchair in the lobby, dressed and well-groomed. During an interview on 06/01/11 at 3:28 p.m., CNA S stated he was reassigned to the north hall, but was not told why. He stated during the two months he worked the Secured Unit, he never cared for Resident #16, and therefore, he denied hurting her. CNA S stated Resident #16 was CNA N's resident. He stated he knew Resident #16 could be combative at times. Interview with LVN M on 06/02/11 at 8:55 a.m., revealed other male staff had worked the Secured Unit in the past few months. Observation on 06/02/11 at 9:18 a.m. revealed Resident #16 was sitting in her wheelchair in her room dressed and well-groomed. When conversation was attempted, it was apparent the resident was very confused. When queried, she stated she did not remember if anyone had hurt her. LVN R confirmed through an interview on 06/02/11 at 11:15 a.m., Resident #16 came to her on 05/13/11 expressing fear about a big man, who had provided care to her. LVN R stated the only male CNA was CNA S, but he did not provide care for Resident #16 as he worked on the left side of Hall 200. LVN R stated CNA N was Resident #16's aide as she worked on the right side of Hall 200. LVN R stated it was possible for Resident #16 to mistake CNA N for a male as she was a tall, big woman who wore her hair pulled back. She stated CNA N had a fast pace about her, which could be taken wrong by demented residents. LVN R stated Resident #16 was a very confused resident and at times called a "she" a "he" and vise versa. LVN R stated CNA N reported the bruises to her while showering Resident #16. LVN R stated when she observed the bruises, they appeared to be fresh bruises and to her they looked like a set of fingerprints on both of her forearms. LVN R stated when the bruises were discovered, she called the nurse, LVN Q, on the prior shift and asked her about the bruises. She stated LVN Q told her she had conducted a routine skin assessment that morning and no bruises were present. LVN R stated Resident #16, however, did have blood work drawn the day before, 06/12/11. Interview with ADON C on 06/03/11 at 10:50 a.m., revealed she was in charge of staffing and in fact had reassigned CNA S and CNA N when Resident #16's allegation of abuse was reported. She stated she reassigned the two CNAs to the hall with the most interviewable residents, residents who could speak up for themselves if they were being abused. ADON C stated she was unaware of the skin assessment conducted by LVN Q and was not aware Resident #16 had blood work drawn the day before. ADON C stated she was not sure if LVN Q or the phlebotomist had been interviewed. She stated the former DON was the person who conducted the investigation and she did not know when ADM A was notified of the incident. 2) Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of May 2011 consolidated physician's orders [REDACTED]. All other medications were PRN. Review of an Incident Report dated 05/10/11 for Resident #21 revealed, "Resident was setting (sic) up in geri chair when I noticed a light blue bruise 4.5 cm x 4.0 cm to the outer (left) forearm. I assessed resident noticed on lower leg (left) blue bruise (with) yellowing around edges 3.0 cm x 2.5 cm...Resident not interviewable. Bruise to (left) lower leg. I did note that it lines up (with) falling to side of gerichair when reclined, and on several occasions I, this nurse have had to lift (Resident #21's) legs up between geri chair leg rest and chair...." Review of an Incident Report dated 05/12/11 for Resident #21 revealed, "Hospice aide here to see res (resident) while showering her she noticed a purple bruise to her (left) hand. She notified this nurse. Dk (dark) purple bruise to back of (left) hand measuring 1.5 cm x 2 cm noted. Res or aide unable to say how or when bruises may have occurred...." Review of an Incident Report dated 05/13/11 for Resident #21 revealed, "Noted 10 cm x 6 cm res to blue bruise to (right) outer forearm. Was reported on 10-6 shift by hospice aide...Resident not interviewable. Talked with off-going nurse (RN PP) she reported Hospice aide reported bruise to her (after) she showered her. (RN PP) said hospice aide had reported resident has been combative during showers...." Review of the Behavior Monitoring Forms for May 2011 for Resident #21 revealed there were no documented episodes of the resident being "Combative (with) Care." Resident #21 had [DIAGNOSES REDACTED]. The report reflected the Incident date was blank and the incident was reported to DADS on 05/16/11 at 5:13 p.m. The Report reflected the incident category was, "Abuse." The Report also reflected the Description of the Allegation was, "Numerous bruises noted over a period of 3 days. Cause unknown." The Report reflected the Description of the Injury was, "05/10/11 Left forearm-light blue 4.5 cm x 4.0 cm, Left lower leg, blue 3 cm x 2.5 cm, 05/12/11- Left Hand-purple 1.5 cm x 2 cm, 05/13/11-Right forearm-blue 10 cm x 6 cm." The Report reflected the Provider response was, "New CNAs on Unit (CNA N and CNA O) were assigned to other units to work with CNAs who have been employed with facility longer. (CNA N and CNA O) were verbally counseled by ___ (ADON C) on safe transfers. Investigation proceeded, continued to obtain witness statements." The next page of the report included an Investigation Summary. It reflected, "...Resident is noted to have multiple bruises over a 4 day period...On 05/10/11 bruising is attributed to resident repositioning self in Geri chair. On 05/12/11 the hospice aide notified the charge nurse of bruise to hand & on 05/13/11 the hospice aide reported a bruise to the right forearm & also reported ___ (Resident #21) had been combative in the shower...After noting an incident with another resident on the secure unit in same time frame ___ (CNA O) and ___ (CNA S) were reassigned to different units & paired with other CNAs...Several staff members witness ___ (Resident #21) repositioning in her Geri-chair with legs under the arm of chair & arms hanging over the side...Provider Action Taken Post-Investigation: ...___ (CNA O) and ___ (CNA S) were inserviced on correct transfer techniques by the physical therapy department... Abuse & Neglect inservices to all staff...." Review of a handwritten Witness Statement Form dated 05/13/11 (timed at 6:00 a.m.) for Resident #21, completed by RN PP revealed, "Hospice aide came to me & asked if I was aware of a bruise on (Resident #21)'s LFA (left forearm). I went & looked & noted a large purple bruise on her LFA as she had said. This was a new bruise. Aide nor resident able to tell how or when bruise occurred. Aide said she noticed it while showering her...." Review of an Investigation Statement, regarding Resident #21's bruising of unknown origin, dated 05/13/11 and completed by LVN Q, revealed, "I had just finished getting report and counting meds to take over from off going nurse (RN PP). I was taking another resident her meds in setting (sic) room when I looked over @ ___ (Resident #21) and I noticed a large bruise on her (right) forearm. Showed it to ___ (RN PP) and she said hospice aide reported to her that resident was combative during shower." Review of an Investigation Statement, regarding Resident #21's bruising of unknown origin, dated 05/10/11, 05/12/11 and 05/13/11 (all three dates were written in the space for the date), completed by CNA N revealed, "Not aware of any bruising on ___ (Resident #21) Never been combative." Review of a handwritten Witness Statement Form dated 05/19/11 (timed at 4:29 p.m.), regarding Resident #21's bruising of unknown origin, and completed by LVN R revealed, "___ (CNA S) worked as a CNA assisting residents in rooms 110-122. ___ (CNA N) worked as a CNA assisting residents in rooms 101-109. These assignments were permanent during this 2-10 shift. During the time ___ (CNA S) worked with me, I never saw or heard any physical roughness. ___ (CNA S) was educated by me to move slightly slower (with) the resident...he did comply...During the time ___ (CNA N) worked (with) me she was abrupt (with) resident care, I did not witness by sight or sound any physical abuse. However, she did not respect my authority...." Review of an inservice, completed on 05/19/11 regarding Safe and Effective Patient Transfers, revealed CNA N and CNA S attended. This was completed nine days after the first bruising was observed on Resident #21, and three days after the Abuse Coordinator (ADM) was made aware of the bruising. Observation on 06/01/11 at 9:31 a.m. revealed Resident #21 was sitting in a Geri-chair in the sitting area of the secured unit. There was no visible bruising observed. Interview on 06/01/11 at 9:31 a.m. with RN PP revealed a hospice aide had reported to her Resident #21 had a bruise on the right hand. She stated she was not able to determine how the bruise had occurred. She added the resident was not able to state how it occurred. RN PP stated she did not notify the Abuse Coordinator or the DON. She stated she did complete the incident report and placed it in the DON's box before she left after her shift was completed at 6:00 a.m. 3) Resident #22's Admission Nursing assessment dated [DATE] reflected the following: transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].[REDACTED] Daily Skilled Nurses Notes dated 06/01/11 at 11:00 a.m. revealed Resident #22 was "Awake and alert and oriented to person only. Redirection unsuccessful, unable to follow simple commands. Attempts to transfer self when advised not to due to safety reasons. New order for Personal Safety Alarm (PSA) at all times. Transfer with assist time one person due to weakness and decrease cognition of safety awareness. Requires constant cueing during meals." Resident #22's Daily Skilled Nurses Notes dated 06/02/11 at 4:00 p.m. reflected, "Resident (Resident #22) found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to rt. forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid." Resident #22's Daily Skilled Nurses Notes dated 06/03/11 at 7:30 a.m. reflected, "Requires constant cueing during meals due to confusion, redirection unsuccessful, removes PSA frequently." Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration on the right side of her head in the area of her temple. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her in the recumbent position, leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the top quarter side rail was up on the right side of the bed. Further observation at this time revealed the alarm was still attached to head of bed. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 & 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help and I ran to the room and called for ____ (RN Y) to come help me, because she was in the hallway." Review of the hospital's Patient Disposition Page dated 06/04/11 revealed Resident #22 also sustained a 1.6 cm laceration on the left hand. A telephone interview on 06/05/11 at 10:35 a.m. with ADM B revealed he had not determined anything about the incident regarding Resident #22, which had occurred on 06/04/11 at this point. He added they did have questions about her medication regimen. At that time, no investigation had been initiated into Resident #22's fall. The surveyors requested the Incident Report for Resident #22's fall, which occurred on 06/04/11, on 06/06/11 at approximately 12:00 p.m. from ADM B, RN FF, and the DON. They informed the surveyors there was no Incident Report and they had not reported the incident to DADS. Review of the Texas Department of Aging and Disability Incident Intake # 0 regarding the above incident, revealed the facility reported the incident to DADS on 06/06/11. The reporter of the incident was identified as ADM B. The notes of the Incident Report reflected the Reporter (ADM B) informed the State agency he first learned of the incident on 06/06/11 at 11:00 a.m. 3) Resident #6 was an [AGE] year-old female who was re-admitted on [DATE] at 12:00 p.m., according to the face sheet dated 06/02/11 with diagnoses, which included Dementia without Behavior Disturbances, Benign Hypertension, [MEDICAL CONDITIONS], and Renal & [MEDICAL CONDITION] Disease. According to the MDS assessment dated [DATE], Resident #6 had inattention and disorganized thinking. The assessment reflected Resident #6 required "stand by assistance" with transfers and was "not steady, only able to stabilize with human assistance" when moving from a seated to standing position. According to the facility's Investigation Summary, dated 05/14/11 at 10:40 a.m., CNA V called LVN X into the shower room, and a head-to-toe assessment was completed by LVN X. The summary reflected Resident #6 had a bruise on her right upper buttock, which was red in color and one inch by three inches in size. The (former) DON was notified, MD AA was notified and Resident #6's family member was notified. According to the facility's Investigation Summary Report dated, 05/15/11 at 10:40 a.m., CNA V was assisting Resident #6 in the shower room. The resident lost her balance when she attempted to stand up from a seated position on the shower chair. The report reflected Resident #6 was beginning to fall, hit her right buttock on the shower chair, and then was assisted to the floor by CNA V. CNA V then called for LVN X. The report also reflected Resident #6 was assessed for injuries by LVN X. The only statement included in the facility's investigation report was CNA V's statement. There was no statement from LVN X included in the Investigation. On 05/31/11 at about 11:15 a.m. during initial rounds on Hall 400, LVN O described Resident #6 as being confused, wandering on the hall, having a history of falls, occasionally incontinent of bowel and bladder and requiring moderate assistance with her activities of daily living. LVN O stated Resident #6, "Has a bruise on her right wrist from a fall on 05/30/11 on 2-10 shift." An observation of Resident #6 on initial tour revealed a purplish bruise on her right wrist. Observation on 05/31/11 at 2:00 p.m. revealed a small, purplish-yellow bruise on Resident #6's right upper quadrant of her buttock. CNA W was questioned while assisting resident up from toilet, how the bruise occurred and the CNA stated, "I heard she fell in the shower. I'm not sure." During an interview with ADM A on 06/03/11 at 3:30 p.m., he was asked when he was informed regarding the incident about Resident #6. He stated, "On the 16th (05/16/11)." When asked if the staff did not call him on the weekends to notify him of incidents, he stated some of the Charge Nurses did and and some of them did not. 5) Interview on 06/03/11 at 3:00 p.m. with ADM A revealed the last QA&A meeting was on 05/30/11. He stated there was a QA&A meeting on 05/10/11. ADM A stated the meeting on 05/10/11 was held before surveyors entered the facility to complete a follow-up visit. When asked what was discussed in the meeting on 05/10/11, ADM A stated they discussed abuse and neglect. He stated he told the committee members he needed to be notified of any incidents of abuse/neglect. He added they discussed the abuse/neglect policy. When asked what else was discussed in the QA&A meeting on 05/10/11, ADM A stated nothing else. When asked what was discussed in the 05/30/11 QA&A meeting, ADM A stated the abuse policy, incident/accident reports, grievances, infection control, pressure ulcers, weight loss and environment. When asked if any problems were identified in the QA&A process, ADM A stated there were problems with housekeeping. When asked if there were any other problems identified, he stated there was not. When asked if they had discussed the surveyors re-citing abuse investigations, ADM A stated they discussed abuse, "generally." He also stated, "We also discussed that we were not cleared on the visit." When asked what the plan of action was for the abuse investigations, ADM A stated, "to enforce the policy." When asked what they identified in the QA&A meeting, ADM A stated they were not investigating or reporting incidents. When asked if they did an action plan, ADM A stated the plan of action was when an incident occurred, he reported it. When asked why the incidents, which occurred from 05/13/11 through 05/14/11, were not reported to DADS until 05/16/11, ADM A stated, "Because they did not report it to me." When asked why he waited until 05/19/11 to inservice his staff on abuse/neglect, he stated sometimes he "verbally" inserviced staff. 6) Review of an inservice dated 05/10/11 entitled, "Abuse and Neglect Inservice - Attached the Policy Please Read Policy and Sign" revealed 12 staff members attended the inservice (RN PP, CNA S and CNA N attended the inservice). 7) Review of an inservice dated 05/11/11 entitled, "Accidents and Incidents Inservice-Attached the Policy Please Read Policy and Sign" revealed 21 staff members attended the inservice. RN PP, CNA S and CNA N attended the inservice. 8) Review of an inservice dated 05/19/11 entitled, "Abuse and Neglect" revealed 15 staff members attended the inservice. 9) Review of the facility's undated policy entitled, "Abuse Program Policy and Procedure" provided by ADM A and identified as the current policy, revealed, "Policy Statement: It is the policy of the facility to maintain an environment free of abuse and neglect... Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Procedure: 1) All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]." Review of the facility's undated policy entitled, "Resident Protection During Abuse Investigation Policy and Procedure," provided by ADM A and identified as the current policy, revealed, "...Procedure: 1) All alleged or suspected neglect or abuse, whether physical, verbal, sexual, involuntary, or mental will be cause for a thorough investigation to be conducted immediately by the management of the facility. 2) Staff must report any incidents or suspicions of abuse without fear of retaliation from the facility, staff, or others. ...4) The Director of Nursing or Charge Nurse will complete the investigation form with a written, dated, and signed statement from all persons involved. 5) The investigation form and written statements from all persons involved will be forwarded to the Administrator within 24 hours of the occurrence. An immediate investigation will be conducted by both the Director of Nursing and the Administrator...." The facility's undated "RESIDENT ABUSE AND PREVENTION POLICY" reflected, "7. The Administrator is responsible for calling the state and notifying in accordance with the most current Provider Letter stating procedures to follow." The facility's current, undated policy entitled, "Resident Protection During Abuse Investigation" reflected, "...5. The investigation form and written statements from all persons involved will be forwarded to the Administrator within 24 hours of the occurrence. ...7. If abuse is suspected or substantiated, the employee will be immediately sent home and full disciplinary action will be enforced including suspension and/or termination of employment pending the outcome of the investigation. 8. The accused employee will not be permitted to enter the facility unless otherwise directed by the Administrator, until the investigation has been completed and final disposition has been given." 10) An IJ was identified on 06/03/11 at 4:45 p.m. in the area of Resident Behavior and Facility Practice. ADM A and the Co-Owner of the facility were informed of the IJ on 06/03/11 at 5:00 p.m. A Plan of Removal was requested at that time. 11) Review of the Plan of Removal (POR) accepted on 06/08/11 revealed the following: All employees who had been hired during the time of ADM A's employment as the Administrator, had been reviewed, and/or completed, to determine eligibility to work in the facility. A new Administrator was appointed effective 06/04/11. All provider investigations were reviewed to determine if the appropriate actions had been implemented. The policy for Abuse was changed to reflect abuse should be reported to the administrator. Each shift was inserviced on Abuse and Neglect prior to working. The POR reflected staff, who were not scheduled to work, would be inserviced prior to their next scheduled shift. A competency test was given after the inservice to ensure competency. 100% skin assessments were completed by 06/08/11 to ensure no additional residents were identified with bruising of unknown origin. Fall assessments were completed on all residents by 06/08/11. The POR reflected they would be hiring two Unit Managers to assist in the monitoring of the care in the facility. One Unit Manager accepted the position, but had to work out a two-week notice prior to starting at the facility. The POR reflected the Medical Director would be contacted for all allegations of abuse. The facility had a QA&A meeting on 06/07/11. The fax machine was replaced and was functional at the time of exit. 21) Interviews on 06/07/11 from 1:45 p.m. through 3:30 p.m. were conducted with the following staff: LVN Q, LVN H, RN Y, LVN O, CNA V, CNA W, CNA U, DA T, Cook EE, LVN X, ADON FF, LVN K, LVN GG, LVN HH, MA JJ, CNA S, CNA LL, CNA KK, CNA MM and CNA F. They were all able to identify the Administrator as the Abuse Coordinator. They would report any identified neglect immediately and were able to give an example of verbal abuse. They were able to identify verbal, sexual, physical, mental, and financial exploitation as types of abuse. They stated it was never acceptable to place a resident in involuntary seclusion, volunteers had a responsibility to report abuse and injuries of unknown origin were always to be reported. Inadequate supervision of residents to prevent physical altercations and allowing residents access to hot water of sufficient temperature to cause tissue injury would be identified as neglect. 42) The IJ was lowered on 06/08/11. However, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not IJ."

Based on observation, interview and record review, it was determined the facility failed to develop and implement written policies and procedures that prohibited mistreatment, neglect, and abuse of residents and misappropriation of resident property as evidenced by the following: 1) Resident #16 was discovered with bruises on both of her forearms and left lower leg. She told LVN R she was scared of the big man who put her in her wheelchair. LVN R described the bruises on the resident's forearms as fingerprints. Written statements were not obtained from other persons involved such as staff from prior shifts, the phlebotomist and other residents. Residents were not protected from the potential of further abuse/neglect when the alleged suspects, CNAs S and N, were reassigned to another hall and were not suspended. 2) Bruises were first discovered on Resident #21 on 05/10/11. New bruises were identified on 05/12/11 and 05/13/11. The bruises were not reported to the Abuse Coordinator/ADM A until 05/16/11 (3-6 days later). The alleged suspects, CNAs N and O, were reassigned to provide care in other halls leaving residents unprotected from the potential of further abuse/neglect. The Abuse Coordinator did not inservice staff on reporting bruises of unknown origin, until 05/19/11 (three days after he was made aware). 3) Resident #22 suffered an unwitnessed fall on 06/04/11 resulting in a laceration on her right temple and left wrist and complaining of head pain. The facility failed to report the incident to the State agency within 24 hours of the incident. 4) Resident #6 slipped and fell in the shower, resulting in a bruise to her right buttock. ADM A was not immediately notified of the incident and the State agency was not notified within 24 hours of the incident. 5) Nine (Housekeeper D, CNA/MA E, CNA F, CNA G, CNA S, RN I, LVN J, Social Worker and ADM A) of eleven employee files reviewed did not have the required screenings (Employee Misconduct Registry, Nurse Aide Registry and/or Criminal Background check) completed prior to hire. An Immediate Jeopardy (IJ) was identified on 06/03/11. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the Plan of Removal. These failures could affect the facility's 73 residents, including Residents #6, #16, #21, and #22, and placed them at risk for the potential of abuse/neglect, mistreatment and misappropriation of property, resulting in residents being fearful of staff providing care, loss of pride and quality of life, resulting in depression and a poor quality of life. Findings included: 1) Review of the facility's undated policy entitled, "Abuse Program Policy and Procedure" provided by ADM A and identified as the current policy, revealed, "Policy Statement: It is the policy of the facility to maintain an environment free of abuse and neglect... Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Procedure: 1) All potential new employees and volunteers will be screened for a history of abuse, neglect, or mistreatment of [REDACTED]." Review of the facility's undated policy entitled, "Resident Protection During Abuse Investigation Policy and Procedure," provided by ADM A and identified as the current policy, revealed, "...Procedure: 1) All alleged or suspected neglect or abuse, whether physical, verbal, sexual, involuntary, or mental will be cause for a thorough investigation to be conducted immediately by the management of the facility. 2) Staff must report any incidents or suspicions of abuse without fear of retaliation from the facility, staff, or others. ...4) The Director of Nursing or Charge Nurse will complete the investigation form with a written, dated, and signed statement from all persons involved. 5) The investigation form and written statements from all persons involved will be forwarded to the Administrator within 24 hours of the occurrence. An immediate investigation will be conducted by both the Director of Nursing and the Administrator...." The facility's undated "RESIDENT ABUSE AND PREVENTION POLICY" reflected, "7. The Administrator is responsible for calling the state and notifying in accordance with the most current Provider Letter stating procedures to follow." The facility's current, undated policy entitled, "Resident Protection During Abuse Investigation" reflected, "...5. The investigation form and written statements from all persons involved will be forwarded to the Administrator within 24 hours of the occurrence. ...7. If abuse is suspected or substantiated, the employee will be immediately sent home and full disciplinary action will be enforced including suspension and/or termination of employment pending the outcome of the investigation. 8. The accused employee will not be permitted to enter the facility unless otherwise directed by the Administrator, until the investigation has been completed and final disposition has been given." 6) Resident #16's MDS assessment, dated 01/07/11, reflected the resident had inattention and disorganized thinking. Resident #16 required limited assistance with transfers and dressing and extensive assistance with bathing. Care plans dated April 2010 reflected Resident #16 had cognitive loss, impaired visual function and a potential for violent behavior. According to the May 2011 consolidated physician's orders [REDACTED]. Review of the laboratory report book revealed Resident #16 had a PT test drawn on 05/12/11. According to the nurse's notes, dated 05/13/11 at 4:50 p.m., Resident #16 came to LVN R and told her she was scared. The notes reflected LVN R asked Resident #16 why, and the resident stated, "that big man just came at me et (and) just got me up et put me. 'She indicated the w/c.' I stayed with resident through most of supper, she calmed but remained scared of the CNA." Nurse's notes, dated 05/13/11 at 8:30 p.m., reflected CNA N called LVN R into the shower room to check Resident #16's skin. The notes reflected, "Resident (#16) has bruise to top LFA (left forearm) 7.8 x 3.8 cm, a bruise to top RFA (right forearm) 5.2 x 3 cm and a bruise to LLE (left lower extremity) 5 x 2.9 cm, (former) DON notified, noted Dr. ___ (Medical Director BB), ___ (family member)." Review of Resident #16's Skin Assessment, dated 05/13/11, revealed no documentation of bruises on her forearms. The assessment reflected a bruise on Resident #16's left hand, which measured 2.5 x 2.5 cm in size. Resident #16's Skin Assessment also reflected, "Blood draw site done 05/12/11." The facility's investigation report, dated 05/16/11, reflected CNA N reported bruises on Resident #16, which she found during a routine shower. The report reflected Resident #16 had been "fearful during the afternoon and told (LVN R) and (former social worker) she was scared, 'that big man just came at me and just got me up...." When interviewed by (former social worker) Resident replied she was just scared, not hurt, 'he got me up real quick.' (Resident #16) was very fearful, holding her arms and rocking back and forth." The report reflected, "bruise to left forearm 7.8 cm x 3.8 cm, bruise to right forearm 5.2 cm x 3.0 cm, and bruise to left lower anterior leg 5 x 2.9 cm." The investigation report reflected two CNAs, CNA S and CNA N, were on duty on 05/13/11 on the Secured Unit, Hall 200. The report reflected both CNAs were reassigned to another part of the building after the bruises were found on Resident #16, and after Resident #16 expressed fear to LVN R that afternoon. The report reflected inservices were conducted on safe transfers and abuse/neglect. The only statements included in the facility's investigation report were from CNA S, CNA N, the former social worker, and LVN R. On 05/31/11 at about 10:30 a.m. during initial rounds on the Secured Unit (Hall 200), LVN Q described Resident #16 as being very confused, incontinent of bowel and bladder and requiring moderate assistance with her activities of daily living. LVN Q stated Resident #16 had a light bruise on her lower leg. Observation on 06/01/11 at 9:00 a.m. of Resident #16 revealed she was sitting in the wheelchair in the lobby, dressed and well-groomed. During an interview on 06/01/11 at 3:28 p.m., CNA S stated he was reassigned to the north hall, but was not told why. He stated during the two months he worked the Secured Unit, he never cared for Resident #16, and therefore, he denied hurting her. CNA S stated Resident #16 was CNA N's resident. He stated he knew Resident #16 could be combative at times. Interview with LVN M on 06/02/11 at 8:55 a.m., revealed other male staff had worked the secured unit in the past few months. Observation on 06/02/11 at 9:18 a.m. revealed Resident #16 was sitting in her wheelchair in her room dressed and well-groomed. When conversation was attempted, it was apparent the resident was very confused. When queried, she stated she did not remember if anyone had hurt her. LVN R confirmed through an interview on 06/02/11 at 11:15 a.m., Resident #16 came to her on 05/13/11 expressing fear about a big man, who had provided care to her. LVN R stated the only male CNA was CNA S, but he did not provide care for Resident #16 as he worked on the left side of Hall 200. LVN R stated CNA N was Resident #16's aide as she worked on the right side of Hall 200. LVN R stated it was possible for Resident #16 to mistake CNA N for a male as she was a tall, big woman who wore her hair pulled back. She stated CNA N had a fast pace about her, which could be taken wrong by demented residents. LVN R stated Resident #16 was a very confused resident and at times called a "she" a "he" and vise versa. LVN R stated CNA N reported the bruises to her while showering Resident #16. LVN R stated when she observed the bruises, they appeared to be fresh bruises and to her they looked like a set of fingerprints on both of her forearms. LVN R stated when the bruises were discovered, she called the nurse, LVN Q, on the prior shift and asked her about the bruises. She stated LVN Q told her she had conducted a routine skin assessment that morning and no bruises were present. LVN R stated Resident #16, however, did have blood work drawn the day before, 06/12/11. Interview with ADON C on 06/03/11 at 10:50 a.m., revealed she was in charge of staffing and in fact had reassigned CNA S and CNA N when Resident #16's allegation of abuse was reported. She stated she reassigned the two CNAs to the hall with the most interviewable residents, residents who could speak up for themselves if they were being abused. ADON C stated she was unaware of the skin assessment conducted by LVN Q and was not aware Resident #16 had blood work drawn the day before. The ADON stated she was not sure if LVN Q or the phlebotomist had been interviewed. She stated the former DON was the person who had conducted the investigation and did not know when ADM A was notified of the incident. Review of CNA S's criminal history check, provided on 06/03/11, revealed two pending results had not been revealed in the full summary report, which would determine if CNA S was employable or not. On 06/03/11 at about 3:00 p.m., Administrator A stated he relied on the office staff to retrieve and interpret the results of the criminal histories. He stated he was uncertain as to what the meaning of the criminal history results were for CNA S or if action needed to be taken. The surveyor had to point out to Administrator A the two pending results had to be revealed to determine whether CNA S was employable or not. 7) Resident #21 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of May 2011 consolidated physician's orders [REDACTED]. All other medications were PRN. Review of an Incident Report dated 05/10/11 for Resident #21 revealed, "Resident was setting (sic) up in geri chair when I noticed a light blue bruise 4.5 cm x 4.0 cm to the outer (left) forearm. I assessed resident noticed on lower leg (left) blue bruise (with) yellowing around edges 3.0 cm x 2.5 cm...Resident not interviewable. Bruise to (left) lower leg. I did note that it lines up (with) falling to side of gerichair when reclined, and on several occasions I, this nurse have had to lift (Resident #21's) legs up between geri chair leg rest and chair...." Review of an Incident Report dated 05/12/11 for Resident #21 revealed, "Hospice aide here to see res (resident) while showering her she noticed a purple bruise to her (left) hand. She notified this nurse. Dk (dark) purple bruise to back of (left) hand measuring 1.5 cm x 2 cm noted. Res or aide unable to say how or when bruises may have occurred...." Review of an Incident Report dated 05/13/11 for Resident #21 revealed, "Noted 10 cm x 6 cm res to blue bruise to (right) outer forearm. Was reported on 10-6 shift by hospice aide...Resident not interviewable. Talked with off-going nurse (RN PP) she reported Hospice aide reported bruise to her (after) she showered her. (RN PP) said hospice aide had reported resident has been combative during showers...." Review of the Behavior Monitoring Forms for May 2011 for Resident #21 revealed there were no documented episodes of the resident being "Combative (with) Care." Resident #21 had [DIAGNOSES REDACTED]. The report reflected the Incident date was blank and the incident was reported to DADS on 05/16/11 at 5:13 p.m. The Report reflected the incident category was, "Abuse." The Report also reflected the Description of the Allegation was, "Numerous bruises noted over a period of 3 days. Cause unknown." The Report reflected the Description of the Injury was, "05/10/11 Left forearm-light blue 4.5 cm x 4.0 cm, Left lower leg, blue 3 cm x 2.5 cm, 05/12/11- Left Hand-purple 1.5 cm x 2 cm, 05/13/11-Right forearm-blue 10 cm x 6 cm." The Report reflected the Provider response was, "New CNAs on Unit (CNA N and CNA O) were assigned to other units to work with CNAs who have been employed with facility longer. (CNA N and CNA O) were verbally counseled by ___ (ADON C) on safe transfers. Investigation proceeded, continued to obtain witness statements." The next page of the report included an Investigation Summary. It reflected, "...Resident is noted to have multiple bruises over a 4 day period...On 05/10/11 bruising is attributed to resident repositioning self in Geri chair. On 05/12/11 the hospice aide notified the charge nurse of bruise to hand & on 05/13/11 the hospice aide reported a bruise to the right forearm & also reported ___ (Resident #21) had been combative in the shower...After noting an incident with another resident on the secure unit in same time frame ___ (CNA O) and ___ (CNA S) were reassigned to different units & paired with other CNAs...Several staff members witness ___ (Resident #21) repositioning in her Geri-chair with legs under the arm of chair & arms hanging over the side...Provider Action Taken Post-Investigation: ...___ (CNA O) and ___ (CNA S) were inserviced on correct transfer techniques by the physical therapy department...Abuse & Neglect inservices to all staff...." Review of a handwritten Witness Statement Form dated 05/13/11 (timed at 6:00 a.m.) for Resident #21, completed by RN PP revealed, "Hospice aide came to me & asked if I was aware of a bruise on (Resident #21)'s LFA (left forearm). I went & looked & noted a large purple bruise on her LFA as she had said. This was a new bruise. Aide nor resident able to tell how or when bruise occurred. Aide said she noticed it while showering her...." Review of an Investigation Statement, regarding Resident #21's bruising of unknown origin, dated 05/13/11 and completed by LVN Q, revealed, "I had just finished getting report and counting meds to take over from off going nurse (RN PP). I was taking another resident her meds in setting (sic) room when I looked over @ ___ (Resident #21) and I noticed a large bruise on her (right) forearm. Showed it to ___ (RN PP) and she said hospice aide reported to her that resident was combative during shower." Review of an Investigation Statement, regarding Resident #21's bruising of unknown origin, dated 05/10/11, 05/12/11 and 05/13/11 (all three dates were written in the space for the date), completed by CNA N revealed, "Not aware of any bruising on ___ (Resident #21) Never been combative." Review of a handwritten Witness Statement Form dated 05/19/11 (timed at 4:29 p.m.), regarding Resident #21's bruising of unknown origin, and completed by LVN R revealed, "___ (CNA S) worked as a CNA assisting residents in rooms 110-122. ___ (CNA N) worked as a CNA assisting residents in rooms 101-109. These assignments were permanent during this 2-10 shift. During the time ___ (CNA S) worked with me, I never saw or heard any physical roughness. ___ (CNA S) was educated by me to move slightly slower (with) the resident...he did comply...During the time ___ (CNA N) worked (with) me she was abrupt (with) resident care, I did not witness by sight or sound any physical abuse. However, she did not respect my authority...." Review of an inservice, completed on 05/19/11 regarding Safe and Effective Patient Transfers, revealed CNA N and CNA S attended. This was completed nine days after the first bruising was observed on Resident #21, and three days after the Abuse Coordinator (ADM) was made aware of the bruising. Observation on 06/01/11 at 9:31 a.m. revealed Resident #21 was sitting in a Geri-chair in the sitting area of the secured unit. She was clean and free of odors. There was no visible bruising observed. Interview on 06/01/11 at 9:31 a.m. with RN PP revealed a hospice aide had reported to her Resident #21 had a bruise on the right hand. She stated she was not able to determine how the bruise had occurred. She added the resident was not able to state how it occurred. RN PP stated she did not notify the Abuse Coordinator or the DON. She stated she did complete the incident report and placed it in the DON's box before she left after her shift was completed at 6:00 a.m. 8) Resident #22's Admission Nursing assessment dated [DATE] reflected the following: transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].[REDACTED] Daily Skilled Nurses Notes dated 06/01/11 at 11:00 a.m. revealed Resident #22 was "Awake and alert and oriented to person only. Redirection unsuccessful, unable to follow simple commands. Attempts to transfer self when advised not to due to safety reasons. New order for Personal Safety Alarm (PSA) at all times. Transfer with assist time one person due to weakness and decrease cognition of safety awareness. Requires constant cueing during meals." Resident #22's Daily Skilled Nurses Notes dated 06/02/11 at 4:00 p.m. reflected, "Resident (Resident #22) found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to rt. forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid." Resident #22's Daily Skilled Nurses Notes dated 06/03/11 at 7:30 a.m. reflected, "Requires constant cueing during meals due to confusion, redirection unsuccessful, removes PSA frequently." Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration on the right side of her head in the area of her temple. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her in the recumbent position, leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the top quarter side rail was up on the right side of the bed. Further observation at this time revealed the alarm was still attached to head of bed. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 & 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help and I ran to the room and called for ____ (RN Y) to come help me, because she was in the hallway." Review of the hospital's Patient Disposition Page dated 06/04/11 revealed Resident #22 also sustained a 1.6 cm laceration on the left hand. A telephone interview on 06/05/11 at 10:35 a.m. with ADM B revealed he had not determined anything about the incident regarding Resident #22, which had occurred on 06/04/11 at this point. He added they did have questions about her medication regimen. At that time, no investigation had been initiated into Resident #22's fall. The surveyors requested the Incident Report for Resident #22's fall, which occurred on 06/04/11, on 06/06/11 at approximately 12:00 p.m. from ADM B, RN FF, and the DON. They informed the surveyors there was no Incident Report and they had not reported the incident to DADS. Review of the Texas Department of Aging and Disability Incident Intake # 0 regarding the above incident, revealed the facility reported the incident to DADS on 06/06/11. The reporter of the incident was identified as ADM B. The notes of the Incident Report reflected the Reporter (ADM B) informed the State agency he first learned of the incident on 06/06/11 at 11:00 a.m. 9) According to the MDS assessment dated [DATE], Resident #6 had inattention and disorganized thinking. The assessment reflected Resident #6 required "stand by assistance" with transfers and was "not steady, only able to stabilize with human assistance" when moving from a seated to standing position. Resident #6 was an [AGE] year-old female, who was re-admitted on [DATE] at 12:00 p.m., according to the face sheet dated 06/02/11 with diagnoses, which included Dementia without Behavior Disturbances, Benign Hypertension, [MEDICAL CONDITIONS], and Renal & [MEDICAL CONDITION] Disease. According to the facility's Investigation Summary, dated 05/14/11 at 10:40 a.m., CNA V called LVN X into the shower room, and a head-to-toe assessment was completed by LVN X. The summary reflected Resident #6 had a bruise on her right upper buttock, which was red in color and one inch by three inches in size. The (former) DON was notified, MD AA was notified and Resident #6's family member was notified. According to the facility's Investigation Summary Report dated, 05/15/11 at 10:40 a.m., CNA V was assisting Resident #6 in the shower room. The resident lost her balance when she attempted to stand up from a seated position on the shower chair. The report reflected Resident #6 was beginning to fall, hit her right buttock on the shower chair, and then was assisted to the floor by CNA V. CNA V then called for LVN X. The report also reflected Resident #6 was assessed for injuries by LVN X. The only statement included in the facility's investigation report was CNA V's statement. There was no statement from LVN X included in the Investigation. On 05/31/11 at about 11:15 a.m. during initial rounds on Hall 400, LVN O described Resident #6 as being confused, wandering on the hall, having a history of falls, occasionally incontinent of bowel and bladder and requiring moderate assistance with her activities of daily living. LVN O stated Resident #6, "Has a bruise on her right wrist from a fall on 05/30/11 on 2-10 shift." An observation of Resident #6 on initial tour revealed a purplish bruise on her right wrist. Observation on 05/31/11 at 2:00 p.m. revealed a small, purplish-yellow bruise on Resident #6's right upper quadrant of her buttock. CNA W was questioned while assisting resident up from toilet, how the bruise occurred and stated, "I heard she fell in the shower. I'm not sure." During an interview with ADM A on 06/03/11 at 3:30 p.m., he was asked when he was informed regarding the incident about Resident #6. He stated, "On the 16th (05/16/11)." When he was then asked if the staff did not call him on the weekends to notify him of incidents, he stated some of the Charge Nurses did and and some of them did not. 6) Review of an employee file for Housekeeper (HK) D revealed she was hired on 03/25/11 (the hire date was written in the front of the file). The facility did not check the Nurse Aide Registry (NAR) until 03/30/11 and did not check the Employee Misconduct Registry (EMR) (per the printed form from the registry). Review of an employee file for CNA/MA E revealed she was hired on 04/07/11 (the hire date was written in the front of the file). There was no evidence in the employee's file to reflect the NAR or EMR had been checked. Review of CNA F's employee file revealed she was hired on 05/27/11 (the hire date was written in the front of the file). The facility did not check the NAR or EMR until 06/01/11 (per the printed form from the registry). The criminal history background check dated 05/12/11 had a different name on it than that of CNA F. The Office Manager provided the survey team with a corrected criminal history background check, which was dated 06/01/11. Review of CNA F's time punch detail reports dated 06/06/11 revealed she worked on the following dates: 05/27/11, 05/28/11, 05/29/11, 05/30/11, 05/31/11, and 06/01/11. She worked a total of six days prior to having a criminal history background check and the NAR/EMR check completed. Review of CNA G's employee file revealed she was hired on 05/28/11 (the hire date was written in the front of the file). The facility did not check the NAR or EMR per the printed form from the registry until 06/01/11. CNA G's criminal history background check dated 04/14/11 reflected a box, which needed to be checked to open the file for the criminal history background check, but the file was never opened. On 05/30/11, when the facility fully checked into CNA G's criminal history background, there was nothing that barred her from employment. Review of CNA G's time punch detail reports dated 06/06/11 revealed she worked on 05/28/11 and 05/29/11, which was two days before her criminal history was checked. Review of RN I's employee file revealed she was hired on 04/15/11 (the hire date was written in the front of the file). Her criminal history check was dated 06/01/11. Review of RN I's time punch detail reports dated 06/06/11 revealed she worked the following dates: 04/19/11, 04/30/11, 05/01/11, 05/07/11, 05/08/11, 05/14/11, 05/15/11, 05/21/11, 05/22/11, 05/28/11 and 05/29/11. She worked eleven days before the criminal history background check was completed. Review of an employee file for LVN J revealed she was hired on 05/25/11 (the hire date was written in the front of the file). Her criminal history check was dated 05/26/11. Review of LVN J's time punch detail reports 06/06/11 revealed she worked on 05/26/11, the day her criminal history background check was completed. Review of the Social Worker's employee file revealed her date of hire was 03/25/11 (the hire date was written in the front of the file). Her criminal history background check was dated 06/02/11, more than two months after she was hired. Review of the employee file for ADM A on 06/03/11 revealed there was no criminal background check completed. His date of hire was 04/15/11 (the hire date was written in the front of the file). The facility completed a criminal history background check on 06/06/11 (72 days after he was hired). Review of ADM A's employee file again on 06/04/11 revealed there was still no criminal history background check. Review of CNA S's criminal history background check revealed two pending results, which were not reflected in the full summary report. When the facility checked the full summary report following surveyor inquiry on 06/01/11 there was nothing that barred her from employment. Interview on 06/01/11 at 11:40 a.m. with the Office Manager revealed she was responsible for the employee background checks, criminal history background checks, EMR and NAR checks. She stated surveyors were in the building earlier in the month and told her she was not completing the required checks before hire on some employees. She also stated the employees, who did not have the required checks at that time, still had not been completed because she "had not had a chance to do" them. She stated all new hires, since the previous surveyor visit, had been done. Interview on 06/02/11 at 2:30 p.m. with the Office Manager revealed no administrative staff had in-serviced her on the correct way to complete the EMR, NAR or criminal history background checks, since the surveyors' last visit in early May 2011. During the end of day conference with ADM A and ADON C on 06/02/11 at 3:30 p.m., they revealed they had offered to assist the Office Manager with the EMR, NAR and criminal history background checks. ADM A stated they had tried to help, but the Office Manager did not want help. Interview on 06/03/11 at 8:30 a.m. with the Office Manager confirmed no administrative staff had in-serviced her on the correct way to complete the EMR, NAR or criminal background checks, since the surveyor's last visit in early May 2011. Interview on 06/03/11 at 3:00 p.m. with ADM A revealed the last QA&A meetings were on 05/10/11 and 05/30/11. ADM A stated on 05/10/11, all they discussed abuse and neglect his need to be notified of incidents of abuse/neglect and the facility abuse/neglect policy. ADM A stated the abuse policy, incident/accident reports, grievances, infection control, pressure ulcers, weight loss and environment were discussed at the 05/30/11 meeting. Problems identified included housekeeping and not being cleared of their deficiencies on that visit. When asked what the plan of action was for the abuse investigations, ADM A stated, "to enforce the policy" by investigating and reporting incidents. When asked why the incidents, which occurred from 05/13/11 through 05/14/11, were not reported to DADS until 05/16/11, ADM A stated, "Because they did not report it to me." When asked why he waited until 05/19/11 to inservice his staff on abuse/neglect, he stated sometimes he "verbally" inse

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #22) of six residents reviewed for falls and monitoring/assessing lab results. Resident #22 had a history of [REDACTED]. Her room was not located close to the nurse's station, and she was left alone in her room. She was found on the floor with lacerations on her right temple and her left hand, which were bleeding profusely. Resident #22 was transferred to the emergency room due to the lacerations and complaints of head pain. Further, facility staff was not monitoring Resident #22's laboratory levels and was unaware the resident's PT/INR levels (measurement of the therapeutic level of [MEDICATION NAME], a blood thinner) were "HIGH" on the 06/01/11 lab results. The physician had not been notified of Resident #22's "HIGH" PT/INR. Following surveyor inquiry, her physician was notified of the elevated PT/INR on 06/04/11 and the resident's [MEDICATION NAME] was immediately discontinued. These failures contributed to Resident #22 falling, sustaining lacerations to her head and left hand, profuse bleeding and placed the resident at risk for additional lacerations, fractures, blood loss and death. An Immediate Jeopardy (IJ) was identified on 06/03/11 and was extended into Quality of Care on 06/04/11. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the 23 residents, who were on anticoagulant therapy, and the 38 residents, who required assistance to transfer, and placed them at risk for hemorrhage, falling, sustaining injuries such as lacerations, fractures, blood loss and death. Findings included: 1) Resident #22's Admission Nursing assessment dated [DATE] reflected the resident was admitted to the facility on the same date. The assessment revealed the following: skin clear; no complaints of pain; transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; Regular No Added Salt diet; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].[REDACTED] Resident #22's admission orders [REDACTED]. The orders further reflected laboratory orders for lab levels to be drawn: CMP, CBC, T4, TSH, Urinalysis with Culture and Sensitivity, PT/INR ([MEDICATION NAME] and International Ratio), [MEDICATION NAME] Level, Lipids A/C, and Micro [MEDICATION NAME]. Orders were included for PT and OT evaluations. 06/01/11 at 11:00 a.m. Daily Skilled Nurses Notes reflected Resident #22 was "Awake and alert and oriented to person only. Redirection unsuccessful. Unable to follow simple commands." Incontinent of bladder and bowel time two this shift. Attempts to transfer self when advised not to due to safety reasons. New Order (N.O.) for PSA (Personal Safety Alarm) at all times. Transfer with assist times one person due to weakness and decreased cognition of safety awareness. Requires constant cueing during meals. Physician's Telephone Orders dated 06/01/11 at 2:00 p.m. reflected Resident #22 was to have a Personal Safety Alarm (PSA) at all times. 06/01/11 at 3:45 p.m. Daily Skilled Nurses Notes reflected, "Lab called (with) two critical results lab values. Msg left for ___ (MD AA) Awaiting call back. ___ (LVN H)" (NOTE: The critical lab results were her [MEDICATION NAME] level and blood sugar level.) 06/01/11 at 5:30 p.m., Daily Skilled Nurses Notes reflected "___ (MD AA) returned call. N.O. received & noted. Advised not to transfer resident to locked unit d/t resident's unstable medical condition. Social worker and Adm notified. Will cont to closely monitor." Review of Resident #22's Physician's telephone orders dated 06/01/11, untimed, revealed, "1) DC [MEDICATION NAME] 2) DC [MEDICATION NAME]-[MEDICATION NAME] 3) DC [MEDICATION NAME] 4) FSBS AC & HS 5) Weekly wt on Thursday." A Physician's Telephone Order for Resident #22 dated 06/01/11 (untimed)reflected Skilled Physical Therapy was not appropriate at that time and Physical Therapy would screen the resident at a later date. The order then referred to "See PT evaluation for details." 06/01/11 at 7:05 p.m., Daily Skilled Nurses Notes reflected the resident required to be fed evening meal by this nurse. Resident attempted to go out of back door. Resident stated she wanted to go home and was not spending the night here. Social worker and Administrator notified of elopement attempt. Resident noted to stand up while holding PSA monitor in hand. 06/01/11 at 9:00 p.m., Daily Skilled Nurses Notes reflected, Blood sugar 51, resident up in wheelchair alert and remains confused. 06/02/11 at 12:01 a.m., Daily Skilled Nurses Notes reflected Resident #22 sitting at nurses station in wheelchair and attempts to get up without assistance and PSA monitor alarms. 06/02/11 at 8:00 a.m., Daily Skilled Nurses Notes reflected Resident #22 removes PSA frequently. Redirection unsuccessful. 06/02/11 at 10:20 a.m., Daily Skilled Nurses Notes reflected Resident #22 removed PSA and sat in the sink. Resident then attempted to roll wheelchair in her closet to go to the bathroom. Redirected resident to the bathroom and assisted to toilet. 06/02/11 at 4:00 p.m., Daily Skilled Nurses Notes reflected Resident #22 was found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to right forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid. 06/03/11 at 7:30 a.m. Daily Skilled Nurses Notes reflected Resident #22 requires constant cueing during meals due to confusion, redirection unsuccessful, removes PSA frequently. 06/03/11 at 3:00 p.m. Resident found ambulating in room across the hallway. Resident detached PSA monitor, remains confused and forgetful. Voided in a cup in bathroom floor and redirected to own bathroom by staff. Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration to her right upper temple area. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom, and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the upper half of the side rail on the right side of the bed was in the upright position. Further observation at this time revealed the PSA was attached to the head of bed. Observation of the hallway at that time revealed five overhead lights were burned out near Resident #22's room, leaving the hallway darkened. CNA V was observed trying to turn them on without success. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 and 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help, and I ran to the room and called for (RN Y) to come help me, because she (Resident #22) was (on the floor) in the hallway." Observation on 06/04/11 at 11:12 a.m. revealed LVN X came to Resident #22's room to assist with getting paperwork ready for Resident #22's transfer to the emergency room via ambulance. Observation on 06/04/11 at 11:15 a.m. revealed CNA V demonstrated for the surveyor how the bed alarm worked. CNA V disconnected the bed alarm from the portion of the sheet covering the head of the bed and the alarm immediately sounded. An interview with CNA V at that time revealed, "We always have to chase her and remind her to sit down. She's been here for like four days." Review of the hospital's Patient Disposition Page dated 06/04/11 revealed Resident #22 also sustained a 1.6 cm laceration on the left hand. Review of Resident #22's June 2011 MAR indicated PT INR Report," which reflected for the Current Medication as "[MEDICATION NAME]" and Dosage as "2 mg," which had been handwritten in with the rest of the form blank, which included: Last lab draw/date, Results, MD notified, New orders, NEW medication, NEW dosage and Repeat PT/INR/date. Review of Resident #22's entire clinical record on 06/04/11 at 12:30 p.m. revealed no copy of the laboratory results for the lab, which was ordered for 06/01/11. The surveyor informed LVN X there were no lab results in the resident's clinical record at that time. Lab results for the resident's PT/INR, which was ordered on [DATE], were requested also. Interview on 06/04/11 at 1:20 p.m. with LVN X revealed, "I faxed a copy of the labs to ____ (MD AA) now, and I can't find where they called the doctor about the PT/INR." Review of the 06/01/11 lab results for Resident #22 on 06/04/11 revealed they were delivered to the facility from the laboratory on 06/04/11 at 12:57 p.m. per LVN X's request. The results reflected Resident #22's: [MEDICATION NAME] Time (PT) was 45.7 seconds (high), normal was 12.4-14.8 seconds, and INR was 3.7 (high), routine therapy is 2.0 - 3.0. 31st Edition Nursing 2011 Drug Handbook, 2011, page 503, reflected the following "Black Box Warning: [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding... Regularly monitor INR in all patients...." Interview on 06/04/11 at 1:26 p.m. with LVN X revealed, "I spoke with ____ (MD AA), and he is discontinuing the [MEDICATION NAME] right now." LVN X was questioned if MD AA was aware of the PT/INR results prior to today and he responded, "____ (MD AA) said he can't recall hearing about this, he was only called the critical labs before. ____ (MD AA) will call today and try to get us a number where we can call and get his dictation. If not today, then Monday." Two telephone calls were made to LVN H on 06/04/11 at 1:30 p.m. and a message was left to return the call. LVN H received the phone call from the lab regarding the critical lab values and would have received the hard copy of the lab results via the facsimile the same day. No call was returned as of 06/08/11. Interview on 06/04/11 at 1:55 p.m. with RN Y revealed she worked 12-hour shifts on Saturday and Sunday. When asked if she had problems with the fax machine receiving labs, RN Y stated on occasion, it did not print, because there was not a cartridge available to replace it. She added they (facility) "do not keep us supplied with the cartridges." She stated there had been "...two to three times the fax had not been functional, in addition to this weekend (06/04/11)." The IJ, which was identified on 06/04/1, was extended into Quality of Care on 06/04/11. ADM B was informed the IJ was extended into Quality of Care on 06/04/11 at 2:20 p.m. and a Plan of Removal was requested for the IJ at that time. Review of the Plan of Removal (POR), accepted on 06/08/11, revealed the following: Fall assessments were completed on all residents by 06/08/11. Fall assessments will be done upon admission, quarterly, and PRN with a screen to therapy for on going evaluations. Fall assessments will be monitored by the DON and Unit Managers. Findings will be reported to the Administrator and the Quality Assurance Committee. The POR reflected two Unit Managers would be hired to assist in the monitoring of the care in the facility. One Unit Manager had accepted the position, but had to work out a two-week notice prior to starting at the facility. The facility had a QA&A meeting on 06/07/11. The fax machine, which had created the problems with delivering the entire copy of Resident #22's lab results on 06/01/11, was replaced and was functional at the time of exit. Critical labs are called to the facility by the lab. The physician is notified of the results. The POR reflected when receiving a telephone call of abnormal and/or critical lab results, the staff would contact the lab if a hard copy was not received by 5:00 p.m. the same day and hard copy results would be obtained immediately. Labs will be faxed to the DON in addition to the Nurse's station effective 06/09/11. PT/INRs are to be monitored and reviewed daily with a log at each nurse's station. Any out-of-range results will be reported to the physician for dosage recommendations. The logs will be reviewed by the DON, Unit Manager or Weekend Supervisor on a daily basis. Effective 06/06/11, all residents on anticoagulant therapy have been assessed and will have repeat PT/INRs on 06/07/11 and 06/08/11 with results available by 06/09/11. Upon admission or new order, nursing will transfer the order to the lab book, call the new order to the lab, initiate a flow sheet for monitoring of anticoagulant therapy to be kept in the front of the MAR for the duration of the therapy. Charge nurses will administer the anticoagulant therapy and will monitor lab values per the physician's orders [REDACTED]. Effective 06/06/11, PT/INR protocol to be reviewed with nursing department and in-serviced shift-to-shift to be completed by 06/09/11. The Staffing Coordinator was given the authority to call Medication Aides, LVNs and/or RNs to cover for any shortage of CNAs. Facility has reviewed applications for nursing staff increases to add one CNA on the 6-2 shift and one CNA to the 2-10 shift. Effective 06/06/11, staffing increases will be accomplished by current staff picking up extra hours until additional staff can be hired. Interviews on 06/07/11 from 1:45 p.m. through 3:00 p.m. with staff revealed they were able to report coffee-ground emesis, black in stools, severe bruising response, bloody urine and bleeding gums could be indicative of too much [MEDICATION NAME] and would be reported to the physician immediately and get orders for a PT/INR. Staff were able to respond to the need to notify physicians immediately if critical or high lab results were called to the facility and to ensure physicians were aware of abnormal lab results. If the physician did not respond within one hour, it would be reported to the DON to see if she wanted him to call the alternate physician and also hold the resident's [MEDICATION NAME] until a physician was contacted. The following staff were interviewed: LVN Q, LVN H, LVN O, LVN X, RN FF, LVN K, LVN GG and LVN HH. Interviews on 06/07/11 from 1:45 p.m. through approximately 4:00 p.m. with staff revealed if a resident was identified with a history of falls, the following interventions were provided by different staff, each verbalizing the need to be vigilant with a resident who was a designated fall risk: a different wheelchair might be tried; ensure the resident had safety alarms on his/her bed and wheelchair; never leave the resident in his/her room alone; place the resident close to the nurse's station, where he/she could be monitored; try to keep him/her occupied by walking in the hall or watching TV in the TV room with supervision; teach the resident to use the call light if capable of understanding and answer the call light as quickly as possible; toilet the resident frequently; put them to bed when they appeared tired; check for Orthostatic [MEDICAL CONDITION] (decrease in blood pressure upon rising to a standing position); check the resident's blood sugar to see if it was low; ensure all staff were aware the resident was at risk for falls; place a pad on the floor beside the resident's bed; and ensure there were no objects on the floor close to the resident, so the resident would not be tempted to reach for the objects and fall. Staff interviewed included: LVN Q, LVN H, LVN O, CNA W, DA T, Cook EE, LVN X, RN FF, LVN K, LVN GG, LVN HH, CNA S, CNA F, CNA V, CNA U, CNA LL, CNA II, MA JJ, CNA KK and CNA MM. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. Review of the facility's 73 residents' MARs revealed 23 residents had PT/INR FLOWSHEETS, which reflected the residents were currently being administered anticoagulants. The facility's Form CMS-672 (Resident Census and Conditions of Residents) dated 06/03/11 and signed by ADON C reflected 32 residents required the assistance of one or two staff to transfer and six residents were totally dependent on staff to transfer.

Based on observation, interview and record review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #22) of 10 residents reviewed for falls. 1) Resident #22 had a history of [REDACTED]. Her room was not located close to the nurse's station and she was left alone in her room. She was found on the floor with a laceration on her head and her left hand, which were bleeding profusely. Resident #22 was transferred to the emergency room due to the laceration, the amount of blood and the resident complaining of her head hurting. These failures contributed to Resident #22 falling and sustaining injuries. An Immediate Jeopardy (IJ) was identified on 06/03/11 and was extended into Quality of Care on 06/04/11. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan or removal. These failures could affect the 38 residents, who needed assistance with transfers, including Resident #22, by placing them at risk of falls and sustaining injuries such as lacerations, bruises, hematomas, and fractures. In addition to the IJ, the following deficient practices were identified: 2) Oxygen tanks were not secured in the 300 Hall Linen Closet and the 300 Hall Nurses' Station. This failure could have caused the tanks to explode if they fell over, potentially injuring any of the 73 residents, family members or staff members that were near. 3) There was a broken unsecured piece of sharp metal protruding from the outside of the dining room door, which led into the courtyard and Resident #26 kicked it. This failure could have caused Resident #26 to obtain a laceration to the foot, causing pain and infection. 4) The steam table in the dining room was left on, was hot to the touch, and there was no staff supervision. There was also a holding cart for hot food, which was accessible to residents. This failure could have caused burns and pain to any of the 52 residents, who resided in the general population of the facility, and who had access to the dining room. 5) The residents on the Secured Unit had access to the outside, anytime, unassisted. There were large, metal grates in the ground with gaps in which residents could have gotten their feet caught. This failure could affect the nine ambulatory residents residing on the Secured Unit by placing them at risk of falls and sustaining injuries such as lacerations, sprains, and fractures. 6) Toilets and/or toilet seats were not secured in the bathrooms for two (Rooms 244 and 305) of 89 rooms; and for one (400 Shower Room) of four shower rooms. This failure could affect the 20 residents residing on Hall 400 and the three residents residing in Rooms 244 and 305 by placing them at risk of falling and sustaining injuries such as lacerations, bruises, hematomas, and fractures. 7) One (Secured Unit) of three sitting areas had two electrical outlets, which were on the water-damaged wall, and they did not have covers on them. This failure could have caused any of the 23 residents in the Secured Unit to be electrocuted. Findings included: 1) Resident #22's Admission Nursing assessment dated [DATE] reflected the resident was admitted to the facility on the same date. The assessment reflected the following: skin clear; no complaints of pain; transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; Regular No Added Salt diet; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #22's admission orders [REDACTED]. The orders further reflected laboratory orders for lab levels to be drawn: CMP, CBC, T4, TSH, Urinalysis with Culture and Sensitivity, PT/INR (Prothrombin and International Ratio), Digoxin Level, Lipids A/C, and Micro Albumin. Orders were included for PT and OT evaluations. 06/01/11 at 11:00 a.m. Daily Skilled Nurses Notes reflected Resident #22 was "Awake and alert and oriented to person only. Redirection unsuccessful. Unable to follow simple commands." Incontinent of bladder and bowel time two this shift. Attempts to transfer self when advised not to due to safety reasons. New Order (N.O.) for PSA (Personal Safety Alarm) at all times. Transfer with assist times one person due to weakness and decreased cognition of safety awareness. Requires constant cueing during meals. Physician's Telephone Orders dated 06/01/11 at 2:00 p.m. reflected Resident #22 was to have a Personal Safety Alarm (PSA) at all times. 06/01/11 at 3:45 p.m. Daily Skilled Nurses Notes reflected, "Lab called (with) two critical results lab values. Msg left for ___ (MD AA) Awaiting call back. ___ (LVN H)" (NOTE: The critical lab results were her Digoxin level and blood sugar level.) 06/01/11 at 5:30 p.m., Daily Skilled Nurses Notes reflected "___ (MD AA) returned call. N.O. received & noted. Advised not to transfer resident to locked unit d/t resident's unstable medical condition. Social worker and Adm notified. Will cont to closely monitor." Review of Resident #22's Physician's telephone orders dated 06/01/11, untimed, revealed, "1) DC Digoxin 2) DC Glyburide-Metformin 3) DC Lantus 4) FSBS AC & HS 5) Weekly wt on Thursday." A Physician's Telephone Order for Resident #22 dated 06/01/11 (untimed)reflected Skilled Physical Therapy was not appropriate at that time and Physical Therapy would screen the resident at a later date. The order then referred to "See PT evaluation for details." 06/01/11 at 7:05 p.m., Daily Skilled Nurses Notes reflected the resident required to be fed evening meal by this nurse. Resident attempted to go out of back door. Resident stated she wanted to go home and was not spending the night here. Social worker and Administrator notified of elopement attempt. Resident noted to stand up while holding PSA monitor in hand. 06/01/11 at 9:00 p.m., Daily Skilled Nurses Notes reflected, Blood sugar 51, resident up in wheelchair alert and remains confused. 06/02/11 at 12:01 a.m., Daily Skilled Nurses Notes reflected Resident #22 sitting at nurses station in wheelchair and attempts to get up without assistance and PSA monitor alarms. 06/02/11 at 8:00 a.m., Daily Skilled Nurses Notes reflected Resident #22 removes PSA frequently. Redirection unsuccessful. 06/02/11 at 10:20 a.m., Daily Skilled Nurses Notes reflected Resident #22 removed PSA and sat in the sink. Resident then attempted to roll wheelchair in her closet to go to the bathroom. Redirected resident to the bathroom and assisted to toilet. 06/02/11 at 4:00 p.m., Daily Skilled Nurses Notes reflected Resident #22 was found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to right forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid. 6/03/11 at 3:00 p.m. Daily Skilled Nurses Notes reflected "Resident found ambulating in room across the hallway. Resident detached PSA monitor, remains confused and forgetful. Voided in a cup in bathroom floor and redirected to own bathroom by staff." 06/03/11 at 7:30 a.m. Daily Skilled Nurses Notes reflected Resident #22 requires constant cueing during meals due to confusion, redirection unsuccessful, removes PSA frequently. 06/03/11 at 3:00 p.m. Resident found ambulating in room across the hallway. Resident detached PSA monitor, remains confused and forgetful. Voided in a cup in bathroom floor and redirected to own bathroom by staff. Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration to her right upper temple area. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom, and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the upper half of the side rail on the right side of the bed was in the upright position. Further observation at this time revealed the PSA was attached to the head of the bed. Observation of the hallway at that time revealed five overhead lights were out near Resident #22's room, leaving the hallway darkened. CNA V was observed trying to turn them on without success. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 and 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help, and I ran to the room and called for (RN Y) to come help me, because she (Resident #22) was (on the floor) in the hallway." Observation on 06/04/11 at 11:12 a.m. revealed LVN X came to Resident #22's room to assist with getting paperwork ready for Resident #22's transfer to the emergency room via ambulance. Observation on 06/04/11 at 11:15 a.m. revealed CNA V demonstrated for the surveyor how the bed alarm worked. CNA V disconnected the bed alarm from the portion of the sheet covering the head of the bed and the alarm immediately sounded. An interview with CNA V at that time revealed, "We always have to chase her and remind her to sit down. She's been here for like four days." An Incident/Accident Report dated 06/04/11 reflected Resident #22 was yelling for help in her room and was found by a CNA. The report reflected Resident #22 was sitting up on her right hip, propping herself up with her arms and she was facing the doorway between the bathroom door and the closet door. The report reflected Resident #22 said she was trying to go to the bathroom. The report reflected she was assessed by the RN and an ambulance was called. The report reflected Resident #22 sustained a laceration to her head and she was alert. The report reflected first aid was administered and she was sent to the hospital five minutes later. Attached to the Incident/Accident Report was an Incident Investigation dated 06/04/11. The investigation reflected Resident #22 was standing and walking when the incident occurred and she was in her room. The investigation also reflected she was confused/disoriented and there had not been a change in her mental status in the last week prior to the fall. The investigation reflected, "A summary of environmental factors that contributed to the incident is present" and yes was checked. The investigation also reflected there had not been in a change in her environment. There was no information with the Incident/Accident Report provided regarding interventions in place to prevent falls or other interventions to be added to prevent a recurrence. Review of the facility's policy entitled, "Safety and Supervision of Residents" dated December 2007, provided and identified as the current policy by ADM A, revealed, "...3) The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment...or if there is a change in the resident's condition...." The facility's current undated policy entitled, "Falls Investigation," reflected, "All falls will be investigated and will be initiated by the charge nurse on duty at the time the fall occurs... Information in this investigation should be used to revise the resident's plan of care... Risk Factors to be Considered: Previous falls (include falls prior to admission of (sic) obtainable...Cognitive impairment (depression, dementia, poor judgement)...Describe Circumstances of Fall: Symptoms/Vital Signs... Time of Day Activity Trauma... Statements from staff who were on duty and/or witnessed the fall Interventions to prevent future occurrences... Notification and final disposition: Physician notification, date and time... If taken to the hospital, date, time and hospital taken to Date and time completed Signature of Nurse completing Administrator or designee notified Administrator signature." The IJ, which was identified on 06/03/11, was extended into the area of Quality of Care on 06/04/11. On 06/04/11 at 2:20 p.m., ADM B was informed the IJ had been extended into the area of Quality of Care and a Plan of Removal was requested at that time. Review of the Plan of Removal (POR) accepted on 06/08/11 revealed a new Administrator had been appointed effective 06/04/11. All provider investigations were reviewed to determine the appropriate actions had been implemented. Fall assessments were completed on all residents by 06/08/11. The POR reflected the facility planned to hire two Unit Managers to assist in the monitoring of the care in the facility and one Unit Manager accepted the position, but had to work out a two-week notice prior to starting at the facility. The facility had a QA&A meeting on 06/07/11. The Staffing Coordinator was given the authority to call Medication Aides, LVNs and/or RNs to cover for any shortage of CNAs, until new staff could be hired. Interviews on 06/07/11 from 1:45 p.m. through approximately 4:00 p.m. with staff revealed if a resident was identified with a history of falls, the following interventions were provided by different staff, each verbalizing the need to be vigilant with a resident who was a designated fall risk: a different wheelchair might be tried; ensure the resident had safety alarms on his/her bed and wheelchair; never leave the resident in his/her room alone; place the resident close to the nurse's station, where he/she could be monitored; try to keep him/her occupied by walking in the hall or watching TV in the TV room with supervision; teach the resident to use the call light if capable of understanding and answer the call light as quickly as possible; toilet the resident frequently; put them to bed when they appeared tired; check for Orthostatic Hypotension (decrease in blood pressure upon rising to a standing position); check the resident's blood sugar to see if it was low; ensure all staff were aware the resident was at risk for falls; place a pad on the floor beside the resident's bed; and ensure there were no objects on the floor close to the resident, so the resident would not be tempted to reach for the objects and fall. Staff interviewed included: LVN Q, LVN H, LVN O, CNA W, DA T, Cook EE, LVN X, RN FF, LVN K, LVN GG, LVN HH, CNA S, CNA F, CNA V, CNA U, CNA LL, CNA II, MA JJ, CNA KK and CNA MM. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan or removal. In addition to the IJ, the following deficient practices were identified: 2) Resident #26 was a [AGE] year-old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She currently resided on the Secured Unit. Observation on 06/02/11 at 1:55 p.m. revealed Resident #26 kicked the broken, unsecured piece of sharp metal protruding from the outside of the dining room door, which led into the Secured Unit's courtyard. There was a piece of gold-colored bar, which was not secured to the door. The surveyor informed the AD at that time. Review of a Witness Statement Form dated 06/02/11 revealed, "Around 2:10 p.m., one of the state surveyors said they saw a resident kicking at the dinning (sic) room door (outside) and wanted to have her checked out. Went over to west hall & reported the incident & ask them to check her out." The form was completed by the AD and had Resident #26's name on it. On 06/08/11 at approximately 3:00 p.m. the surveyors requested the Incident/Accident Report from ADM B, the DON, and ADON FF. The surveyors, ADM B, the DON, and ADON FF searched through stacks of paperwork, but they could not locate the Incident/Accident Report for Resident #26. 3) On 06/02/11 at 11:22 a.m. and at 12:43 p.m., the steam table in the main dining room was observed. Steam was coming from the wells, and the water inside the wells measured at 170 degrees F. The exterior was also hot to touch. The steam table was accessible to residents as there was no barrier or separation to close it off from anyone who walked past. Approximately six unidentified residents were observed ambulating in and around the steam table at that time. A holding cart for hot food was also observed next to the steam table and was also accessible to residents. The exterior thermometer on the cart measured a temperature of 154 degrees F. During the observation on 06/02/11 at 11:22 a.m., there were six residents in and around the area of the steam table. Interview with the DM on 06/02/11 at about 1:15 p.m., revealed he had discussed the location and potential danger of the main dining room steam table to ADM A last week. The DM had requested a half-wall or some kind of barrier to keep the residents away from the steam table. 4) Observation on 05/31/11 at 11:00 a.m. in the shower room on the 400 Hall revealed the toilet seat was not secured tightly to the toilet. The bathroom was not locked. 5) Observation on 05/31/11 at 11:05 a.m. on the 300 Hall revealed inside the clean linen closet was an unsecured bottle of oxygen. 6) Observation on 05/31/11 at 11:06 a.m., behind the 300 Hall nurse's station revealed an unsecured tank of oxygen, which was propped up in the corner. 7) Observation on 05/31/11 at 11:09 a.m. in the Secured Unit revealed a sitting area off the main activity area. There was a cove base, which was missing from the wall. The wall was observed with water damage. Sheetrock was missing in areas. There was brown paper taped to the floor, below the water-damaged wall. There were two electrical outlets, which were on the water damaged wall, and they did not have covers on them. 8) Observation on 05/31/11 at 1:04 p.m. in Room 244 revealed the toilet in the room was not secured to the floor. The surveyor was able to turn the toilet 15 degrees with her foot. The 300 Hall nurse confirmed the resident in 244 B used the toilet in that bathroom. The surveyor requested the Maintenance Man to come to Room 244. During this observation, the resident in the B bed said she used that bathroom. Interview on 05/31/11 at 1:10 p.m. with the Maintenance Man revealed he was not aware of the toilet not being secured to the floor. When asked if he was aware of any other toilets he had recently repaired, or were in need of repair, the Maintenance Man stated there were no other toilets in need of repair. He stated he would repair the toilet at that time. The Maintenance Man and the 300 Hall nurse returned to the room at 1:20 p.m. The nurse provided the surveyor with the maintenance request log. The log reflected on 05/23/11, "Toilet seat broke...loose toilet." The entry had not been signed off, which indicated it had not been repaired. 9) Observation on 06/02/11 at 1:55 p.m. of the outside courtyard of the Secured Unit revealed a metal grate with approximately one and one-half inch openings in the grates. The door to the courtyard was not locked. 10) The CMS-672 (Resident Census and Conditions of Residents) dated 06/03/11 and provided by ADON C reflected the census was 73 with 38 residents needing assistance with transfers. The facility's Room Roster dated 05/31/11 reflected 20 residents resided on Hall 400, three residents resided in Rooms 244 and 305, and 23 residents resided on the Secured Unit. Initial tour on 05/31/11 of the Secured Unit from 9:22 a.m. through approximately 11:00 a.m. revealed nine residents on the Unit were ambulatory.

Based on observation, interview and record review, it was determined the facility failed to promptly notify the physician of lab results for one (Resident #22) of six residents reviewed for laboratory services. Resident #22 had a history of [REDACTED]. She was found on the floor with lacerations on her right temple and her left hand, which were bleeding profusely. Facility staff was unaware the resident's PT/INR levels (measurement of the therapeutic level of [MEDICATION NAME], a blood thinner) were "HIGH" on the 06/01/11 lab results, and the physician had not been notified of Resident #22's "HIGH" PT/INR. Following surveyor inquiry, her physician was notified of the elevated PT/INR on 06/04/11 and the resident's [MEDICATION NAME] was immediately discontinued. The resident was transferred to the ER for treatment. This failure could have contributed to Resident #22 falling, which resulted in lacerations with profuse bleeding and placed the resident at risk for additional lacerations, fractures, blood loss and death. An Immediate Jeopardy (IJ) was identified on 06/03/11 and was extended into Administration on 06/04/11. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures could affect the 23 residents, who were on anticoagulant therapy and placed them at risk for hemorrhage, falling, sustaining injuries such as lacerations, fractures, blood loss and death. Findings included: Resident #22's Admission Nursing assessment dated [DATE] reflected the resident was admitted to the facility on the same date. The assessment reflected the following: skin clear; no complaints of pain; transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].[REDACTED] Resident #22's admission orders [REDACTED]. The orders further reflected laboratory orders for lab levels to be drawn: CMP, CBC, T4, TSH, Urinalysis with Culture and Sensitivity, PT/INR ([MEDICATION NAME] and International Ratio), [MEDICATION NAME] Level, Lipids A/C, and Micro [MEDICATION NAME]. Orders were included for PT and OT evaluations. 06/01/11 at 3:45 p.m. Daily Skilled Nurses Notes reflected, "Lab called (with) two critical results lab values. Msg left for ___ (MD AA) Awaiting call back. ___ (LVN H)" (NOTE: The critical lab results were her [MEDICATION NAME] level and blood sugar level.) 06/01/11 at 5:30 p.m., Daily Skilled Nurses Notes reflected "___ (MD AA) returned call. N.O. received & noted. Advised not to transfer resident to locked unit d/t resident's unstable medical condition. Social worker and Adm notified. Will cont to closely monitor." Review of Resident #22's Physician's telephone orders dated 06/01/11, untimed, revealed, "1) DC [MEDICATION NAME] 2) DC [MEDICATION NAME]-[MEDICATION NAME] 3) DC [MEDICATION NAME] 4) FSBS AC & HS 5) Weekly wt on Thursday." 06/02/11 at 4:00 p.m., Daily Skilled Nurses Notes reflected Resident #22 was found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to right forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid. Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration to her right upper temple area. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom, and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the upper half of the side rail on the right side of the bed was in the upright position. Further observation at this time revealed the PSA was attached to the head of the bed. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 and 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help, and I ran to the room and called for (RN Y) to come help me, because she (Resident #22) was (on the floor) in the hallway." Observation on 06/04/11 at 11:12 a.m. revealed LVN X came to Resident #22's room to assist with getting paperwork ready for Resident #22's transfer to the emergency room via ambulance. Review of the hospital's Patient Disposition Page dated 06/04/11 revealed Resident #22 also sustained a 1.6 cm laceration on the left hand. Review of Resident #22's June 2011 MAR indicated PT INR Report," which reflected for the Current Medication as "[MEDICATION NAME]" and Dosage as "2 mg," which had been handwritten in with the rest of the form blank, which included: Last lab draw/date, Results, MD notified, New orders, NEW medication, NEW dosage and Repeat PT/INR/date. Review of Resident #22's entire clinical record on 06/04/11 at 12:30 p.m. revealed no copy of the laboratory results for the lab, which was ordered for 06/01/11. The surveyor informed LVN X there were no lab results in the resident's clinical record at that time. Lab results for the resident's PT/INR, which was ordered on [DATE], were requested also. Interview on 06/04/11 at 1:20 p.m. with LVN X revealed, "I faxed a copy of the labs to ____ (MD AA) now, and I can't find where they called the doctor about the PT/INR." Review of the 06/01/11 lab results for Resident #22 on 06/04/11 revealed they were delivered to the facility from the laboratory on 06/04/11 at 12:57 p.m. per LVN X's request. The results reflected Resident #22's: [MEDICATION NAME] Time (PT) was 45.7 seconds (high), normal was 12.4-14.8 seconds, and INR was 3.7 (high), routine therapy is 2.0 - 3.0. 31st Edition Nursing 2011 Drug Handbook, 2011, page 503, reflected the following "Black Box Warning: [MEDICATION NAME] ([MEDICATION NAME]) can cause major or fatal bleeding... Regularly monitor INR in all patients...." Interview on 06/04/11 at 1:26 p.m. with LVN X revealed, "I spoke with ____ (MD AA), and he is discontinuing the [MEDICATION NAME] right now." LVN X was questioned if MD AA was aware of the PT/INR results prior to today and he responded, "____ (MD AA) said he can't recall hearing about this, he was only called the critical labs before...." Interview on 06/04/11 at 1:55 p.m. with RN Y revealed she worked 12-hour shifts on Saturday and Sunday. When asked if she had problems with the fax machine receiving labs, RN Y stated on occasion, it did not print, because there was not a cartridge available to replace it. She added they (facility) "do not keep us supplied with the cartridges." She stated there had been "...two to three times the fax had not been functional, in addition to this weekend (06/04/11)." An IJ, which was identified on 06/03/11, was extended into the area of Administration on 06/04/11. ADM B was informed of the IJ on 06/04/11 at 2:20 p.m. and a Plan of Removal was requested for the IJ at that time. Review of the Plan of Removal (POR), accepted on 06/08/11, revealed the following: Fall assessments were completed on all residents by 06/08/11. Fall assessments will be done upon admission, quarterly, and PRN with a screen to therapy for on going evaluations. Fall assessments will be monitored by the DON and Unit Managers. Findings will be reported to the Administrator and the Quality Assurance Committee. The POR reflected two Unit Managers would be hired to assist in the monitoring of the care in the facility. One Unit Manager had accepted the position, but had to work out a two-week notice prior to starting at the facility. The facility had a QA&A meeting on 06/07/11. The fax machine, which had created the problems with delivering the entire copy of Resident #22's lab results on 06/01/11, was replaced and was functional at the time of exit. Critical labs are called to the facility by the lab. The physician is notified of the results. The POR reflected when receiving a telephone call of abnormal and/or critical lab results, the staff would contact the lab if a hard copy was not received by 5:00 p.m. the same day and hard copy results would be obtained immediately. Labs will be faxed to the DON in addition to the Nurse's station effective 06/09/11. PT/INRs are to be monitored and reviewed daily with a log at each nurse's station. Any out-of-range results will be reported to the physician for dosage recommendations. The logs will be reviewed by the DON, Unit Manager or Weekend Supervisor on a daily basis. Effective 06/06/11, all residents on anticoagulant therapy have been assessed and will have repeat PT/INRs on 06/07/11 and 06/08/11 with results available by 06/09/11. Upon admission or new order, nursing will transfer the order to the lab book, call the new order to the lab, initiate a flow sheet for monitoring of anticoagulant therapy to be kept in the front of the MAR for the duration of the therapy. Charge nurses will administer the anticoagulant therapy and will monitor lab values per the physician's orders [REDACTED]. Effective 06/06/11, PT/INR protocol to be reviewed with nursing department and in-serviced shift-to-shift to be completed by 06/09/11. The Staffing Coordinator was given the authority to call Medication Aides, LVNs and/or RNs to cover for any shortage of CNAs. Facility has reviewed applications for nursing staff increases to add one CNA on the 6-2 shift and one CNA to the 2-10 shift. Effective 06/06/11, staffing increases will be accomplished by current staff picking up extra hours until additional staff can be hired. Interviews on 06/07/11 from 1:45 p.m. through 3:00 p.m. with staff revealed they were able to report coffee-ground emesis, black in stools, severe bruising response, bloody urine and bleeding gums could be indicative of too much [MEDICATION NAME] and would be reported to the physician immediately and get orders for a PT/INR. Staff were able to respond to the need to notify physicians immediately if critical or high lab results were called to the facility and to ensure physicians were aware of abnormal lab results. If the physician did not respond within one hour, it would be reported to the DON to see if she wanted him to call the alternate physician and also hold the resident's [MEDICATION NAME] until a physician was contacted. The following staff were interviewed: LVN Q, LVN H, LVN O, LVN X, RN FF, LVN K, LVN GG and LVN HH. While the IJ was removed on 06/08/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. Review of the facility's 73 residents' MARs revealed 23 residents had PT/INR FLOWSHEETS, which reflected the residents were currently being administered anticoagulants.

The facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for eight (Residents #3, #4, #7, #10, #12, #16, #20 and #22) of eight residents as determined by resident assessments and individual plans of care. Further residents affected included the residents residing on the Secure Unit, the 400 & 500 Halls and the North Hall, which had short staffing. 1) Resident #22 had a history of [REDACTED]. She was sent to the ER for treatment. The resident fell on [DATE] and was found wandering multiple times, but Resident #22 was not moved closer to the nurses' station so she could be monitored more closely and nothing more than the personal alarm (she kept removing) was implemented in the five days she was in the facility. Two CNAs were assigned to Resident #22's hall and another hall when she fell on [DATE]. The CNA had returned her to her room and left her along and unsupervised. The two CNAs had 34 residents to provide care for. The failure to provide adequate supervision and monitoring for Resident #22 resulted in unwitnessed falls with lacerations, bleeding and complaints of head pain, with the need for evaluation and treatment at the ER. The resident did not return to the facility, but was transferred to another facility per family request when discharged from the hospital. 2) There was never a posting of the daily staffing in the facility from 05/31/11 through 06/09/11. 3) Five confidential interviews reported staffing shortages with residents left soiled and the need for family members to provide incontinent care for the residents. 4) LVN K revealed she was overwhelmed with providing professional nursing care in addition to assisting the CNA with ADLs for 19 residents. 5) On 05/31/11 at 9:20 a.m. on the Secure Unit with 24 residents, there was LVN Q, LVN M and CNA QQ to provide care. 6) Resident #4 was observed to wander in and out of seven rooms with only the Housekeeper providing redirection. Nursing staff were at medication carts and provided no redirection to the resident. This failure placed Resident #4 at risk for the potential of harm by wandering in and out of other residents' rooms with other residents potentially reacting negatively to the resident entering their rooms, possibly physically injuring her. 7) Resident #3 remained positioned in a Geri-chair for four and one-half hours, not being repositioned or provided incontinent care and taken to lunch without being checked for incontinent care until 1:20 p.m. when she was returned to her room. 8) When Resident #12 was found on the floor of the "common room," having sustained a raised area on her forehead, LVN R documented the reason for the fall as "Not enough staff." 9) ADON C was not able to provide the survey team with a weekly schedule. She made the schedule up on a daily basis asking staff to work the next day, and was not able to state with accuracy who had worked the previous week. 10) ADON C had stacks and stacks of unsigned MDS assessments in her office, and said she was trying to catch up on getting the MDS assessments completed. 11) CNA S stated he was the only 2-10 shift CNA assigned to two halls on on 05/31/11 with a total of 34 residents to provide care for. 12) Resident #10 refused to take showers in the common shower room when it had not been cleaned due to a lack of staff to clean it after each use. On 06/03/11, the shower room Resident #10 used had multiple smears of fecal material on the floor, shower chair and toilet. 13) Residents #7, #12, #16 and #20 were seated in the lobby of the Secure Unit wearing socks on their feet with no shoes. 14) CNA RR and LVN SS were the two staff assigned to the North Hall on 06/05/11 for the day shift to provide care for 19 residents. Seven residents were two-person transfers, six residents required two-person toileting, three residents were bed-bound and one resident was transferred via Hoyer lift. These failures placed the facility's 73 residents, including Residents #3, #4, #7, #10, #12, #16, #20 and #22, and placed them at risk for falls, injuries, inadequate incontinent care, inadequate bathing, not having their health and psycho-social needs met, having a negative impact on their quality of life, health and well-being. Findings included: 1) Resident #22's Admission Nursing assessment dated [DATE] reflected the following: transfers with assist of one person; hearing and vision was adequate; communication was clear; needed assistance with eating; assistance with personal hygiene, grooming and dressing; disoriented to time and place; alert and friendly; wanders mentally and answers questions inappropriately; continent of bladder with dribbles and continent of bowel (sic). Resident to receive physical therapy, occupational therapy and speech therapy (sic). Resident #22's Fall Risk assessment dated [DATE] reflected a total score of 10, which reflected the resident as being at High Risk for falls. The resident's Fall Risk Assessment reflected Resident #22 had a history of [REDACTED]. Resident #22, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].[REDACTED] Daily Skilled Nurses Notes dated 06/01/11 at 11:00 a.m. revealed Resident #22 was "Awake and alert and oriented to person only. Redirection unsuccessful, unable to follow simple commands. Attempts to transfer self when advised not to due to safety reasons. New order for Personal Safety Alarm (PSA) at all times. Transfer with assist time one person due to weakness and decrease cognition of safety awareness. Requires constant cueing during meals." Resident #22's Daily Skilled Nurses Notes dated 06/02/11 at 4:00 p.m. reflected, "Resident (Resident #22) found on floor in room across the hall from her own by family member. Resident unable to recall what happened due to impaired memory. Skin tear noted to rt. forearm. Skin tear cleansed with wound cleanser, triple antibiotic ointment and covered with band aid." Resident #22's Daily Skilled Nurses Notes dated 06/03/11 at 7:30 a.m. reflected, "Requires constant cueing during meals due to confusion, redirection unsuccessful, removes PSA frequently." Observation on 06/04/11 at 11:05 a.m. revealed Resident #22 was sitting on the floor in the doorway of her room with a laceration on the right side of her head in the area of her temple. Resident #22 was assisting CNA V to apply pressure to the site of the laceration with a white towel. A profuse amount of blood was observed on the resident's blouse, hands, towel, carpet and CNA V's gloves. Resident #22 stated, "I was trying to get to the bathroom and I fell . My head hurts." CNA V took Resident #22's vital signs and RN Y completed an assessment of Resident #22, keeping her in the recumbent position, leaning back with the support of CNA V. Resident #22's wheelchair was observed next to the bed and the top quarter side rail was up on the right side of the bed. Further observation at this time revealed the alarm was still attached to the head of the bed. Interview with CNA V on 06/04/11 at 11:10 a.m. revealed, "On Hall 400 & 500 we have two nurses and two CNAs. ___ (CNA Z) is working this hallway with me. The last shift told me she (Resident #22) was awake the whole night and went to bed about 4:00 a.m. At 6:00 a.m. we woke her up and took her to the dining room for breakfast. She took her alarm off. I heard her yelling for help and I ran to the room and called for ____ (RN Y) to come help me, because she (Resident #22) was in the hallway." Review of the hospital's Patient Disposition Page dated 06/04/11 revealed Resident #22 also sustained a 1.6 cm laceration on the left hand. 2) Observation of the facility, during the initial tour, on 05/31/11 at a.m. revealed there was no posting of the daily staffing. Interview on 05/31/11 at 2:10 p.m. with the SW revealed they would get the nurse staffing posted immediately. Observation of the facility every day from 05/31/11 through 06/08/11 revealed there was never any posting of the daily staffing. 3) The following interviews were confidential: Interview #1: It was reported to the surveyor the Secure Unit was "understaffed." and there was a lot of staff turn-over. The past Saturday (05/29/11) there was only one nurse and one CNA on the Secure Unit. He/She said ____ (resident's name) was "dirty and wet." The shortage of staff "happens a lot, especially on the weekends," and "it's worse on the PM (2-10) shift." "___ (resident's name) is wet 8 of 10 visits." He/She said the resident had been wet from his/her waist to his/her socks. It was also reported at times, the resident had not had a bath. He/She said, "I'm scared not to come up every day - scared to death. ____ (the resident) needs to be taken care of." Interview #2: It was also reported they were tired of having to do the CNA's job. The resident being visited was always wet or dirty and in need of cleaning, which one of the visitors would have to provide, and there was always a shortage of CNAs, which was why the visitors had to provide the resident's care. Confidential #1: There "normally" are two CNAs on the ___ hall, but sometimes the staff was "short-handed." Confidential #2: They were supposed to have two CNAs on the hall, but they are "always short (of staff)." "Sometimes I get angry. People work out of the goodness of their heart...." Confidential #3: One CNA had to work on the hall alone "three times," and then "everything slows down." 4) Interview on 05/31/11 at 9:40 a.m. with LVN K revealed for three weeks on the 6 - 2 shift, there had only been one CNA and herself taking care of 19 residents. LVN K stated she was having to do "aide" work and felt "overwhelmed." Approximately a week ago, a newly hired CNA oriented with her for two days, but never came back to work. 5) When the surveyor entered the Secure Unit for orientation tour on 05/31/11 at 9:20 a.m., there were two LVNs (LVN Q and LVN M) and one CNA (CNA QQ). There were 24 residents on the Secure Unit according to LVN Q. Review of a handwritten schedule, provided by ADON C, for 05/31/11, revealed there were two CNAs scheduled for the Secure Unit. However, one CNA was a "Call in." 6) Resident #4 was an [AGE] year-old female, who was admitted to the facility on [DATE], according to the face sheet (date unreadable). During orientation rounds on 05/31/11 at 10:15 a.m., Resident #4 was observed ambulating in the hallway and in the sitting area of the Secure Unit. LVN M stated she sometimes "refused care," "was combative," "wanders," and changed her clothes several times a day. Resident #4 was observed to wander in and out of seven rooms Rooms 117, 116, 118, 120, 121, 119, and 111 on 05/31/11 from 2:45 p.m. to 2:53 p.m. The only staff person, who intervened was the Housekeeper. The resident was not re-directed and continued to wander in and out of other residents' rooms. Nursing staff were observed at the medication carts. No MDS was found for Resident #4 in the stack of MDs furnished for surveyors. The morning of 06/02/11 (time unknown) the surveyor asked for Resident #4's MDSs. No initial or quarterly MDSs were furnished to surveyors prior to the exit conference on 06/08/11. 7) Resident #3 was a [AGE] year-old female, who was admitted to the facility on [DATE], according to the face sheet (date unreadable). During orientation rounds on 05/31/11 at 10:22 a.m. Resident #3 was observed to be asleep in her Geri-chair in the sitting area. There was a large bruised area on the left side of her forehead and cheek area near her left eye. LVN M stated she was "total care" requiring incontinent care, assistance with transfers, and has to fed and dressed by staff. Surveyors remained on the Secure Unit from 8:45 a.m. until 1:20 p.m. on 06/01/11. Resident #3 was under constant observation during that time. She was lying in a reclining Geri-chair in the sitting area. She was not repositioned nor moved from the Geri-chair. She was not changed or provided incontinent care. Staff did not check her before taking her to lunch to see if she needed to be changed. Staff took her to the dining room, fed her, and returned her to the sitting area. This was over a period of four and one-half hours. During the end-of-day meeting on 06/01/11 at 4:20 p.m., the surveyor asked ADON C for Resident #3's MDS assessments and the HCP The morning of 06/02/11 (time unknown) the surveyor asked again for Resident #3's MDSs and HCP. On 06/02/11 at 2:02 p.m. ADON C advised the MDS and HCP were not done. 8) Resident #7 was an [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the last quarterly MDS assessment dated [DATE] revealed Resident #7 was severely cognitively impaired, frequently incontinent of bowel/bladder, ambulated using a walker, wanderer up and down the halls, and had violent behavior episodes. An observation on 06/01/11 at 9:30 a.m., Resident #7 was ambulating down the hallway using her walker to go to the beauty shop. Resident #7 was observed wearing socks without shoes. A review of the Nurse's Notes dated 05/30/11 at 11:45 a.m. revealed Resident #7 was agitated, cursing, and grabbed the nurses hands/wrists and refused to let go. Review of Resident #7's entire clinical record revealed the last quarterly MDS assessment was completed 10/26/10. There were no quarterly MDS assessments for January 2011 and April 2011. An interview on 06/03/11 at 11:10 a.m. with ADON C revealed the facility did not have enough help. ADON C stated, "Right now, I have to do it all." ADON C said she was responsible for completing the MDS assessments, care plans if she had time, thinning charts, putting physician orders [REDACTED]. ADON C said the facility did not have enough administrative staff. ADON C said she used to check the MARs at the end of the month, but she was too busy now. ADON C stated, "I'm one person. I can only do so much. Too many hats." During an interview on 06/03/11 at 11:50 a.m., the surveyor queried ADON C whether the quarterly MDS assessments and HCPs were completed for all residents because several were not in the residents' clinical records and had not been brought to the conference room when requested. ADON C said if they were not brought to the conference room to the survey team, then they were not done. 9) Resident #12 was an [AGE] year-old female, who was admitted to the facility on [DATE], according to the face sheet (date unreadable). During orientation rounds on 05/31/11 at 9:52 a.m. Resident #12 was observed to be in her wheelchair in the hallway and was able to move about without assistance. The left side of her forehead had a fading bruise. Review of a facility incident report dated 05/19/11 at 8:20 p.m. revealed Resident #12 was found on the floor of the "common room" on her left side with her personal alarm sounding. A 4.4 cm x 5.7 cm raised area was found on her forehead. In the Investigative Summary area of the report, LVN R documented: "No one saw fall, unknown if she tried to get (up arrow) or if she just fell forward out of w/c." On the checklist of Environmental Factors, "Other factors contributing to incident" reflected: "Not enough Staff." The surveyor asked ADON C for the MDS assessments and HCPs for Resident #12 on 06/03/11 at 11:09 a.m. No initial MDS was furnished to surveyors that was dated within 14-days of her admitted on 12/09/10. No HCP was provided to surveyors prior to the exit conference on 06/08/11. 10) ADON C was interviewed about the staffing schedule on 05/31/11 at 4:20 p.m. She reported she put two CNAs and two LVNs on the Secure Unit. She was repeated requested to provide a schedule of staff assigned to work at the facility. She said she did not have a schedule "right now. I am asking people to work." She explained during every day she went around to staff asking them if they wanted to work the next day and put their names down when they said they would. She said she was unable to provide a schedule for the previous week, because she said she really was not sure who had worked. She stated when she began working at the facility, the Former DON was doing the staffing. ADON C said she "felt sorry for her because she was overwhelmed and took staffing." The ADON stated, "No one wants to do it." 11) Interview on 06/01/11 at 8:40 a.m. with ADON C revealed she normally completed the MDS assessments and left them on her desk for the DON to sign. She added the "piles" of MDS assessments, which were currently on her desk had not been signed. She said she was trying to catch up on getting them done, but she had just not had the time. The survey team requested the MDS assessments, which had not been signed to be brought to the survey team. Observation on 06/01/11 at 10:55 a.m. revealed ADON C wheeled in a two-shelf metal cart, with stacks of MDS assessments on both bottom and top shelves. The multiple stacks of unsigned MDS assessments were more than one-foot thick. ADON C stated she just did not have time to do the MDS assessments like they were supposed to be done, because she was only "one person." Interview on 06/01/11 at 11:15 a.m. with the Co-Owner of the facility revealed she was not aware the MDS assessments had not been signed. Interview on 06/01/11 at 11:25 a.m. with the Co-Owner and the SW revealed most of the MDS assessments, which were on ADON C's desk had not been signed. 11) On 06/01/11 at 3:28 p.m., CNA S stated he was the only 2-10 shift CNA on the 400 and 500 halls on 05/31/11. He stated he almost quit, because it was too much to do for one CNA. "They begged me to stay." Review of the resident roster, dated 05/31/11, revealed there were approximately 19 residents on 400 hall and 15 residents on the 500 hall. The schedule (handwritten and provided by ADON C) revealed there were two CNAs clocked in on 05/31/11 on the 2-10 shift. There was another CNA scheduled to work from 5:00 p.m. to 10:00 p.m. during that shift. 12) Resident #10 was a [AGE] year-old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. MDS assessment dated [DATE]. Resident #10 was able to complete an interview. Resident #10 required limited assistance and was dependent on one staff member for dressing, toilet use, personal hygiene and transfers during bathing. Resident #10 used a wheelchair for mobility. Review of Resident #10's entire clinical record revealed there was no quarterly MDS assessment completed, which would have been due May 2011. Interview on 06/03/11 at 3:00 p.m. revealed Resident #10 complained to staff "all the time" about feces left behind in the shower room on Hall 300. The resident refused to take a shower in the shower room when feces was present. Resident #10 stated staff had to clean the shower and place towels on the floor before she would agree to use the shower room. The staff were sometimes "too busy to clean the shower," and Resident #10 then went without a shower. Observation of the Hall 300 shower room on 06/03/11 at 3:20 p.m. revealed smears of brown fecal material on the shower room floor beside the shower and beside the toilet. Brown fecal smears were also observed on the front of a shower chair, and dried brown fecal material was observed on the front of the toilet. 13) Observation on 06/04/11 at 11:30 a.m., revealed Resident #7 was sitting in the lobby of the Secure Unit with brown stains on the front of his shirt and pants. She was wearing only socks on her feet and no shoes. 14) Observation on 06/04/11 at 11:35 a.m. revealed Residents #16 and #20 sitting in the lobby of the Secure Unit wearing only socks on their feet and no shoes. Resident #16's MDS assessment, dated 01/07/11, reflected the resident had inattention and disorganized thinking. Resident #16 required limited assistance with transfers and dressing and extensive assistance with bathing. Care plans dated April 2010 reflected Resident #16 had cognitive loss, impaired visual function and a potential for violent behavior. According to the May 2011 consolidated physician's orders [REDACTED]. 15) Observation on 06/04/11 at 11:36 a.m. revealed Resident #12 was sitting in a wheelchair in the lobby of the Secure Unit wearing only socks on her feet and no shoes. Resident #12 was loudly repeating, "Can you bring my shoes to me, Honey?" while beckoning to anyone within her sight. Staff did not respond to Residents #7, #12 or #16 or try to ensure they had shoes on their feet. 16) Staffing was observed during the monitoring visit on 06/05/11 at 8:40 a.m. on the North Hall. There was one CNA (CNA RR) and one LVN (LVN SS) for 19 residents. LVN SS said she had to assist CNA RR with two-person transfers. The surveyor asked how many two-person transfers there were. LVN SS counted seven residents, who required two-person transfers. She stated they toileted six residents, three were bed-bound, and they used a Hoyer lift to transfer Resident #1. Review of the staffing, time-punch detail for 06/05/11 revealed there were five CNAs on the day shift for the entire facility. However, one of the CNAs was only there from 6:00 a.m. to 10:30 a.m. There were three LVNs, who were identified on the time-punch detail as having been there for the entire building. 11) Surveyors asked new Administrator B about the staffing ratio at the facility on 06/05/11 at 10:00 a.m. He responded, "I don't know (what the ratio is). But we will look at it. That's one of the top things on the list." 12) The Form CMS-672 (Resident Census and Conditions of Residents) dated 06/03/11 and signed by ADON C reflected there was a census of 73 residents along with the following: two residents with an indwelling or external catheter, 24 residents occasionally or frequently incontinent of bladder, 20 residents occasionally or frequently incontinent of bowel, three residents were bedfast all or most of the time, 46 residents were in the chair all or most of the time, nine residents were independently ambulatory, 15 residents ambulated with assistance or assistive devices and 19 residents had contractures. The space for the number of residents with contractures on admission was left blank. Sixty-nine residents required assistance with bathing, nine residents were totally dependent on staff for bathing, 57 residents required assistance with dressing, five residents were totally dependent on staff for dressing, 32 residents required assistance with transfers, six residents were totally dependent for transfers, 49 residents required assistance with toileting, six residents were totally dependent for toileting, 33 residents required assistance with eating and three residents were totally dependent upon staff for eating. There were 31 residents with documented signs/symptoms of Depression, 10 residents with a documented psychiatric diagnosis (excluding Dementia and Depression), 33 residents with Dementia and 29 residents with behavioral symptoms.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of seven residents reviewed for administration of medications was provided pharmaceutical services to meet their needs, as ordered by the physician. Resident #1 was admitted on [DATE] with physician's orders [REDACTED]. The dose of Coumadin would be adjusted based on the lab results. Due to a transcription error, Resident #1 was administered 7.5 mg of Coumadin instead of the intended 4 mg and did not have any lab draws for PT/INRs until he was sent to the hospital on [DATE] with a Hemoglobin level of 8 g/ml (reference range: 11.7-13.8 g/ml). These failures resulted in Resident #1's hospitalization and could put the seven residents on Coumadin at risk for not receiving the desired control of the blood's clotting ability. Findings included: A review of the face sheet for Resident #1 revealed she was admitted from an acute care facility on 12/06/10 with a [DIAGNOSES REDACTED]. Review of Resident #1's December 2010 MAR indicated [REDACTED].o. Q PM. Instructions for the administration included: "Hold if INR > 2.5." Review of the physician's admission orders [REDACTED]> 2.5. The physician admission orders [REDACTED]. An interview was conducted with LVN B, Resident #1's admitting nurse, on 12/29/10 at 1:55 PM. LVN B was queried as to how she established the admission orders [REDACTED]. At that time, LVN B produced from the resident's clinical record the hospital transfer orders dated 12/06/10, which included the following order: "When patient transferred to Rehab, will need PT/INR every Monday and Thursday and adjust Coumadin as needed." The transfer orders also included an order to decrease the daily dose of Coumadin to 4 mg. A document entitled "Pharmacy" dated 12/05/10 (one day prior to transfer) was with the transfer orders and reflected an order for [REDACTED]. During the same interview, LVN B stated the normal procedure for admission orders [REDACTED]. LVN B said she faxed Resident #1's orders to the physician, but she could not recall whether she received a response from the physician. As the interview was continued, LVN B was queried regarding the lack of orders to monitor Resident #1's PT/INR, and the order to lower the Coumadin dosage. LVN B stated she made a mistake; she was so overwhelmed the night Resident #1 was admitted . She also revealed she was new to long term care, and Resident #1 was her first admission. Review of Resident #1's December 2010 MAR indicated [REDACTED]. At that time, the surveyor asked LVN B how she determined if the Coumadin should be administered based on the specified parameters, since no PT/INR was done. LVN B stated she administered the Coumadin, but she "just messed up." Further review of the December 2010 MAR indicated [REDACTED] A telephone interview was conducted with the attending physician for Resident #1 on 12/30/10 at 9:15 AM. The physician was asked if he was aware Resident #1's transfer orders included PT/INRs, which were not done. He said he was unaware the PT/INRs were not done until the resident was transferred to the hospital with a drop in her Hemoglobin. Review of an entry in the nurses notes dated 12/27/10 revealed the laboratory reported a critical Hemoglobin level of 8.0 g/ml for Resident #1 at 1:30 PM. The notes further revealed orders to transfer Resident #1 to the hospital. On 12/30/10 at approximately 1:30 PM, Resident #1's December 2010 MAR indicated [REDACTED]. The DON identified the the staff whose initials were documented on the December 2010 MAR indicated [REDACTED]. The DON provided a list of residents on 12/29/10, which identified seven residents received Coumadin.

Based on interview and record review, it was determined the facility failed to ensure one (Resident #1) of seven residents reviewed for laboratory services was provided laboratory services to meet the resident's needs as ordered by the physician. Resident #1 was admitted on [DATE] with physician's orders [REDACTED]. The dose of [MEDICATION NAME] would be adjusted based on the lab results. Due to a transcription error, Resident #1 was administered 7.5 mg of [MEDICATION NAME] and did not have any lab draws for PT/INRs until he was sent to the hospital on [DATE] with a Hemoglobin level of 8 g/ml (reference range: 11.7-13.8). These failures resulted in Resident #1's hospitalization and could put the seven residents on [MEDICATION NAME] at risk for bleeding, hemorrhage, and a low blood count (Hemoglobin). Findings included: A review of the face sheet for Resident #1 revealed she was admitted from an acute care facility on 12/06/10 with [DIAGNOSES REDACTED]. Review of Resident #1's December 2010 MAR indicated [REDACTED].o. Q PM. Instructions for the administration included: "Hold if INR > 2.5." Review of the physician's admission orders [REDACTED]> 2.5. The physician admission orders [REDACTED]. An interview was conducted with LVN B, Resident #1's admitting nurse, on 12/29/10 at 1:55 PM. LVN B was queried as to how she established the admission orders [REDACTED]. At that time, LVN B produced from the resident's clinical record the hospital transfer orders dated 12/06/10, which included the following order: "When patient transferred to Rehab, will need PT/INR every Monday and Thursday and adjust [MEDICATION NAME] as needed." The transfer orders also included an order to decrease the daily dose of [MEDICATION NAME] to 4 mg. A document entitled "Pharmacy" dated 12/05/10 (one day prior to transfer) was with the transfer orders and reflected an order for [REDACTED]. During the same interview, LVN B stated the normal procedure for admission orders [REDACTED]. LVN B said she faxed Resident #1's orders to the physician, but she could not recall whether she received a response from the physician. As the interview was continued, LVN B was queried regarding the lack of orders to monitor Resident #1's PT/INR and the order to lower the [MEDICATION NAME] dosage. LVN B stated she made a mistake; she was so overwhelmed the night Resident #1 was admitted . She also revealed she was new to long term care, and Resident #1 was her first admission. Review of Resident #1's December 2010 MAR indicated [REDACTED]. At that time, the surveyor asked LVN B how she determined if the [MEDICATION NAME] should be administered based on the specified parameters, since no PT/INR was done. LVN B stated she administered the [MEDICATION NAME], but she "just messed up." Further review of the December 2010 MAR indicated [REDACTED] A telephone interview was conducted with the attending physician for Resident #1 on 12/30/10 at 9:15 AM. The physician was asked if he was aware Resident #1's transfer orders included PT/INRs, which were not done. He said he was unaware the PT/INRs were not done until the resident was transferred to the hospital with a drop in her Hemoglobin. Review of an entry in the nurses notes dated 12/27/10 revealed the laboratory reported a critical Hemoglobin level of 8.0 g/ml for Resident #1 at 1:30 PM. The notes further revealed orders to transfer Resident #1 to the hospital. On 12/30/10 at approximately 1:30 PM, Resident #1's December 2010 MAR indicated [REDACTED]. The DON identified the the staff whose initials were documented on the December 2010 MAR indicated [REDACTED]. The DON provided a list of residents on 12/29/10, which identified seven residents received [MEDICATION NAME].