Every finding on record at Honey Grove Nursing Center

Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care for each resident receiving hospice services, to ensure the quality of care for the resident ensuring communication with the hospice medical team and others participating in the provision of care for 1 of 11 (Resident #1) residents reviewed for hospice services. The facility failed to coordinate care with Resident #1's hospice provider in that they administered IV fluids without notifying the hospice provider. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to lack of documentation, coordination of care, and communication of resident's needs. Findings included: Record review of Resident #1's face sheet dated 05/06/2026 revealed Resident #1 was a [AGE] year-old female admitted [DATE] with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease, a progressive lung disease that makes breathing difficult), Alzheimer's Disease (a progressive disorder that affects memory, thinking, and behavior), Hypertension (high blood pressure), peripheral vascular disease (a circulation disorder that blocks blood flow) and insomnia (difficulty sleeping). Record review of the consolidated physician's orders dated May 2024 revealed Resident #1 had an order to admit to hospice services dated 07/11/2025 with a diagnosis of Senile degeneration of the brain. Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had minimal hearing difficulty, was usually understood, usually understood what was said to her and had a BIMS score of 0 which indicated severe cognitive impairment. Further review of this quarterly MDS revealed Resident #1 was dependent in eating, required maximum assistance in toileting bed mobility and transfers, and required moderate assistance in upper and lower body dressing. Record review of the comprehensive care plan, accessed 05/06/2026, revealed Resident #1 had a terminal prognosis and was receiving hospice services. The goal of this care plan was that Resident #1 would have her comfort, dignity and autonomy maintained at the highest level. The interventions included to adjust provision of ADL's to compensate for resident's changing abilities, consult with the physician and social services, work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs and no laboratory services, weights or other diagnostic services except as ordered by the hospice. Record review of Resident #1's physician's orders revealed an order dated 04/09/2026 for laboratory services to obtain a BNP, CBC and CMP (medical laboratory tests of the blood used to diagnosis heart failure, detect infections, organ function and electrolyte balance) and a subsequent order dated 04/09/2026 for IV hydration Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride), use 60 cc intravenously every hour for IV hydration until 04/11/2026. This order was received from the attending physician, placed in the EMR system and the medication administered by LVN A. Record review of nursing progress notes dated 04/09/2026 revealed no documentation that a facility staff member notified the hospice agency of the orders for Sodium Chloride Intravenous Solution 0.9% (Sodium Chloride), use 60 cc intravenously every hour for IV hydration until 04/11/2026 obtained from the attending physician. During an interview on 05/06/2026 at 1:52 p.m., the Hospice Nurse stated that she was Resident #1's nurse who completed facility visits. The Hospice Nurse stated she was not notified by the facility that the non-hospice physician had given orders to obtain blood samples or to receive IV fluids prior to the implementation of these orders. The Hospice Nurse stated that she has only worked with this hospice agency for a few months, but it was her understanding that all services provided should be coordinated with the hospice services agency prior to implementation. The Hospice Nurse stated that IV hydration could be used as a form of comfort measure that would be acceptable for a hospice resident. During an interview on 05/06/2026 at 2:00 p.m., the ADON stated that she was aware that Resident #1 had received IV fluids, but she was not involved in obtaining the order and was not aware if any of the nursing staff involved had notified the hospice agency of the new orders. The ADON stated she had not contacted the hospice agency prior to obtaining blood work and administration of IV fluids. During an interview on 05/06/2026 at 2:31 p.m., the DON stated that the facility received an order from the attending physician to draw labs for blood work and based on the results of the blood work, obtained orders from the attending physician to administer IV fluids. The DON stated that the resident had received approximately 100 cc of fluids and then the fluids were discontinued at family request after resident had pulled the IV out on 04/10/2026. The DON stated that she did not contact the hospice agency to inform them of the orders received. The DON stated the facility is able to accept orders from the attending physician in conjunction with the hospice agency and that she did not feel the hospice needed to be contacted in this instance because the attending physician and the facility were acting on the resident's best interest. During an interview on 05/06/2026 at 3;22 p.m., LVN A stated that she did place the orders in the EMR for IV fluids for Resident #1 based on the directions provided to her from the DON and the MDS Nurse. The LVN stated that the DON had informed her that everything had been done and that all she had to do was to put the orders in the EMR and initiate IV fluids. LVN A confirmed that she did not contact the hospice agency or the family because she had understood the DON and the MDS Nurse had already contacted them. During an interview on 05/06/2026 at 4:00 p.m., the MDS Nurse stated that she was aware that the physician had given orders for IV fluids and notified the charge nurse to implement the IV fluids, but she assumed the charge nurse would contact the hospice agency to coordinate the care. The MDS Nurse stated she did not contact the hospice agency herself. During an interview on 05/06/2026 at 4:30 p.m., the DON stated that she felt if the attending physician gave orders, the facility should follow them, but in the future, she would ensure the nursing staff notified the hospice agency for care coordination. The DON acknowledged that failure to notify the hospice agency could result in poor care for the resident or go against the hospice agency and family wishes for palliative care measures. The DON stated she is responsible for ensuring nursing staff notify the hospice agency to coordinate residents care. During an interview on 05/06/2026 at 4:40 p.m., the Administrator stated that it was important to coordinate services provided with the appropriate hospice agency and that the Director of Nurses was responsible for ensuring care coordination to ensure palliative care measures are agreed upon by all entities involved to include the attending physician, the family, the facility staff and the hospice staff. Record review of the Hospice Program policy dated 2001 indicated hospice services were available to residents at the end of life. 1. Our facility has an agreement with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. 9. In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including a. determining the appropriate hospice plan of care .c. providing medical direction, nursing and clinical management of the terminal illness. 12. Our facility has designated the DON to coordinate care provided to the resident by our facility staff and the hospice staff. a. Collaborating with hospice representatives and other healthcare providers participating in the hospice care planning process for resident receiving there services; b. communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and the family and 13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain he resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 9 of 15 resident rooms on Hall's 2 and 3 (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9). The facility failed to ensure that Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 12/16/25 at 10:58 AM of Resident room [ROOM NUMBER] reflected thick brownish dirt stains on the floor near a fall mat. The bathroom floor had grayish stains on the floor near the sink and toilet. Back wall and floor in the bathroom had brownish stains. A nightstand in the room had dark stains along the top edge of the stand. An observation on 12/16/25 at 11:06 AM of Resident room [ROOM NUMBER] reflected brownish spotted dirt stains on the floor near a waste basket. An observation on 12/16/25 at 11:10 AM of Resident room [ROOM NUMBER] reflected the inside toilet bowl had a dark stain circling it. The corner of bathroom floor, behind the toilet, had brownish stains. An observation on 12/16/25 at 11:13 AM of Resident room [ROOM NUMBER] reflected the floor tiles, leading into the bathroom, were broken, which was a tripping hazard. The bathroom floor had brownish dirt stains circling the toilet. The room floor, near the door entrance, had dark dirt stains along the corner of the door jams. An observation on 12/16/25 at 11:17 AM of Resident room [ROOM NUMBER] reflected the room floor had broken tiles near the resident's bed. The floor, leading into the bathroom, had gaps separating the room floor and bathroom floor, which was a tripping hazard. An observation on 12/16/25 at 11:20 AM of Resident room [ROOM NUMBER] reflected the door entrance, had dark dirt stains along the corner of the door jams. The bathroom floor had brownish stains circling the toilet. The bathroom floor had dark dirt stains near the wall. An observation on 12/16/25 at 11:29 AM of Resident room [ROOM NUMBER] reflected the bathroom linoleum peeling away from the floor along the entrance and near a wall in the bathroom, which was a tripping hazard. The bathroom floor had brownish dirt stains circling the toilet. An observation on 12/16/25 at 11:30 AM of Resident room [ROOM NUMBER] reflected the room floor near the bed had brownish dirt stains. An observation on 12/16/25 at 11:32 AM of Resident room [ROOM NUMBER] reflected the door entrance, had dark dirt stains along the corner of the door jams. An area of the floor near the wall had a red stain on it. The bathroom floor had grayish stains on the floor near the sink and toilet. In an interview on 12/17/25 at 1:19 AM, the Administrator was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, and #9. She stated she did not see a risk to the residents with the room in the condition observed and it was more an aesthetic issue. She stated her Housekeeping Supervisor did a good job ensuring the resident rooms were cleaned daily. In an interview on 12/18/25 at 11:19 AM, the House Keeping Supervisor was shown pictures of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, and #9. She stated it was her and housekeeping's responsibility to thoroughly clean the rooms. She stated she had gotten with the maintenance director to assist with cleaning the stains around the inside of the toilets, and they attempted to clean the stains on the floor around the toilets, but it was hard to get them back to their original state. She stated she had gotten with the maintenance director about replacing the bathroom floors. She stated she did not check all the rooms daily, but she did spot check the rooms for cleanliness. She stated the impact to the residents was the smell could bother them and could result in an infection. In an interview on 12/18/25 at 11:32 AM, Housekeeping B stated she had been at the facility for 3 weeks. She stated they were responsible for cleaning the bathroom, sleeping areas, floors, and from top to bottom. She stated she received training when she started and had housekeeping experience. She was shown photos of the concerns observed in Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, and #9. She stated she had tried to clean the toilets, but a special cleaner was needed, the floors needed to be stripped and repaired, and the floor around the toilet needed to be redone. She stated the concerns observed could result in the residents having an infection and was a hazard. In an interview on 12/18/25 at 11:45 AM, the Maintenance Supervisor stated he had only been at the facility for 2 months. He was shown concerns with the residents' floors, and he stated they were going to replace the flooring in the residents' bathrooms and was waiting on getting supplies. He stated they also received cleaning supplies to remove the stains on the inside of the toilets on 12/16/25 and would be giving it to housekeeping. Review of the facility's policy for Housekeeping Cleaning & Disinfecting (2021) revealed Purpose: To keep facilities clean and odor free, while providing the residents, their families, and staff with the safest environment possible and projecting a positive image.

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 the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure the ice machine in the dining area was thoroughly cleaned. This failure placed residents at risk of exposure to food contamination and illness. Findings include: An observation on 12/16/25 at 9:08 AM revealed an ice machine, located in the dining room, had a thick white substance along the inside walls of the ice machine and on the inside door of the ice machine. In an interview and observation on 12/16/25 at 9:08 AM, the Administrator unlocked and opened the door to the Ice machine and the inside door and upper section of the machine had a thick white substance all over it. The Administrator stated housekeeping, or maintenance was responsible for cleaning the ice machine, but she was not sure. Shen stated she did not know if there was any risk to the residents with the white substance being on the inside of the ice machine. In an interview on 12/17/25 at 12:30 PM the Dietary Manager was advised about the Ice Machine having a thick white substance along the inside walls of the ice machine and on the inside door of the ice machine. She stated it was her and the lead cook's responsibility to clean the ice machine weekly. She stated the ice machine was not cleaned last week. She stated the risk of the ice machine not being cleaned could result in the ice getting contaminated and residents getting ill. Record Review of the Facility's policy on 'Dietary Food Service Personnel Policy and Procedures, undated, revealed It is important that these be followed at all times in order to maintain the efficiency of the department and make this a pleasant place for you and others to work. The resident is the reason that we are here and our job in the resident's care plan is to serve attractive, appetizing, nourishing, and high-quality food to help keep them healthy Review of TITLE 21--FOOD AND DRUGS CHAPTER I--FOOD AND DRUG ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER B - FOOD FOR HUMAN CONSUMPTION PART 110 -- CURRENT GOOD MANUFACTURING PRACTICE IN MANUFACTURING, PACKING, OR HOLDING HUMAN FOOD

Based on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #7) of 6 residents reviewed for dignity. The facility failed to provide a privacy bag for Resident #7's catheter bag (collects urine from the urinary bladder) on 12/16/2025.This failure could place the residents at risk of not having their right to a dignified existence maintained. Findings included: Record review of Resident #7's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male who admitted on [DATE]. The resident was diagnosed with obstructive and reflux uropathy (blockage that prevents urine from flowing properly). Record review of Resident #7's Comprehensive MDS Assessment, dated 11/04/2025, reflected the resident was cognitively intact with a BIMS score of 13. Section H (Bowel and Bladder) reflected an indwelling urinary catheter. Record review of Resident #7''s Comprehensive Care Plan, dated 11/11/2025, reflected an indwelling urinary catheter. One intervention was to Position catheter bag and tubing below the level of the bladder and in a privacy bag. During an observation and interview on 12/16/2025 at 9:25 AM, Resident #7 was lying in bed awake. His catheter bag was hanging on the side of the bed facing the door. It was not in a privacy bag. Resident #7 stated he did not know if it was covered. He stated he did not leave his room very often. In an interview on 12/16/2025 at 9:31 AM, RN D stated she was not sure where the privacy bag was. She stated Resident #7 pulled at it sometimes. She stated it was important to keep the catheter bag covered for his privacy. RN D stated she would get a privacy bag for Resident #7. In an interview on 12/17/2025 at 11:24 AM, the ADON stated Resident #7's catheter bag should have been in a privacy bag. She stated it was important to keep it covered for his dignity. In an interview on 12/17/2025 at 11:29 AM, the DON stated the catheter bag should have been covered. She stated it was important for the resident's dignity. Record review of the facility's policy Resident Rights, undated, reflected A facility must treat each resident with dignity and respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of each resident.The right to receive the services and/or items in the plan of care. The facility did not have a policy related to covering catheter bags.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #42) of 16 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #42's room was in a position that was accessible to the resident on 12/16/2025.This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Record review of Resident #42's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with psychomotor deficit (affects how a person moves and thinks) following a nontraumatic subarachnoid hemorrhage (brain bleed). Record review of Resident #42's Comprehensive MDS Assessment, dated 11/28/2025, reflected severe cognitive impairment with a BIMS score of 00. Section GG (Functional Abilities) indicated Resident #42 was dependent on staff for self-care and mobility needs.Record review of Resident #42's Comprehensive Care Plan, dated 11/04/2025, reflected a communication problem related to expressive aphasia (individuals struggle to produce clear and fluent speech). One intervention was to ensure the call light was within reach. An observation on 12/16/2025 at 9:13 AM revealed Resident #42 lying in bed awake. The call light was on the floor behind her bed. It was not within the resident's reach. When asked about her call light, Resident #42 did not answer. During an observation and interview on 12/16/2025 at 9:18 AM, CNA C stated Resident #42's call light should have been placed where she could reach it. She stated Resident #42's call light was attached to a stuffed bear. CNA C stated when she was feeding her breakfast, Resident #42 tried to put the stuffed bear in her mouth. CNA C stated she moved the call light to the side of the bed, and it must have fallen on the floor. CNA C picked up the call light and placed it near Resident #42. She stated it was important for the residents to be able to call staff. During an interview on 12/17/2025 at 11:24 AM, the ADON stated Resident #42's call light should have been in reach. She stated call lights should have been on the residents' beds. She stated all the call light cords had a clip to secure to the bed. She stated it was important to ensure the residents' call lights were in their reach in case they needed help.During an interview on 12/17/2025 at 11:29 AM, the DON stated it was important for Resident #42 and all residents to have their call light. She stated residents should be able to call staff. She stated it was good for staff to be able to reach the call light when needing assistance with a resident. Record review of the facility's policy Resident Rights, undated, reflected The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.The right to receive the services and/or items included in the plan of care. The facility did not have a policy related to placement of call lights.

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's care plan was revised upon her return from her hospital stay on 08/28/25 for breathing complications. This failure could place residents at risk of their needs not being met. Findings include:Record review of Resident #5's Face Sheet, dated 12/17/25, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnosis of COPD. Record review of Resident #5's Quarterly MDS Assessment, dated 11/18/25, reflected Resident #5 had a moderate cognitive impairment response. The Quarterly MDS Assessment reflected the resident had an active diagnosis of COPD. Record review #5's Comprehensive Care Plan, dated 10/22/25, reflected the resident's care plan for Oxygen therapy and swallowing problems was last reviewed on 7/07/25. Record review of #5 progress notes reflected the resident was transferred to the hospital on [DATE] due to a change in respiratory, and the resident returned to the facility on 8/28/25. In an interview on 12/17/25 at 10:35 PM, the DON stated Resident #5 was hospitalized on [DATE] because she had breathing problems. She stated the resident had returned from the hospital on [DATE], and it was recommended she used a straw to drink fluids to reduce the chances of choking, and she had a change in medication. She stated the resident's care plan should have been revised with the updated interventions to ensure the resident had received the required care. She stated it was the DON's responsibility to update the resident's acute care, but she was not at the facility when the resident had returned from the hospital. The DON stated the MDS nurse should have included the intervention during the resident's Quarterly Comprehensive Care plan review on 10/22/25. She stated she was out of the office for a few months and they had Interim DONs while she was out. She stated they also did not have an MDS nurse until 08/16/25 and she was trying to get caught up with updating care plans. She stated she had reviewed the care plan for Resident #5 and noticed it was not updated upon the resident's return from the hospital, and she would be updating it immediately. She stated they have daily meetings with the MDS nurse to discuss medication and treatment changes so the care plan can be updated. In an interview on 12/17/25 at 11:26 AM, the Regional Compliance Nurse was advised of Resident #5's care plan not being revised upon her return from the hospital on [DATE]. She stated she was made aware of this by the DON, and she stated it should have been updated so staff would be aware of her plan of care. In an interview on 12/17/25 at 1:50 PM the Regional MDS Nurse and MDS Nurse stated they were told about Resident #5 not having a revised care plan when she had returned from the hospital on [DATE]. They stated the IDT team, which consisted of the nursing staff, should have revised the resident's care plan to include any changes to the resident's care. The Regional MDS Nurse stated they did not have a DON at the time, and the IDT team did not have consistent staff, and it was overlooked. She stated the MDS nurse should have updated it during the resident's quarterly comprehensive care plan review, but they had just gotten a new MDS nurse at the time. They stated not updating the care plan could impact the resident not receiving appropriate care. Record review of facility's policy, Comprehensive Care Planning, undated, reflected The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record review, the facility failed to ensure each resident's environment remained as free from accident hazards as possible for 1 (Resident #2) of 5 residents reviewed for environmental hazards. The facility failed to ensure Resident #2's fall mat was properly placed next to his bed on 12/16/2025. This failure could place the residents at risk for injury. Findings included:Review of Resident #2's Face Sheet, dated 12/16/2025, reflected a [AGE] year-old male who admitted on [DATE]. Resident #2 had diagnoses which included Parkinson's disease (brain disorder that can affect body motions) and muscle wasting and atrophy. Resident #2 was on hospice care services. Review of Resident #2's Quarterly Assessment, dated 12/04/2025, reflected severely impaired cognition with a BIMS score of 05. Section J (Health Conditions) reflected Resident #2 had one fall with no injury. Review of Resident #2's Comprehensive Care Plan, dated 12/15/2025, reflected Resident #2 was at risk for falls related to gait/balance problems, unaware of safety needs, and vision/hearing problems. One intervention was to place fall mat at right side of bed. In an interview and observation on 12/16/2025 at 09:08 AM, Resident #2 was lying in bed awake. Resident #2's fall mat consisted of two separate pieces which were the length of the resident when pushed together. One section was on the floor near the upper part of his body. Resident #2's bedside table was next to the fall mat and placed over the bed. The other half of the fall mat was at the end of the bed, approximately two feet past the bedside table. When asked if he had fallen, Resident #2 replied yes. He was unable to provide details. During an observation and interview on 12/16/2025 at 9:18 AM, CNA C entered Resident #2's room and stated the fall mat was not supposed to be placed like that. She stated the section at the end of the bed was supposed to be positioned under the resident's bedside table. She stated the section near the head of the bed was wider and the other was narrower and fit between the legs of the bedside table. She stated it allowed the bedside table to be placed across the resident's bed while having a fall mat next to the bed. CNA C stated the fall mat prevented the resident from hitting the floor hard if he fell. She stated the fall mat could keep him from breaking a bone or having a serious injury. CNA C moved the fall mat under the bedside table, so it was touching the floor mat near the head of the bed.In an interview on 12/16/2025 at 9:31 AM, RN D stated hospice provided Resident #2 an air mattress. She stated it was important for the fall mat to be in place in case he rolled out of the bed. She stated the fall mat did no good if it was not placed where it was supposed to be. She stated the nurses and CNAs monitored fall mat placement during rounds. RN D stated staff may have moved it to provide care and forgot to put it back. She stated if he fell, it could prevent a serious injury. In an interview on 12/17/2025 at 11:24 AM, the ADON stated the fall mat should have been properly placed next to Resident #2's bed. She stated the mat helped protect the resident from injury if he fell. In an interview on 12/17/2025 at 11:29 AM, the DON stated the fall mat should have been placed next to the resident's bed. She stated the mat was used to cushion a fall and help prevent injury to the resident. Record review of the facility's policy Resident Rights, undated, reflected A facility must treat each resident with dignity and respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of each resident.The right to receive the services and/or items in the plan of care. The facility did not have a policy related to the placement of fall mats.

Based on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A performed safe bed positioning on 4/15/2025 while performing incontinent care on Resident #1 when CNA A did not follow the Kardex (plan of care) which stated Resident #1 was a two person assist with bed positioning, resulting in Resident #1 falling from the elevated bed causing major injury of a left hip fracture (broken bone), lacerations above her left eye, and a hematoma (collection of blood) to her forehead.The noncompliance was identified as PNC. The IJ began on 4/15/25 and ended on 4/16/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury.Findings included:Record review of Resident #1's face sheet dated 9/26/25 indicated she was [AGE] years old and admitted to the facility initially on 3/08/22 and re-admitted on [DATE] with diagnoses including a history of psychomotor (mental processes and physical activity) deficit following a nontraumatic subarachnoid hemorrhage (brain bleed), hemiplegia (unable to move or severe weakness on one side of the body), dementia (decline in cognitive function severe enough to interfere with daily life), anxiety (excessive worry, fear, nervousness), bipolar disorder (mental health disorder extreme mood swings between elevated mood and depression-sadness), and left intertrochanter femur fracture (broken top part of the upper leg bone).Record review of Resident #1's quarterly MDS dated [DATE] indicated she had a BIMS score of 1, which indicated she had severe cognitive impairment. Resident #1 had functional limitations in range of motion of all extremities. Resident #1 was dependent on staff for most ADLs but required substantial assistance with rolling side to side in bed.Record review of Resident #1's Care Plan last reviewed on 3/04/25 indicated she had an ADL self-care performance deficit related to impaired balance, limited mobility, and stroke and required total assistance of two staff for bed mobility. Resident #1 had a fall and was at risk for further falls related to dementia, balance and anxiety medication and had interventions for bed in lowest position.Record review of an Event Nurses' Note-Fall dated 4/15/25 indicated LVN B was called to Resident #1's room by CNA (not named) and resident was lying face down on the floor with blood noted on the floor. Resident #1 was repositioned and assessed and was noted to have two lacerations above her left eye and a knot on her forehead and she complained of pain when moved. In the pain section, LVN B indicated Resident #1 had severe pain in the area of her hip and legs. Resident #1 was sent to the emergency room.Record review of Resident #1's hospital records dated 4/16/25 indicated the reason for the visit was left hip fracture. The records indicated Resident #1 fell out of bed landing on her hip and hitting her head at the nursing facility and had a closed left lesser trochanter femur fracture and laceration to left eyelid, which required five sutures. The records indicated the physician had discussed the fracture with Resident #1's RP and it was determined there would not be surgical intervention at that time.On 9/29/25 at 11:26 AM and 12:07 PM, CNA A was called but there was no answer, the voicemail was full and was unable to leave voicemail. On 9/29/25 at 3:06 PM, CNA A was texted a detailed message and requested a return call. On 9/30/25 at 12:10 PM, CNA A was called but there was no answer and was unable to leave a voicemail. CNA A did not return the calls or text message prior to the surveyor exiting the facility.During an interview on 9/29/2025 at 1:45 PM, LVN B said she had worked at the facility for three years on the 6 AM-6 PM shift. LVN B said she was the nurse on duty on the day Resident #1 fell. LVN B said the fall with Resident #1 was horrible. LVN B said CNA A came and told her Resident #1 had fallen from the bed. LVN B said Resident #1 was face down on the floor and was unable to use her arms to catch herself and took a blow to her face. LVN B said the bed was elevated due to CNA A was performing incontinent care. LVN B said CNA A said she had looked for someone to help her perform incontinent care, but CNA A said she thought she could do it alone, even though Resident #1 was a two person assist. LVN B said when CNA A rolled Resident #1 onto her side to put the incontinent brief on, Resident #1 was too close to the edge and Resident #1 rolled off the bed. LVN B said Resident #1 was saying she was hurting. LVN B said she assessed Resident #1 and sent her to the hospital. LVN B said CNA A was a sweet aide and would have never done anything intentionally to hurt Resident #1. LVN B said staff should look at the Kardex to see how much care/assistant a resident needed or required. LVN B said she had received the in-services on bed positioning and ADL assistance, and abuse and neglect.During an interview on 9/30/25 at 11:27 AM, the ADON said she had worked at the facility since 2011. The ADON said she had already left for the day when she was called and was told Resident #1 had fallen out of bed. The ADON said she was told Resident #1 had rolled off the bed while CNA A was performing incontinent care by herself. The ADON said she called CNA A on the phone, and CNA A said she had done Resident #1's care by herself. The ADON said she had just had an in-service with the staff on using the Kardex and ensuring using the appropriate amount of staff when performing care and had discussed what residents required two-person assistance during ADL care. The ADON said CNA A said she got between Resident #1's bed and the wall and rolled Resident #1 away from her and Resident #1 fell out of the bed. The ADON said CNA A told her she always did Resident #1 that way. The ADON said CNA A knew she had to have two persons during bed position and incontinent care of Resident #1 and knew about the Kardex. The ADON said CNA A told her she did not attempt to find anyone to ask for assistance because everyone was busy. The ADON said CNA A knew she was wrong for trying to perform bed positioning and incontinent care on Resident #1 alone. The ADON said CNA A was very upset and remorseful for the incident. The ADON said the nurse assessed Resident #1 and sent her to the hospital. The ADON said Resident #1 was determined to have a fractured hip and they opted not to do surgery. The ADON said CNA A was suspended and they started in-servicing and quizzing staff on how to find the Kardex and the assistance needed to provide ADLs safely. The ADON said they ended up terminating CNA A because she did not follow Policy and Procedures or ask for help and CNA A knew she should have. During an interview on 9/30/25 at 9/30/25 at 1:47 PM, the ADON said she knew she had in-serviced the nursing staff approximately a month prior to the incident with Resident #1 because she had to show the DON and ADM that the staff had been previously in-serviced on looking in the Kardex to know what amount of assistance residents needed with ADL tasks approximately a month prior to the incident. The ADON said she was unable to locate the in-services. The ADON said she had given the in-services to the DON and the ADM during the investigation of Resident #1's fall and the ADON said that was how they were able to prove CNA A knew she should have used two people during Resident #1's incontinent care/bed positioning. The ADON said the DON and the ADM were no longer working at the facility and she did not know where to locate the in-service related to using the Kardex to determine the amount of assistance a resident needed or required during ADLs.During an interview on 9/30/25 at 2:07 PM, DON O said CNA A told her and others, she went into Resident #1's room to perform incontinent care and reposition her and did not want to bother anyone. DON O said CNA A said she went between Resident #1's bed and the wall and rolled Resident #1 over to place the brief and Resident #1 rolled off the bed. DON O said CNA A was very much aware and knew she had done wrong and was sorry for it. DON O said they terminated CNA A for not following policy and procedures which caused injury to Resident #1. DON O said they did in-service all the nursing staff to always refer to the Kardex to see what amount of assistance the resident required and if a resident was a two-person assist then staff were not to perform the task if there were not two persons. DON O said Resident #1 was a two person assist at the time of the incident and CNA A was aware prior to attempting to perform bed position/incontinent care with just herself. DON O said they had in-serviced nursing staff on using the Kardex to see what amount of assistance a resident required upon hire, quarterly, and with their annual competencies. DON O said she did not remember exactly when the in-service had been completed prior to the incident, but it had not been long. DON O said CNA A had never had any other issues to her knowledge.During an interview on 9/30/25 at 2:50 PM, ADM Q said she had been the Interim ADM for four weeks. ADM Q said she did not have any knowledge of the incident with Resident #1 other than she knew they were continuing to in-service staff on using the Kardex to ensure they were using the appropriate amount of staff to perform ADLs for safe.During an interview on 10/01/25 at 5:37 PM, ADM P returned a phone call and said she had been the ADM at the facility from February 2025 until July 7, 2025. ADM P said the incident with Resident #1 was a fall from the bed while CNA A was providing incontinent care by herself and had rolled the resident over and Resident #1 rolled off the bed onto the floor. ADM P said CNA A was interviewed and CNA A knew Resident #1 was a two person assist during incontinent care/bed positioning and did not do so. ADM P said Resident #1 was assessed by the nurse and sent to the emergency room. ADM P said they started in-servicing the staff on two-person assist during ADLs and began ongoing monitoring for compliance. ADM P said they suspended CNA A immediately, but after investigating the incident CNA A was terminated for not following policy and procedures. Record review of a CNA Proficiency Audit dated 3/12/25, indicated CNA A had a S in the column beside CNA care plans/worksheets and Turns/Repositions residents timely and correctly, which indicated CNA A performed those areas of care satisfactorily.Record review of CNA A's handwritten signed statement dated 4/15/25, indicated she was changing Resident #1. CNA A said she was holding Resident #1 and putting a brief under her, she rolled and fell off the bed.Record review of ADM P's Witness Statement dated 4/15/25, indicated CNA A stated she was lifting Resident #1 and placing a brief underneath the resident and Resident #1 slid off the bed.Record review of the ADON's Witness Statement dated 4/17/25, indicated CNA A stated she was aware resident was a two person assist and also stated she did not ask for help because LVN B and CNA F were busy doing something else.Record review of the facility's Employee Disciplinary Report dated 4/18/25 indicated CNA A failed to meet job duty/responsibility expectations and it was found that CNA A failed to follow policies and procedures when handling a resident on 4/15/25. CNA A attempted to move a resident without assistance knowing the resident was a two person assist. CNA A was not able to lift the resident alone and the resident ended up sliding off the bed. CNA A raised concerns for resident safety and security due to not following resident orders. CNA A was aware of their job duties/responsibilities and code of conduct expectations by their signature on the employee handbook acknowledgement and job description.Record review of the facility's undated policy titled Fall Policy indicated . Preventing falls requires an interdisciplinary program that focused on modifying the extrinsic factors, correcting intrinsic factors, and educating the resident and family . appropriate interventions will be addressed on the interdisciplinary plan of care . Interventions would be resident centered . staff must be trained in safe transfer technique .ADM Q was notified of PNC IJ on 9/30/25 at 9:25 AM due to the above failures. ADM Q was provided with the IJ template on 9/30/25 at 9:29 AM. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy and the facility had corrected the noncompliance on 04/16/25 by the following: The facility performed a skin assessment of Resident #1 after fall on 4/15/25. The facility initiated neurological assessments on Resident #1 after fall on 4/15/25. The facility sent Resident #1 to the emergency room on 4/15/25. CNA A was placed on suspension on 4/15/25 during the investigation. CNA A was terminated on 4/18/25 due to resident mistreatment, failed to follow policies and procedures when she attempted to move a resident without assistance, knowing the resident was a two person assist. Staff surveys were performed asking if staff had witnessed a staff member performing ADLs with the wrong amount of staff - all answered no. All nursing staff (nurses & CNAs) were in-serviced on 4/15/25 on Do Not Perform a Task (ADL) without Proper Amount of staff, finding amount of assist needed in the Kardex, and fall policy. All staff in-serviced 4/15/25 on Abuse, Neglect, and Exploitation. All nursing staff (nurses & CNAs) were in-serviced on 4/16/25 on Bed positioning. The facility performed weekly monitoring of at least 10 to ensure the proper number of staff was providing assistance with bathing, bed mobility, transferring, walking, and incontinent care. The facility conducted staff surveys of 10 staff members per week about how to locate, how much assistance was needed for a resident task and what they would do if the proper number of staff was not present.All staff interviewed (LVN B, LVN G, LVN H, LVN L, LVN N, RN C, CNA D, CNA E, CNA F, CNA J, CNA K, & CNA M) on 9/29/25 from the 6 AM-6 PM shifts and 6 PM-6 AM shifts which included: 1 of 3 RNs, 5 of 7 LVNs, and 6 of 12 CNAs, which also included newly hired staff, were able to answer appropriately where they would find the amount of assistance a resident needed for ADL care, proper bed positioning while performing ADLs, and Abuse/Neglect.During an observation on 9/29/2025 beginning at 2:40 PM, CNA F and RN C performed incontinent care on Resident #1. CNA F and RN C positioned themselves on each side of Resident #1's bed and performed safe bed positioning while performing incontinent care. Record review of undated staff surveys indicated 15 staff members said they had not witnessed a staff member performing ADL with the wrong amount of staff.Record review of an In-service Training Attendance Roster with training topic titled Do Not Perform a Task (ADL) Without Proper Amount of Staff, Finding Amount of Assist Needed in Kardex, and Fall policy and dated 4/15/25 indicated all nursing staff had signed the in-service.Record review of an In-service Training Attendance Roster with training topic titled Abuse, Neglect, and Exploitation Inservice and dated 4/15/25 indicated all staff had signed the in-service.Record review of an In-service Training Attendance Roster with training topic titled Bed Positioning and dated 4/16/25 indicated all nursing staff had signed the in-service.Record review of the facility's weekly monitoring of a least 10 to ensure the proper number of staff was providing assistance with bathing, bed mobility, transferring, walking, and incontinent care indicated it was initiated 4/15/25 and continued weekly to present.Record review of the facility's weekly monitoring of asking at least 10 staff members how to locate how much assistance was needed for a resident task and what they would do if the proper amount of staff was not present, indicated it was initiated on 4/15/25 and had continued weekly to present.The noncompliance was identified as PNC. The noncompliance began on 4/15/24 and ended on 4/16/24. The facility had corrected the noncompliance before the survey began.

Based on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 5 residents (Resident #42) reviewed for accident hazards and supervision. 1. The facility did not ensure Resident #42 received adequate supervision to prevent exiting the facility without staff knowledge on 09/15/24. 2. The facility did not ensure exits accessible to residents who could exit unsupervised alarmed loud enough to allow staff to respond in a timely manner. An IJ was identified on 09/23/24. The IJ template was provided to the facility on [DATE] at 5:32 p.m. While the IJ was removed on 09/24/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk of serious injury or harm. Findings included: Record review of Resident #42's face sheet, dated 09/26/24, indicated Resident #42 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the Admission MDS assessment, dated 06/14/24, indicated Resident #42 made himself understood and understood others. Resident #42's BIMS score was 4, which indicated his cognition was severely impaired. Resident #42 did not have disorganized thinking, behaviors, wandering, or refusal of care. Resident #42 used a wheelchair. Record review of the comprehensive care plan, revised 07/19/24, indicated Resident #42 was a at risk for wandering. The care plan interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc., monitor my location frequently through the day while I am up & out of bed, and wear owander alert bracelet in place (on w/c) & check for placement q shift. Record review of the comprehensive care plan, revised 09/15/24, indicated Resident #42 was at risk for elopement as evidenced by: resident history of exit seeking and exiting out of door of facility. The care plan interventions included, resident moved to secure care unit, assess/record/report to MD risk factors for potential elopement such as: Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital, supervise closely, and make regular compliance rounds whenever resident is in room, determine the reason the resident is attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate, provide structured activities: for inside and outside, reorientation strategies including signs, pictures, and memory boxes, distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books, and if the resident is exiting seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of the referral paperwork from a sister facility dated 06/05/24 revealed Resident #42 would be sent to a secure unit facility. Record review of Resident #42's elopement assessment, dated 06/05/24, reflected Resident #42 was at risk for elopement. Record review of the electronic medical records indicated Resident #42 was admitted to the secure unit on 06/05/24 but was moved off from the secured unit on 07/01/24. Record review of the MAR dated 09/01/24-09/31/24 indicated Resident #42 had a wanderguard and had been checked every shift for placement and function with a d/c date of 09/15/24. Record review of a progress note dated 07/01/24 at 4:05 p.m., completed by LVN D indicated Resident #42 attempted to exit door at the end of hall 5. Resident #42 was redirected, and alarm reset. No acute distress noted. Record review of a progress note dated 07/01/24 at 5:45 p.m., completed by LVN D indicated Resident #42 stated his truck got stole and he has been looking for his truck. Resident #42 tried to exit through the end of hall 5 door. Resident #42 stated, I don't know what the hell happened. Record review of Resident #42's elopement assessment, dated 07/01/24, reflected Resident #42 was at risk for elopement. Record of a progress note dated 07/10/24 at 4:10 a.m., completed by LVN E indicated Resident resting quietly in bed with eyes closed. Resident has been exit seeking this shift. Resident made out the door at the end of hall 5. When the staff was trying to redirect the resident, the resident became even more upset and was cursing yelling. Resident was finally distracted enough to come back in the building, by saying that it was to hot outside and the resident could be come dehydrated. Once the resident was back in the building. The resident made four other attempts to exit the building without success. However, each time his efforts did not produce the wanted outcome the resident became more and more upset. Re-direction was very difficult, with even stating that his truck was in the shop, offering food and Dr. Pepper, resident still remained upset for about 30-45 minutes. Resident filly calmed down approximately 10 p.m, while talking to female resident in the front lobby. Resident then went to his room and took a Dr. Pepper from his fridge and then went to bed at approximately 11:30 PM. Safety precaution met and call light and fluids within reach. Record review of Resident #42's elopement assessment, dated 07/20/24, reflected Resident #42 was at risk for elopement. Record review of the event nurses' note, dated 09/15/24, revealed Resident #42 was outside in the parking lot and was seen by Housekeeping Aide H as she was entering the parking lot via vehicle. Record review of the provider investigation report dated 09/15/24 indicated Housekeeping Aide H was pulling in the parking lot and saw Resident #42 outside. RN P had gone to get gloves when she heard the front door alarm, when she returned to the nurse's station, she asked about the door alarm. At that time LVN N was headed outside to assist Housekeeping Aide H with Resident #42. Resident #42 may have been outside for 2 minutes, no injuries. Record review of Resident #42's elopement assessment, dated 09/15/24, reflected Resident #42 was at risk for elopement. Record review of the electronic medical records indicated Resident #42 was moved on the secured unit 09/15/24. During an observation on 09/23/24 at 9:15 a.m., the front door had no locking mechanism or alarming system upon entrance to the building. The facility was located on a busy highway. During an observation and interview on 09/23/24 at 2:32 p.m., RN G and the state surveyor tested the alarm at the front door area which was not heard down the hallways by the other state surveyors. The front door wanderguard alarm was only audible to the front door area. RN G stated she had observed exit seeking behaviors in the past with Resident #42 on several different occasions, but he was able to be redirected easily. RN G stated interventions for residents at risk for elopement was redirection. During an observation and interview on 09/23/24 beginning at 4:54 p.m. with the Maintenance Supervisor he performed a door alarm check on all halls. 3 out of 7 facility exit doors did not alarm when opened by the Maintenance Supervisor. 2 out of 7 facility exit doors were attached to the wanderguard system. The Maintenance Supervisor stated the alarms should sound when the door was opened but was unsure why the door alarm was not activated. The Maintenance Supervisor stated he performed weekly door alarm checks. The Maintenance Supervisor stated the risk of the door alarms not been activated when the door opened would put residents at risk for elopement. Record review of sheet titled Task #317502 indicated the Maintenance Supervisor performed door alarm checks on all halls 09/12/24. During an attempted interview on 09/23/24 at 11:15 a.m. with Resident #42, indicated he was non-interview able. During an interview on 09/23/24 at 11:28 a.m., CNA O stated she was the CNA for the secured unit. CNA O stated Resident #42 was admitted on the secured unit but was removed off when there was an incident between him and another resident and him required to be transferred by hoyer lift. CNA O stated Resident #42 did have exit seeking behaviors prior to being removed off the unit but was able to be redirected. CNA O stated on 09/15/24 the day Resident #42 eloped she was in the kitchen getting cereal for another resident when Housekeeping Aide H came in and stated LVN N needed assistance with getting Resident #42 back in the building. CNA O stated when she went outside Resident #42 was halfway in the parking lot. CNA O stated she assisted LVN N with getting him back in the building. CNA O stated she could not recall the reason why Resident #42 stated he was outside. CNA O stated the front door wanderguard alarm did sound when Resident #42 was brought back in the building. CNA O stated Resident #42 was placed on 1:1 until the nurse obtained an order to place him on the secured unit. CNA O stated it was unsure how Resident #42 got out the building. During an interview on 09/23/24 at 12:46 p.m., Housekeeping Aide H stated she was coming into work on 09/15/24 and saw Resident #42 sitting in his wheelchair between 2 cars which was approximately 50 feet from the front door. Housekeeping Aide H stated she tried to redirect Resident #42 back in the building but was unsuccessful. Housekeeping Aide H stated she left Resident #42 in the parking lot by himself while she went in the facility to get assistance. Housekeeping Aide H stated she grabbed LVN N and told her Resident #42 was found outside in the parking lot. Housekeeping Aide H stated LVN N told her she needed a CNA, so she went back in the building to grabbed one while LVN N stayed with Resident #42. Housekeeping Aide H stated CNA O came out to assist LVN N with getting Resident #42 back in the building. During an interview on 09/23/24 at 2:54 p.m., RN P stated the day Resident #42 eloped she was down the hallway with CNA Q attempting to find the supply closet because she was new to the facility. RN P stated during that time she thought she had heard an alarm going off but only for a short time. RN P stated she started coming up the hallway when Housekeeper Aide H had come up saying LVN N needed help with Resident #42 who was found outside in the parking lot. RN P stated she went outside, and Resident #42 was easily redirected into the facility. RN P stated the Administrator, and the Regional Compliance Nurse were notified, and she was instructed to sit 1:1 with him until an order was obtained for the secured unit. RN P stated multiple elopement drills were completed the day of the incident, in-servicing was performed on abuse/neglect and elopement prevention and response. RN P stated that no other staff members had heard an alarm during the investigation, so she assumed she was just hearing things. RN P stated that when Resident #42 was brought inside the facility the wander guard system on his wheelchair set the front door alarm off, so they knew the door alarm was working. RN P stated that when Resident #42 was back inside the facility, an assessment was completed. RN P stated Resident #42 had no visible issues. During an interview on 09/23/24 at 3:20 p.m., CNA R stated she was in a room down the hall and did not hear any door alarms going off while in the room when Resident #42 was found outside. During an interview on 09/23/24 at 3:53 p.m., the ADON stated Resident #42 was admitted to the facility on [DATE] to the secured unit because the facility he was at he was having exit seeking behaviors. The ADON stated Resident #42 was removed off on 07/01/24 due to an incident with another resident and requiring a hoyer lift for transfer. The ADON stated if a resident required a hoyer lift they did not meet the secured unit requirement. The ADON stated Resident #42 did have exit seeking behaviors but was easily redirected. The ADON stated he would always state he was looking for his truck. The ADON stated when Resident #42 tried to elope on 07/01/24 and 07/10/24 the only interventions she was aware was the wanderguard and redirection. The ADON stated she did not reassess Resident #42 after the attempted elopements back in July. The ADON stated the DON was on medical leave at this time and she did not know if she reassessed the resident to ensure safety. The ADON stated the ADO came in the week on 09/02/24 and saw Resident #42 exit seeking and asked her why he was not on the unit. The ADON stated after she told her the reason why he was not she stated a hoyer lift transfer could be on the unit. The ADON stated after the conversation with the ADO, Resident #42 was not placed on the because when he started to exhibit exit seeking behaviors, he was able to be redirected so putting him back on the unit was never brought back up until he eloped on 09/15/24. The ADON stated the risk for residents eloping was a serious injury. During an interview on 09/23/24 at 4:14 p.m., LVN D stated she was on the unit passing medications when Resident #42 was found outside in the parking lot. LVN D stated Housekeeping Aide H came and told her Resident #42 was outside in the parking lot and LVN N was with him. LVN D stated she was unable to leave the residents by themselves on the secured unit, so she had to wait until CNA O came back on the unit. LVN D stated once CNA O came to relieved her, she went out and completed a head-to-toe assessment on Resident #42. LVN D stated all the responsible parties were notified and Resident #42 was moved to the secure unit when an order was obtained. LVN D stated she had observed exit seeking behaviors from Resident #42 when he was on Hall 5 off the secured unit. LVN D stated Resident #42 would state he was looking for his white ford truck or his big rig. LVN D stated Resident #42 was easily redirected at times, but she has had to reset the alarm before because Resident #42 would get close to the door and set the alarm off. LVN D stated interventions for Resident #42 been at risk for elopement was redirection and the wandergaurd system. During an observation on 09/23/24 at 6:10 p.m., the speed limit sign in front of the facility changes from 45 to 55 miles per hour. During an interview on 09/24/24 at 11:38 a.m., LVN N stated she was at the end of Hall 2 when Housekeeping Aide H came in hollering Hey, Someone Help Me. LVN N stated Housekeeping Aide H stated Resident #42 was found outside in the parking lot when she arrived at work. LVN N stated when her and Housekeeping Aide H went outside Resident #42 was by a tree beside the facility that was approximately 150 feet from the front door entrance. LVN N stated when she asked Resident #42 where he was going, he stated, I'm going home. LVN N stated she was able to redirect Resident #42 back in the building. LVN N stated when Resident #42 was brought inside the facility the wander guard system on his wheelchair set the front door alarm off. During a telephone interview on 09/25/24 at 10:21 a.m., Administrator S stated she was the Administrator for the facility when Resident #42 eloped back in July. Administrator S stated Resident #42 was moved off the unit because she was told by the DON Resident #42 was not exhibiting exit -seeking behaviors. Administrator S stated she could not remember the incidents on 07/01/24 or 07/10/24. Administrator S stated she did not remember Resident #42 exit seeking when she was there. Administrator S stated if resident tried to elope on 07/01/24 and 07/10/24 he should have gone back to the unit because he was still at risk for elopement. Administrator S stated the risk for residents eloping was a serious injury. During an interview on 09/26/24 at 11:22 a.m., Administrator T stated she had observed Resident #42 exit seeking while sitting at her desk in the front lobby, but he was easily redirected. Administrator T stated she thought the wandergard system was enough to be safe since he was easily to be redirected. Administrator T stated the front door remained unlocked all day and felt like it was just fine. Administrator T stated she monitored resident safety by discussing any incidents during morning meetings, rounds and collaborating with the DON/ADON. Administrator T stated the risk for residents eloping was a serious injury. Record review of the facility's policy titled, Elopement Prevention, revised 10/27/10, indicated, Every effort will be made to prevent elopement episodes while maintaining the least restrictive for residents who are at risk for elopement .Physical Plan (1) All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts . (2) All other exits not considered fire exits will be locked when not occupied by staff members . This was determined to be an IJ on 09/23/24 at 5:30 p.m. The Administrator was notified. The Administrator was provided with the IJ template on 09/23/24 at 5:32 p.m. The following plan of removal submitted by the facility was accepted on 09/24/24 at 1:00 p.m. and included the following: Interventions: 1. On 9/23/24, Resident #42 resides on the secure unit inside the facility. 2. All door alarms were checked for proper functioning and alarming by the maintenance director on 9/23/24. All doors are alarming properly. 2 of 2 doors with wander guard volume increased on 9/23/24. All other doors with locking mechanism are at a volume that is audible throughout the facility on 9/23/24. 3. All residents with wander guards had their devices checked for proper functioning by ADON and Charge Nurses on 9/23/24. All devices are functioning properly. Front door Wander guard alarm volume increased on 9/23/24. 4. Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee on 9/23/24. No additional concerns were identified. 5. All elopement risk care plan interventions were reviewed on 9/23/24 by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned. 6. The Administrator and ADON were in-serviced 1:1 by the ADO and Regional Compliance Nurse on 9/23/24 on the following: a. Elopement Prevention Policy to include implementing interventions for residents at risk for elopement. b. Elopement Response Policy c. Abuse and Neglect Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement. The Elopement Risk Assessment will be completed upon admission by the charge nurse. The assessment will be completed by reviewing the resident's medical history and social history. Information may be obtained by reviewing current medical records, if available, interview with resident/family, or conference with the interdisciplinary team member. The Elopement Risk Assessment is to be completed at least quarterly, after an elopement attempt, upon new exit seeking behavior, and upon change of condition. The Elopement Risk Assessment will be completed by the charge nurse or designee. The DON/ADON will be responsible for ensuring the completion and review of the assessment. This will begin 9/23/24. All residents who are at risk for elopement will be assessed by the interdisciplinary team. This will begin 9/23/24. The resident's care plan will be modified by the DON, MDS Coordinator, or designee to indicate the resident is at risk for elopement with appropriate interventions to prevent elopement attempts. This will begin 9/23/24. 7. Medical Director notified of the immediate jeopardy on 9/23/24. 8. An ADHOC QAPI meeting was conducted on 9/23/24 to discuss the immediate jeopardy citation and subsequent plan of correction. In-services: 1. The Regional Compliance Nurse, Administrator and ADON will in-service all staff on the following topics below. All staff not present for the in-services will not be allowed to work their next shift until the in-services are complete. All new hires will be in-serviced during orientation prior to working their shift. All agency staff will be in-serviced prior to assuming scheduled shift. a. All staff were in-serviced on the elopement response policy by the Compliance Nurse, Administrator and ADON on 9/23/24. b. All staff were in-serviced on elopement prevention by Compliance Nurse, Administrator and ADON on 9/23/24. c. All staff were in-serviced on Abuse and Neglect by the Compliance Nurse, Administrator, and ADON on 9/23/24. d. Charge Nurses in-serviced on 9/23/24 on Checking door alarms and wander guard alarms 2 times daily at change of shift. On 09/24/24 the survey team confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: 1. During an observation on 09/24/24 at 11:01 a.m., Resident #42 was observed on the secure unit inside the facility. 2. During an observation on 09/24/24 with the Maintenance Supervisor and a state surveyor beginning at 2:50 p.m., the door alarms were checked for proper functioning and alarming. All other doors with locking mechanism were at a volume that was audible throughout the facility. No additional concerns were identified. 3. During an observation on 09/24/24 with the Maintenance Supervisor and a state surveyor beginning at 2:50 p.m., a wanderguaard device was checked for proper functioning by attempting to go out the front door entrance. Front door Wander guard alarm volume increased. 4. Record review of the elopement risk assessments audit, were completed on 09/23/24, revealed all residents were assessed for elopement. No additional concerns were identified. 5. Record review of the elopement risk care plan interventions audit, were completed on 09/23/24, revealed all care plan interventions were in place and care planned. 6. Record review of the in-service form dated 09/23/24 revealed the Administrator/ADON had received 1:1 in-service training with the ADO and Regional Compliance Nurse on elopement prevention, elopement response policy and abuse and neglect. 7. During a telephone interview on 09/24/24 at 1:52 p.m., the Medical Director stated he was notified of the immediate jeopardy situation and attended a QAPI meeting via phone over the immediate jeopardy and subsequent plan of removal on 09/23/24. 8. Record review of the ADHOC QAPI meeting, dated 09/23/24, revealed a meeting was conducted on 09/23/24 to discuss the IJ citation and subsequent plan of correction. 9. During interviews conducted on 09/24/24 between 2:10 p.m. and 3:10 p.m., revealed LVN D, RN G, Housekeeping Aide H, [NAME] L, LVN N, CNA O, RN P, CNA Q, CNA R, CNA V, Housekeeper Aide W, Activity Director, Human Resource Coordinator, Dietary Manager, Floor Maintenance, Housekeeping Supervisor, Maintenance Supervisor, Social Worker, PT Assistant, Rehab Director, OT, Marketing/Admissions, from all shifts were in serviced on elopement response policy, elopement prevention, abuse/neglect policy and checking the door alarms and wander guard alarms 2 times daily at change of shift. The Administrator was informed the IJ was removed on 09/24/24 at 3:36 p.m. The facility remained out of compliance at a severity level with potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the can opener blade was free of a black substance. The facility failed to ensure the steam table wells were clean and free of food debris. The facility failed to ensure the fryer was cleaned after use and free of food debris, and the fryer baskets free from hard cooked on food on the bottom of the baskets appearing to be French fries. The facility failed to ensure 3 skillets were free from carbon build up on the cooking surface of the pan. The facility failed to ensure the stove top was free from black burned on material in the burner wells. The facility failed to ensure a bag of [NAME] were dated and labeled in the walk-in cooler. The facility failed to ensure a large plastic container of pudding, and a large plastic container of Oreo cheesecake was properly covered. Cook M failed to effectively clean the food processor after pureeing green peas before pureeing meatloaf. The facility failed to ensure DM, 2 cooks, and 1 dietary aide wore their hair nets effectively covering all their hair. Cook L failed to glove her hand when she used the resident beverage cup to scoop ice in a large pot of ice then filled the same cup with the beverage of choice. These failures could place residents at risk of foodborne illness, and food contamination. Findings included: During the initial tour observation on 9/23/2024 at 9:59 a.m. to 10:19 a.m. included: 1)The can open blade had black substance on the triangle part that punctures the can. 2)The steam table wells had cloudy water with food particles floating in the water. 3)The fryer had dark brown oil with food particles floating in the oil. The fryer baskets had hard cooked food on the bottom resembling French fries. 4)The hanging dish rack had three skillets of varying sizes with carbon build up on the outside and on the inside cooking surface. 5)The stove top burner wells had a black cooked on food spills. 6) The walk-in cooler had an unlabeled and undated large gallon sized bag of [NAME], and 2 large plastic containers one with pudding and one with Oreo cheesecake filling, covered with aluminum foil paper and not a sealing lid. 7) The DM, [NAME] M, and the Dietary Aide K were wearing their hair nets leaving their hair uncovered in the temple area of the side of their head, and around the neck area. During an interview on 9/23/2024 at 10:19 a.m., [NAME] M said the fryer was normally cleaned after each use. [NAME] M said the fryer was used on last Friday 9/20/24 to fry fish. [NAME] M said, I am pregnant and cleaning the fryer was hard, so she was waiting on help. [NAME] M said the stove top was cleaned monthly. [NAME] M said the stove top had burned on food material and was not clean. [NAME] M said the can opener had gunk on the blade. [NAME] M said the can opener should be cleaned after each use . During an observation and interview on 9/23/2024 at 11:32 a.m., [NAME] M was pureeing the meatloaf for lunch. When the state surveyor asked [NAME] M what the bright green material in the blender was, she replied by saying green peas. [NAME] M went on to say after she blended the green peas, she just rinsed the bowl of the food processor, and what the state surveyor saw was the remnants of green peas not washed out of the food processor. [NAME] M said she often rinsed not washed the blender between foods. [NAME] M said this gives the food more nutrients and would be beneficial to the resident. [NAME] M's hair was outside of her hair net around the temporal area and the back of her neck . During an observation and interview on 9/23/2024 at 11:30 a.m., the DM said she had recently been promoted to the DM role. The DM said she had not been enrolled yet in the training course. The DM had her hair out around her hair net in the temporal region, and around her neck. DA K was preparing the rolls with the DM for serving. DA K also had his hair exposed from underneath his hair net around his neck. During an observation on 9/24/2024 at 11:23 a.m., the DM's hair was out around the temporal region and the back of the neck. During an observation and interview on 9/24/2024 at 11:32 a.m., [NAME] L was preparing resident drinking cups. [NAME] L handled the drinking cups with an ungloved hand, used the cup as a scoop while she scooped out of a large pan of ice filling each resident cup with ice and then the beverages. [NAME] L said she normally filled the resident drinking cups in this method. During an observation and interview on 9/24/2024 at 11:58 a.m., a DM U said she was from another facility and was there to help today. DM U took the 3 skillets from the pot hanging rack. DM U then took two skillets in the dish room and indicated the skillets should be cleaned using a degreaser and threw one in the trash indicating the skillet could not be used . DM U said the skillets could not be cleaned well and this could cause food borne illness. During an observation on 9/24/2024 at 12:33 p.m., [NAME] L was preparing a grilled cheese sandwich while her hair was out of her hair net around the temporal region and the back of her neck region. During an interview on 9/26/2024 at 1:00 p.m., the DM said she had not been trained yet and was aware of needed training in the kitchen. The DM said the fryer, stove, and the can opener should have been cleaned after each use. The DM said items in the walk-in cooler should be labeled, dated, and covered with a sealing lid. The DM said the blender should be run through the dish machine after each use. The DM said she was unaware of a failure with using the resident's drinking cup for scooping into the ice container while barehanded. The DM said hair nets should be worn to cover all the exposed hair. The DM said kitchen sanitation was important to prevent food borne illness . During an interview on 9/26/2024 at 11:34 a.m., Administrator T said she expected the cleanliness of the kitchen to meet requirements. Administrator T said although the kitchen has some need for improvement overall there had been improvement since she arrived. Administrator T said she expected sanitary food practices were followed to prevent food borne illness. Record review of a Food Storage and Supplies policy dated 2012 indicated all facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure stage areas are clean, organized, dry and protected from vermin, and insects 4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. Record review of an Equipment Sanitation policy dated 2012 indicated we will provide clean and sanitized equipment for food preparation. The facility will clean all food services equipment in a sanitary manner. 1. Equipment must be thoroughly sanitized between use in different food preparation task, salad preparation, raw meat cutting and cooked meat cutting. 8. Blenders and food processor bowls should be inverted after cleaning to drain dry on shelves or trays with vented slots or bar netting. 9. Large equipment is to be sanitized by spraying or wiping with a chemical sanitizing solution at least twice the minimum strength of solutions needed form immersion sanitizing. Record review of an Infection Control policy dated March 2012 indicated we will ensure that all employees practice infection control in Food and Nutrition Services Department and maintain sanitary food preparation. All dietary service employees will follow Infection Control Policies as established and approved by the Infection control committee. 1. Personal cleanliness is required in sanitary food preparation b. Clean hair is required. It is to be covered with an effective hair restraint. 5. Equipment Sanitation: a. All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces https://www.dshs.texas.gov/sites/default/files/foodestablishements/pdf/GuidanceDoc/TFER-2021_August-2021.pdf: accessed on 9/30/2024 indicated: TITLE 25 HEALTH SERVICES PART 1 DEPARTMENT OF STATE HEALTH SERVICES CHAPTER 228 RETAIL FOOD ESTABLISHMENTS SUBCHAPTER A GENERAL PROVISIONS S228.1. Purpose and Regulations. (a) The purpose of this chapter is to implement Texas Health and Safety Code, Chapter 437, Regulation of Food Service Establishments, Retail Food Stores, Mobile Food Units, and Roadside Food Vendors. (b) The department adopts by reference the U.S. Food and Drug Administration (FDA) Food Code 2017 (Food Code) and the Supplement to the 2017 Food Code. TFER S228.43 states that food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. It does not apply to food employees such as counter staff who only serve TEXAS DEPARTMENT OF STATE HEALTH SERVICES DIVISION FOR REGULATORY SERVICES ENVIRONMENTAL AND CONSUMER SAFETY SECTION POLICY, STANDARDS, AND QUALITY ASSURANCE UNIT PUBLIC SANITATION AND RETAIL FOOD SAFETY GROUP PSRFSGRC - No.19 Hair Restraints April 1, 2016 (Revised February 21, 2017) Page 2 Public Sanitation and Retail Food Safety Group ? PO Box 149347, Mail Code 1987 ? [NAME], Texas 78714-9347 (512) [PHONE NUMBER] ? Facsimile: (512) [PHONE NUMBER] ? According to the TFER, the container of ready-to-eat TCS food shall be marked to indicate the date by which food shall be consumed on the premises, sold, or discarded. The ready-to-eat TCS food if held at 41 F can only be held for a maximum of 7 days, with day of preparation being day 1. https://www.fda.gov/media/164194/download?attachment accessed on 9/30/2024 indicated: 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2. Management and Personnel Chapter 2 - 22 contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. (L) EMPLOYEES are properly SANITIZING cleaned multiuse EQUIPMENT and UTENSILS before they are reused, through routine monitoring of solution temperature and exposure time for hot water SANITIZING, and chemical concentration, pH, temperature, and exposure time for chemical SANITIZING; Preventing contamination from the premises 3-305.11 Food Storage. 3-305.12 Food Storage, Prohibited Areas. Pathogens can contaminate and/or grow in food that is not stored properly. Drips of condensate and drafts of unfiltered air can be sources of microbial contamination for stored food. Shoes carry contamination onto the floors of food preparation and storage areas. Even trace amounts of refuse or wastes in rooms used as toilets or for dressing, storing garbage or implements, or housing machinery can become sources of food contamination. Moist conditions in storage areas promote microbial growth. Refer also to the public health reasons for S 2-501.11

Based on observations, interviews, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 7 residents (Resident #40) reviewed for medication administration. 1. The facility did not ensure Resident #40 was given the correct dosage of alprazolam (antianxiety medication). 2. The facility did not ensure Resident #40's alprazolam (antianxiety medication) and Tylenol #3 (pain medication) labels from the pharmacy matched the orders placed in the electronic charting system. 3. The facility did not ensure RN G updated Resident #40's losartan potassium (blood pressure medication) order to match the clarification orders received from the physician. This failure could place residents at an increased risk for inaccurate drug administration and not receiving the care and services to meet their individual needs. The findings included: Record review of the face sheet, dated 09/26/2024, revealed Resident #40 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behaviors (group of symptoms that affects memory, thinking, and interferes with daily life), gastrostomy status (tube that is placed directly into the stomach to deliver medication and nutrients, usually from problems with swallowing), and essential hypertension (high blood pressure). Record review of the quarterly MDS assessment, dated 07/19/2024, revealed Resident #40 had clear speech, was understood by others, and was able to understand others. The MDS assessment revealed Resident #40 had a BIMS score of 2, which indicated severe cognitive impairment. The MDS revealed Resident #40 had no behaviors or refusal of care. The MDS revealed Resident #40 used a feeding tube while a resident. The MDS revealed Resident #40 was taking an antianxiety medication and an opioid medication. Record review of the comprehensive care plan, last reviewed 07/05/2024, revealed Resident #40 had a feeding tube and received her medications by the enteral route (through the feeding tube). The care plan further revealed Resident #40 received an antianxiety and pain medication. Record review of the order summary report, dated 09/25/2024, revealed Resident #40 had an order for the following: 1. Alprazolam 0.25mg - give one tablet by gastrostomy tube two times a day for anxiety, which started on 09/24/2024. 2. Tylenol #3 300-30mg - give 1 tablet by gastrostomy tube every 6 hours for pain, which started on 05/30/2023. 3. Losartan potassium 50 mg - give 1 tablet by gastrostomy tube one time a day related to hypertension (hold for systolic blood pressure less than 100, diastolic blood pressure less than 60, and heart rate less than 60), which started on 04/06/2024. Record review of the MAR, dated September 2024, revealed Resident #40 received alprazolam (antianxiety medication) and Tylenol #3 (pain medication) daily. The MAR further revealed Resident #40's losartan potassium (blood pressure medication) was held 10 out of 25 days for heart rate less than 60. During an observation and interview on 09/25/2024 beginning at 10:03 AM, RN G obtained Resident #40's blood pressure, which read 131/73 with a heart rate of 50. RN G then prepared Resident #40's medications which included Tylenol #3, alprazolam 0.5mg, and losartan potassium 50 mg. Resident #40's Tylenol #3 card from the pharmacy had instructions to administer the medication by mouth. Resident #40's alprazolam 0.5mg card from the pharmacy had instructions to administer the medication by mouth. Resident #40's losartan potassium 50mg card from the pharmacy had instructions to hold the medication for a heart rate less than 60. RN G stated hospice nurse and physician had given clarification regarding Resident #40's blood pressure medications a few days prior. RN G stated the hospice nurse had noticed Resident #40's blood pressure had been elevated and the losartan potassium was held. RN G stated the hospice nurse spoke with the doctor and instructed her to take the heart rate parameters off the order because the medication did not affect the heart rate. There were no order change stickers on any of the medication cards. RN G administered all medication one at a time into the gastrostomy tube. During an interview on 09/26/2024 beginning at 10:38 AM, the Regional Compliance Nurse stated the medication cards from the pharmacy should have matched the orders in the electronic charting system. The Regional Compliance Nurse stated if an order was changed in the electronic charting system, then a order changed sticker should have been placed on the medication card to alert staff . During an interview on 09/26/2024 beginning at 11:26 AM, RN G stated she did not realize the route was different from the order on Resident #40's alprazolam and the Tylenol #3. RN G stated Resident #40 only received medication by the gastrostomy tube, so she did not think to check the card to ensure the correct route was listed. RN G stated she was unsure what the protocol was for checking medication in from the pharmacy because they usually came on the night shift. RN G stated it was important to ensure the card from the pharmacy matched the orders in the electronic charting system to prevent a medication error. During an interview on 09/26/2024 beginning at 1:24 PM, RN G stated she had not realized Resident #40's order for alprazolam had changed. RN G stated it was not passed on during report that morning. RN G stated she administered the wrong dose of alprazolam to Resident #40 on 09/25/2024. RN G stated she should have checked the card to the order more closely. RN G stated Resident #40 had been receiving 0.5mg and the order was reduced to 0.25mg to attempt a gradual dose reduction. RN G stated if the pharmacy cards did not match the orders in the computer, then the doctor should have been notified immediately, and the order clarified. RN G stated if the order was changed then a sticker should have been placed on the card to alert staff of an order change. RN G stated after an order was clarified by the physician, it should have been updated in the computer immediately. RN G stated she updated the hold orders for Resident #40's losartan potassium in the electronic charting system. RN G stated it was important to administer the correct dosage of medication and to ensure hold parameters were updated in the electronic charting system to prevent adverse effects from medication errors. During an interview on 09/26/2024 beginning at 1:43 PM, Administrator T stated she expected nursing staff to follow the physician orders and the facility protocol for medication administration. Administrator T stated the DON and the ADON were responsible for monitoring to ensure medications were administered properly, orders were updated, and medication cards matched the orders. Administrator T stated it was important to ensure medication cards matched the order, hold parameters were clarified by the physician, and the correct dosage was given to prevent medication error and to ensure accuracy . Record review of the Medication Administration Procedures policy, undated, revealed a specific order must be obtained from the physician to change the dosage form of a resident's medication .medication errors and adverse drug reactions are immediately reported .the ten rights of medication should always be adhered to .right dose .rights route .right documentation .

Based on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not service a whole egg roll with the lunch meal on 9/26/2024. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of a Weekly Menu 2024 Week 3 dated 4/10/2024 indicated on Thursday September 26, 2024, the facility menu was Teriyaki chicken, Lo Mein Noodles, Hibachi Vegetables, Egg roll, Gingerbread bar with glaze, and iced tea. Record review of a Recipes to Scale dated Thursday, September 26, 2024, indicated a serving size was 1 pork and vegetable egg roll, and the amount needed was 43 . During an observation and interview on 9/26/2024 at 12:05 p.m., the DM was cutting the egg rolls in 1/2 and then placing the 1/2 cut portion on each resident's plate with a regular or mechanical soft diet. The DM said there were no egg rolls and they had to go out and purchase these for the lunch. The DM said the egg roll was considered the resident's bread and was unsure of what the serving portion should be . During an interview on 9/26/2024 at 1:23 p.m., Administrator T said she expected the DM to follow the menu and provide the correct portion size. Administrator T said she was unsure why there were not any egg rolls available since they have received such large orders of food for the menu. Administrator T said the DM was new, needed more training, and was enrolled for the upcoming DM training course offered at a college . The Administrator said not serving the appropriate serving sizes of food items could cause weight loss. Record review of the Dietary Services policy, last revised on 2012 indicated, .Fundamental Information: A preplanned menu is provided to the facility, which has been planned or reviewed by a Registered Dietitian and includes meals that are adequate to meet the average resident's nutritional needs.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 4 of 7 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 9/26/2024 for confidential residents. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. Findings included: During a confidential group interview on 9/25/2024 at 2:00 p.m., 4 residents said the food trays served on the halls and in the dining room were cold, overcooked, and not flavorful. Record review of the food temperature log dated 9/26/2024 indicated the regular meat's temperature at the time of serving was 180 degrees Fahrenheit, the cooked noodles/vegetables were 189 degrees Fahrenheit, mechanical soft chicken was 187 degrees Fahrenheit, and the purred noodles were 147 degrees Fahrenheit, and the pureed and regular eggs rolls were 165. During an observation on 9/26/2024 at 12:50 p.m., the DM after completing all the trays except one, which needed a pureed egg roll, stopped the trays, and pureed the egg roll and then completed the plating. Once the DM completed the plating the tray cart left the kitchen. During an observation on 9/26/2024 at 12:55 p.m , the tray cart with the test tray left the kitchen preparation area. The tray cart was reviewed by nurses, and they left the dining room and went to the hall at 12:59 p.m. The trays were passed starting from 12:59 p.m. and ending when the test tray arrived in the work room at 1:08 p.m. The resident trays and the test tray were prepared on warmed plates using a plate warmer. During a test tray interview with the Dietary Manager and State Surveyors on 9/26/2024 1:08 p.m., the Dietary Manager stated the following regarding the regular food diet for lunch served on 9/26/2024: agreed the plate had 1/2 an egg roll which was cool, the noodle/vegetable mix was warm and bland, the chicken teriyaki was warm and lacked the teriyaki seasoning flavor, and the gingerbread cake was moist and had flavor. The DM said she liked the meal and said she did not feel this affected the residents. During an interview on 5/09/2024 R 12:52 p.m., Administrator T said she expected the meals to be palatable regarding temperature and taste. Administrator T said palatability ensured enjoyable meals. Administrator T said she was surprised since she ate from the kitchen 2-3 times weekly and enjoyed the meals. Administrator T said she had had some food complaints in the past regarding palatability, but she had believed these were resolved. Administrator T said the dietary department was responsible for ensuring meals were palatable. Administrator T failed to provide a policy regarding palatability of meals . The Administrator said a resident could lose weight when the foods were not appetizing.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 (Resident #40 and #42) and 1 of 1 laundry cart reviewed for infection control practices. 1)The facility failed to ensure CNA F and RN G properly cleaned the perineal/genital areas for Resident #'s 40 and 42 during incontinent care . 2)The facility did not ensure Housekeeper H covered the clean linen cart while passing out clean linens on 09/23/2024. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: 1)Record review of a face sheet dated 9/26/2024 indicated Resident #40 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (loss of memory). Record review of a comprehensive care plan dated 11/10/2022 and revised on 7/05/2024 indicated Resident #40 was incontinent of bowel and bladder and was dependent for toileting. The goal of the care plan was Resident #40 would have a decreased likelihood of skin breakdown. The care plan interventions for Resident #40 included to monitor for symptoms of a urinary tract infection, provide incontinent care as needed, and report any changes in bladder status such as low urine output, foul urine, discolored urine, pain, bladder distention, urine frequency, urgency, or fever. Resident #40's comprehensive care plan also indicated she required assistance with her ADLs related to impaired mobility, weakness, medications, and dementia. The goal of Resident #40's care plan was she would be clean, dry, and comfortable. The care plan interventions included Resident #40 required extensive assistance of 2 staff with personal hygiene and toileting. Record review of the Quarterly MDS dated [DATE] indicated Resident #40 understands and was understood. The MDS indicated Resident #40 had severe cognitive impairment. The MDS in Section E-Behavior indicated she had not rejected care. The MDS in Section GG-Functional Abilities and Goals indicated Resident #40 was dependent with the helper providing all the effort for toileting, and personal hygiene. The MDS in Section H-Bladder and Bowel indicated Resident #40 was always incontinent of bowel and bladder. Record review of a Licensed Nurse Proficiency Audit dated 7/26/2024 - 7/30/2024 indicated RN G was checked off as satisfactory in the Infection Control area including proper hand hygiene, prevention of cross contamination, and universal precautions. The audits provided failed to address perineal/incontinent care. During an observation on 9/25/2024 at 8: 57 a.m., RN G donned her PPE (disposable gown and gloves), with gloved hands RN G picked up the bedside trash can and moved it closer to her right side. RN G then obtained several pair of gloves and placed them on Resident #40's bed. RN G then removed Resident #40's brief, rolling it in on itself, then she took wiped Resident #40's anal/buttock area twice. RN G removed her gloves, washed her hands, applied clean gloves, then positioned the draw sheet and the clean brief underneath Resident #40. Resident #40 was then repositioned; the clean brief was applied, and she was repositioned for comfort. RN G failed to clean Resident #40's perineal (female genital) area. During an interview on 9/25/2024 at 2:26 p.m., RN G said she done a horrible job when she provided incontinent care to Resident #40. RN G said I forgot to clean Resident #40's perineal area. RN G said failing to do incontinent care correctly placed Resident #40 at risk for infections. 2) Record review of a face sheet dated 9/25/2024 indicated Resident #42 was a [AGE] year-old male who admitted [DATE] with the diagnosis of Alzheimer's Disease (memory loss disease). Record review of the Comprehensive Care Plan dated 6/11/2024 indicated Resident #42 had a care plan problem of bladder incontinence. The goal of the care plan was Resident #42 would be free from skin breakdown due to incontinence. The comprehensive care plan interventions for Resident #42 included to provide incontinent care every 2 hours, monitor and document symptoms of urinary tract infections, increased pulse, increased temperature, urinary frequency, and foul urine. The comprehensive care plan also included bowel incontinence for Resident #42. The goal of the was Resident #42 would not have any complications related to bowel incontinence. The comprehensive care plan intervention for Resident #42 included check Resident #42 every two hours and assist with toileting, provide peri-care after each incontinent episode. The comprehensive care plan indicated Resident #42 required assistance with ADL self-care. The goal of ADL self-care care plan was Resident #42 would maintain or improve his current level of function. The care planned interventions for Resident #42 included toileting requiring 2 staff and a lifting device. Record review of the Admission MDS dated [DATE] indicated understands and was understood by others. The MDS indicated Resident #42 had severe cognitive impairment. The MDS in Section E-Behavior indicated Resident #42 had not demonstrated rejection of care behaviors. The MDS in Section GG-Functional Abilities and Goals indicated Resident #42 required supervision or touching assistance with toileting hygiene. The MDS in the Section H-Bladder and Bowel indicated Resident #42 was occasionally incontinent of bowel and bladder. Record review of a CNA Proficiency Audit dated 4/10/2024 indicated CNA F was checked off on the provision of incontinent care for a male and a female and passed the evaluation with a score of satisfactory. During an observation on 9/25/2024 at 7:09 a.m., Resident #42 was sitting on the edge of his bed. Resident #42 had an adult pull up and a pair of shorts on around his lower legs. CNA F Instructed Resident #42 to stand using his walker. Resident #42 after several attempts stood up, then CNA F removed his wet adult diaper and placed it in the trash can. CNA F Removed her gloves, applied another pair of gloves, obtained two wipes, and cleaned Resident #42's buttocks, she then pulled up his adult pull-up and shorts. CNA F Failed to cleanse Resident #42's genitals or complete hand hygiene between glove changes. During an interview on 9/25/2024 at 7:16 a.m., CNA F Said she had not done well on the incontinent care observation. CNA F said she failed to cleanse Resident #42's genitals (perineal area) and wash her hands in between glove changes. CNA F said when not providing incontinent care to Resident #42's genitals (perineal area) it could cause a risk of infection. During an interview on 9/26/2024 at 11:05 a.m., the ADON said she expected the staff to cleanse the perineal area when completing incontinent care. The ADON said she monitored the provision of incontinent care by annual checks offs and spot checks. The ADON said urinary tract infections could arise from failing to cleanse a resident's perineal area . The ADON said the staff should wash their hands when visible soiled. The ADON said hand sanitizer could be used between glove changes. During an interview on 9/26/2024 at 11:31 a.m., the Administrator said the DON was not available for interview due to her own health conditions. The Administrator said she expected the nursing staff to provide the appropriate incontinent care. The Administrator said this system was monitored with annual check offs and she expected spot checks to be performed. The Administrator said hand hygiene should be completed according to their policy. The Administrator said she had only been in her role for 2 months but believed her staff required more training. The Administrator said there was a risk of infection when incontinent care was not performed correctly . 47006 3) During an observation on 09/23/2024 at 10:37 AM, Housekeeper H was passing out clothing from her clean linen cart on Hall 5. The metal linen cart had no cover for the basket that was filled with clean linen. The purple linen cover was rolled up in the basket beside the clean linens. The metal linen cart had a rack to hang up clothing. Clothing was hanging on the rack with the purple linen cover pulled back, which exposed the clean clothing. During an interview on 09/26/2024 beginning at 11:47 AM, the Housekeeping Supervisor stated linen carts should have been covered while passing out clean linens. The Housekeeping Supervisor stated she expected the housekeeping staff to ensure the linen carts were kept covered. The Housekeeping Supervisor stated Housekeeper H could have been nervous. The Housekeeping Supervisor stated the purple linen covers were what the facility used to cover the clean linens. The Housekeeping Supervisor stated she was going to talk to the white glove company when they came to the facility about new linen carts and covers but had not talked to them yet. The Housekeeping Supervisor stated she was responsible for monitoring to ensure linen cart covers were used. The Housekeeping Supervisor stated it was important to ensure clean linen cart covers were used to prevent cross contamination. During an interview on 09/26/2024 beginning at 12:33 PM, Housekeeper H said she was always taught only one linen cart cover needed to be used. Housekeeper H said she was unaware the bottom of the metal linen cart basket needed to be covered as well. Housekeeper H said she was aware the top rack of the clean linen cart should have been covered completely but she was used to leaving it open while she was in the resident rooms. Housekeeper H said it was important to ensure the linen cart covers were used properly to prevent contamination. During an interview on 09/26/2024 beginning at 1:28 PM, the ADON stated she was the infection control preventionist at the facility. The ADON stated the clean linen cart should have been kept covered while passing out laundry. The ADON stated the Housekeeping Supervisor was responsible for ensuring the clean linen carts were kept covered but she was responsible for ensuring infection control education was provided to the housekeeping staff. The ADON was unsure when the last education had been provided to the housekeeping staff. The ADON stated it was important to ensure clean linens were kept covered to prevent the spread of infection and contamination of clean linens. During an interview on 09/26/2024 beginning at 1:43 PM, Administrator T stated she expected the housekeeping staff to ensure clean linens were kept covered while passing out laundry. Administrator T stated the Housekeeping Supervisor was responsible for monitoring to ensure the linen carts were kept covered. Administrator T stated new linen cart covers had been ordered after the Housekeeping Supervisor had told her about the incident. Administrator T stated it was important to ensure clean linen carts were covered properly for infection control. Record review of the in-service training attendance roster, dated 09/26/2024, revealed the Housekeeping Supervisor initiated an in-service training on Proper Handling and Distribution for Clean Linen. Housekeeper H was listed on the signage sheet for being called. Record review of the Infection Control Plan: Overview, updated March 2024, revealed Personnel will handle, store, process, and transport linens so as to prevent the spread of infection . Record review of a Perineal Care policy with an effective date of 5/11/2022 indicated an incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . The policy purpose indicated was to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritations, and observing resident's skin condition Start: 10) perform hand hygiene, 11) apply gloves and all other PPE standard precautions, 12) soak towels in wash basin .or remove an adequate number of pre-moistened cleansing wipes, 13) reposition the resident on their back with legs flexed and separated as able, 14) limit resident exposure to the perineal area-provide privacy at all times, 15) if required, use a towel or extra incontinence pad to protect the mattress cover form being soiled, 16) wipe across the pubis area, 17) gently perform perineal care, wiping from clean, urethral area, to dirty rectal area, to avoid contaminating the urethral area. Female resident: working from front to back, wipe one side of the labia majora, the outside folds of the perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. Male resident: Pull back the foreskin on uncircumcised males. Hold the penis by the shaft, wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh 20) Reposition the resident to their side, 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area 24) remove gloves and PPE, 25) perform hand hygiene. Record review of the Infection Control policy updated 3/2024 indicated the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 16 resident rooms (Resident #38) reviewed for environment. The facility failed to ensure Resident #38's door was properly functioning. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of a face sheet dated 09/24/2024, indicated Resident #38 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease with early onset (progressive disease that destroys memory and other important mental functions starting earlier in life) and heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of the Quarterly MDS assessment dated [DATE], indicated Resident #38 was able to make herself understood and understood others. The MDS assessment indicated Resident #38 had a BIMS score of 6, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #38 required set-up or clean-up assistance for eating, oral hygiene, and partial/moderate assistance for toileting hygiene and showering/bathing self. Record review of Resident #38's care plan last reviewed 09/06/2024 indicated she had impaired cognitive function/dementia (deterioration of memory, language, and other thinking abilities) or impaired thought processes to provide the resident with a homelike environment. During an observation and interview on 09/24/2024 at 10:19 AM, Resident #38's door was dragging on the bottom and the floor had skid marks where the door was dragging. Resident #38's door was not easily opened and closed. Resident #38 said when the CNAs checked on her early in the morning when they opened the door it made loud noises, and it would wake her up. Resident #38 said the nurses and the CNAs knew the door needed to be fixed that they got frustrated with it all the time. During an interview on 09/25/2024 at 8:51 AM, CNA A said Resident #38's door to her room was dragging on the floor and had caused visible scrapes. CNA A said the Maintenance Director was aware that it needed to be repaired. CNA A said the door had been dragging since she started working on the floor about a month or two ago. CNA A said the door dragging on the floor startled Resident #38 in the mornings. CNA A said it was important for the residents' rooms to be repaired because it was their home, and they had the right to have as much of a comfortable home as possible. During an interview on 09/25/2024 at 9:04 AM, the Maintenance Director said he was responsible for fixing the rooms. The Maintenance Director said the staff had mentioned to him that Resident #38's door to her room needed to be fixed. The Maintenance Director said he was not sure how long ago it was mentioned to him. The Maintenance Director said he realized there was a portion of Resident #38's door rubbing on the floor, but he had not had a chance to sand it down. The Maintenance Director said he checked every room once a month. The Maintenance Director said Resident #38's door dragging on the flood could affect how she was entering and exiting the room. The Maintenance Director said it was important for the residents' rooms to be in good repairs so the residents could access their living environment and be in a safe environment. During an interview on 09/26/2024 at 11:05 AM, Administrator T said she was not aware Resident #38's door needed to be repaired. Administrator T said she expected for the Maintenance Director to be notified of any repairs that needed to be made and for him to make the required repairs. Administrator T said it was important for repairs to be made for the residents' safety and happiness just like we would like in our own home. Record review of the maintenance logs provided by the Maintenance Director dated from 04/23/24-09/25/2024 did not indicate a request for Resident 38's door to be fixed. Record review of the facility's policy titled, Resident Rights, indicated, .Safe environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 16 residents (Residents #42 and #43) reviewed for MDS assessment accuracy. 1. The facility did not ensure Resident #42's MDS assessment was accurately coded for wandering. 2. The facility failed to ensure Resident #43's antibiotic use was accurately coded. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #42's face sheet, dated 09/26/24, indicated Resident #42 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of the Admission MDS assessment, dated 06/14/24, indicated Resident #42 made himself understood and understood others. Resident #42's BIMS score was 4, which indicated his cognition was severely impaired. Resident #42 did not have disorganized thinking, behaviors, wandering, or refusal of care. Resident #42 used a wheelchair. Record review of the comprehensive care plan, revised 07/19/24, indicated Resident #42 was a at risk for wandering. The care plan interventions included, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, identify pattern of wandering, if the resident is exit seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc., monitor my location frequently through the day while I am up & out of bed, and wear owander alert bracelet in place (on w/c) & check for placement q shift. Record review of the comprehensive care plan, revised 09/15/24, indicated Resident #42 was at risk for elopement as evidenced by: resident history of exit seeking and exiting out of door of facility. The care plan interventions included, resident moved to secure care unit, assess/record/report to MD risk factors for potential elopement such as: Wandering, Repeated requests to leave facility, statements such as I'm leaving I'm going home, attempts to leave facility, elopement attempts from previous facility, home, or hospital, supervise closely, and make regular compliance rounds whenever resident is in room, determine the reason the resident is attempting to elope. Is the resident looking for something or someone? Does it indicate the need for more exercise? Intervene as appropriate, provide structured activities: for inside and outside, reorientation strategies including signs, pictures, and memory boxes, distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books, and if the resident is exiting seeking, stay with the resident and notify the charge nurse by calling out, sending another staff member, call system, etc. Record review of the referral paperwork from a sister facility dated 06/05/24 revealed Resident #42 would be sent to a secure unit facility. Record review of Resident #42's elopement assessment, dated 06/05/24, reflected Resident #42 was at risk for elopement. Record review of the progress note dated 06/08/24 completed by LVN X indicated Resident #42 was wondering up and down hallway agitated and confused about why he is here in facility. Attempts to redirect unsuccessful due to confusion. 46892 2. Record review of a face sheet dated 09/26/2024 indicated Resident #43 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #43 was able to make herself understood and understood others. The MDS assessment indicated Resident #43 had a BIMS score of 2, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #43 received an antibiotic during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #43's Order Summary Report dated 09/25/2024 did not indicate orders for an antibiotic. Record review of Resident #43's care plan last reviewed 07/08/2024 did not indicate the use of an antibiotic. Record review of Resident #43's August 2024 MAR did not indicate Resident #43 received an antibiotic. During an interview on 09/26/2024 at 8:59 AM, Regional Reimbursement Nurse B said he had started completing MDS assessments at the facility 2 weeks ago. Regional Reimbursement Nurse B said the facility currently did not have an MDS nurse, but there was one starting 09/30/2024. Regional Reimbursement Nurse B said Resident #43 should not have been coded as taking an antibiotic because she had not taken an antibiotic in the look back period. Regional Reimbursement Nurse B said Resident #42 should have been coded as wandering for 1-3 days because it was noted in the progress notes that he wandered on 1 day in the look back period. Regional Reimbursement Nurse B said he did not know who had completed Resident #42's and #43's MDS assessment. Regional Reimbursement Nurse B said the person who signed a completed MDS signed for the accuracy of the MDS assessment. Regional Reimbursement Nurse B said it was important for the MDS assessments to be accurate because it reflected the resident. During an interview on 09/26/2024 at 11:07 AM, Administrator T said she expected for the MDS assessments to be coded accurately by the MDS nurses. Administrator T said the regional corporate person was responsible for providing oversight to the MDS nurse. Administrator T said they currently did not have a MDS nurse. The previous MDS nurse's last day was last Friday 09/20/24, and the new MDS nurse was starting 9/30/24. Administrator T said it was important for the MDS assessments to be coded accurately for billing purposes. During an attempted phone interview on 09/26/2024 at 11:24 AM, MDS Coordinator C did not answer the phone. Record review of the facility's undated policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy 2.2021 CMS RAI 10.2023, indicated, Purpose/Policy The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being . Federal regulations at 42 CFR 483.20 (b)(l)(xviii), (g), and (h) require that: 1. The assessment accurately reflects the resident's status .

Based on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 16 residents (Resident #1) reviewed for care plans. The facility failed to care plan that Resident #1 was PASRR positive for mental illness and an intellectual disability. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings included: Record review of a face sheet dated 09/25/2024 indicated Resident #1 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, bipolar type (mood disorder that can involve delusions, hallucinations, depression, disorganized thinking and speech) and intellectual disabilities. Record review of the Comprehensive MDS assessment dated [DATE], indicated in Section A1510 Resident #1 was considered by the state level II PASRR process to have serious mental illness and an intellectual disability. The MDS assessment indicated Resident #1 understood others and was able to make herself understood. The MDS assessment indicated Resident #1 had a BIMS score of 12, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #1 required supervision/touching assistance for toileting, showering/bathing self, and personal hygiene. Record review of Resident #1's PASRR Level 1 Screening completed on 07/16/2024 indicated in section C0100 that there was evidence or an indicator that this individual had mental illness, and in section C0200 that there was evidence or an indicator that this individual had an intellectual disability. Record review of Resident #1's PASRR Evaluation dated 07/17/2024 indicated she had an intellectual disability which manifested before the age of 18, and mental illness which included a mood disorder, schizoaffective disorder, and panic or other severe anxiety disorder. Resident #1's PASRR Evaluation indicated based on the QMHP assessment Resident #1 met the PASRR definition of mental illness. Record review of Resident #1's care plan last reviewed 09/06/2024 did not address Resident # 1's PASRR status. During an interview on 09/26/2024 at 8:59 AM, Regional Reimbursement Nurse B said he had looked at a couple care plans but he was not really completing them. Regional Reimbursement Nurse B said the care plans were being completed by the staff in the facility. During an interview on 09/26/2024 at 10:27 AM, the Regional Compliance Nurse said Resident #1's care plan should have included PASRR. The Regional Compliance Nurse said it must have been an oversight that it was not included in Resident #1's care plan. The Regional Compliance Nurse said it was the responsibility of the MDS nurse to ensure PASRR was included in the residents' care plans. The Regional Compliance Nurse said it was important for PASRR to be included in the residents' care plans so that everyone knew the specialized services they were receiving. During an interview on 09/26/2024 at 11:10 AM, Administrator T said the MDS Coordinator, and the nurses were responsible for completing the care plans. Administrator T said she expected for PASRR services to be included in the residents' care plans. Administrator T said it was important for the PASRR services to be included in the resident's care plan to ensure staff knew they received specialized services and to ensure they were providing the best care possible. During an attempted phone interview on 09/26/2024 at 11:24 AM, MDS Coordinator C did not answer the phone. Record review of the facility's policy titled, Comprehensive Care Plans, revised 02/13/2007, indicated, The facility will develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a resident=s [sic] medical, nursing, and mental and psycho-social needs that are identified in the comprehensive assessment .

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #40 and Resident #42) reviewed for incontinent care. The facility failed to ensure CNA F and RN G properly cleaned the perineal/genital areas for Resident #'s 40 and 42 during incontinent care. These failures could place residents at risk for urinary tract infections. Findings included: 1)Record review of a face sheet dated 9/26/2024 indicated Resident #40 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (loss of memory). Record review of a comprehensive care plan dated 11/10/2022 and revised on 7/05/2024 indicated Resident #40 was incontinent of bowel and bladder and was dependent for toileting. The goal of the care plan was Resident #40 would have a decreased likelihood of skin breakdown. The care plan interventions for Resident #40 included to monitor for symptoms of a urinary tract infection, provide incontinent care as needed, and report any changes in bladder status such as low urine output, foul urine, discolored urine, pain, bladder distention, urine frequency, urgency, or fever. Resident #40's comprehensive care plan also indicated she required assistance with her ADLs related to impaired mobility, weakness, medications, and dementia. The goal of Resident #40's care plan was she would be clean, dry, and comfortable. The care plan interventions included Resident #40 required extensive assistance of 2 staff with personal hygiene and toileting. Record review of the Quarterly MDS dated [DATE] indicated Resident #40 understands and was understood. The MDS indicated Resident #40 had severe cognitive impairment. The MDS in Section E-Behavior indicated she had not rejected care. The MDS in Section GG-Functional Abilities and Goals indicated Resident #40 was dependent with the helper providing all the effort for toileting, and personal hygiene. The MDS in Section H-Bladder and Bowel indicated Resident #40 was always incontinent of bowel and bladder. Record review of a Licensed Nurse Proficiency Audit dated 7/26/2024 - 7/30/2024 indicated RN G was checked off as satisfactory in the Infection Control area including proper hand hygiene, prevention of cross contamination, and universal precautions. The audits provided failed to address perineal/incontinent care. During an observation on 9/25/2024 at 8: 57 a.m., RN G donned her PPE (disposable gown and gloves), with gloved hands RN G picked up the bedside trash can and moved it closer to her right side. RN G then obtained several pair of gloves and placed them on Resident #40's bed. RN G then removed Resident #40's brief, rolling it in on itself, then she took and wiped Resident #40's anal/buttock area twice removing urine and bowel movement. RN G removed her gloves, washed her hands, applied clean gloves, then positioned the draw sheet and the clean brief underneath Resident #40. Resident #40 was then repositioned; the clean brief was applied, and she was repositioned for comfort. RN G failed to clean Resident #40's perineal (female genital) area. During an interview on 9/25/2024 at 2:26 p.m., RN G said she done a horrible job when she provided incontinent care to Resident #40. RN G said I forgot to clean Resident #40's perineal area. RN G said failing to do incontinent care correctly placed Resident #40 at risk for infections. 2) Record review of a face sheet dated 9/25/2024 indicated Resident #42 was a [AGE] year-old male who admitted [DATE] with the diagnosis of Alzheimer's Disease (memory loss disease). Record review of the Comprehensive Care Plan dated 6/11/2024 indicated Resident #42 had a care plan problem of bladder incontinence. The goal of the care plan was Resident #42 would be free from skin breakdown due to incontinence. The comprehensive care plan interventions for Resident #42 included to provide incontinent care every 2 hours, monitor and document symptoms of urinary tract infections, increased pulse, increased temperature, urinary frequency, and foul urine. The comprehensive care plan also included bowel incontinence for Resident #42. The goal of the was Resident #42 would not have any complications related to bowel incontinence. The comprehensive care plan intervention for Resident #42 included check Resident #42 every two hours and assist with toileting, provide peri-care after each incontinent episode. The comprehensive care plan indicated Resident #42 required assistance with ADL self-care. The goal of ADL self-care care plan was Resident #42 would maintain or improve his current level of function. The care planned interventions for Resident #42 included toileting requiring 2 staff and a lifting device. Record review of the Admission MDS dated [DATE] indicated Resident #42 understands and was understood by others. The MDS indicated Resident #42 had severe cognitive impairment. The MDS in Section E-Behavior indicated Resident #42 had not demonstrated rejection of care behaviors. The MDS in Section GG-Functional Abilities and Goals indicated Resident #42 required supervision or touching assistance with toileting hygiene. The MDS in the Section H-Bladder and Bowel indicated Resident #42 was occasionally incontinent of bowel and bladder. Record review of a CNA Proficiency Audit dated 4/10/2024 indicated CNA F was checked off on the provision of incontinent care for a male and a female and passed the evaluation with a score of satisfactory. During an observation on 9/25/2024 at 7:09 a.m., Resident #42 was sitting on the edge of his bed. Resident #42 had an adult pull up and a pair of shorts on around his lower legs. CNA F Instructed Resident #42 to stand using his walker. Resident #42 after several attempts stood up, then CNA F removed his wet adult diaper and placed in the trash can. CNA F Removed her gloves, applied another pair of gloves, obtained two wipes and cleaned Resident #42's buttocks, she then pulled up his adult pull-up and shorts. CNA F Failed to cleanse Resident #42's genitals or complete hand hygiene between glove changes. During an interview on 9/25/2024 at 7:16 a.m., CNA F Said she had not done well on the incontinent care observation. CNA F said she failed to cleanse Resident #42's genitals (perineal area) and wash her hands in between glove changes. CNA F said she just forgot to cleanse Resident #42's genitals. CNA F said when not providing incontinent care to Resident #42's genitals (perineal area) could cause a risk of infection. During an interview on 9/26/2024 at 11:05 a.m., the ADON said she expected the staff to cleanse the perineal area when completing incontinent care. The ADON said she monitors the provision of incontinent care by annual checks offs and spot checks. The ADON said urinary tract infections could arise from failing to cleanse a resident's perineal area. During an interview on 9/26/2024 at 11:31 a.m., Administrator T said the DON was not available for interview due to health conditions. Administrator T said she expected the nursing staff to provide the appropriate incontinent care. Administrator T said this system was monitored with annual check offs and she expected spot checks to be performed. Administrator T said she only been in her role for 2 months but believed her staff required more training. Administrator T said there was a risk of infection when incontinent care was not performed correctly. Record review of a Perineal Care policy with an effective date of 5/11/2022 indicated an incontinent resident of urine and/or bowel should be identified, assessed, and provided appropriate treatment and services to restore as much normal bladder/bowel function as possible . The policy purpose indicated was to maintain the resident's dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritations, and observing resident's skin condition Start: 10) perform hand hygiene, 11) apply gloves and all other PPE standard precautions, 12) soak towels in wash basin .or remove an adequate number of pre-moistened cleansing wipes, 13) reposition the resident on their back with legs flexed and separated as able, 14) limit resident exposure to the perineal area-provide privacy at all times, 15) if required, use a towel or extra incontinence pad to protect the mattress cover form being soiled, 16) wipe across the pubis area, 17) gently perform perineal care, wiping from clean, urethral area, to dirty rectal area, to avoid contaminating the urethral area. Female resident: working from front to back, wipe one side of the labia majora, the outside folds of the perineal skin that protect the urinary meatus and the vaginal opening. Continue perineal care to the inner thigh. Male resident: Pull back the foreskin on uncircumcised males. Hold the penis by the shaft, wash in a circular motion from the tip down to the base. Continue perineal care to the scrotum and inner thigh 20) Reposition the resident to their side, 21) Gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area 24) remove gloves and PPE, 25) perform hand hygiene. Record review of the Infection Control policy updated 3/2024 indicated the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 1 of 1 resident (Resident #10) reviewed for respiratory care. 1. The facility failed to administer Resident #10's oxygen as ordered by the physician. 2. The facility failed to ensure Resident #10's oxygen flow meter on the oxygen concentrator was functioning properly and undamaged. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care. The findings included: Record review of the face sheet, dated 09/24/2024, revealed Resident #10 was an [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of COPD (term for certain types of irreversible lung and airway damage that block (obstruct) your airways and make it hard to breathe). Record review of the quarterly MDS assessment, dated 08/26/2024, revealed Resident #10 had clear speech and was understood by others. The MDS revealed Resident #10 was able to understand others. The MDS revealed Resident #10 had a BIMS score of 7, which indicated severe cognitive impairment. The MDS revealed Resident #10 had no behaviors or refusal of care. The MDS revealed Resident #10 received oxygen therapy while a resident at the facility. Record review of the comprehensive care plan, last reviewed on 09/23/2024, revealed Resident #10 received oxygen therapy related to COPD. The interventions included: oxygen will be set at 2-4 LPM as needed and will check oxygen sats every shift and record. Record review of the order summary report, dated 09/24/2024, revealed Resident #10 had an order, which started on 12/22/2023, for oxygen at 2 - 4 LPM as needed via nasal cannula. During an observation and interview on 09/23/2024 at 10:45 AM, Resident #10 was laying in his bed with the head of the bed slightly elevated. Resident #10 was wearing a nasal cannula in his nose. The oxygen flow meter on the oxygen concentrator was covered in a white powdery substance that made the oxygen flow difficult to read. The silver ball, which indicated the oxygen flow in LPM, was shadowed at approximately 1 LPM. Resident #10 had no evidence of respiratory distress. Respirations were even, unlabored. Resident #10 stated he normally wore oxygen at all times. Resident #10 stated he was having no trouble breathing and the facility staff checked on his oxygen level frequently. During an observation and interview on 09/23/2024 at 10:33 AM, Resident #10 was laying in his bed with the head of the bed slightly elevated. Resident #10's oxygen tubing was laying on the bed above his head. Resident #10 stated his oxygen tubing fell off his face. The oxygen flow meter on the oxygen concentrator was covered in a white powdery substance that made the oxygen flow difficult to read. The silver ball, which indicated the oxygen flow in LPM, was shadowed at approximately 1 LPM. During an observation and interview on 09/23/2024 at 10:36 AM, LVN D stated she was going into Resident #10's room to give him his medication. LVN D attempted to read Resident #10's oxygen flow meter to determine the LPM. LVN D stated it was hard to read because there was a white powdery substance inside the flow meter, but it appeared to be set at less than 1 LPM. LVN D turned the oxygen flow meter up to 2 LPM and placed the nasal cannula in Resident #10's nostrils. LVN D stated she had checked the oxygen concentrator early that morning and it was set at 2 LPM. LVN D stated his oxygen level that morning was 94%. LVN D stated the machine flow meter had been difficult to read for a while, but she had not reported it to anyone. LVN D was unable to estimate how long the machine had been difficult to read. LVN D placed the pulse oximeter onto Resident #10's finger. Resident #10's oxygen level fluctuated and decreased from 91% to 83%. LVN D asked Resident #10 if he was having trouble breathing and he explained that it was difficult for him to take a deep breath. LVN D explained the protocol was to keep oxygen levels above 90%. LVN D increased his oxygen flow meter from 2 LPM to 3 LPM to 4 LPM. The oxygen level stayed below 89%. LVN D then obtained an oxygen tank and new oxygen tubing. LVN D placed the nasal cannula in Resident #10's nostrils and set the flow at 3 LPM. Resident #10's oxygen level increased to 98% on 3 LPM. LVN D stated defected, damaged, or any issues with an oxygen concentrator should have been reported to management staff. LVN D stated it was important to ensure the oxygen concentrator was functioning properly and set at the correct settings to prevent neglect, hypoxic brain injury, or hypoxia (low oxygen levels). During an observation and interview on 09/24/2024 at 11:16 AM, LVN D stated she had changed out Resident #10's oxygen concentrator and she was continuing to monitor his oxygen levels. LVN D stated she had removed his old concentrator and placed it behind the nurses' station with a sticker that stated, does not work. The machine was a Companion Eco 5 and had no sticker to indicate the last date of service. LVN D stated as she understood, the machines were only serviced if they were not functioning properly. LVN D stated Medical Records was responsible for scheduling the serving of the oxygen concentrators. LVN D stated the Medical Records person or nursing management would have had the user manual for the oxygen machine. During an interview on 09/24/2024 at 11:22 AM, the ADON stated the Medical Records person had the user manual for the oxygen concentrators. During an interview on 09/26/2024 at 10:04 AM, CNA A stated she had a lot of titles and jobs at the facility. CNA A stated she was a CNA, medication aide, and also did medical records as well. CNA A stated the facility received the current oxygen concentrators in October 2023, when the current company took over. CNA A stated when a machine went down, she contacted corporate and sent over a requisition. CNA A stated then corporate would pick up the machine and get it fixed. CNA A stated if no concentrators were available in the facility, she was able to rent from a supply company. CNA A stated she relied on the nursing staff to tell her if an oxygen machine was defected or not functioning properly. CNA A stated she was unaware anything was wrong with Resident #10's oxygen concentrator prior to this week. CNA A stated it was important to ensure the oxygen machines were serviced and maintained to prevent decreased oxygen levels, which could cause brain damage. During an interview on 09/26/2024 at 10:38 AM, the Regional Compliance Nurse stated there was no facility policy on oxygen concentrator maintenance. The Regional Compliance Nurse stated she expected the nursing staff to ensure oxygen machines were in functioning condition. The Regional Compliance Nurse stated if the machine was not functioning properly or was damaged, the staff should have replaced the machine and sent the old one for maintenance. During an interview on 09/26/2024 at 1:28 PM, the ADON stated oxygen concentrators and oxygen flow should have been checked every day. The ADON stated anyone who noticed an issue with the oxygen concentrator should have reported it to the nursing staff. The ADON stated if the concentrator was not functioning properly or defective, the nursing staff should have replaced the oxygen concentrator. The ADON stated the nursing staff was responsible for ensuring the oxygen was set at the correct settings. The ADON stated it was important to ensure the oxygen concentrator was not defective, functioning properly, and set at the correct settings to prevent respiratory distress. During an interview on 09/26/2024 at 1:43 PM, Administrator T stated she expected staff to ensure the oxygen flow meter was clear and easy to read. Administrator T stated if there was an issue with an oxygen concentrator the machine should have been replaced. Administrator T stated she expected nursing staff to ensure the oxygen level was set at the correct settings as ordered by the physician. Administrator T stated it was important to ensure the oxygen concentrator was functioning properly and set at the correct settings to prevent any issues with the residents breathing. Record review of the Oxygen Administration policy, revised 02/13/2007, revealed . the resident will maintain oxygenation with safe and effective delivery of prescribed oxygen .become familiar with type of oxygen administration, medical diagnosis and reason for oxygen, intermittent or continuous use of oxygen, amount to be delivered .

Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 2 of 2 (Residents #19 and #4) residents reviewed for special eating equipment and assistance when consuming meals. 1. The facility failed to provide Resident #19's physician ordered sippy cup with each meal tray. 2. The facility failed to ensure Resident #4 had a physician's ordered cup with lid and handles for drinking fluids. These failures could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Findings included: 1. Record review of Resident #19's face sheet, dated 09/26/24, indicated Resident #19 was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain disease that alters brain function or structure). Record review of the quarterly MDS assessment, dated 08/20/24, indicated Resident #19 rarely/never made herself understood and rarely/never understood others. The assessment did not address the BIMS score. Resident #19 required set up or clean up assistance with eating. Record review of the comprehensive care plan, revised on 07/04/24, indicated Resident #19 had a potential for spillage during meal/snacks time. The care plan interventions included, assist Resident #19 at meal and snack times, assist with donning clothing protector at meal and snack times, and assist with serving food in small separate bowls for easy handling and a cup with lids. Record review of the order summary report, dated 09/26/24, indicated Resident #19 was ordered a 2-handle cup with lid with a start date of 01/01/24. Record review of the lunch meal ticket dated 09/23/24 for Resident #19 indicated Resident #19 was on a fortified/enhanced diet and required a sippy cup; two handle cup. During an observation and interview on 09/23/24 at 12:21 p.m., Resident #19 had iced tea in a clear regular drinking cup. An attempted interview with Resident #19, indicated she was non-interview able. During an interview on 09/23/24 at 12:25 p.m., CNA O stated Resident #19 should have her beverages in a sippy cup. CNA O stated she was told by the dietary staff that there were no lids for the sippy cup. CNA O stated Resident #19 was ordered a sippy cup to prevent spillage on her clothes because she was unable to hold a regular cup without spilling. CNA O stated this failure could cause a dignity issue. During an interview on 09/25/24 at 2:27 p.m., the Dietary Manager stated Resident #19 required a sippy cup because she was unable to hold a regular cup. The Dietary Manager stated there were cups but without lids. The Dietary Manager stated when the cups go out the lids did not return with the cups. The Dietary Manager stated she had reported the issue to the Administrator. The Dietary Manager stated this issue had been going on for about 4 months. The Dietary Manager stated this failure was a dignity issue. During an interview on 09/26/24 at 11:05 a.m., the ADON stated Resident #19 required a sippy cup to prevent spillage on herself. The ADON stated she was not aware there were no cups with lids available until the state surveyor intervention. The ADON stated she could have gone to a local store or ordered them. The ADON stated the Dietary Manager was responsible for monitoring and overseeing to ensure adaptive devices were available to residents. The ADON stated this failure was a dignity issue. During an interview on 09/26/24 at 11:22 a.m., the Administrator stated it was brought to her attention on 09/26/24, that sippy cups were not available to residents. The Administrator stated she expected the dietary staff to inform her when there were not adaptive devices available. The Administrator stated the previous Dietary Manager's last day was 09/05/24. The Administrator stated the Dietary Manager was responsible for monitoring and overseeing the kitchen. The Administrator stated it was important to ensure physician orders were followed. The Administrator stated this failure was a dignity issue. 33249 2)Record review of a face sheet dated 9/26/2024 indicated Resident #4 was an [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia (memory loss), and difficulty swallowing. Record review of the comprehensive care plan dated 5/30/2024 indicated Resident #4 required adaptive equipment at meals (two handled cup with lid). The goal of Resident #4's care plan was she would be able to drink coffee without spilling it on herself. The care plan interventions were thatould Resident #4 would use a sippy cup for drinking coffee and occupational therapy to evaluate as needed. Record review of an Annual MDS dated [DATE] indicated Resident #4 was understood and understood others. The MDS indicated Resident #4 had severe cognitive impairment. The MDS in section GG-Functional Abilities and Goals indicated Resident #4 required substantial/maximal assistance with eating. The MDS indicated Resident #4 had a height of 64 inches and a weight of 148 pounds with no weight loss or weight gain in the last 6 months. Record review of the consolidated physician's orders dated 9/26/2024 indicated on 6/25/2024 Resident #4 was ordered a pureed diet with thin liquids, fortified foods, and an adult cup with a lid and handles due to weight loss. During an observation on 9/23/2024 at 12:25 p.m., the ADON asked the Dietary Aide K for a lid to the sippy cups. Dietary Aide K said to the ADON there were 5 cups without lids. Dietary aide K informed the ADON the cups returned to the kitchen but not the lids. During an observation and interview on 9/23/2024 at 12:44 p.m., Resident #4 had iced tea in her drinking cup with handles but without a lid. RN G said Resident #4 could not use a straw therefore would have to drink her liquids from the cup without the lid. RN G said Resident #4 lets the fluids run out of her mouth and the sippy cup with the lid and handles helps to prevent spillage. RN G said when the device was not available a result of dehydration or weight loss could occur. During an interview on 9/26/2024 at 11:05 a.m., the ADON said the dietary department had the cups without enough lids. The ADON said if they had of known the cups with lids were unavailable, they could have attempted to purchase locally in order to have the sippy cups with lids. The ADON said Resident #4 had been ordered the cup due to her arm dropping and causing spills. The ADON said Resident #4 was at risk for dehydration and loss of dignity when the cup with lid was unavailable. During an interview on 9/26/2024 at 11:28 a.m., Administrator T said she was unaware of the sippy cups not having lids available. Administrator T said she expected the dietary department to inform her of needed devices. Administrator T said the sippy cups with lids should be available for the resident to use. Administrator T said when the assistive device sippy cup was not available it places the resident at risk for dignity issues related to spills of fluids on their clothing. Administrator T said the DON was unavailable for interview due to health conditions. Record review of the facility's titled Adaptive Eating Devices, dated 2012, indicated . we will enable residents to achieve and maintain their highest practicable level of eating independence and provide appropriate equipment to the residents . Dietary Manager: ensures that the resident tray card states the specific adaptive device needed. The nutritional documentation in the resident's chart reflects the need for the desired results and the success of the self-feeding device .

Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 8 of 15 residents (Resident #2, Resident #10, Resident #20, Resident #23, Resident #25, Resident #28, Resident #29, and Resident #31) and 2 of 4 medication carts (Hall 5 and Hall 6) reviewed for pharmacy services. The facility failed to ensure Resident #29 received Ribavirin (An antiviral medication that is used to treat chronic hepatitis C. Ribavirin is not effective when used alone) and Epclusa (a medication that contains a combination of sofosbuvir and velpatasvir antiviral medications that prevent hepatitis C virus from multiplying in your body it may sometimes be used with another antiviral medication, Ribavirin), as ordered by the physician, medications for treatment of his hepatitis C to prevent liver failure. The facility failed to have a process in place to ensure Epclusa was received and administered as ordered to Resident #29. The facility failed to monitor Resident #29 for side effects of the Ribavirin. An Immediate Jeopardy (IJ) situation was identified on 07/27/2023 at 5:00 PM. The IJ template was provided to the facility on [DATE] at 5:29 PM. While the IJ was removed on 07/28/2023 at 5:15 PM, the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility failed to ensure LVN C, LVN K, and LVN L had a witness when wasting controlled medications for Resident #2, Resident #10, Resident #20, Resident #23, Resident #28, and Resident #31. The facility failed to ensure LVN H and LVN E notified the DON when the controlled medication count for Resident #20's Lorazepam (controlled medication used for anxiety) was not correct. The facility failed to ensure LVN C, LVN E, and LVN M notified the DON when there was a discrepancy with the count of Resident #25's whiskey. The facility failed to ensure LVN F and LVN M counted controlled drugs every shift change. These failures could place residents at risk for harm or death related to inappropriate medication therapy, not having medications available for use, and drug diversion. Findings included: 1. Record review of a face sheet dated 07/28/2023, indicated Resident #29 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and subacute hepatic failure without coma (acute liver failure symptoms include yellowing of the skin and eyeballs, swollen belly, nausea, vomiting, disorientation, confusion, tremors, sleepiness), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia unspecified affecting left nondominant side (paralysis of the left side of the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #29 was able to make self-understood and understood others. The MDS assessment indicated Resident #29 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #29 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #29 had an active diagnosis of acute and subacute hepatic failure without coma. Record review of the care plan with date initiated 03/20/2023, last revised 07/28/2023, indicated Resident #29 was at risk of complications related to liver disease due to a diagnosis of hepatitis C (a viral infection that causes inflammation of liver that leads to liver inflammation). Resident #29's care plan indicated he would be free from signs and symptoms of liver complications including infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline, or mental status changes. Resident #29's care plan indicated he had an appointment scheduled on August 22, 2023, with an infectious doctor and his family member would take him to the appointment and all records would be sent with his family member, and labs would be forwarded to the infectious doctor and medical director, monitor labs as needed and as prescribed by infectious doctor and medical director. Record review of Complaint #402920 indicated on 01/31/2023, the Complainant said on 10/22/2022 the disease specialist doctor prescribed two medications to be administered for Resident #29's hepatitis C. The Complainant said the facility received one of the prescriptions called Ribavirin (200 mg capsule to be administered twice daily) and the facility started this medication. The Complainant said this medication had a black box warning that it was not supposed to be administered by itself. That it should be administered with another medication. The Complainant said for approximately three months, Ribavirin had been administered to Resident #29 by itself. The Complainant said during Resident #29's hospitalization in January of 2023 the liver doctor had stated Resident #29's hepatitis C was very active, and the nursing facility was supposed to be treating Resident #29 for hepatitis C. The complainant said the facility had administered the Ribavirin without reading the black box warning. The complainant said the Ribavirin and Epclusa were supposed to be administered simultaneously to kill the hepatitis virus. The complainant said the nursing facility failed to administer the Epclusa medication and as a result Resident #29 was delusional and experienced side effects. The complainant said the liver doctor said the facility had dropped the ball, and the Ribavirin and Epclusa had to be restarted and administered simultaneously to treat Resident #29's hepatitis C on 01/26/2023. Record review of Ribavirin's Important Warning on Medline Plus (medlineplus.gov) indicated, Ribavirin will not treat hepatitis C (a virus that infects the liver and may cause severe liver damage or liver cancer) unless it is taken with another medication. Your doctor will prescribe another medication to take with ribavirin if you have hepatitis C. Take both medications exactly as directed . If you experience any of the following symptoms, call your doctor immediately: excessive tiredness, pale skin, headache, dizziness, confusion, fast heartbeat, weakness, shortness of breath, or chest pain . Record review of the Order Summary Report with order date range from 10/01/2022-07/31/2023, indicated Resident #29 had a discontinued order for Ribavirin Tablet 200 MG give 1 tablet by mouth two times a day for Hepatitis C with a start date of 10/22/2022, no end date. Resident #29's Order Summary Report did not indicate there was an order for Epclusa Oral Tablet 400-100 mg (Epclusa is a medication that contains a combination of sofosbuvir and velpatasvir antiviral medications that prevent hepatitis C virus from multiplying in your body it may sometimes be used with another antiviral medication, Ribavirin) to take with the Ribavirin on 10/22/2022. The Order Summary Report for Resident #29 had a discontinued order for Ribavirin Oral tablet 200 mg give 1 tablet by mouth two times a day for Hepatitis C give with food with a start date of 01/26/2023, the discontinued date was not indicated on the order summary report. Resident #29's Order Summary report indicated a discontinued order for Epclusa Oral Tablet 400-100 MG give 1 tablet by mouth one time a day for Hepatitis C take with food with a start date of 01/26/2023, the discontinued date was not indicated on the order summary report. Record review of Resident #29's October 2022 MAR indicated he had an order for Ribavirin tablet 200 mg give 1 tablet by mouth two times a day for hepatitis C with a start date of 10/22/20223 and discontinued date of 01/12/2023. The October 2022 MAR indicated Resident #29 received the Ribavirin as ordered from 10/22/2022 to 10/31/2022. The October 2022 MAR did not indicate an order for Epclusa, and it did not indicate Epclusa had been administered. Record review of Resident #29's November 2022 MAR indicated he had an order for Ribavirin tablet 200 mg give 1 tablet by mouth two times a day for hepatitis C with a start date of 10/22/20223 and discontinued date of 01/12/2023. The November 2022 MAR indicated Resident #29 received the Ribavirin as ordered from 11/01/2022 to 11/30/2022. The November 2022 MAR did not indicate an order for Epclusa, and it did not indicate Epclusa had been administered. Record review of Resident #29's December 2022 MAR indicated he had an order for Ribavirin tablet 200 mg give 1 tablet by mouth two times a day for hepatitis C with a start date of 10/22/20223 and discontinued date of 01/12/2023. The December 2022 MAR indicated Resident #29 received the Ribavirin as ordered from 12/01/2022 to 12/31/2022. The December 2022 MAR did not indicate an order for Epclusa, and it did not indicate Epclusa had been administered. Record review of Resident #29's January 2023 MAR indicated Epclusa Oral Tablet 400-100 MG (Sofosbuvir-Velpatasvir) give 1 tablet by mouth one time a day for hepatitis c take with food with a start date of 01/26/2023 and a discontinued date of 04/19/2023. The Epclusa was administered as ordered from 01/26/2023 to 01/31/2023. Record review of Resident #29's January 2023 MAR indicated Ribavirin tablet 200 mg give 1 tablet by mouth two times a day for hepatitis c take with food with a start date of 01/26/2023 and discontinue date of 04/19/2023. The Ribavirin was administered as ordered from 01/26/2023 to 01/31/2023. Record review of Resident #29's visit with the infectious disease doctor dated 09/07/2022 indicated in the assessment/plan that he had a history of hepatitis C, and once the infectious disease doctor had all labs available, he would start the process for approval of medication to treat Resident #29's hepatitis C. The infectious disease doctor indicated it took about 3-4 months for the medication to be approved, and the medication would be sent directly to his nursing facility. Record review of Resident #29's progress notes beginning on 10/14/2022 did not indicate there was an order to start Ribavirin or Epclusa. The progress notes did not indicate when the Ribavirin was started or monitoring of Resident #29 after the start of the Ribavirin. The progress notes indicated on 10/24/2022 at 8:41 PM an entry by LVN S indicated, Resident #29 was sitting up on his bedside commode and became nonresponsive for approximately 7 min due to a possible TIA. Resident #29 then became responsive and was assisted back to his bed with the assistance of 3 attendants. Resident #29 had no complaints of any pain or discomforts after getting him back to his bed. The progress notes indicated an entry on 10/31/2022 at 7:00 AM by the ADON that Resident #29 was confused that morning and the CNA was in the room to get Resident #29 up and he did not know where he was at. Resident #29 thought he was on the highway running. The ADON noted twitching to his right upper extremity and face/head, and he was incontinent of urine that morning. Resident #29 stated, he did not know he had urinated. Resident #29 was transferred via Hoyer lift due to him having weakness. The ADON indicated she would notify the doctor of changes and would continue to monitor. Record review of an entry in the progress notes made by LVN R on 11/02/2022 at 8:35 AM indicated Resident #29 was to start Rocephin and Cipro (both antibiotic medications) for a urinary tract infection. Record review of an entry in the progress notes made by RN N on 11/15/2022 at 10:58 AM indicated Resident #29 was lethargic and did not eat breakfast. He was not answering simple questions and his behavior appeared to be different. The Medical Director was notified of this by the ADON. Record review of an entry in the progress notes made by the facility's Medical Director on 12/13/2022 at 3:44 PM indicated Resident #29 was doing a little better an assessment included on peripheral neuropathy (a disease that causes weakness, numbness and pain in the feet and hands), allergic rhinitis, chronic back pain, coronary artery disease, chronic obstructive pulmonary disease, traumatic brain injury, seizures, left hemiplegia, left foot drop. The Medical Director's progress note did not address the Ribavirin or the hepatitis C treatment. Record review of an entry in the progress notes by the ADON on 12/28/2022 at 2:31 PM, indicated Resident #29 had vomited and reported nausea the Medical Director was notified, and he was started on Zofran (medication used for nausea) 4mg one tab by mouth every 4 hours as needed for 14 days. Record review of an entry in the progress notes by LVN H on 01/06/2023 at 5:22 PM indicated upon entering the room, LVN H observed Resident #29 laying in a prone (face down) position in the bathroom his wheelchair was directly behind him in the doorway. Resident #29 denied having pain, blood was noted on the floor, he was not moved, and 911 was called at this time the Medical Director was notified and a new order was received to send to the ER for evaluation. Record review of Resident #29's hospital records dated 07/27/2023 indicated he was admitted on [DATE] with diagnoses of syncope and liver failure and discharged on [DATE].The hospital records indicated Resident #29 was admitted to the hospital for further stabilization of life-threatening conditions which included liver failure. During an attempted interview on 07/24/2023 at 3:07 PM, the complainant did not answer the phone. During an interview on 07/25/2023 at 3:19 PM, Resident #29 said all he knew was that he was supposed to be taking medications for his hepatitis C, but he did not know about when he was supposed to start it or anything. Resident #29 did not know what the medications to treat his hepatitis C were. Resident #29 was unable to provide details regarding his hospitalization s. During an interview on 07/27/2023 1:41 PM, LVN T, the infectious disease doctor's nurse, said on 10/19/2022 she had received notice from the pharmacy that Resident #29's Epclusa and Ribavirin had been approved and would be sent to the nursing facility. LVN T said on 10/19/2022 she called the nursing facility and spoke with the ADON. LVN T said she gave the ADON verbal orders for both the Epclusa and Ribavirin and instructed her both medications had to be administered at the same time. LVN T said for nursing facility patients she gave verbal orders to the nurses at the facility, and faxed the doctors order for the medications to the pharmacy. LVN T said she provided the ADON the pharmacy's number for her to call and check on the medications. LVN T said the Ribavirin should not be taken alone because it would not treat the hepatitis C if taken alone. LVN T said on 10/22/2022 the ADON called her and notified her that Resident #29 had started the Ribavirin. LVN T said she was not informed by the ADON that Resident #29 did not start the Epclusa. LVN T said on 01/16/2023 the ADON called her to notify her Resident #29 was about to complete the Ribavirin and informed her Resident #29 had never started the Epclusa. LVN T said the ADON informed her that Resident #29 had been discharged from the hospital with a diagnosis of liver failure and the Ribavirin had been discontinued. LVN T said the hepatitis C was not treated effectively due to not receiving both medications. LVN T said the infectious disease doctor had given orders to restart both the Epclusa and Ribavirin on 01/26/2023 and Resident #29 had completed both medications on 04/18/2023. LVN T said the infectious disease doctor was currently out of the country and unable to be reached for interview. During an interview on 07/27/2023 at 2:03 PM, the ADON said Resident #29 was seeing the infectious disease doctor and she was notified by LVN T that Resident #29's Epclusa and Ribavirin would arrive to the facility by mail from the pharmacy. The ADON said the Ribavirin arrived at the facility by mail, and she put the physician's order in Resident #29's electronic health record for the Ribavirin to be started. The ADON said she called the infectious disease doctor and notified LVN T that Resident #29 had started the Ribavirin. The ADON said she did not notify LVN T that the Epclusa had not been received and it was not started. The ADON said she did not notify LVN T the Epclusa had not been received because LVN T should have asked her if they had received the Epclusa. The ADON said LVN T had given verbal orders for both the Ribavirin and the Epclusa. The ADON said she did not remember if the Ribavirin came with a black box warning. The ADON said she did not remember if when she put in the physician's order for the Ribavirin the black box appeared in the electronic health record. The ADON said if a medication had a black box warning, when the physician's order was entered the black box warning automatically appeared and had to be dismissed to continue entering the physician's order. The ADON said if a black box warning appeared in the electronic health record when she input Resident #29's order for Ribavirin, she was supposed to notify the doctor for further instructions. The ADON said she was not aware that Ribavirin had a black box warning, and that it should not be administered alone for the treatment of hepatitis C. The ADON said when she did not receive the Epclusa she should have called and checked on the medication. The ADON did not specify why she had not followed up with the pharmacy after the Epclusa was not delivered. The ADON said if a medication was ordered to be delivered by mail and it did not arrive, she was supposed to call the pharmacy to follow up on the medication and notify the doctor. During an interview on 07/27/2023 at 3:25 PM, the DON said she was not employed at the facility in October 2022. The DON said if the ADON was aware Resident #29 was supposed to take both the Ribavirin and Epclusa, when the Epclusa was not delivered the ADON should have called the infectious disease doctor's office and notified them. The DON said when a physician's order was entered into a resident's electronic health record, if the medication had a black box warning it would pop up before allowing the staff to continue. The DON said if a black box warning appeared when inputting an order the physician should be notified of the warning for further instructions, and it should be documented in the resident's progress notes. The DON said the black box warning associated with the Ribavirin indicated the Ribavirin would not treat hepatitis C unless taken with another medication, and it could cause liver damage or liver cancer if taken alone. During an interview on 07/28/2023 at 10:10 AM, Pharmacist Consultant V said he reviewed Resident #29's medication orders in October 2022, November 2022, and December 2022. Pharmacist Consultant V said he was aware of the black box warning for the Ribavirin. Pharmacist Consultant V said the black box warning indicated the Ribavirin was not supposed to be taken alone. Pharmacist V said he did not make any recommendations to the facility regarding the Ribavirin because he thought it was what the doctor had ordered according to the physician's order. Pharmacist Consultant V said he was not aware that the Ribavirin had to be taken with the Epclusa. During an interview on 07/28/2023 at 1:20 PM, the Medical Director said he was aware Resident #29 was started on Ribavirin and Epclusa. The Medical Director said since that was a special medication, and it was prescribed by the infectious disease doctor he was not familiar with the medications. The Medical Director said if there was a black box warning associated with the Ribavirin the nurses should have contacted the infectious disease doctor for further instructions. Record review of the facility's policy titled, Pharmacy Services Overview, last revised April 2019, indicated, The facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medication and biologicals, and the services of a licensed consultant pharmacist. Policy Interpretation and Implementation 1. Pharmaceutical services consists of: a. the processes of receiving and interpreting prescriber's orders; acquiring, receiving, storing, controlling, reconciling, compounding (e.g. intravenous antibiotics), dispensing, packaging, labeling, distributing, administering, monitoring responses to using and/or disposing of all medications, biologicals, chemicals; b. the provision of medication-related information to health care professionals and residents; c. the process of identifying, evaluating, and addressing medication-related issues including the prevention and reporting of medication errors; and d. the provision, monitoring and/or the use of medication-related devices. 2. The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support the residents' needs, are consistent with current standards of practice, and meet state and federal requirements . 4. Residents have sufficient supply of their prescribed medications and receive mediations (routine, emergency, or as needed) in a timely manner .5. Nursing staff communicate prescriber orders to the pharmacy and are responsible for contacting the pharmacy if resident's medication is not available for administration . Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice . The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): a. acquisition and availability of medications: (1) receipt, labeling, and storage of medications; (2) reconciliation of medications from the pharmacy; (3) control of medications from point of receipt to secured storage areas; and (4) facility staff roles and responsibilities during the receipt and storage of medication. b. medication packaging and dispensing systems; c. administration of medications; d. disposition of medications; e. authorization, training and competency of personnel; and f. documentation of processes, as applicable. Record review of the facility's policy titled, Medication and Treatment Orders, last revised July 2016, indicated, . only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record. 3. Drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. Such orders are reviewed by the consultant pharmacist on a monthly basis . verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order . The Administrator was notified on 07/27/2023 at 5:19 PM that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 07/27/2023 at 5:29 PM. The facility's Plan of Removal was accepted on 07/28/2023 at 1:45 PM and included: Plan of Removal: Immediate Actions Taken: Resident #29 is no longer taking antiviral medications as of 4/18/2023, which was the conclusion of the 12 week treatment plan. The original order was to begin antiviral medications on 1/25/2023 and stop on 4/19/2023. The facility has implemented the following process, as of 07/27/23 to ensure medications are received and administered as ordered. Licensed nursing staff and medication aides will be in-serviced on 07/28/23 on the below process. Staff will not be allowed to work unless they have completed the in-services. o Order received. o Order entered into PCC. o If Black Box Warning Notification - physician will be contacted, and order verified; physician will make the decision to continue with the order or to change to a different drug regimen. Response of physician will be documented in the clinical record. o Medication is ordered. o If Medication is being ordered through a mail order process, physician will be contacted and give order to administer medication once received or change the order to a different drug regimen. o When medication is ordered the resident will be placed on daily charting until medication received. o Follow up with physician will be conducted every 7 days to verify continuance of current plan or change to different drug therapy. Resident #29 is no longer on antiviral medications. Side effects for antiviral medications will be entered into PCC and monitored by nursing staff. Resident #29's care plan was updated on 03/20/23 to reflect diagnosis of hepatitis. Resident #29's care plan was updated on 7/28/2023 to reflect chronic hepatitis C diagnosis. Resident #29 is no longer on antiviral medication. The care plan was updated on 07/28/2023 by MDS Coordinator. All resident care plans are being reviewed to ensure all chronic conditions/medications are documented. This audit will be completed on 7/28/2023. Review of all resident medication orders revealed no residents are currently receiving antiviral medications. DON and/or Designee pulled a list of all residents that are on medications that have a black box warning and we will notify physician of this warning and orders will be verified, physician specific response will be documented in the clinical record. The audit will be completed on 7/28/2023, the DON and/or Designee will complete the audit. All licensed nurse staff and medication aides will be in-serviced on the following topics. The in-service will be completed by 11 AM on 7/28/23. The DON and ADON will be responsible for providing the in-service training. Black Box Warning Notification - the in-service will include the following process - physician will be contacted, and order verified; physician will make the decision to continue with the order or to change to a different drug regimen. Response of physician will be documented in the clinical record. Documentation of the reason for giving a medication and documentation of complications or side effects. Rights of Medication Administration Antiviral Medications and Side Effects Mail order medications - delivery and administration. If Medication is being ordered through a mail order process, physician will be contacted and give order to administer medication once received or change the order to a different drug regimen. When medication is ordered the resident will be placed on daily charting until medication received. Follow up with a physician will be conducted every 7 days to verify continuance of current plan or change to different drug therapy. On 7/27/23, on 2nd shift, the DON under the guidance of the Regional Nurse Consultant initiated an in-service with all licensed nurses on duty to cover the topics of: Black Box Warning Notification - physician will be contacted, and order verified; physician will make the decision to continue with the order or to change to a different drug regimen. Response of physician will be documented in the clinical record. Documentation of the reason for giving a medication and documentation of complications or side effects. Rights of Medication Administration Antiviral Medications and Side Effects Mail order medications - delivery and administration. If Medication is being ordered through a mail order process, physician will be contacted and give order to administer medication once received or change the order to a different drug regimen. When medication is ordered the resident will be placed on daily charting until medication received. Follow up with a physician will be conducted every 7 days to verify continuance of current plan or change to different drug therapy. In-servicing of all nursing staff will be completed by 11 AM on 7/28/23. Demonstration of and acknowledgement that all licensed nurses are aware of the above- The DON/ADON Designee will contact all licensed nurse staff and get a verbal acknowledgement as a return demonstration of understanding that- Medications must be received and administered as ordered by physician. Side effects of antiviral medication must be monitored. Nursing staff that aren't available for training will be in-serviced before they are allowed to work their next scheduled shift. On 7/27/23, the facility Administrator, DON, and Regional Nurse Consultant held an ad hoc QAPI meeting with Medical Director via phone. Impromptu agenda items were: IJ (Immediate Jeopardy) was cited on 7/27/23 as evidenced by facility's failure to: F755 Pharmacy Services o The facility failed to ensure Resident #29 received Epclusa 400-100 mg by mouth one time per day as prescribed by the physician. o The facility failed to have a process in place to ensure medications were received and administered as ordered. o The facility failed to monitor Resident #29 for side effects of the antiviral medication. o The facility failed to have a care plan for Resident #29's chronic hepatitis C and antiviral medication. The pharmacy consultant has been notified of the IJ (Immediate Jeopardy). Training for all licensed nurse staff and newly hired staff will include: Black Box Warning Notification - physician will be contacted, and order verified; physician will make the decision to continue with the order or to change to a different drug regimen. Response of physician will be documented in the clinical record. Documentation of the reason for giving a medication and documentation of complications or side effects. Rights of Medication Administration Antiviral Medications and Side Effects Mail order medications - delivery and administration. If Medication is being ordered through a mail order process, physician will be contacted and give order to administer medication once received or change the order to a different drug regimen. When medication is ordered the resident will be placed on daily charting until medication received. Follow up with a physician will be conducted every 7 days to verify continuance of current plan or change to different drug therapy. Continued Monitoring: New medication orders will be reviewed in the daily IDT meeting. Any new antiviral medication orders will be audited to ensure that medications are available and administered according to physician orders; ensure side effects are in PCC and monitored; and ensure that the care plans are updated to reflect the medication. All new admits will have a Medication Management Review completed by the pharmacist. Follow up and monitoring will be conducted by the DON and/or Designee. Results of the audits will be reported to the QAPI to ensure proper adherence to this process. Any deviations or omissions will be addressed immediately with the necessary staff member/members. This will be reviewed monthly in the QAPI to ensure continued compliance. On 07/28/2023 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review was done of Resident #29's care plan and it indicated it was updated on 07/28/2023 to reflect Resident #29 had a diagnosis of chronic hepatitis C. Record reviews were done of 13 of 13 residents' (Resident #1, Resident #4, Resident #8, Resident #11, Resident #12, Resident #15, Resident #17, Resident #21, Resident #23, Resident #25, Resident #29, Resident #30, Resident #38) care plans updated on 07/28/2023 to include chronic conditions. Record reviews of progress notes and orders were done for 44 residents with black box warnings to ensure the physician had been notified and physician response documented in the residents' clinical record. Record review was done of the following in-services: 07/27/2023 completed by the DON Antiviral medications 07/27/2023 completed by the DON Drug administrati [TRUNCATED]

Based on interview and record review the facility failed to ensure any irregularities noted by the pharmacist during the review were documented on a separate, written report that was sent to the attending physician and the facility's medical director and director of nursing and listed, at minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified for 1 of 6 residents (Resident #29) reviewed for drug regimen review. The facility failed to ensure Pharmacist Consultant V notified the facility of the black box warning associated with Resident #29's Ribavirin (an antiviral medication that is used to treat chronic hepatitis C, Ribavirin is not effective when used alone). This failure could place residents at risk of having adverse consequences related to medications not being properly reviewed. Findings included: 1. Record review of a face sheet dated 07/28/2023, indicated Resident #29 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and subacute hepatic failure without coma (acute liver failure symptoms include yellowing of the skin and eyeballs, swollen belly, nausea, vomiting, disorientation, confusion, tremors, sleepiness), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia unspecified affecting left nondominant side (paralysis of the left side of the body). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #29 was able to make self-understood and understood others. The MDS assessment indicated Resident #29 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #29 required extensive assistance with bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS assessment indicated Resident #29 had an active diagnosis of acute and subacute hepatic failure without coma. Record review of Resident #29's care plan date initiated 03/20/2023, last revised 07/28/2023, indicated an intervention to monitor the pharmacist's drug regimen review for identification of potential drug interactions. Record review of the Order Summary Report with order date range from 10/01/2022-07/31/2023, indicated Resident #29 had a discontinued order for Ribavirin Tablet 200 MG (an antiviral medication that is used to treat chronic hepatitis C Ribavirin is not effective when used alone) give 1 tablet by mouth two times a day for Hepatitis C with a start date of 10/22/2022, no end date. Record review of Ribavirin's Important Warning on Medline Plus (medlineplus.gov) indicated, Ribavirin will not treat hepatitis C (a virus that infects the liver and may cause severe liver damage or liver cancer) unless it is taken with another medication. Your doctor will prescribe another medication to take with ribavirin if you have hepatitis C. Take both medications exactly as directed . If you experience any of the following symptoms, call your doctor immediately: excessive tiredness, pale skin, headache, dizziness, confusion, fast heartbeat, weakness, shortness of breath, or chest pain . Record review of the pharmacy recommendations for October 2022-December 2022 did not indicate Pharmacist Consultant V provided the facility a recommendation that the Ribavirin had a black box warning indicating monotherapy (using one medication to treat) is not effective for the treatment of chronic hepatitis C infection and should not be used alone for this indication. During an interview on 07/28/2023 at 10:10 AM, Pharmacist Consultant V said he reviewed Resident #29's medication orders in October 2022, November 2022, and December 2022. Pharmacist Consultant V said he was aware of the black box warning for the Ribavirin. Pharmacist Consultant V said the black box warning indicated the Ribavirin was not supposed to be taken alone. Pharmacist V said he did not make any recommendations to the facility regarding the Ribavirin because he thought it was what the doctor had ordered according to the physician's order. Pharmacist Consultant V said he was not aware that the Ribavirin had to be taken with the Epclusa. During an interview on 07/28/2023 at 11:55 AM the DON said Pharmacist Consultant V performed the monthly reviews and gave them the pharmacy recommendations. The DON said after receiving the pharmacy recommendations she would send them to the doctors and follow up on the doctors' orders to implement any new orders. The DON said she was responsible for reviewing the pharmacy recommendations. The DON said she had only been at the facility for approximately 6 months. The DON said the Ribavirin for Resident #29 had a black box warning therefore, Pharmacist Consultant V should have sent a recommendation addressing the Ribavirin not being taken alone. The DON said it was important for Pharmacist Consultant V to review the residents' medications and make appropriate recommendations so the residents would not take unnecessary medications and to keep the residents safe and healthy. Record review of the facility's policy titled, Pharmacy Services Overview, last revised April 2019, indicated, . The facility shall contract with a licensed consultant pharmacist to help it obtain and maintain timely and appropriate pharmacy services that support the residents' needs, are consistent with current standards of practice, and meet state and federal requirements . The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including (but not limited to): a. acquisition and availability of medications: (1) receipt, labeling, and storage of medications; (2) reconciliation of medications from the pharmacy; (3) control of medications from point of receipt to secured storage areas; and (4) facility staff roles and responsibilities during the receipt and storage of medication. b. medication packaging and dispensing systems; c. administration of medications; d. disposition of medications; e. authorization, training and competency of personnel; and f. documentation of processes, as applicable.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent elopement for 1 of 14 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1 window would not open greater than 6 inches. The facility failed to ensure Resident #1 was provided appropriate supervision to prevent further elopement. This failure resulted in an identification of an Immediate Jeopardy (IJ) at 5:04 p.m. on 7/26/22. While the IJ was removed on 7/28/22, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of suffering heat related illness or injury/death from a vehicle accident. Findings included: 1. Record review of the consolidated physician orders dated 7/28/22 indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including [CONDITION(S)] with delusions (serious mental illness called a [CONDITION(S)]). Record review indicated the comprehensive MDS was not complete on Resident #1 due to resident being newly admitted to the facility. Record review of the care plan dated revised on 7/26/22 indicated Resident #1 was exit seeking. The care plan indicated Resident #1 had an elopement through his room window with interventions including every 15-minute checks and finding more secured placement. Record review of the elopement assessment dated [DATE] indicated Resident #1 was a high risk for elopement with a score of 15. Record review of the secured unit assessment dated [DATE] indicated Resident #1 required placement on the secured unit due to habitual wandering, wandering out of building and unable to find their way back, and was exit seeking. Record review of the nursing progress note dated 7/222/22 at 5:59 a.m. indicated Resident #1 was angry and belligerent with staff. The nursing progress note indicated Resident #1 stated we wanted to leave the facility and would break the door down to do so. The nursing progress noted indicated Resident #1 had hit the glass window on the door until he broke through the glass. Record review of the nursing progress noted date 7/23/22 at 6:21 a.m. indicated Resident #1 became increasingly agitated. Resident #1 tried to escape out the window. Resident #1 got out into the secured courtyard and tried squeeze through the fence. Record review of the nursing progress note dated 7/23/22 at 7:35 p.m. indicated LVN A had been alerted by the CNA Resident #1 had eloped from the facility through his bedroom window. The nursing progress noted indicated LVN A notified the Administrator of the elopement and staff searched the parameter of the facility. The nursing progress noted indicated LVN A got in his vehicle to look for the resident. The nursing progress note indicated LVN A found Resident #1 on foot walking down Main Street/Highway 56 headed towards downtown. The nursing progress note indicated LVN A was able to convince Resident #1 to return to the facility with him. The nursing progress note indicated LVN A performed a head-to-toe assessment on Resident #1 upon getting Resident #1 back to the facility. The nursing progress note indicated LVN A offered Resident #1 water which he took liberally. Record review of the provider investigation report dated 7/23/22 indicated Resident #1 eloped from the facility by prying the window in his room open. The provider investigation report indicated Resident #1 was found to be missing on 7/23/22 at 7:35 p.m. and found at 7:44 p.m. The provider investigation report indicated staff were in-serviced on monitoring residents on the secured unit at all times and the CNA assigned to the unit must notify the nurse before leaving residents unattended. The provider investigation report indicated Resident #1 had been on every 15-minute check 7/23/22 from 3:15 a.m. until 7:00 a.m. The provider investigation report indicated Resident #1 was on one-on-one observations on 7/24/22. The provider investigation report indicated Resident #1 was put back on every 15-minute checks on 7/25/22. Record review of the weather for 7/23/22 at www.worldweatheronline.com indicated the temperature in Honey Grove, TX was 100.4 degrees Fahrenheit at 6:00 p.m. and 93.2 degrees Fahrenheit at 9:00 p.m. Record review of the nursing progress note dated 7/26/22 at 11:22 p.m. indicated Resident #1 was observed being agitated and constantly asking staff how to get to the highway. The nursing note indicated Resident #1 was packing his belongings and walking around the unit with his bag, asking staff when he could leave. Record Review of the facility's 15-minute Face Checks indicated Resident # 1 had been placed on 15-minute checks on 7/23/22 at 3:15 a.m. The 15-minute Face Checks indicated the 15-minute check on Resident #1 had continued from 3:15 a.m. until 7:00 a.m. on 7/23/22 and then stopped. The 15-minute Face Checks indicated Resident #1 had been on 15-minute checks again on 7/24/22 at 3:15 a.m. until 5:45 a.m. The 15-minute Face Checks indicated on 7/24/22 at 6:00 a.m. Resident #1 had been placed on one-on-one observations until 7/25/22 at 3:15 a.m. The 15-minute Face Checks indicated Resident #1 was placed back on 15-minute checks on 7/25/22 at 3:15 a.m. Record review of the facility's Wander Book had a copy of Resident #1's face sheet with picture and the facility's elopement policy. During an interview on 7/26/22 at 10:22 a.m. CNA B said Resident #1 was confused and wanted to return home. CNA B said she had not witnessed Resident #1 attempting to exit the facility. CNA B said there was one CNA assigned to the unit for 14 residents. CNA B said there were three exit doors in the unit all with alarms (one to the secured courtyard, one to the main area of the facility, and one to an unsecured area outside). During an observation on 7/26/22 at 10:28 a.m. Resident #1's window in his room was able to open all the way and was not facing the secured courtyard. Resident #1's window faced the side of the building and a parking lot area. During an observation on 7/26/22 at 10:32 indicated the speed limit on Main Street/Highway 56 in front of the facility was 55 miles per hour. During an interview on 7/26/22 at 12:15 p.m. Resident #1 said he wanted to go to Dallas, TX. Resident #1 said he lived in [NAME], TX. Resident #1 said he had got into a fight with his brother where his brother hit him in the back of the head, knocked him out, and brought him here. Resident #1 said his brother had his wallet with is resident card (Green card granting permission to live and work in the United States). Resident #1 said if immigration came, they would send him back to Mexico. Resident #1 asked for directions to Dallas, TX. During an interview on 7/26/22 at 12:25 p.m. LVN A said he had been passing medications when the CNA (CNA E) working the secured unit informed him of Resident #1 eloping. LVN A said Resident #1 had raised the window to his room and climbed out the window. LVN A said he found Resident #1 walking towards town. LVN A said up until the elopement he had not been the nurse assigned to the secured unit and was unfamiliar with Resident #1. LVN A said the CNA (CNA E) working the unit provided 15-minute checks on Resident #1 after his elopement. During an interview on 7/26/22 at 12:40 LVN C said she was an agency nurse, and it was her first shift at the facility. LVN C said she was the nurse assigned to the unit. LVN C said Resident #1 had not had any exit seeking behaviors this shift. LVN C said Resident #1 was on every 15-minute checks. During an interview on 7/26/22 at 12:46 p.m. the SW said Resident #1 had not been referred for psychiatric or social services. During an interview on 7/26/22 at 12:53 p.m. Resident #1's family member said Resident #1 had a history of eloping from facilities. Resident #1's family member said he had eloped 5 or 6 times from a previous facility. Resident #1's family member said Resident #1 was a master electrician and had disarmed a door alarm at a previous facility. Resident #1's family member said Resident #1 would ask multiple times a day about his wallet and resident card. Resident #1's family member said Resident #1's previous physician had diagnosed him with alcohol induced dementia with amnesia. During an interview on 7/26/22 at 1:05 p.m. LVN D said she had worked 7/23/22 and 7/24/22 on the 6:00 a.m. to 6:00 p.m. shift and had been the nurse assigned to the secured unit. LVN D said Resident #1 had exhibited exit seeking behavior on both days. LVN D said Resident #1 asked about going home, his wallet, and his wife. LVN D said Resident #1 required continuous redirection. LVN D said Resident #1 was on one-on-one observation on 7/24/22. LVN D said they monitored one-on-one observations by documenting on a printed form that the resident was being observed and by who. During an interview on 7/26/22 at 1:12 p.m. CNA E said he worked 7/23/22 the 6:00 p.m. to 6:00 a.m. shift on the secured unit. CNA E said Resident #1 was sitting on the couch of the day room in the secured unit when he took another resident to the restroom. CNA E said he was in the restroom with the other resident approximately 10 minutes. CNA E said when he came out he could not find Resident #1. CNA E said he discovered Resident #1's room window raised and he notified the charge nurse. CNA E said Resident #1 had not been on every 15 minutes checks prior to his elopement. CNA E said Resident #1 had attempted to elope from the facility the day before on 7/22/22. CNA E said Resident #1 was easily redirected. During an interview on 7/26/22 at 1:28 p.m. the DON and Administrator said they were unaware of Resident #1's history of elopement prior to him admitting to the facility. The DON and Administrator said they found out from Resident #1's family after his admission to the facility about Resident #1's history of eloping. The DON and Administrator said Resident #1 was put in the facility elopement book, placed on the secured unit, and staff were made of aware of his exit seeking behavior on admission. The DON and Administrator said no interventions had been put in place to Resident #1's window after his elopement. The DON and Administrator said Resident #1's window had initially had clamps to prevent the window from being opened all the way, but Resident #1 had broken the clamp. The DON and Administrator said the maintenance supervisor had ordered more clamps for the windows. The maintenance supervisor was off work and unable to be interviewed on 7/26/22. During an interview on 7/26/22 at 3:15 p.m. the Administrator said Resident #1 had been taken off one-on-one observations on 7/25/22 because he had settled down and was sleeping. During an observation on 7/26/22 at 3:32 p.m. all windows in the rooms on the secured units had clamps in place prohibiting them from raising up all the way except Resident #1's window. Record review of the facility's undated Wandering/Missing Residents policy indicated, .The facility must ensure the resident's safety while utilizing the least restrictive means available. To meet this, need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering .The resident's name, picture, and physical description are placed in the wander book located at the nurse's station. All staff are responsible for knowing whose name is on the list and be able to recognize the resident and be able to intervene a necessary .Upon return to the facility (after and elopement), the resident will be assessed for injuries and the attending physician will be advised of the situation. A thorough incident report will be filled out by the charge nurse and given to the Administrator . The administrator was notified on 7/26/22 at 5:04 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The administrator was provided the Immediate Jeopardy template on 7/26/22 at 5:10 p.m. The facility's Plan of Removal was accepted on 7/27/22 at 5:02 p.m. and included: Facility Administrator, with assistance from the Maintenance Director, ensured Resident #1's bedroom window was secured mechanically only to raise 4 inches on 7/26/22. This was done by securing an L bracket to the wall with screws and restricting the window movement to four inches. Facility Administrator, with assistance from the Maintenance Director, ensured that all other windows, (22 total) including other residents bedroom windows were secured mechanically to only raise 4 inches on 7/26/22. Facility Administrator, with assistance from the Maintenance Director, physically placed a permanent marking on the facing of the window at the 4-inch mark where the secure mechanism was placed for ease of visual validation by staff on 7/26/22. Facility Administrator and DON will ensure that the staff will receive in-services regarding ensuring that windows on the secured unit have the mechanism for ensuring the windows ability to not open past the 4 inch mark, Elopement policy and procedures, identification of wandering/exit seeking behavior and intervention techniques, and understanding that all windows on the secured will have mechanism in place that the windows are unable to open past the 4 inch mark and that it is mandatory to report any deviation from this to the Administrator or designee immediately. On 7/28/22 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: During an observation 7/28/22 at 8:30 a.m. Resident #1's window was equipped with an L-bracket attached by screws to prevent his window from raising past 4 inches. Interviews of nursing staff (3-nurses on the 6:00 a.m.-6:00 p.m. shift; 2-nurses on the 6:00 a.m.-6:00 p.m. shift; 2-CNAs on the 6:00 a.m.-6:00 p.m. shift; 2-CNAs on the 6:00 p.m.-6:00 a.m. shift, 1-Physical Therapy Assistant; 1-Housekeeper; 1-CMA on the 6:00 a.m-6:00 p.m. shift; and 1-Social Worker) were performed. During these interviews' staff were able to correctly identify steps to take in the event of an elopement per the facility's policy, types of exit seeking behaviors, interventions for exit seeking behaviors, understanding of the windows in the unit's physical mechanisms to prevent them from opening more than 4 inches, the for the windows to be checked daily and where to document the checks, and the immediate need to notify the Administrator or designee of any deviation of the physical mechanism on the windows on the secured unit. On 7/28/21 at 11:10 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs with inadequate monitoring for one (Resident #4) of 7 residents reviewed for medications. The facility failed to adequately monitor Resident #4's PT/INR levels at least monthly while taking [MEDICATION(S)] (anticoagulant medication) 4 mg daily since 03/23/22. Resident #4's last lab dated 03/22/22 reflected Pro Time (PT) was 26.5 and INR was 2.5. On 06/08/22, Surveyor notified the facility of Resident #4's PT/INR lab not being completed since 03/22/22. Facility ordered a Stat PT/INR lab to be drawn on 06/08/22. Resident #4's PT was 44.3 and INR was 4.5 (high out of therapeutic range) on 06/08/22. Resident #4's INR was 4.5 which placed her at a greater risk for bleeding while on [MEDICATION(S)] medication and on 06/09/22 physician ordered Resident #4's [MEDICATION(S)] medication to be held at least 2 days and when INR level is 3 or below. Resident #4's physician ordered PT/INR labs be drawn next 2 days. Pharmacy Consultant did not have access to residents' labs to ensure PT/INR labs were completed for residents on [MEDICATION(S)] medication. There was not a system in place to ensure and monitor resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Immediate Jeopardy (IJ) was identified on 06/09/22. While the IJ was removed on 06/10/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated due to facility continuation of in-servicing and monitoring of the plan of removal. This failure placed residents on anticoagulant medications with inadequate monitoring, at risk of major or fatal bleeding, hospitalization or death. Findings included: Review of Resident #4's face sheet dated 06/09/22 reflected she was an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #4's Admission MDS assessment dated [DATE] reflected she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a BIMS of 10 indicating she was moderately cognitively intact. Resident #4 required supervision with ADLs of transfers, dressing, toileting, personal hygiene with one-person physical assistance. Resident #4 was on anticoagulant and diuretic medications. Review of Resident #4's Comprehensive Care Plan date initiated and last revised 05/24/22 reflected the following: -Resident #4 was on anticoagulant therapy ([MEDICATION(S)]) related to disease process of Coronary Artery Disease. Interventions initiated on 03/01/22 included the following: to monitor/document/report to MD prn s/sx (signs and symptoms) of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or sudden changes in v/s (vital signs). Revised on 06/08/22 reflected PT/INR labs monthly. Report abnormal lab results to the MD. -revised on 02/02/22 reflected Resident #4 had a fall and at risk for further falls due to unsteady gait. Resident #4 had falls on 02/01/22 and 02/02/22 with no injury. Review of Consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - start date of 03/02/22 of [MEDICATION(S)] tablet 4 mg give 1 tablet by mouth of one time a day related to [CONDITION(S)]. - start date of 03/19/22 for PT/INR. There was no frequency or timeframe noted. Review of Resident #4's PT/INR lab collected on 03/22/22 at 10:53 am and received on 03/22/22 at 4:14 pm reflected Resident #4 had a PT (pro time) level of 26.5 and INR of 2.5 (therapeutic range of 2.0 to 3.0). Dated and time signed 0600 am - Nurse signed waiting for doctor's response. Then written on lab Continue with [MEDICATION(S)] 4 mg Recheck PT/INR with physician signature. Review of Resident #4's labs from 03/23/22 to 06/09/22 revealed there were no PT/INR levels completed since 03/22/22. Review of Resident #4's Nurse note by LVN K dated 03/23/23 reflected PT/INR reported to [Physician G]. No change in dose at this time. No bleeding episodes noted. Record Review of Nurse's MAR for March to June 2022 reflected the following for Resident #4: March 2022 - Resident #4 was administered [MEDICATION(S)] tablet 4 mg ([MEDICATION(S)] sodium) 1 tablet at 5 pm from 03/02/22 to 03/14/22, 03/16/22 to 03/31/22. 03/15/22 was blank. April 2022 - Resident #4 was administered [MEDICATION(S)] tablet 4 mg ([MEDICATION(S)] sodium) 1 tablet at 5 pm on 04/01/22, 04/05/22 to 04/26/22, 04/30/22. On 04/02/22, 04/03/22, 04/28/22 and 04/29/22 Resident #4 was out on pass. May 2022 - Resident #4 was administered [MEDICATION(S)] tablet 4 mg ([MEDICATION(S)] sodium) 1 tablet at 5 pm from 05/01/22 to 05/04/22, 05/06/22, 05/09/22 to 05/20/22, 05/22/22 to 05/31/22. On 05/07/22, 05/08/22, and 05/21/22 resident was out on pass. June 2022 - Resident #4 was administered [MEDICATION(S)] tablet 4 mg ([MEDICATION(S)] sodium) 1 tablet at 5 pm from 06/01/22 to 06/08/22. Review of Resident #4's PT/INR lab collected at 06/08/22 at 11:30 PM and received on 06/09/22 at 6:42 AM revealed PT was 44.3 and INR was 4.5. DON wrote on lab to hold x 2 days PT/INR tomorrow and next day. Record Review of Pharmacy Consultant recommendations for April and May 2022 reflected no pharmacy recommendations for Resident #4. She was reviewed for medications. Record Review of Resident #4's Pharmacy Consultant recommendation printed 02/01/22 reflected Resident #4 was receiving [MEDICATION(S)] 3 mg without routine lab monitoring. Due to potential bleeding problems with INR is above range, please consider a [MEDICATION(S)] lab with INR to be done monthly. This pharmacy recommendation had no physician/prescriber response. Observation and Interview on 06/08/22 at 4:15 PM revealed Resident #4 was sitting in her recliner with no bruising or bleeding. Resident #4 stated she was on [MEDICATION(S)] and had been on [MEDICATION(S)] for [AGE] years. She stated she did not have any bruising or bleeding. She denied any bleeding in her gums. She stated in the past she had bruises but currently had no bruising at this time. She stated she bleeds easily. She stated she was not aware the facility had not drawn her PT/INR labs to check her [MEDICATION(S)] since March 2022. She stated her physician at previous facility checked her PT/INR lab levels every 2 weeks. She stated she would like her PT/INR labs drawn to check her levels since she took [MEDICATION(S)] medication. Resident #4 stated she had no recent falls. Interview on 06/08/22 at 4:08 PM with Resident # 4's physician (Physician G) revealed Resident #4 should be checked for PT/INR labs once a month since her last INR was stable (2.5) and facility should have a protocol of how often PT/INR labs should be drawn for residents on [MEDICATION(S)]. Resident #4's physician stated the facility should have been redrawn Resident #4's PT/INR monthly after 03/22/22. He stated [MEDICATION(S)] medication is the drug which levels fluctuate frequently and resident's eating and other medications she took can affect it. He stated the risk of PT/INR labs not being drawn are that [MEDICATION(S)] levels can go up and go down and it can put you more at risk for bleeding. Interview on 06/08/22 at 4:20 PM with ADON A revealed the facility did not have a standing order or protocol for [MEDICATION(S)] and how often PT/INR levels should be checked. She stated at minimum PT/INR levels should be checked at least monthly for Resident #4 and last time it was checked was on 03/22/22. She stated they reviewed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated in the past we had trouble with physician asking for it to be re-checked earlier than the routine lab order so when PT/INR results are given to doctor the nurse needs to find out from doctor when next time it needs to be ran. ADON A stated she was aware that the pharmacy consultant did not review lab orders of PT/INR levels and requirements for [MEDICATION(S)] medication. She stated Resident #26 is the only other resident who was on [MEDICATION(S)] at the facility. Interview on 06/08/22 at 4:30 PM revealed DON and ADON A stated there was not anything in electronic record that would catch if a resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON A stated Resident #26's physician ordered her PT/INR checks to be done weekly. DON stated Resident #4's PT/INR labs were not being completed since 03/22/22 and should have been done monthly. DON stated they had contacted Resident #4's physician after becoming aware of PT/INR levels not being completed after surveyor intervention to have it drawn tomorrow to check Resident #4's PT/INR levels. DON stated they can contact Resident #4's physician to do the PT/INR order STAT so Resident #4's results will be available in the morning. They were not aware of any facility policy on [MEDICATION(S)] or lab monitoring. Follow-up interview on 06/09/22 at 9:20 AM with Physician G revealed Resident #4's PT/INR lab was higher and his concern was the INR being at 4.5. He stated he ordered Resident #4's [MEDICATION(S)] 4 mg daily to be held at least for next 2 days and have labs redrawn the next 2 days. Physician G stated Resident #4's [MEDICATION(S)] medication will be held until INR is below 3 and will start her back on a lower dose of [MEDICATION(S)] once it gets below 3. He stated the nurse will contact him with the PT/INR results. He stated residents on [MEDICATION(S)] should have PT/INR checked at least monthly or more often depending on the results. He stated residents on [MEDICATION(S)] should be monitored for falls and are at risk for falls, bleeding and skin tears. Physician G stated Resident #4's INR was 2.5 which was in stable range on 03/22/22 and should have been checked monthly. He stated the INR of 4.5 was high which placed Resident #4 at a greater risk of bleeding. Interview on 06/09/22 at 9:30 AM with Pharmacy Consultant revealed monthly she reviewed new physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she checked residents' controlled drug documentation including prn controlled drug medications. She stated she reviewed resident [CONDITION(S)] meds for dosage reduction. She stated she had not checked Resident #4's labs to see if PT/INR labs were completed for resident on [MEDICATION(S)] in April or May 2022. She stated PT/INR labs should be checked monthly at least or more often if ordered from physician. She stated PT/INR levels fluctuate could go too low and higher which places residents at risk for bleeding. She stated if she had reviewed Resident #4's clinical record for PT/INR labs and reviewed the lab orders she would have recommended to physician about a timeframe for routine lab orders for PT/INR. She stated she had not reviewed labs for PT/INR lab levels for Resident #4 or any residents on [MEDICATION(S)] medication. She stated she did not have access to resident's labs to review the labs. Interview on 06/09/22 at 1:48 PM revealed DON was not aware of facility's policy for [MEDICATION(S)] and lab order monitoring until today. She did not know the facility had a policy for [MEDICATION(S)] and lab order monitoring. Interview on 06/09/22 at 3:35 PM with Administrator revealed the communication between Physician G and the nurse was not very clear about when next time the PT/INR lab should be drawn for Resident #4. Administrator stated the nurse who reported Resident #4's PT/INR results on 03/23/22 was an agency nurse and should have found out when Physician G wanted the PT/INR labs to be redrawn. He further stated nurse should have put a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated he expected his staff to follow the policy on [MEDICATION(S)] and lab monitoring. Review of facility's policy [MEDICATION(S)] dated 02/17/20 reflected the facility was to monitor residents receiving anticoagulant therapy. Under procedure 1. Residents on [MEDICATION(S)] will be monitored for signs and symptoms of bleeding. 2. PT/INR will be checked as ordered by the physician. 3. Licensed Nurse will notify the physician of the PT/INR results and document any new orders. 4. If applicable physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility's policy Lab Monitoring dated 03/08/20 reflected the policy was that physician ordered laboratory services will be provided and monitored. Under procedure 1. Lab monitoring requires a physician order. 2. Lab orders will be obtained for all drugs that require therapeutic monitoring. Follow these steps: a. Request an order from the physician for a baseline order b. Request ongoing (therapeutic) lab orders. c. Notify lab of new orders following center's laboratory service procedure. d. Complete a lab requisition: hard copy or enter online depending on lab used. e. Enter orders into clinical software assign and document in progress notes. f. Enter the lab on the lab tracking form at the front of the book to enter lab to be drawn, date drawn, return receipt of the results and the physician notification g. Licensed nurse will continue to document on the lab tracking form until steps of tracking are complete. 3. When physician does not choose to order labs for baseline or therapeutic levels, documentation of same will be noted in the resident's clinical software in the progress notes. 4. All lab results will be reviewed by a nurse. The nurse will date and document the time the result was reviewed or confirm results in the clinical software. 5. Lab results at are within normal limits will be reported to the physician. 6. Critical lab results will be called to the physician or on-call physician immediately. Initial, date and time the lab result. Note if new orders were received. Document same in resident's clinical software progress notes. 7. Abnormal lab results will be sent to the physician. Note any medications the resident is taking that could affect the lab value and note all treatments that have been done (i.e., UA), date and signature of nurse .The following is a list of medications for therapeutic lab tests. [MEDICATION(S)] ([MEDICATION(S)]) medication required prothrombin time for frequency of every month for the purpose to monitor therapy range. Review of facility's policy Lab Orders dated 03/08/20 reflected the facility was to provide or obtain laboratory services to meet the needs of its residents. [Facility] is responsible for the timeliness of the services. [Facility] must notify the attending physician of the lab results. Procedure 1. Lab orders will be entered in the clinical software and assigned to the appropriate flow sheet. 2. The Director of Nursing/designee will be responsible to monitor lab orders to ensure that a ordered labs have been drawn as ordered by the physician. 3. Lab personnel will be responsible to report to the charge nurses all labs that have been drawn that day. Charge nurse will be responsible to initial date lab is drawn on the MAR/TAR. The Director of Nursing/designee will be responsible to notify the lab when a lab result is not received in a timely manner. 5. The attending physician will be notified promptly of lab results. 6. Laboratory results will be maintained in the resident's clinical record. Review of [MEDICATION(S)] - FDA prescribing information, side effects and uses from https://www.drugs.com/pro/[MEDICATION(S)].html#content retrieved on 06/09/22 reflected under [MEDICATION(S)] Dosage and Administration the following: The dosage and administration of [MEDICATION(S)] must be individualized for each patient according to the patient's International Normalized Ratio (INR) response to the drug. Adjust the dose based on the patient's INR and the condition being treated. Consult the latest evidence-based clinical practice guidelines regarding the duration and intensity of anticoagulation for the indicated conditions. Recommended Target INR Ranges and Durations for Individual Indications An INR of greater than 4.0 appears to provide no additional therapeutic benefit in most patients and is associated with a higher risk of bleeding. [CONDITION(S)] .In patients with non-valvular AF, anticoagulate with [MEDICATION(S)] to target INR of 2.5 (range, 2.0-3.0). The Administrator and DON were notified of the Immediate Jeopardy on 06/09/22 at 1:49 pm due to the above failures and provided the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted and RDCO was notified on 06/10/22 at 2:13 PM. The accepted Plan of Removal for the Immediate Jeopardy included the following: The Texas Department of Health and Human Services Committee (TXHHSC) entered facility for annual survey. During their investigation an IJ (Immediate Jeopardy) was cited in regard to [MEDICATION(S)] Management on 6/9/2022. -Resident(s) found to be affected: Resident #4 Immediate interventions: 6/8/22 1604: Provider was notified that the orders were received 1604: STAT PT/INR ordered 1625: Resident was assessed, found no bruising, bleeding or injury. 1943: DON called facility to check statis of lab draw 2127: DON called facility to check statis of lab draw 2140: DON called facility to check statis of lab draw 2150: DON called facility to check statis of lab draw 2153: Nurse returned DON's call saying the tech has not arrived 2200: CCL called about STAT Lab 2220: Nurse returned DON saying tech has not arrived 2318: Nurse returned DON saying tech has not arrived 2245: Notified Tech on the way o 2346: Phlebotomist at facility for STAT lab- sample acquired Immediate interventions: 6/9/22 0642: Lab results reported to provider with new orders obtained*INR 4.5 Physician G was called. Left a message 0659: Physician G returned the call: gave a new order to hold [MEDICATION(S)] for 2 days, repeat PT/INR on 6/10 and 6/11. 0800: Resident assessed for petechiae along with any signs of bleeding or bruising, none noted. Vital signs, stools, urination, weights, ADL, activities are consistent with baseline. Resident is stable, thriving and happy with care. 0915: Physician G came in to assess resident- unremarkable o 1015: Received new orders from Physician G: PT/INR daily until INR is below 3.0, then start [MEDICATION(S)] 3mg by mouth 1 tab daily. Then PT/INR weekly o 1215: Physician completed assessment note and spoke to the survey team. Asked ADON A to contact Resident #4's cardiologist to see if it would be safe to change [MEDICATION(S)] to [MEDICATION(S)]. ADON A called Resident #4's cardiologist but spoke to his nurse. The nurse said that per cardiologist, Resident #4 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1215: RDCO emailed Consultant Pharmacy regarding the pharmacy consultant failing to note the missing PT/INR for Resident #4's [MEDICATION(S)], o 1604: Cardiologist nurse called back and said he recommends discontinuing [MEDICATION(S)] and change to [MEDICATION(S)]. The dosage depends on her kidney function so PCP Physician G will provide the appropriate order. 16:33 RDCO emailed Consultant Pharmacy again asking for an immediate in-service to the consultant on monitoring for labs required for medication management and safety. Then followed up with a call for expediency. A plan was set in motion for the consultant's supervisor to provide an in-service as asked and a different consultant will complete an audit of the facility's medications requiring lab monitoring. PCC log in and lab portal access was provided. Expected to be completed by 6/10/22 3PM 1723: Physician G gave orders to draw CMP for 6/10 and he will decide on the dose once he has received the results. 2030: Pharmacy Consultant received in-service from her supervisor on the requirements of monitoring therapeutic lab values as it relates to Medication management and safety. 6/10/22 Interventions completed 0930: RDCO re-educated the DON/ADON A and Medical Records tech on medication management, and the policy and procedures of Consolidation of Monthly Orders. 0930: RDCO re-educated the DON that she is ultimately responsible for the accurate completion of the Consolidation of Monthly Orders. 0930: RDCO re-educated the DON that she is ultimately responsible for ensuring the pharmacy consultant has reviewed the lab monitoring by reviewing the pharmacy consultant recommendations report. 0930: RDCO re-educated DON/ADON A on monitoring for lab documentation and follow up. -Potential residents to be affected by identified practice: o The facility has reviewed all [MEDICATION(S)] orders and has identified one resident who is on [MEDICATION(S)]. The resident has received [MEDICATION(S)] management in accordance with provider orders. No further action needed at this time. Corrective action implemented so identified practice will not recur with root cause analysis: 5/27/22 a certified letter by overnight carrier notice of contract termination with Central Clinical Labs and Xray services to be complete on July 26, 22. On 6/9/22 RDCO has re-educated the DON/ADON on PT/INR procedures and lab process per the [MEDICATION(S)] management policy. On 6/9/22 RDCO has re-educated on the STAT lab requirements of 4 hours to draw and 2 hours to result. On 6/9/22 DON has educated the nurses on STAT lab requirements of 4 hours to draw lab and 2 hours to receive results. On 6/9/22 The DON/designee educated all nurses on Policy for [MEDICATION(S)] management. o On 6/9/22 RDCO has re-educated DON/ADON that the nurse on duty at the time of receipt of lab results and STAT lab results is responsible to notify the physician and orders resulting. Then DON/ADON will verify the next morning that those lab results have been processed properly and it will be discussed in IDT. On 6/9/22 DON educated the nurses that the nurse on duty at the time of receipt of lab results and STAT lab results is responsible to notify the physician and orders resulting. On 6/9/22 The DON created a PT/INR binder that contains the policy for reference and the log sheets and educated the nurses on the expectations of completion and follow up. DON/ADON will monitor this binder daily. On 6/9/22 Lab login is posted at the nurse's station o On 6/9/22 A PT/INR flow sheet has been developed to track labs, therapeutic range, and orders- to be managed by DON/designee and place in a binder at the nurse's station. Nurses have been educated by the DON and placed in a binder. On 6/9/22 The Regional Director of Clinical Operations (RDCO) has re-educated the Inter-Disciplinary Team (IDT) to follow-up with orders post-test results of PT/INR, system changes and processes. o Any nurse on vacation or that works PRN or new nurse or agency nurse will receive this reeducation prior to working their next schedule shift. The nurse will demonstrate competency by passing the designated quiz. This re-education will be provided either by DON/ADON and/or other additional designees. o If the staff nurse does not properly demonstrate understanding, they will receive continued education prior to working their shift. On 6/10/22 Pharmacy Regional Director of Clinical Operations has arranged for a consultant to perform a full audit of all medications requiring lab monitoring. On 6/10/22 Pharmacy Regional Director of Clinical Operations will conduct an in service to the current pharmacy consultant who failed to note a missing PT/INR and monitoring therapeutic lab values. On 6/9/22 The physician has been re-educated on carefully reviewing consolidated orders to include needed therapeutic values via phone. Will obtain official signature 6/10/22. On 6/10/22 received the history and physical from the cardiologist that includes the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He defers to the PCP (Physician G) to decide about ordering [MEDICATION(S)] or not. Tracking and Monitoring: The DON/ designee will audit the nurse's return demonstration of proper [MEDICATION(S)]/ PT/INR process. Findings will be reported to IDT and to monthly QAPI x3 months at which time the QAPI Committee will determine if further monitoring is needed. The DON/ designee will audit the [MEDICATION(S)] flow sheets and process. Audit findings will be reported to IDT and to monthly QAPI x3 months at which time the QAPI Committee will determine if further monitoring is needed. The DON/ designee will conduct random audit of IDT staff knowledge for monitoring PT/NR results and orders. Audit findings will be reported to IDT and to monthly QAPI x3 months at which time the QAPI Committee will determine if further monitoring is needed. Pharmacy Consult will perform monthly audits for therapeutic lab values for appropriate medications. This will be reviewed monthly in QAPI until compliance is met. Pharmacy consultant completed a new recommendation audit of Resident #4. The facility's implementation of the IJ Plan of Removal for pharmacy services was verified through the following: Record Review of List of Residents on anticoagulants revealed Residents #4 and #26 were the only 2 residents on [MEDICATION(S)] medications. Record Review of Resident #26's clinical record revealed Resident #26 had a current PT/INR lab order to be drawn weekly. Reviewed Resident #26 lab orders, progress notes and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of five of five residents for medications revealed no concerns with significant medications or lab orders. Interview on 06/10/22 at 03:21 PM with DON revealed she had looked and was unable to find Resident #4's pharmacy recommendation with physician's response. She did not know what happened or if it even got to the physician. Record Review on 06/09/22 to 06/10/22 of Resident #4's clinical record revealed Resident #4's [MEDICATION(S)] was placed on hold on 06/09/22 and 06/10/22. Facility did Resident #4's PT/INR labs, notified physician and followed physician orders. Record Review of In-services dated 06/09/22 PT/INR test follow up by RDCO reflected IDT will list and discuss each resident on anticoagulants in the IDT meeting and minutes. This will include the resident name, drug and next lab draw day. Notes will be written and validated lab results, new orders/physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff in-serviced were IDT members. Observation and Interview on 06/10/22 at 12:05 PM with Corporate Pharmacy Consultant revealed he was at facility to do a full complete on residents who have medications that require therapeutic lab monitoring and especially residents on anticoagulant medications. He stated going forward the facility's assigned pharmacy consultant would be reviewing these medications which require therapeutic lab monitoring including [MEDICATION(S)], physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of In-service dated 06/08/22 and 06/09/22 Lab process, PT/INR procedure and [MEDICATION(S)] Management revealed MDS Coordinator, LVN B, LVN C, LVN F, LVN H, LVN I, LVN J and RN Weekend Supervisor. Interviews on 06/10/22 from 1:48 PM to 3:03 PM with 5 of 5 LVN (LVN B, LVN C, LVN F, LVN H and LVN I) including facility and agency nurses from all shifts revealed they had been in-serviced on protocol for [MEDICATION(S)] and lab monitoring of PT/INR for residents on [MEDICATION(S)]. All five LVNs were knowledgeable that any residents on [MEDICATION(S)] should be receiving at least monthly or more frequently if ordered by physician. They were in-serviced on when discussing resident 's PT/INR lab results with physician to find out if any changes in dosage, when next the physician wants the PT/INR ordered and to put a lab order along with physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . They were knowledgeable of facility starting a system of lab monitoring including PT/INR binder at nurse's station. Interview on 06/10/22 at 2:36 PM with RN Weekend Supervisor revealed she had been in-serviced on the protocol and facility policy for residents on [MEDICATION(S)] and lab monitoring. She stated residents on [MEDICATION(S)] medication must have a PT/INR ran monthly or more frequently if physician ordered. She stated when they receive PT/INR lab results, they contact physician immediately with PT/INR lab results and put in any new medication changes' physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of In-service provided by consultant pharmacy group dated 06/09/22 reflected pharmacy consultant was in-serviced on medication monitoring guidelines including [MEDICATION(S)] ([MEDICATION(S)]) and on monitoring of lab results. She was in-serviced on consultant role of recommending routine labs and follow-up on results) and steps to taken when additional facility follow up needed. Interview on 06/10/22 with 02:34 PM revealed Pharmacy Consultant was in-serviced to look at residents with [MEDICATION(S)] to ensure PT/INR lab orders are being completed and PT/INR physician lab orders have frequency of when PT/INR should be checked. She stated she was provided access to resident labs now and if a resident is missing lab orders find them she will be contacting DON to check on labs. She knew types of medications like [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] and could go over what labs are required of each. She stated PT/INR should be checked at least monthly or more often if physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Follow-up interview on 06/10/22 at 5:57 PM revealed Pharmacist Consultant stated the pharmacy recommendations she did monthly went to DON, physician and Administrator. She could not recall the pharmacy recommendation for Resident #4 dated 02/01/22. Record Review of facility's in-services for DON and ADON A by RDCO on 06/09/22: -PT/INR - [MEDICATION(S)] process DON/ADON A will do the following: All residents on [MEDICATION(S)] will be entered on the [MEDICATION(S)] flow sheet including PT/INR, Dose and next scheduled lab. Lab PT/INR - will be drawn in accordance with doctor orders. DON/ADON A will also list each resident in the IDT meeting minutes with their drug and next lab draw. IDT will discuss and validate it on flow sheet. DON/ADON A will ensure a note is placed in the medical record when lab results are received, Doctor notified, order changes and next scheduled lab draw was discussed. Policy for [MEDICATION(S)] Management reviewed. - DON/ADON ensure nurses understand they are responsible for processing all lab results STAT or otherwise when they are received to include calling the lab if not received timely, notify physician, any new orders or dose changes. DON/ADON A will validate this process and discuss in IDT meeting. Interview on 06/10/22 at 03:34 PM with ADON A revealed she was in-serviced and was aware of the facility's policy on [MEDICATION(S)] protocol and PT/INR lab monitoring. She stated residents on [MEDICATION(S)] medication should have PT/INR lab orders to include when to be checked and/or frequency of lab. She

Based on observation, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for one(Resident#1) of four residents reviewed for accidents CNA A failed to ask for assistance when she transferred Resident #1, who was cared planned for transfer assistance of two persons. The mechanical lift tilted and fell over with the resident in the sling. Resident #1 sustained a fracture thumb, skin tear and an abrasion. This was determined to be past noncompliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could affect the four residents who required Hoyler lift transfers four residents by placing them at risk for injury, pain, and hospitalization s. Finding included: 1.The face sheet dated 11/03/13 for Resident #1 reflected the resident was an [AGE] year old male with an admission date of [DATE] with the [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 was severely cognitively impaired, was totally dependent on two or more staff with transfers. Review of Resident #1's Care Plan dated 06/07/17 revealed the resident must be lifted mechanically, two staff members required at all times to use the mechanical lift. Review of the nurse's progress notes dated 05/21/17 at 1:00 p.m. reflected CNA transferring (Resident #1) to bed with Hoyer lift. CNA lifted the resident up on the lift and began to push resident toward bed. CNA closed legs on the lift to push under bed and turned resident's body. The lift began to tilt and the CNA was unable to stop lift from tilting over. Lift tilted toward other bed and landed on bedside table, slid off of the table to floor. His head and shoulders landed on the other bed. Head to toe assessment, 0.5 cm skin tear to right thumb, 1cm skin tear x2 to right forearm, 2cm x2 cm abrasion to top of left foot. No other redness or bruising noted moves all extremities freely, Neurological check within normal limits for resident. Dr. notified. Message left for wife and notified DON. Review of the nurse's progress notes dated 05/23/17 at 11:00 a.m. for Resident #1 reflected delayed injuries noted to right thumb with bruising .New order x-ray right thumb 1x1 cm bruise to back of hand resident complaining of pain all over. Tylenol 650 mg. given will continue to monitor. Review of the nurse's progress notes dated 05/23/17 at 4:30 p.m. for Resident #1, reflected, X-ray of right thumb received impression is the second metacarpal neck, likely subacute fracture. Review of Physician telephone orders dated 05/23/17, for Resident #1, reflected the first order X-Ray right thumb, second, send to ER, and third, return to nursing home continues medications as previously ordered. Wear Velcro splint for comfort on right /wrist. Review of X-ray report dated 05/23/17, for Resident #1, reflected second metacarpal neck subacute fracture. Review of the nurse's progress notes dated 05/23/17 at 16:40 p.m. (4:40 p.m.) for Resident #1 reflected new order send to ER for splint to right hand of metacarpal neck subacute fracture. Review of Physician telephone orders dated 05/24/17 for Resident #1, reflected 1. Remove right hand splint every shift to check for skin integrity and circulation 2. Leave right hand splint on x 2 weeks and re-evaluate. Review of Physician telephone orders dated 06/09/17, for Resident #1 reflected x-ray right thumb. Review of the x-ray record dated 06/09/17, for Resident #1, reflected the findings are stable without acute dislocation or fracture. An observation on 06/23/17 at 4:20 p.m. revealed Resident #1 resting in bed. He was unable to engage in a conversation related to flight of ideas and yelling out at the staff. An interview on 06/23/17 at 9:25 a.m. with LVN B revealed she was the charge nurse who was responsible for Resident #1 on 05/21/17. She stated CNA A summoned her to Resident #1's room. When she entered the room, the resident was still in the sling up against the bedside table with his head and trunk resting on the other bed in the room. She was standing beside him holding the trunk of his body. She called for help. CNA C and CNA E arrived and helped us lower the sling to the floor. LVN B stated at that time she did a head to toe assessment on the resident, and noted a skin tear to his right arm, right thumb and an abrasion to his left foot. The four of them manually lifted him onto the bed. She removed the Hoyer lift from use until it could be checked for malfunctioning. She stated she called the DON, physician and resident's family member family member. She counseled CNA A and told her to never use a Hoyer by herself, always use two people. LVN B revealed CNA A did not ask her or other staff members for help. She stated if the nurse was not available other CNAs would assist with a Hoyer transfer. She started neurological checks and the resident was monitored every shift for 72 hours, On 05/23/17 Resident #1 complained of pain to his right thumb. The physician was notified an X-ray was ordered. The x-ray results indicated a fracture to his thumb. He was sent to the hospital and returned with a soft splint in place. A follow-up x-ray was done on 06/09/17, and the fracture was healed. An interview on 06/23/17 at 2:18 p.m. with CNA C revealed he was working on the memory care unit when he and CNA E were called to assist LVN B and CNA A to get Resident #1 into bed. He stated when he entered the room Resident #1 was in a Hoyer sling with the lift against the table and half of his head and shoulders were on the bed and his lower trunk on the bedside table. He stated all four staff members lowered the lift with the resident to the floor, unhooked the sling from the lift, and then all four lifted the resident onto the bed with the sling. CNA C stated you must always use two people when using a Hoyer lift. He also stated he had training with a test and he had to pass before he could use a Hoyer lift. Interview with the Director of Nurses (DON) on 06/23/17 at 8:40 a.m. revealed she interviewed CNA A on 05/22/17. CNA A stated she was in a hurry and had personal problems on her mind and just was not thinking correctly. She admitted she had transferred Resident #1 by herself with the Hoyer lift. She was transferring Resident #1 from his wheelchair to the bed. She had positioned the Hoyer lift over his wheelchair with the Hoyer legs pulled apart, hooked the sling to the lift and moved the lift over to the bed and she had closed the legs of the Hoyer and was moving the resident's legs around to be over the bed before lowering the lift, at that time the Hoyer tilted and turned over while the resident was in the sling. The lift landed on the bedside table with his head and shoulder hitting the mattress on the other bed in the room. She called for LVN B to come and help. CNA C and CNA E assisted CNA A and LVN B to get the resident back into the bed. The DON revealed CNA A was terminated related to neglect. An interview with CNA A was attempted on 06/23/17 via telephone, no answer, left message to return phone call. Review of the CNA A's employee record revealed a hire date of 05/11/17. She completed the Hydraulic Lift (Hoyer Lift) demonstration competency based training on 05/18/17 with satisfactory results. A Separation Report, dated 05/26/17, reflected CNA A's last day worked was 05/21/17 (date of incident). Review of the facility's Policy and Procedure for Safe Lifting and Movement of Residents, Lifting machine (Hoyer lift) dated December 2013, reflected, Two (2) nursing assistants are required to perform this procedure. The facility's policy to prohibit the Mistreatment, Neglect and Abuse of Residents and the Misappropriation of Resident Property undated .Each resident has the right to be free from mistreatment, neglect ,and misappropriation of property . The DON was interview on 06/23/17 at 09:25 a.m. and asked the following questions (1) How are the CNAs informed of the residents that require two person assist or a Hoyer Lift? She responded, The Kiosk -provides information and displays the information on a screen for all residents, such as bathing eating and transfers. She continued to state there were residents care sheets available in the shift sign book at the front nurse's station. The sheets have information about each resident that they can put into your pocket for reference. (2) How do you provide training on the use of a Hoyer lift? The DON responded that all new hires must have a return demonstration on the use of a Hoyer lift and be checked off on the skill to show competency with satisfactory after completion of the skill. (3) When was the last time an in-service was done on the use of Hoyer lift? An all staff in-service was held on 05/22/17 after Resident #1 was transferred with only one assist. The DON further revealed the Physical Therapy Department had checked off every staff member on Hoyer lifts and gait belt transferring. 2. Review of the facility's corrective action in response to the incident revealed the following: The Hoyer Lift involved in the incident with Resident #1 was removed from the floor until manufacture personnel inspected the lift for safe use. Then each Hoyer would be checked by the manufacture personnel quarterly. An in-service was conducted on 05/22/17 by the DON for all employees regarding Hoyer lift Transfers. The In-Serv ice Report, dated 05/22/17, reflected the topic: All Hoyer lifts require two staff members to transfer and sling placement. It further noted the DON would observe two Hoyer lift transfers per week for six weeks and she would conduct Hoyer lift proficiency training weekly that was competency based. The maintenance department will inspect lifts monthly to ensure good working condition. The Hoyer slings will be assessed monthly for wear and tear. The sling will be replaced if needed. 3. To verify the faciltiy implemented their correction actiona plan the following observation, record review and interviews were conducted: Review of a report from an outside vendor, dated 05/30/17, reflected quarterly Certification inspection for the Hoyer lift indicated the lift function test: ok, wheels and brakes: ok, inspected all nuts and bolts, tighten as needed: yes, physical condition: good. An observation on 06/23/17 at 4:03 p.m. of a Hoyer lift transfer with CNA L and CNA M displayed competency of the transfer. An interview on 06/23/17 at 2:18 p.m. with CNA C stated two people were required to use the Hoyer lift. He stated he found the information of the residents who required two person assistance with transfer or Hoyer lifts from the Kiosk. An interview on 06/23/17 at 9:15 a.m. with CNA F revealed she was trained on the use of a Hoyer lift when she was hired and annually and also was in-serviced on the use of a Hoyer lift since the incidents. She stated two persons were required to use the Hoyer lift and she could find the information of the resident who required two persons assistance with transfers or Hoyer lift transfers from the Kiosk or the resident's care sheets that she could put in her pocket. An interview on 06/23/17 at 9:15 a.m. with CNA G revealed she worked on the 6-2 shift and the 2-10 shifts. She was trained on the use of a Hoyer lift when she was hired and annually. She had in-service on the use of a Hoyer lift since the incident. She stated two persons were required to use the Hoyer lift and she could find the information of the resident who required two persons assistance with transfers or Hoyer lift transfers from the Kiosk or the resident's care sheets that she could put in her pocket. An interview on 06/23/17 at 9:15 a.m. with CNA H revealed she worked on the 6-2 shift. She was trained on the use of a Hoyer lift when she was hired and annually. She stated she also had an in-service on the use of a Hoyer lift since the incident. CNA H stated two people were required to use the Hoyer lift. She stated two persons were required to use the Hoyer lift and she could find the information of the resident who required two persons assistance with transfers or Hoyer lift transfers from the Kiosk or the resident's care sheets that she could put in her pocket. An interview on 06/23/17 at 9:15 a.m. with CNA I revealed she worked on the 6-2 and 2-10 shifts. She was trained on the use of a Hoyer lift when she was hired and also had an in-service on the use of a Hoyer lift since the incident. She stated two persons were required to use the Hoyer lift and she could find the information of the resident who required two persons assistance with transfers or Hoyer lift transfers from the Kiosk or the resident's care sheets that she could put in her pocket. An interview on 06/23/17 with LVN B at 9:30 a.m. revealed she visually monitored the CNAs using the Hoyer lift and would assist them with the transfers. An interview on 06/23/17 with LVN K at 3:25 p.m. revealed she visually monitored the CNAs using the Hoyer lift. She also assisted them with the transfers. An interview on 06/23/17 with LVN J at 4:20 p.m. revealed she visually monitored the CNAs using the Hoyer lift and assisted them with the transfers. 4. An interview with the DON on 06/23/17 at 4:15 p.m. revealed four residents required Hoyer lift transfers.

Based on observation, interview and record review, it was determined the facility's Administrator and DON failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently for for one (Resident #2) of seven residents reviewed for abuse/neglect, for four (Residents #2, #7, #9 and #11) of seven residents reviewed for pressure ulcers, and for six (Residents #2, #4, #5, #7, #13, and #15) of 15 residents reviewed for quality of care. The facility administrator failed to: 1) Ensure implementation of the facility's policy and procedures regarding Abuse Prohibition: a) When Resident #2 fell due to CNA F's failure to ensure another staff member assisted her with incontinent care; b) Failed to thoroughly investigate the incident; c) Report the incident to the Stage agency without surveyor intervention; d) Report Resident #2's development of significant bruising to the State agency. 2) Monitor and supervise the DON to ensure she carried out her responsibilities. The DON failed to ensure: a) Nursing staff were monitored in providing nursing care to the facility residents; b) Nursing staff were adequately trained to provide care to the facility residents; c) Charge Nurses were supervising and monitoring the care provided by CNAs to the facility residents. d) CNAs were following the residents' plans of care. These administrative failures resulted in: 1A) On 07/16/12, CNA F failed to have another staff member assist her, as the resident's care plan indicated, when she provided incontinent care to Resident #2. During the care, the unlocked bed rolled out from under the resident and CNA F lowered the resident to the floor. 1B) The ADM and DON failed to investigate the bruising, which developed on 07/23/12, to Resident #2's breast area, which extended from her mid chest wall to her lateral left torso and the hematoma which also developed on her mid chest wall. 1C) Resident #2 sustained a 5 inch abrasion to her thigh and a bruise on her abdomen, when she was lowered to the floor. These failures also resulted in a delay in care and treatment for [REDACTED]. 1D) On 08/22/12, CNA E failed to have another staff member assist her when she provided incontinent care to Resident #2 and the resident almost rolled out of bed. CNA E's body prevented the resident from rolling off the bed. 2A) Resident #2 fell on [DATE]. The facility failed to: * Monitor the resident, who was on [MEDICATION NAME] (anticoagulant), for bleeding and/or injury; * Assess the resident's bruising with measurements and a description of the color of the skin; * Provide the physician with an accurate description on 07/23/12 of the resident's bruising measurements and color of bruise) and remind the physician the resident was on [MEDICATION NAME]; * Follow-up with the physician in a timely manner when there was no response about the resident's bruising; * Write the physician's orders [REDACTED]. * Ensure two staff assisted the resident with ADLs; 2B) Resident #2 went to the hospital 10 days post fall with a hematoma on her breast and had to receive at least two units of Packed Red Blood Cells. 2C) Resident #7 starting experiencing symptoms of a change in condition on 06/03/12. The facility failed to: * Assess and monitor the resident when she experienced, cognitive changes along with weakness, loss of appetite and overall decline; * Keep the physician apprised of the resident's changes in condition. 2D) Resident #7 was admitted to the hospital with [REDACTED]. 3A) Resident #9 - The facility failed to: 1. Ensure the resident's heels were off-loaded to relieve pressure; 2. Ensure the resident was turned and repositioned every two hours; 3. Ensure communication for prompt identification and treatment; 4. Provide accurate and complete skin assessment for early detection and treatment of [REDACTED]. 5. Ensure complete and accurate descriptions of pressure ulcers, including staging, for continued monitoring. After surveyor inquiry, the resident was assessed with [REDACTED]. 3B) Resident #7 - The facility failed to: 1. Provide accurate and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; 3. Ensure identified pressure ulcers received the correct and appropriate treatment; 4. Ensure every skin area/pressure ulcer, once identified, was documented with current descriptions and treatments. An unstageable pressure ulcer was identified as a Stage II. The Wound Care nurse was not following physician's orders [REDACTED]. 3C) Resident #2 - The facility failed to: 1. Ensure communication for prompt identification and treatment; and 2. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. Nursing did not identify the pressure ulcer on their Weekly Skin Assessments. After surveyor inquiry, unstageable pressure ulcers to her buttocks. CNA F was aware the resident had a pressure ulcer and was providing prevention treatment to it. She did not notify the nurse of the suspected pressure ulcer. 3D) Resident #10 - The facility failed to: 1. Ensure communication for prompt identification and treatment; 2. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 3. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; and 4. Notify the physician promptly for treatment orders. Resident #10 had a Stage II pressure ulcer identified by a night shift nurse on 07/21/12. The physician and treatment nurse were not notified. The treatment nurse discovered the wound after the resident approached her and complained of pain. Following her assessment, the Wound Care Nurse failed to document the findings, notify the physician and obtain treatment orders. An Immediate Jeopardy (IJ) was identified on 08/23/12. On 08/25/12, the Immediate Jeopardy was removed. However, the facility remained out of compliance at a severity level of "Actual Harm that is not Immediate Jeopardy" and a scope of "Pattern," because the facility had fully implemented their Plan of Removal and had not yet monitored their plan for effectiveness. These failures could affect 35 of 35 residents on the three halls where LVN K provided care and services, and placed them at risk for a lack of assessment when the residents experienced a change in condition, assessed for pain, no acknowledgement of how the potential side effects from their medication could affect the residents, which could result in a further decline in health, hemorrhage, the need for further medical attention, hospitalization and death. These failures placed 15 residents having sustained falls at risk for not dtecting intercranial bleeds as soon as possible resulting in brain damage, nerve damage and possible death. Failure to accurately assess/stage pressure ulcer, and consult with the resident's physician's to obtain the physician's recommendations could result in the deterioration of existing pressure ulcers or cause the development of pressure ulcers for all 66 residents identified as receiving preventative skin care. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. 1) Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Gastrostomy and [MEDICAL CONDITION], per the quarterly MDS assessment dated [DATE]. Further review of the MDS assessment revealed Resident #2 required two or more persons physical assistance for toileting, bed mobility and dressing. The MDS assessment reflected Resident #2 required one-person physical assistance for bathing. Further review of Resident #2's MDS assessment revealed she had long and short-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected Resident #2 was 68 inches tall and weighed 164 pounds. Resident #2's Comprehensive Care Plan reflected the areas of concern (Problems) with the date they were identified and the approaches or interventions planned. These included: (a) ADL functions (03/29/12) including Bed Mobility; Transfers; Dressing; Eatuing; Toileting; Personal Hygeine; and Bathing. The resident was totally dependent with all functions and required 1-2 person's to accomplish the task. (Note: Bathing did not specify the number of persons needed to assist.) Approaches included "Assist with ADL's as needed." The Care Plan was updated on 06/21/12 and 08/08/12 but no apparent changes were made. The Care Plan did not address any the resident's use of blood thinners. Review of a Care Plan Meeting Summary, located in Resident #2's clinical record, dated 06/21/12 revealed, "...Toilet Use: 2+ persons physical assist...." On 08/24/12 at 12:10 PM, the DON was shown Resident #2's blank Care Plan for bathing and asked how many staff were required for assistance in bathing. The DON stated, "It's left up to interpretation." Review of the physician's orders [REDACTED]. Re(check) PT/INR on Monday...." laboratory results dated [DATE] reflected the PT was high at 24 seconds (reference range 9.8 0 - 12.9) and the INR (ratio) was low at 1.95 (reference range 2.00 - 3.00). Resident #2's BLOOD THINNERS administration record for July 2012 reflected the resident received [MEDICATION NAME] 10 mg daily. The July MAR further reflected, "Check skin for bruising or excessive bleeding...." Documentation reflected the resident was monitoring BID. Review of the Incident/Accident Report dated 07/16/12 revealed, "...Time of incident/accident: 1600 (4:00 PM)...Findings: CNA was attempting to provide incont (incontinent) care to Resident and when the CNA turned Resident the bed was unlocked and slid out from underneath the Resident. CNA intercepted Resident from falling to the floor and eased her to the floor...Conclusion/Summary: ensure bed is locked prior to incont care...Recommendations/Interventions: ensure bed is locked prior to incont care. Always have 2 CNA's for care." Resident #2's Nurse's Note dated 07/16/12 at 4:00 PM reflected, "CNA was attempting to provide incont care to Resident & when the CNA turned the Resident, the bed was unlocked and slid out from underneath the Resident. CNA intercepted the Resident from falling to the floor, instead she caught the Resident and eased her to the floor. VS (vital signs) stable. 5 in (inch) scrape noted to R (right) leg and 2 in x 2 in bruise to abdomen.(No) pain according to FlACC (The Face, Legs, Activity, Cry, Consolability scale). MD paged. (Resident #2's family member) notified. Will cont to monitor." An interview on 08/22/12 at 2:21 PM with CNA F revealed she provided incontinent care to Resident #2 on 07/16/12. CNA F stated she rolled Resident #2 onto her left side, facing the wall. She stated she then pulled the resident's bed away from the wall and stood in between the bed and the wall. CNA F said Resident #2 started rolling off the bed, towards the wall. She stated she grabbed Resident #2's gown to break her fall. CNA F said Resident #2 sustained a laceration to her leg and no other injuries were found. When asked if there was another CNA present during incontinent care, CNA F stated there was not. CNA F stated a large bruise on Resident #2's left shoulder and breast appeared approximately one week after the fall on 07/16/12. CNA F stated it was routine to use one CNA to provide incontinent care or to give Resident #2 a bed bath. CNA F was asked if any other residents required two people for assistance. CNA F identified two other residents. When CNA F was asked where to look or how to determine if a resident required required one or two persons assistance, the CNA said she did not know. When asked if she felt Resident #2 was safe, CNA F stated, "If they put a rail on the other side (of the bed) by the wall, she would be." A Care Plan for falls was not implemented after Resident #2 fell on [DATE]. During an interview on 08/22/12 at 5:15 PM with the Administrator, DON, Corporate Nurse and the facility's only ADON, the DON stated, following Resident #2's incident on 07/16/12, she "told everybody and probably yelled at them" to utilize two staff when providing care to the resident. The DON stated there was no documentation of the in-service. The Nurse's Notes dated 07/17/12 at 12:00 AM reflect, "No delayed injuries noted from previous incident" and at 8:30 AM, "2+ [MEDICAL CONDITION] & bruising noted to R foot. Xray R foot ordered stat. Review of the x-ray report dated 07/17/12 revealed "No dislocation or fracture." Nurse's Notes dated 07/18/12 at 11:00 AM reflected "[MEDICAL CONDITION] & discoloration noted to Rt ankle/foot. Rt. leg (elevated) on pillow...5 in (inch) abrasion to Rt. thigh area noted...." Nurse's Notes on 07/19/12 at 12:00 AM and 07/20/12 at 11:00 AM reflected no "delayed inuries" were noted from the incident. LVN K was then asked if Resident #2 showed signs of pain after her fall on 07/16/12. LVN K stated, "Yes. She would fight me when I changed her tube ([DEVICE] dressing) with two hands (prior to the fall on 07/16/12). After the fall (on 07/16/12), she would only move her right arm. This also happened during passive range of motion." LVN K stated Resident #2 showed signs of pain by facial grimaces from 07/17/12 through 07/22/12. Resident #2's Nurse's Note dated 07/17/12 at 8:30 AM revealed, "2 + (plus) [MEDICAL CONDITION] & bruising noted to R (right) foot. Xray R foot ordered stat." Resident #2' s Nurse's Note dated 07/17/12 at 12:00 PM reflected, "NNO (no new order) r/t (related to) xray report of R foot. Will monitor. (No) further injuries noted." Resident #2's Nurse's Note dated 07/18/12 at 1:00 AM reflected, "Cont. to note [MEDICAL CONDITION] and discoloration to R ankle/foot. Foot up on pillow. Skin warm/dry to touch. No s/s (signs or symptoms) of pain or discomfort noted." Resident #2's Nurse's Note dated 07/18/12 at 11:00 AM reflected, "[MEDICAL CONDITION] & discoloration noted to Rt (right) ankle/foot...5 in (inch) abrasion to Rt thigh area...." Resident #2's Nurse's Note dated 07/23/12 at 9:00 PM reflected, "Large bruise noted to L (Left) breast, (No) apparent pain. Beefy red stoma protrusion noted from peg site. MD faxed." Review of the Incident/Accident Report dated 07/23/12 revealed, "...Time of incident/accident: 0900 (9:00) AM...Findings: Large bruise noted to L breast. Delayed injury from 7/16/12 fall. (No) apparent pain using Flacc. Incident Type: delayed injury from fall...Conclusion/Summary: Res (resident) (with) recent fall. She is on [MEDICATION NAME]. Area to breast (with) verying (sic) discoloration. No other incident area to breast seems to be from earlier fall...." An interview on 09/11/12 at 12:32 PM with LVN K revealed Resident #2's bruises appeared "several days" after she fell on [DATE]. LVN K stated she found the bruises on 07/23/12, but did not measure the size of the bruises, stating "No, or I would've written it down." LVN K stated she documented the size and color of the bruises when they were discovered. When asked if she completed incident reports when a bruise of unknown origin was found, LVN K stated, "It depends." LVN K said she followed normal procedure and faxed the information to the physician. LVN K then stated she observed Resident #2's bruise as it became larger and spread from her chest wall to her shoulder and then down the left side of her body. LVN K revealed she monitored Resident #2's bruising, but did not document her findings anywhere. LVN K stated, "If it was a critical lab, we would've called. I didn't feel this (bruising) warranted a phone call." When asked how the physician responded to faxes received, she stated the physician reported back by fax. LVN K was asked how nursing staff knew when a physician sent a fax regarding a resident's treatment or care. LVN K replied, "It prints out on our fax. Someone in the office (business office) checks it regularly, and I check it periodically." LVN K was asked if she documented in the resident's Nurse's Notes when a physician sent a fax communication. LVN K stated, "I usually do." When asked specifically about the communication with Resident #2's physician on 07/23/12, LVN K stated the physician responded via fax and ordered a referral to a surgeon regarding the resident's [DEVICE]. LVN K was asked if it concerned her that MD B's fax on 07/23/12 did not address Resident #2's newly discovered bruise. LVN K replied, "I guess from my notes and thought process, as the days went on, the bruise got worse. It started on her left breast then spread across her chest. I paged the doctor (on 07/26/12) to let him know." When asked if she thought Resident #2's [MEDICATION NAME] contributed to Resident #2's extensive bruising at the time, LVN K replied, "We knew she (Resident #2) was on [MEDICATION NAME]. That was a thought; that it could be the [MEDICATION NAME]." LVN K was asked if MD B knew Resident #2 was on [MEDICATION NAME]. LVN K replied, "Yes. He (MD B) remembers all his patients." LVN K was asked whose responsibility it was to prompt physicians and trigger their memory when a resident was on [MEDICATION NAME] and when extensive bruising occurred. LVN K stated, "We (nurses) do." When asked if she notified MD B Resident #2 was on [MEDICATION NAME] after the bruising appeared on 07/23/12, LVN K stated, "I don't remember." LVN K did not recall if she spoke to MD B prior to documenting Resident #2's [MEDICATION NAME] was to be held on 07/25/12. LVN K then stated MD B did not order Resident #2's PT/INR to be done STAT. LVN K stated, "I probably called him (MD B) back at 4 o'clock (4:00 PM on 07/25/12). I know my notes don't support that." LVN K said she usually called the doctor and completed an incident report when a resident on [MEDICATION NAME] had a bruise of unknown origin. When asked if she also checked labs in such a case, LVN K replied, "He'll (MD B) order one but usually not STAT." An interview on 09/11/12 at 1:53 PM with the facility's only ADON revealed, "Anytime they (nursing staff) find something new. We fax them (the physicians) and tell them about the bruise." The ADON was asked if it was common practice for a nurse to notify a physician a resident was on [MEDICATION NAME] when reporting a bruise of unknown origin. The ADON stated, "Yes, or if they're (the residents) on Aspirin. We let them (the physicians) know if they're (the residents) diabetic and taking insulin. He (MD B) usually faxes back; will initial and send it (fax) back to us. It depends on what nurses write." Resident #2's Nurse's Note dated 07/24/12 at 11:45 AM reflected, "...Lg (large) dk (dark) discoloration noted to Lt (left) breast...stoma beefy & red...." Resident #2's Nurse's Note dated 07/25/12 at 9:30 AM reflected, "Large bruise to mid chest wall extending to lateral L torso. 4 x 4 hematoma noted to L CW (chest wall). MD paged." Resident #2's Nurse's Note dated 07/25/12 at 3:00 PM reflected, "N.O. (new order) Check PT/INR, CBC and apply ice pack to hematoma. (x-ray company) called." Resident #2's Nurse's Note dated 07/25/12 at 4:00 PM reflected, "N.O. (new order) Hold [MEDICATION NAME] (blood thinner) until PT/INR results arrive." Resident #2's Nurse's Note dated 07/25/12 at 10:00 PM reflected, "Awaiting final report - Xray shows no fx (fracture) re (regarding) rib cage. No fx L shoulder, both Osteoporotic. Appears comfortable - facial expression or movement of hand or other s/s of restlessness." Resident #2's Nurse's Note dated 07/26/12 at 9:30 AM reflected, "...Bruise to L breast and chest cont to be purple and brown in color. Cont to show pain (with) movement of L arm...." Resident #2's laboratory report dated 07/26/12 reflected: Resident #2's lab results dated 07/26/12 reflected: WBC 16.9 K/ul, High (reference range of 4.0 - 11.0 K/ul); RBC 2.07 M/ul, Low (reference range 3.80 - 5.50 M/ul); HGB 6.5 g/dL, Critical Low (reference range 12.0 - 17.0 g/dL); and HCT 20.4%, Critical Low (reference range 37.0 - 50.4 %). Resident #2 s PT/INR results dated 07/26/12 reflected: PT 46.9, High (reference range 9.8 0 - 12.9) and INR 4.22, High (therapeutic range 2.00 - 3.00). Resident #2's Nurse's Note dated 07/26/12 at 11:50 AM reflected, "Critical labs faxed over (MD P)...." Resident #2's Nurse's Note dated 07/26/12 at 12:20 PM reflected, "(MD P) returned call N.O. to send to ER." An interview on 09/11/12 at 1:53 PM with the facility's only ADON revealed she was not aware of Resident #2's extensive bruises of unknown origin until she was sent to theER on [DATE]. The ADON stated Resident #2's bruises were not documented on the skin assessment sheet on 07/20/12. When asked if she was usually made aware of extensive bruising of unknown origin the ADON stated, "No. The DON was handling all of the skin. I took the critical (lab) call and had her sent out (to the ER)." The ADON revealed Resident #2's fall on 07/16/12 was mentioned during a morning stand-up meeting but not the extensive bruising that followed. When asked who monitored the Charge Nurses, the ADON stated, "I now have a daily list from (Interim DON). Before I worked the floor and didn't monitor, but I am now." Review of an SBAR (Situation-Background-Assessment-Recommendation), Physician/NP/PA Communication and Progress Note dated 07/26/12 revealed, "...Pain level/location/status: Grimaces when move L arm ...Progress Note: Lab results came back (with) critical labs...Res to be sent to ER (emergency room ). Bruising noted last wk (week) post fall...." Review of a hospital History and Physical dated 07/26/12 revealed, "...she (Resident #2) ended up having a large hematoma on the left breast, and now there is a significant drop in her H&H (hemoglobin and hematocrit) ...Laboratory...Sodium 115 mmol/L (Reference range: 140-148 mmol/L), BUN 40 (Reference range: 7-18 mg/dl) potassium 3.4 (Reference range: 3.5-5.2). When she came, her H&H was low at 6.5 g/dL and 19%. Left breast appears to be significantly enlarged with a subcutaneous hematoma. Assessment: 1) [MEDICAL CONDITION] probably secondary to blood loss in the left breast. No other evidence of blood loss from the history or the exam. She has been on [MEDICATION NAME] and probably that has made the bleeding or hematoma worse. 2) Coagulopathy...Plan...Transfuse packed cells and watch her potassium closely...." Review of hospital Physician's Admit Orders dated 07/26/12 revealed, "... Transfuse 2 units PRBC (packed red blood cells) today. (slowly each unit over 4 hours)...." Resident #2's facility's Nurse's Note dated 07/31/12 at 3:00 PM reflected she was readmitted to the facility with multiple bruises on her arms, leg, and chest wall, which was related to her fall on 07/16/12. The Note also reflected the resident had three plus [MEDICAL CONDITION] to left arm and three plus [MEDICAL CONDITION] to her left hand. Resident #2's Admission Nursing Evaluation dated 07/31/12 reflected admitting [DIAGNOSES REDACTED]. Resident #2's new Fall Risk Evaluation dated 07/31/12 reflected a total score of 21. The Fall Risk Evaluation reflected a score of 10 and above indicated the resident was at high risk for falls. Nurse's Notes dated 08/14/12 at 6:00 PM for Resident #2 reflected the [MEDICAL CONDITION] in the resident's left arm no longer remained. The physician was notified and orders were received to have lab drawn for a CBC and BMP in the morning. Nurse's Notes dated 08/17/12 at 1:00 PM reflected related to the lab results from the CBC and BMP, a new order was received to restart Resident #2's [MEDICATION NAME] 5 mg by mouth daily with a PT/INR scheduled to be drawn on 08/23/12. Review of a [MEDICATION NAME] administration schedule for August 2012 revealed Resident #2 began receiving [MEDICATION NAME] 5 mg at 4:00 PM on 08/17/12. Resident #2's Telephone Orders dated 08/24/12 reflected an order to increase the resident's [MEDICATION NAME] to 6 mg every day and to have a PT/INR drawn in one week. Resident #2's Telephone Orders dated 08/29/12 reflected an order to increase the resident's [MEDICATION NAME] to 7 mg daily and to have a PT/INR drawn in one week. Review of Resident #2's [MEDICATION NAME] administration schedule for August 2012 revealed the resident began receiving [MEDICATION NAME] 6 mg on 08/29/12 (five days late) and on 08/30/12, began receiving 7 mg of [MEDICATION NAME]. Observation on 08/22/12 at 10:53 AM revealed Resident #2 was lying in the middle of her bed, on her left side, and she was receiving a bed bath from CNA E. The resident's bed was against the wall and the resident was facing the wall at that time. The CNA tucked the clean linens beneath the resident and rolled the resident onto her back and then onto her right side. The resident's right shoulder and part of her upper back were off the mattress at that time. CNA E then reached over the top of the resident and pulled the linens out from under her to the other side. The resident's body was rolling further to her right at that time as though she were going to slide off the bed. CNA E's body prevented Resident #2 from falling off the bed. No side rail was up at that time. The CNA then rolled the resident onto her back and continued with care. The resident's left breast had purple and pale green bruising around the lower portion of the breast extending to her left arm pit and the inside of her upper left arm. Her left arm was swollen from her shoulder to her fingers. Resident #2's [DEVICE] site was red with bloody drainage on the dressing. The site had a raw appearance. When asked about the swelling of Resident #2's arm and whether it was new, CNA E replied, "Kinda. Like it comes and goes." When CNA E was queried about the injuries, she stated, "I think they said it was from the medicine." When asked if she knew Resident #2 had fallen out of bed, CNA E replied, "Yes." When asked if she was there at the time of the fall, CNA E replied, "No. I was off. I think it happened on evening shift." When asked if she had received any training or new instructions about caring for Resident #2 since her fall, CNA E replied, "No. I've been working here [AGE] years." Review of the current facility policy "Falls and Fall Risk, Managing" dated December 2007 revealed: "Policy Statement - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling; Policy Interpretation and Implementation: ...1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified...." The facility's undated, current Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property reflected,"...If at any time abuse and neglect are reported the staff will follow the facility policy on reporting and investigating abuse...Staff are knowledgeable in recognizing suspicious bruising, swelling, pain...All allegations, no matter what types of incidents reported will be investigated fully...An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing...Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences...." The facility's undated, current Abuse/Neglect Prohibition Policy and Procedure reflected, "All employees are to report suspected abuse or neglect at any time it is identified...Any bruising on any resident will be documented upon discovery and all efforts will be made to determine if abuse/neglect could have occurred. The administrator or his designee will report the alleged abuse/neglect to the Texas Department of Aging and Disability Services and/or other appropriate agency and/or the appropriate law enforcement agency per regulation." The facility's undated, current, Resident Abuse Policy reflected, "The resident has the right to be free from...injury from an unknown source...In the event if any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility, or to state officials as posted in the facility. Upon report of any allegations or violations the administrator or his/her designated respresentative will thoroughly investigate the situation in accordance with Texas law. Any employee suspected of abuse or neglect will be removed from the direct care of the resident/residents while the investigation is in process. The investigation will include but not limited to the following facts...5. Any evidence of injury or abuse present on the resident's body...." 2) An IJ was identified on 08/23/11. The Administrator and the DON were informed of the IJ on 08/23/11 at 3:40 PM. The Administrator and the DON were requested to provide a Plan of Removal for the IJ at that time. 3) The facility's Plan of Removal provided on 08/24/12 reflected, "...3. (DON) was terminated as facility Director of Nurses effective 8/24/12. (Corporate name) corporate RN supervisor will assume the responsibility of Nursing Director until a new qualified DON can be hired and oriented. Corporate Nursing team will continue to be responsible for the monitoring of this plan until substantial compliance is achieved. 4) The Accunurse documentation system reflects '2 person' assist for all transfers and ADL care. This is also reflective in the written nursing plan of care. In addition an alert page has been placed on (Resident #2) to remind all staff of the need for 2 persons to assist in all care. This was validated by the (corporate name) corporate RN supervisor(s)...6) On 8/22 at 7:00 PM the CNA's (sic) received a competency based in-service regarding this resident's ADL assistance needs by (ADON) was initiated. All nursing staff will receive this education by 8 AM on 8/24 or prior to the start of any shift. This education was be (sic) performed by DON and ADON unde

Based on observation, interview and record review, the facility failed to ensure residents received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing for four (Residents #2, #7, #9 and #10) of seven residents reviewed for pressure ulcers. Resident #9 - The facility failed to: 1. Ensure the resident's heels were off-loaded to relieve pressure; 2. Ensure the resident was turned and repositioned every two hours; 3. Ensure communication for prompt identification and treatment; 4. Provide accurate and complete skin assessment for early detection and treatment of [REDACTED]. 5. Ensure complete and accurate descriptions of pressure ulcers, including staging, for continued monitoring. After surveyor inquiry, the resident was assessed with [REDACTED]. Resident #7 - The facility failed to: 1. Provide accurate and complete skin assessments for early detection and treatment of [REDACTED]. 2. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; 3. Ensure identified pressure ulcers received the correct and appropriate treatment; 4. Ensure every skin area/pressure ulcer, once identified, was documented with current descriptions and treatments. An unstageable pressure ulcer was identified as a Stage II. The Wound Care nurse was not following physician's orders [REDACTED]. Resident #2 - The facility failed to: 1. Ensure communication for prompt identification and treatment; and 2. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. Nursing did not identify the pressure ulcer on their Weekly Skin Assessments. After surveyor inquiry, unstageable pressure ulcers to her buttocks. CNA F was aware the resident had a pressure ulcer and was providing prevention treatment to it. She did not notify the nurse of the suspected pressure ulcer. Resident #10 - The facility failed to: 1. Ensure communication for prompt identification and treatment; 2. Provide accurate, timely and complete skin assessments for early detection and treatment of [REDACTED]. 3. Ensure complete and accurate descriptions of pressure ulcers, including staging for continued monitoring; and 4. Notify the physician promptly for treatment orders. Resident #10 had a Stage II pressure ulcer identified by a night shift nurse on 07/21/12. The physician and treatment nurse were not notified. The treatment nurse discovered the wound after the resident approached her and complained of pain. Following her assessment, the Wound Care Nurse failed to document the findings, notify the physician and obtain treatment orders. An Immediate Jeopardy (IJ) was identified on 08/23/12. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because not all staff had been trained and the facility was still monitoring the Plan of Removal. Failure to accurately assess/stage pressure ulcer, and consult with the resident's physician's to obtain the physician's recommendations could result in the deterioration of existing pressure ulcers or cause the development of pressure ulcers for all 66 residents identified as receiving preventative skin care. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. 1) Resident #9 was a [AGE] year-old male admitted to the facility 02/04/12 with daignoses including: [MEDICAL CONDITION], Anxiety Disorder, [MEDICAL CONDITION] Arthritis, [MEDICAL CONDITION], nad [MEDICAL CONDITION], per the MDS assessment dated [DATE]. The assessment further reflected the resident was at risk for development of a pressure ulcer but did not have a hsitory of pressure ulcers and did not have one at the time of the assessment. Resident #9's Care Plan addressed the problems of skin breakdown related to incontinence and bed mobility. The onset date was identified as 03/01/12 and was revised on 05/03/12 and again on 08/14/12. The goal was that the resident's skin would remain clean, dry, and intact without evidence of breakdown for the next 90 days, and no skin breakdown for 180 days. The approaches included the following: assist with repositioning as needed, using padding between pressure areas, monitor the resident for skin breakdown and report to the physician and responsible party, provide pressure relieving devices as needed, assess skin weekly and record findings, and turn and reposition Resident #9 every two hours as needed. The most current MDS assessment date 05/08/12 reflected the resident was at risk for development of a pressure ulcer but did not have a hsitory of pressure ulcers and did not have one at the time of the assessment. Resident #9's Weekly Skin Integrity Review sheets reflected his skin was intact and dry for the weeks of 07/06/12, 07/13/12, and 07/20/12. Resident #9's (re)Admission Nursing Evaluation dated 07/31/12 timed at 6:45 PM reflected the resident's skin was warm and he had [MEDICAL CONDITION] in both of his hands. An anatomical representation of the resident's body indicated the presence of a [DEVICE]. No other comments were made under the skin assessment. Resident #9's (re)Admission Nursing Evaluation dated 08/08/12 at 6:15 PM reflected the resident's skin was warm and he had [MEDICAL CONDITION] in both of his hands. An anatomical representation of the resident's body indicated the presence of a [DEVICE]. No other comments were made under the skin assessment. Resident #9's Weekly Skin Integrity Review sheets for 08/13/12 and 08/21/12 reflected the presence of an "incision for peg tube." No other skin problems were identified. On 8/21/12 at approximately 10:00 AM Resident #9 was observed in bed on initial rounds. Resident #9 was on a pressure relieving mattress. Resident #9 was receiving oxygen via nasal cannula at 2 liters per minute. Resident #9 was lying with the head of the bed slightly elevated flat on his back. Resident #9's feet could be seen with a pillow underneath both feet. At this time, LVN EE stated Resident #9 was bedfast, required total care for ADLs and was incontinent. She stated Resident #9 fell in July 2012 and fractured his hip. LVN EE stated Resident #9 went to the hospital and during the hospitalization a [MEDICAL CONDITION] Feeding Tube was inserted. She stated Resident #9 returned to the facility on [DATE]. LVN EE stated the resident had required several hospitalization for reinsertion of the feeding tube sencondary to his pulling them out. On 8/14/12 pulled the tube out. Resident #9's family requested the tube not be reinserted. Resident #9 was observed on 08/21/12 at 1:50 PM still lying on lying on his back. Resident #9 was again observed on 08/21/12 at 3:00 PM in the same position, still lying on his back. On 08/22/12 at 9:14 AM Resident #9 was observed in bed lying on his back with a pillow under his feet. Observation of Resident #9 at 11:00 AM on 08/22/12 revealed he was still lying on his back. An observation on 08/22/12 at 2:30 PM revealed Resident #9 was lying on his back. At this time, CNA F removed the top sheet from Resident #9 to provide incontinent care. Resident #9 was wearing cloth heel protectors, but the heels were not off-loaded. CNA F provided incontinent care to Resident #9. A circular, reddened area on his upper right hip approximately 3.0 cm in diameter was observed. After incontinent care, CNA F removed Resident #9's heel protectors. On the left outer side of the resident's left heel was a dark, purplish, brown, dried hardened area approximated 5.0 cm x 3.0 cm. Resident #9's entire left heel was a deep, reddish color. CNA F stated the resident's heel felt "mushy." On the outer side of Resident #9's right heel was a closed, hardened, beige discolored area approximately 0.5 cm x 1.0 cm. The top of Resident #9's right foot had 2+ [MEDICAL CONDITION]. Pressure ulcers should be staged according to the NPUAP staging system... a. Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue found to be painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. (Retrieved on 09/25/12 at http://c.ymcdn.com/sites/www.wocn.org/resource/resmgr/Docs/pressure_ulcer_staging.pdf) Review of Nurse Notes from 08/18/12 - 08/22/12 revealed no documentation of Resident #9 having any skin problems. Resident #9's August 2012 Treatment Sheet was reviewed and there were no treatment orders for his heels. On 08/22/12, after surveyor inquiry, the facility conducted skin rounds on all the residents in the facility. Resident #9's updated Weekly Skin Integrity Review Sheet dated 08/22/12 reflected the left heel measurement was 4.0 cm x 2.0 cm with necrotic (dead) tissue. The documentation reflected his right heel was mushy and the reddened area measured 0.5 cm. The report did not identify the type of wounds (pressure ulcers) or stage the wounds. An interview on 08/23/12 at 12:55 PM with the Wound Care Nurse revealed she was unaware of Resident #9's heels prior to the surveyor inquiry. She stated no one told her about the area. The Wound Care Nurse stated she found out "this morning," after the overnight skin checks. The Wound Care Nurse further stated the nurse, who found the area, was supposed to get the treatment orders. The Wound Care Nurse stated the nurse said she would obtain the treatment orders, but did not. The Wound Care Nurse stated she just found out there were no orders. On 08/23/12 at 1:15 PM the surveyor accompanied the Corporate Nurse and DON to Resident #9's room. The DON measured the pressure ulcer on the right heel pressure ulcer at 4 cm X 1.8 cm. The DON stated the physician would be called and orders would be obtained at that time. The Corporate Nurse stated the pressure ulcer was found on the overnight skin rounds. The surveyor informed the DON and Corporate Nurse the pressure uclcer was found by the surveyor prior to the overnight skin round. The surveyor informed the DON that CNA F was present and saw the pressure ulcer when the surveyor found the area. On 8/23/12 at 2:37 PM an interview was conducted with CNA F. At that time CNA F was queried as to whether she reported the findings regarding Resident #9's heels. CNA F stated she did not report to anyone what she had seen on Resident #9's feet. CNA F was asked why she did not report to anyone about Resident #9's feet. CNA F did not answer the question. A physician's orders [REDACTED]. The order also reflected to "Off-Load Heels." 2) Observation during initial tour on 08/21/12 at 10:45 AM revealed Resident #7 was in her room in bed. She was alert and oriented and was identified by LVN C as having a pressure ulcer on her heel. Review of Resident #7's Annual MDS assessment dated [DATE] revealed the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] from a hospital. The MDS assessment reflected she was cognitively intact, required supervision only for transfers, was independent for ambulation and locomotion on the unit. The MDS assessment further reflected Resident #7 required "limited assistance" for dressing and personal hygiene; she was "occasionally incontinent" of urine and "always continent" of bowel. Resident #7's Face Sheet dated 08/22/12 reflected an admission date of [DATE], and the resident was her own responsible party. Resident #7's Comprehensive Care Plan dated 02/22/12 and reviewed on 07/02/12 and again on 08/01/12. On both dates, it was reflected to continue the plan of care for 90 days. reflected she was "...at risk for impaired skin integrity r/t (related to) occasional urinary incontinence." Approaches included: "Follow house protocol/regime for treating breaks in skin integrity/pressure ulcers ...Lic. (licensed) nurse will conduct weekly skin assessments with documentation ...Assess risk for skin breakdown (Braden scale) upon admission, qtrly (quarterly) and prn." There were no changes or new interventions included in the approaches. Resident #7's Admission Nursing Evaluation dated 07/17/12 reflected an admission date of [DATE] at 5:55 PM. The following Skin Conditions were identified: Both heels were dark red and spongy with the left heel ' s red area measuring 5.2 cm x 4.6 cm. The left coccyx had an open area measuring 5.1 cm x 2.4 cm. The right coccyx area had a reddened area measuring 1.4 cm x 1.7 cm. The middle coccyx area had a reddened area measuring 4.1 cm x 2.6 cm.c The right hand was swollen due IV infiltration in the hospital. On her back, midspine, there was a scabbed area 1.3 cm x 1.4 cm. Resident #7's Braden Scale For Predicting Pressure Sore Risk dated 07/17/12 reflected a score of 16. A score of 15-18 reflected one was at risk for developing pressure ulcers. Resident #7 ' s Interim Plan of Care dated 07/17/12 reflected for the prevention of pressure ulcers, the resident was to be turned and repositioned and to have he skin inspected according to facility protocol. To reduce the size and facilitate healing of pressure ulcers, treatment was to be given according to the physician's order [REDACTED]. Resident #7's Wound Treatment and Progress Record (directions indicated one sheet for one sheet for one wound) revealed: *07/17/12 - A pressure ulcer described as Stage I, 5.2 cm x 4.6 cm, and "spongy, red discoloration." On the reverse side of the form, it reflected: 07/17/12 - Cleanse the peri area of the wound with Normal Saline and apply [MEDICATION NAME]. *07/17/12 - Another sheet reflected a Stage II pressure ulcer with no necrotic tissue or sloughing noted and measuring 5.1 cm x 2.4 cm. On the reverse side of the form, it reflected: 07/18/12 - On the left side of the coccyx, cleanse with normal saline, aply santyl and collage, cover with foam dressing; change every day. There was no further documentation on these Records. The Wound Treatment and Progress Record for 07/17/12 did not include identifation of a left heel pressure ulcer. A Weekly Skin Integrity Review for 07/18/12 reflected there was redness on the left heel and an open area on the left side of the coccyx, which was new. There was no mention of the peri area. Review of Resident #2's Care Summary dated 07/22/12 revealed for skin conditions, one Stage II pressure ulcer was identified. There was nothing identified for the resident's feet and for the Skin and Ulcer Treatments, the resident was to be on a turning/repositioning program and was to receive pressure ulcer care. Review of Resident #7 ' s Interim Plan of Care dated 07/27/12 revealed for the prevention of pressure ulcers, the resident was to be turned and repositioned. To reduce the size and facilitate healing of pressure ulcers, treatment was to be given according to the physician's order [REDACTED]. The MDS assessment dated [DATE] for Resident #7 reflected she was readmitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #7 was cognitively intact and required the extensive assistance of two plus persons with bed mobility, transfers, dressing, toileting and personal hygiene and the extensive assistance of one person with locomotion on the unit and bathing. Resident #7 was frequently incontinent of urine and occasionally incontinent of bowel. Resident #7 was identified as being at risk for developing pressure ulcers and had one Stage II pressure ulcer upon reentry to the facility (on 07/27/12). Resident #7's Braden Scale For Predicting Pressure Sore Risk dated 07/27/12 reflected a score of 16. A score of 15-18 reflected one was at risk for developing pressure ulcers. Resident #7's Physician Telephone Order dated 07/27/12 reflected: "Tx (treatment) to L (left) heel clean (with) NS, apply skin protectant to peri (perimeter) area of wound, apply TAO (triple antibiotic ointment), cover (with) non adherent dsg & tape." Resident #7's Physician Telephone Order dated 07/31/12 reflected: "D/C tx to R (right) (sic L) heel: Apply [MEDICATION NAME] to heel, change 3x wk...." Resident #2's Care Plan Conference Summary dated 08/02/12 revealed when skin was discussed, the comments included: Stage II to coccyx. There was no reference to the resident's left heel. Resident #7's Wound Treatment & Progress Record for the month of August 2012 reflected no assessment or description of the pressure ulcer, including measurements. The following order dated 07/27/12 was included on the record: "L heel-Cleanse (with) NS. Apply skin prep to peri area of wound. Apply TAO. Cover (with) non adherent dsg. Adhere with tape." There was no order for [MEDICATION NAME]. Resident #7's Evaluation dated 08/20/12 reflected the resident had one Stage II pressure ulcer, she was on a turning/repositioning program and was receiving presssure ulcer care. An observation was made on 08/22/12 at 9:20 AM of the Wound Care Nurse performing wound care on Resident #7. The Wound Care Nurse removed the soiled dressing consisting of a non-adherent dressing and tape. There was a moderate amount of brown/yellow drainage on the dressing. The pressure ulcer was approximately 3 cm in diameter, was partially open (Stage II) and was partially covered in eschar (dead tissue making the pressure ulcer unstageable: unable to determine the extent of the wound). The pressure ulcer was cleaned with normal saline, a triple antibiotic ointment was applied and the wound was covered with a non-adherent dressing and secured with tape. The dressing was initialed but not dated. Interview with the Wound Care Nurse during the dressing change revealed she was responsible for skin assessments on all the residents. When asked what the procedure was if she found a problem, the Wound Care nurse replied, "...when I find something, what I have done so far here, I call the doctor, fax what I found, he faxes back orders." During an Interview on 08/22/12 at 1:04 PM, the DON identified the ADON as responsible for checking monthly orders to ensure accuracy. The DON was shown the order for [MEDICATION NAME] for Resident #7 and informed the order was not on the Treatment Sheet for August 2012. Review of Resident #7's Weekly Skin Integrity Reviews revealed the following: 07/27/12- "Blisters" to right heel (no further description of the pressure ulcer). 07/31/12- "Open area ...New" to right heel (no further description of the pressure ulcer). 08/01/12 - "Open area ...Old" to right heel (no further description of the pressure ulcer). During an interview on 08/22/12 at 11:52 AM, Resident #7's Wound Treatment and Progress Records were reviewed with the Wound Care Nurse. When asked where the description of the pressure ulcer and measurements were to be documented, the Wound Care Nurse pointed to the appropriate area and stated, "That's where it should be; I just started and am (now) finding these." When asked how often the wound description and measurements should be documented, she replied, "They haven't told me, but I assume every week. That's how it was at my other facility." On 08/22/12 at 2:37 PM, when the Wound Care Nurse was asked who was responsible for the weekly skin assessments, she replied, "I'm going to be doing the weekly skin assessments. " When asked who was supposed to be doing them, she replied, "The Wound Care Nurse." The Wound Care Nurse was shown the order for the treatment change for Resident #7's pressure ulcer at that time. She was not aware the treatment order had been changed. On 08/22/12 at 4:46 PM, the DON provided the facility ' s Skin Reports as requested by the surveyor. The most recent report was dated 08/22/12; the prior report was dated 07/27/12. When asked if she had other reports reflecting the tracking of pressure ulcers, the DON replied, "I'm between treatment nurses and this one has been keeping me abreast." The DON explained she had no other documentation of skin issues other than what was found in the treatment books. The DON further explained the previous treatment nurse's last day was 07/31/12, and the charge nurses had been temporarily responsible for the weekly skin assessments. The Skin Report provided by the DON dated 07/27/12 reflected no entry for Resident #7. Review of the facility Skin Report dated 08/22/12 and provided by the DON revealed Resident #7 had a Stage II pressure ulcer, which measured 1.5 cm X 1 cm. The pressure ulcer had "No" drainage, "No" changes and was treated with "TAO" and "Non-adherent " dressing. No interventions were listed as used. During an end of day meeting on 08/22/12 at 5:15 PM with the Administrator, DON, ADON, and Corporate Nurse, the survey team shared concerns about the identification of pressure ulcers and treatment including Resident #7 not receiving the physician-ordered treatment all month. The Corporate Nurse stated a "skin sweep" would be conducted that evening by the DON, ADON and unit nurses. During an observation of Resident #7's wound care and measurements with the Wound Care Nurse on 08/23/12 at 9:31 AM, the Wound Care Nurse assembled the items for the dressing change. The items included TAO, a non-adherent dressing, and tape. She picked them up from the treatment cart then walked to Resident #7's room. At that time, the surveyor questioned the Wound Care Nurse whether these were the items ordered for her wound care and if she remembered being told the day before about the order written on 07/31/12. Following surveyor inquiry, the Wound Care Nurse returned the items, obtained Resident #7's chart and wrote the correct physician's orders [REDACTED]. Upon entering the room, Resident #7 was observed lying in bed with her left foot elevated on a pillow. Her sock had a large area with dried, light-brown drainage. When the sock was removed, the dressing (still a non-adherent dressing with tape) was saturated with yellow-brown drainage. Resident #7 commented someone had been in late the night before to look at her pressure ulcer. The soiled dressing was removed. Observation revealed the pressure ulcer was wet and very macerated (softening caused by extended exposure to moisture) along all the edges. The pressure ulcer measured at 3.3 cm x 2.4 cm x 0.1 cm. It was irregularly shaped and had an area of eschar, which was unstageable. Review of a Skin Report dated 08/23/12 provided by the DON revealed Resident #7 was identified as having a Stage II pressure ulcer on her left heel measuring 3.5 cm X 2 cm. No unstageable area was identified. The treatment orders reflected: "Clean, TAO & Dsg." No interventions were identified. Review of another Skin Report dated 08/23/12 and provided on 08/24/12 revealed Resident #7 had an "unstageable" pressure ulcer on her left heel that, which measured 3.0 cm x 2.5 cm x U (unstageable). The pressure ulcer was identified as having eschar. Treatment orders reflected: "NS [MEDICATION NAME] q 3(days)." Following surveyor inquiry, Resident #7's Comprehensive Care Plan dated 08/23/12 now included a care plan specific to the resident's left heel pressure ulcer: "Resident has a pressure area: Location: (L) heel; Stage: Unstageable; Measurements: 3 (cm) x 2.5 (cm)." Approaches included: "1) Perform treatment per order ... 4) Keep family/responsible party and M.D. informed of residents progress...." A Physician's Telephone Order dated 08/24/12 for Resident #7 reflected the following: "Start treatment cleanse wound with NS, skin prep barrier film to peri wound area apply Santyl (used to debride dead tissue) then Collagen to wound bed, cover (with) bordered foam dressing, change daily." A telephone interview with Resident #7's physician, MD B, on 08/24/12 at 3:40 PM revealed he was aware Resident #7 had a pressure ulcer and had assessed it the day before. He stated he thought she came from the hospital with it, and thought they had been doing dressing changes. MD B described the pressure ulcer as a Stage II with an area that was "a little black." 3) Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's Braden Scale assessments dated 01/25/12, 03/28/12, 06/18/12, and 07/31/12 each revealed a high risk of developing pressure sores. Resident #2's Comprehensive Care Plan reflected the areas of concern (Problems) with the date they were identified and the approaches or interventions planned. These included: (a) ADL functions (03/29/12) including Bed Mobility; Transfers; Dressing; Eatuing; Toileting; Personal Hygeine; and Bathing. The resident was totally dependent with all functions and required 1-2 person's to accomplish the task. (b) High risk for skin breakdown due to dependent bed mobility and incontinence (03/29/12). Approaches included the use of pressure relieving device on the bed and chair, turning every 2 hours and prn, lifting using a "lift sheet," padding of bony prominences, and "assess skin q day during care and report any redness and/or irritation." All approaches were assigned to nursing. (c) Sherring/reddness/rough skin to bilater buttocks (03/29/12). Approaches included "Follow house protocol/regime for treating breaks in skin integrity/pressure ulcers...Lic. nurse will conduct weekly skin assessments w/ documentation...Assess risks for skin breakdown (Braden scale) when admitted , qtrly (quarterly), prn...tx as per order, assess effectiveness and/or lack there of, notify MD...." The Care Plan was updated on 06/21/12 and 08/08/12 but no apparent changes were made. The Care Plan did not address any current pressure ulcers or skin problems. Review of the (re)Admission Nursing Evaluation dated 07/31/12 revealed Resident #2 had discoloration on the chest, torso, and extremities. No skin concern was identitied on her buttocks. Weekly Skin Integrity Review dated 08/03/12 revealed multiple bruises on Resident #2's limbs and torso. No skin concern was identitied on her buttocks. Note: There was not Weekly Skin Integrity Review for 08/10/12. Weekly Skin Integrity Review dated 08/17/12 revealed multiple bruises on Resident #2's limbs and torso and an incision for PEG tube was identified. No skin concern was identitied on her buttocks. Resident #2's MDS assessment dated [DATE] reflected the resident had no current pressure ulcer but was at risk for development of a pressure ulcer. Review of Resident #2's August 2012 physician's orders [REDACTED].= weekly skin assessment completed on Friday...." There was also an order [REDACTED]. "Left Buttock ...Cleanse area with NS, apply skin prep then zinc BID PRN." Review of Resident #2's August 2012 TAR revealed the the Weekly Skin Assessments were complited on 08/03/12 and 08/17/12. The TAR further reflected on treatments to done as ordered on Resident #2's left buttock. Observation on 08/22/12 at 10:53 AM revealed Resident #2 was lying in the middle of her bed, on her left side facing the wall. She was receiving a bed bath from CNA E. The resident's bed was against a wall and the resident was facing the wall at that time. An open wound approximately 1 cm x .3cm x .2 cm was observed on her left buttock. The wound was pink at the base and edges and had clear drainage. When CNA E was asked how long the wound had been there she replied, "Not long, a month, maybe a month and a half." The CNA covered the wound with a barrier cream, tucked her new clean linens beneath the resident and rolled the resident onto her back and then onto her right side. An interview on 08/22/12 at 2:21 PM with CNA F revealed she was aware Resident #2 had a pressure ulcer on her left buttocks. When asked about the pressure ulcer CNA F stated, "It's been there awhile. It wasn't bad. It hasn't changed." CNA F revealed she did not notify a nurse of the open area on Resident #2's buttocks. CNA F stated she "applied [MEDICATION NAME] and Aloe Vera" during incontinent care. CNA F revealed she had worked on Resident #2's hall as recently as 08/21/12. During an interview on 08/22/12 at 2:39 PM Wound Care Nurse revealed she had been the Wound Care Nurse at the facility for one week. When asked if she was currently providing treatment to Resident #2, Wound Care Nurse stated, "No." When asked who performs weekly skin care assessments Wound Care Nurse stated, "I do." Wound Care Nurse revealed she did a head-to-toe skin assessment on 08/17/12. When asked what the circle notation around the right buttock on the 08/17/12 Weekly Skin Integrity Review represented, Wound Care Nurse replied, "I think redness. No bruising. No open area." Wound Care Nurse voluntarily revealed she had a treatment order for Resident #2's peg site and stated, "It looked red today." When asked if she documented the redness to Resident #2's peg site or called Resident #2's doctor, Wound Care Nurse replied, "No." Wound Care Nurse revealed she performed Weekly Skin Assessments without the assistance of staff and that her observations were hampered due to the inability to effectively turn residents that require two persons assistance. Wound Care Nurse stated, "When I try to turn them (residents) I can't get a CNA." Wound Care Nurse was asked why she did not request a nurse, the ADON or DON to assist her reposition residents during skin care assessments. Wound Care Nurse replied, "I'm not going to say anything. I don't want to lose my job." When asked if she relied on CNAs to notify her when an open area had been identified during care, Wound Care Nurse replied, "Yes. I gave them (CNA's) a pink slip to come tell me right away. No one has yet and they probably won't." A Wound Care * Skin Integrity * Evaluation for Resident #2 included, the Stage II Pressure Ulcer to the left buttock, an Unstageable Pressure Ulcer measuring 0.80 x 1.0 on the right buttocks identified on 08/22/12. Review of August 2012 nurse's notes revealed no documentation of Resident #2's skin assessments or findings until 08/22/12, post surveyor intervention. 4) Resident #10 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment further revealed she was receiving scheduled and PRN pain medication and was in pain "almost constantly." She was identified as "at risk of developing pressure ulcer" but was not identified as having a pressure sore. Resident #10 had both legs amputated. Review of Resident #10's Braden Scale for Predicting Pressure Sore Risk revealed the most recent assessment was completed on 07/03/12 and reflected a score of "15" which indicated "At Risk." Review of Resident #10's Weekly Skin Integrity Review sheets for the months of June 2012 and July 2012 revealed she had "redness" to her bottom on 07/04/12, 07/11/12, 07/18/12, and 07/25/12. "Stage 2 on buttocks X 2" was entered on 08/08/12 and 08/15/12. Review of Resident #10's Nurses' Notes dated 08/22/12 PM revealed an entry made by RN M which reflected: "Open sore noted to coccyx during incontinent care. Peri area cleansed & [MEDICATION NAME] applied, MD will be notified." The next entry was dated 08/23/12 and was made by the Wound Care Nurse. The entry reflected: "Notified (MD B) of wound and started new orders." Resident #10's Physician Telephone Orders dated 08/22/12 reflected: "

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 six (Residents #2, #4, #5, #7, #13, and #15) of 15 residents reviewed for quality of care. 1. Resident #2 fell on [DATE]. The facility failed to: * Monitor the resident, who was on [MEDICATION NAME] (anticoagulant), for bleeding and/or injury; * Assess the resident's bruising with measurements and a description of the color of the skin; * Provide the physician with an accurate description on 07/23/12 of the resident's bruising measurements and color of bruise) and remind the physician the resident was on [MEDICATION NAME]; * Follow-up with the physician in a timely manner when there was no response about the resident's bruising; * Write the physician's orders [REDACTED]. * Ensure two staff assisted the resident with ADLs; Resident #2 went to the hospital 10 days post fall with a hematoma on her breast and had to receive at least two units of Packed Red Blood Cells. These failures could affect 35 of 35 residents on the three halls where LVN K provided care and services, and placed them at risk for a lack of assessment when the residents experienced a change in condition, assessed for pain, no acknowledgement of how the potential side effects from their medication could affect the residents, which could result in a further decline in health, hemorrhage, the need for further medical attention, hospitalization and death. 2. Resident #7 starting experiencing symptoms of a change in condition on 06/03/12. The facility failed to: * Assess and monitor the resident when she experienced, cognitive changes along with weakness, loss of appetite and overall decline; * Keep the physician apprised of the resident's changes in condition. Resident #7 was admitted to the hospital with [REDACTED]. These failures could place all of the facility's 74 residents at risk for further decline in health, hospitalization and death. An Immediate Jeopardy (IJ) was identified on 08/23/12. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. 3. Resident #13 left the facility three times a week for [MEDICAL TREATMENT] treatments. The facility failed to: * Obtain physician orders [REDACTED]. * Monitor and assess the resident following [MEDICAL TREATMENT] treatments. These failures affected Residents #13, the facility's only resident receiving [MEDICAL TREATMENT] services, at risk for bleeding, infection and cardiovascular complications. 4. Resident #15 had five falls, between 02/7/12 and 07/12/12, either hitting his head or the fall was unwitnessed. The facility failed to perform neurological assessments as indicated. 5. Resident #4 had an unwitnessed fall on 08/18/12. The facility failed to perform neurological assessments as indicated. 6. Resident #5 had two falls, between 07/05/12 and 08/10/12, one of the falls was unwitnessed. The facility failed to perform neurological assessments as indicated. These failures placed 15 residents having sustained falls at risk for not detecting intercranial bleeds as soon as possible resulting in brain damage, nerve damage and possible death. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. 1) Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Gastrostomy and [MEDICAL CONDITION], per the quarterly MDS assessment dated [DATE]. Further review of the MDS assessment revealed Resident #2 required two or more persons physical assistance for toileting, bed mobility and dressing. The MDS assessment reflected Resident #2 required one-person physical assistance for bathing. Further review of Resident #2's MDS assessment revealed she had long and short-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected Resident #2 was 68 inches tall and weighed 164 pounds. Resident #2's Comprehensive Care Plan reflected the areas of concern (Problems) with the date they were identified and the approaches or interventions planned. These included: (a) ADL functions (03/29/12) including Bed Mobility; Transfers; Dressing; Eating; Toileting; Personal Hygiene; and Bathing. The resident was totally dependent with all functions and required 1-2 person's to accomplish the task. (Note: Bathing did not specify the number of persons needed to assist.) Approaches included "Assist with ADL's as needed." (b) High risk for skin breakdown due to dependent bed mobility and incontinence (03/29/12). Approaches included the use of pressure relieving device on the bed and chair, turning every 2 hours and prn, lifting using a "lift sheet," padding of bony prominence's, and "assess skin q day during care and report any redness and/or irritation." All approaches were assigned to nursing. (c) Sheering/redness/rough skin to both buttocks (03/29/12). Approaches included "Follow house protocol/regime for treating breaks in skin integrity/pressure ulcers...Lic. nurse will conduct weekly skin assessments w/ documentation...Assess risks for skin breakdown (Braden scale) when admitted , qtrly (quarterly), prn...tx as per order, assess effectiveness and/or lack there of, notify MD...." The Care Plan was updated on 06/21/12 and 08/08/12 but no apparent changes were made. The Care Plan did not address any current pressure ulcers or the use of blood thinners. Review of the physician's orders [REDACTED]. Re(check) PT/INR on Monday...." laboratory results dated [DATE] (Resident #2's most recent) reflected the PT was high at 24 seconds (reference range 9.8 0 - 12.9) and the INR (ratio) was low at 1.95 (reference range 2.00 - 3.00). Resident #2's BLOOD THINNERS administration record for July 2012 reflected the resident received [MEDICATION NAME] 10 mg daily. The July MAR further reflected, "Check skin for bruising or excessive bleeding...." Documentation reflected the resident was monitoring BID. Review of an Incident/Accident Report dated 07/16/12 revealed, "...Time of incident/accident: 1600 (4:00 PM)...Findings: CNA was attempting to provide incont (incontinent) care to Resident and when the CNA turned Resident the bed was unlocked and (the bed) slid out from underneath the Resident. CNA intercepted Resident from falling to the floor and eased her to the floor...Conclusion/Summary: ensure bed is locked prior to incont care...Recommendations/Interventions: ensure bed is locked prior to incont care. Always have 2 CNAs for care." Resident #2's Nurse's Note dated 07/16/12 at 4:00 PM reflected, "CNA was attempting to provide incont care to Resident & when the CNA turned the Resident, the bed was unlocked and slid out from underneath the Resident. CNA intercepted the Resident from falling to the floor, instead she caught the Resident and eased her to the floor. VS stable. 5 in (inch) scrape noted to R (right) leg and 2 in x 2 in bruise to abdomen. (no) pain according to FLACC (The Face, Legs, Activity, Cry, Consolability scale). MD paged. (Resident #2's family member) notified. Will cont (continue) to monitor." The Nurse's Notes dated 07/17/12 at 12:00 AM reflect, "No delayed injuries noted from previous incident" and at 8:30 AM, "2+ [MEDICAL CONDITION] & bruising noted to R foot. Xray R foot ordered stat. Review of the x-ray report dated 07/17/12 revealed "No dislocation or fracture." Nurse's Notes dated 07/18/12 at 11:00 AM reflected "[MEDICAL CONDITION] & discoloration noted to Rt ankle/foot. Rt. leg (elevated) on pillow...5 in (inch) abrasion to Rt. thigh area noted...." Nurse's Notes on 07/19/12 at 12:00 AM and 07/20/12 at 11:00 AM reflected no "delayed injuries" were noted from the incident. Nurse's Notes dated 07/23/12 at 9:00 AM reflected, "Large bruise noted to L breast, (no) apparent pain,. Beefy red Stoma protrusion noted from peg site. MD faxes." Review of the Incident/Accident Report dated 07/23/12 revealed, "...Time of incident/accident: 0900 (9:00) AM...Findings: Large bruise noted to L breast. Delayed injury from 7/16/12 fall. (No) apparent pain using Flacc (The Face, Legs, Activity, Cry, Consolability scale). Incident Type: delayed injury from fall...Conclusion/Summary: Res (resident) (with) recent fall. She is on [MEDICATION NAME]. Area to breast (with) verying (sic) discoloration. No other incident area to breast seems to be from earlier fall...." A Fax Cover Sheet dated 07/23/12 at 12:22 PM and sent to Resident #2's physician reflected, "___ (Resident #2) has large bruise all around & on (left) breast. Also, beefy red stoma protruding through PEG site noted. Possible blood in the PEG tube." There was no mention of the resident receiving [MEDICATION NAME]. A handwritten response reflected, "Refer to surgeon ___ ." The reply was dated 07/23/12 at 4:11 PM. Resident #2's Nurse's Note dated 07/24/12 at 11:45 AM reflected, "...Lg (large) dk (dark) discoloration noted to Lt breast...stoma beefy & red...." Review of Resident #2's Nurse's Note dated 07/25/12 at 9:30 AM revealed, "Large bruise to mid chest wall extending to lateral L torso. 4 x 4 hematoma noted to L CW (chest wall). MD paged." Review of Resident #2's Nurse's Note dated 07/25/12 at 3:00 PM revealed, "N.O. Check PT/INR, CBC and apply ice pack to hematoma. (Mobile x-ray company) called." Resident #2's Nurse's Note dated 07/25/12 at 4:00 PM reflected, "N.O. Hold [MEDICATION NAME] until PT/INR results arrive." Resident #2's Nurse's Note dated 07/25/12 at 10:00 PM reflected, "Awaiting final report - Xray shows no fx (fracture) re (regarding) rib cage. No fx L shoulder, both Osteoporotic. Appears comfortable - facial expression or movement of hand or other s/s of restlessness." Resident #2's Nurse's Note dated 07/26/12 at 9:30 AM reflected, "...Bruise to L breast and chest cont to be purple and brown in color. Cont to show pain (with) movement of L arm...." Resident #2's lab results dated 07/26/12 reflected: WBC 16.9 K/ul, High (reference range of 4.0 - 11.0 K/ul); RBC 2.07 M/ul, Low (reference range 3.80 - 5.50 M/ul); HGB 6.5 g/dL, Critical Low (reference range 12.0 - 17.0 g/dL); and HCT 20.4%, Critical Low (reference range 37.0 - 50.4 %). Resident #2 s PT/INR results dated 07/26/12 reflected PT 46.9, High and INR 4.22, High. Resident #2's Nurse's Note dated 07/26/12 at 11:50 AM reflected, "Critical labs faxed over ___ (MD P)...." Resident #2's Nurse's Note dated 07/26/12 at 12:20 PM reflected, "___ (MD P) returned call N.O. to send to ER." During an interview on 09/11/12 at 12:32 PM, LVN K was queried about Resident #2's incidents and bruising. LVN K said Resident #2's bruises appeared "several days" after she fell on [DATE]. LVN K stated she found the bruises on 07/23/12, but did not measure the size of the bruises, stating "No, or I would've written it down." LVN K stated she documented the size (Large) and color of the bruises when they were discovered. When asked if she normally completed incident reports when a bruise of unknown origin was found, LVN K stated, "It depends." LVN K said she followed "normal procedure" and faxed the information to the physician. LVN K then stated she observed Resident #2's bruise as it became larger and spread from her chest wall to her shoulder and then down the left side of her body. LVN K said she monitored Resident #2's bruising, but did not chart her findings anywhere. LVN K stated, "If it was a critical lab, we would've called. I didn't feel this (bruising) warranted a phone call." When asked how the physician responded to faxes received, she stated the physician reported back by fax. LVN K was asked how nursing staff knew when a physician sent a fax regarding a resident's treatment or care. LVN K replied, "It prints out on our fax. Someone in the office (business office) checks it regularly, and I check it periodically." LVN K was asked if she documented in the resident's Nurse's Notes when a physician sent a fax communication. LVN K stated, "I usually do." When asked specifically about the communication with Resident #2's physician on 07/23/12, LVN K stated the physician responded via fax and ordered a referral to a surgeon regarding the resident's PEG. LVN K was asked if it concerned her that MD B's fax on 07/23/12 did not address Resident #2's newly discovered bruise. LVN K replied, "I guess from my notes and thought process, as the days went on, the bruise got worse. It started on her left breast then spread across her chest. I paged the doctor (on 07/26/12) to let him know." When asked if she thought Resident #2's [MEDICATION NAME] contributed to Resident #2's extensive bruising at the time, LVN K replied, "We knew she (Resident #2) was on [MEDICATION NAME]. That was a thought; that it could be the [MEDICATION NAME]." LVN K was asked if MD B knew Resident #2 was on [MEDICATION NAME]. LVN K replied, "Yes. He (MD B) remembers all his patients." LVN K was asked whose responsibility it was to prompt physicians and trigger their memory when a resident was on [MEDICATION NAME] and when extensive bruising occurred. LVN K stated, "We (nurses) do." When asked if she notified MD B Resident #2 was on [MEDICATION NAME] after the bruising appeared on 07/23/12, LVN K stated, "I don't remember." LVN K did not recall if she spoke to MD B prior to documenting Resident #2's [MEDICATION NAME] was to be held on 07/25/12. LVN K then stated MD B did not order Resident #2's PT/INR to be done STAT. LVN K stated, "I probably called him (MD B) back at 4 o'clock (4:00 PM on 07/25/12). I know my notes don't support that." LVN K said she usually called the doctor and did an incident report when a resident on [MEDICATION NAME] had a bruise of unknown origin. When asked if she also checked labs in such a case, LVN K replied, "He'll (MD B) order one but usually not STAT." LVN K was then asked if Resident #2 had pain after her fall on 07/16/12. LVN K stated, "Yes. She would fight me when I changed her tube (peg tube dressing) with two hands (prior to the fall on 07/16/12). After the fall (on 07/16/12), she would only move her right arm. This also happened during passive range of motion." LVN K stated Resident #2 showed signs of pain by facial grimaces from 07/17/12 through 07/22/12. LVN K stated Resident #2 would push her away when she was messing around with her upper left side of her body. She stated the resident was in pain when she touched her chest and moved her breast. On 09/11/12 at 1:53 PM, the facility's only ADON was asked when nursing staff was supposed to notify a doctor after discovering a bruise of unknown origin. The ADON replied, "Anytime they (nursing staff) find something new. We fax them (the physicians) and tell them about the bruise." The ADON was asked if it was common practice for a nurse to notify a physician a resident was on [MEDICATION NAME] when reporting a bruise of unknown origin. The ADON stated, "Yes, or if they're (the residents) on Aspirin. We let them (the physicians) know if they're (the residents) diabetic and taking insulin. He (MD B) usually faxes back; will initial and send it (fax) back to us. It depends on what nurses write." The ADON was asked if nurses documented in the Nurse's Notes when they notified a physician by fax of a resident's change of condition. The ADON stated, "No. We just keep the fax. We used to not keep them. Now we keep them on the chart. That's our new procedure (since the IJ was identified)." The ADON said she was not aware of Resident #2's extensive bruises of unknown origin until she was sent to theER on [DATE]. The ADON said Resident #2's bruises were not documented on the skin assessment sheet on 07/20/12. When asked if she was usually made aware of extensive bruising of unknown origin, the ADON stated, "No. The DON was handling all of the skin. I took the critical (lab) call and had her (Resident #2) sent out (to the ER)." The ADON said Resident #2's fall on 07/16/12 was mentioned during a morning stand-up meeting but not the extensive bruising that followed. The ADON was not aware of Resident #2's beefy red stoma either. When asked who monitored charge nurses, the ADON stated, "I now have a daily list from (the Interim DON). Before I worked the floor and didn't monitor but I am now." Review of Resident #2's hospital History and Physical dated 07/26/12 revealed, "...she (Resident #2) ended up having a large hematoma on the left breast, and now there is a significant drop in her H&H...When she came, her H&H was low at 6.5 and 19. Left breast appears to be significantly enlarged with a subcutaneous hematoma. Assessment: 1) [MEDICAL CONDITION] probably secondary to blood loss in the left breast. No other evidence of blood loss from the history or the exam. She has been on [MEDICATION NAME] and probably that has made the bleeding or hematoma worse. 2) Coagulopathy (defect in blood-clotting mechanism)...Plan...Transfuse packed cells and watch her potassium closely...." Review of the hospital Physician's Admit Orders dated 07/26/12 for Resident #2 revealed, "...Transfuse 2 units PRBC (packed red blood cells) today (slowly each unit over 4 hours)...." Resident #2's facility's Nurse's Note dated 07/31/12 at 3:00 PM reflected she was readmitted to the facility with multiple bruises on her arms, leg, and chest wall, which was related to her fall on 07/16/12. The Note also reflected the resident had three plus [MEDICAL CONDITION] to left arm and three plus [MEDICAL CONDITION] to her left hand. Resident #2's Admission Nursing Evaluation dated 07/31/12 reflected admitting [DIAGNOSES REDACTED]. Nurse's Notes dated 08/14/12 at 6:00 PM for Resident #2 reflected the [MEDICAL CONDITION] in the resident's left arm no longer remained. The physician was notified and orders were received to have lab drawn for a CBC and BMP in the morning. Nurse's Notes dated 08/17/12 at 1:00 PM reflected related to the lab results from the CBC and BMP, a new order was received to restart Resident #2's [MEDICATION NAME] 5 mg by mouth daily with a PT/INR scheduled to be drawn on 08/23/12. Review of a [MEDICATION NAME] administration schedule for August 2012 revealed Resident #2 began receiving [MEDICATION NAME] 5 mg at 4:00 PM on 08/17/12. Observation on 08/22/12 at 10:53 AM revealed Resident #2 was lying in the middle of her bed, on her left side, and she was receiving a bed bath from CNA E. The resident's bed was against the wall and the resident was facing the wall at that time. The CNA tucked the clean linens beneath the resident and rolled the resident onto her back and then onto her right side. The resident's right shoulder and part of her upper back were off the mattress at that time. CNA E then reached over the top of the resident and pulled the linens out from under her to the other side. The resident's body was rolling further to her right at that time as though she were going to slide off the bed. CNA E's body prevented Resident #2 from falling off the bed. No side rail was up at that time. The CNA then rolled the resident onto her back and continued with care. The resident's left breast had purple and pale green bruising around the lower portion of the breast extending to her left arm pit and the inside of her upper left arm. Her left arm was swollen from her shoulder to her fingers. Resident #2's [DEVICE] site was red with bloody drainage on the dressing. The site had a raw appearance. On 08/22/12 at approximately 11:05 AM, CNA E was interveiwed. When asked about the swelling of Resident #2's arm and whether it was new, CNA E replied, "Kinda. Like it comes and goes." When CNA E was queried about the injuries, she stated, "I think they said it was from the medicine." When asked if she knew Resident #2 had fallen out of bed, CNA E replied, "Yes." When asked if she was there at the time of the fall, CNA E replied, "No. I was off. I think it happened on evening shift." When asked if she had received any training or new instructions about caring for Resident #2 since her fall, CNA E replied, "No. I've been working here [AGE] years." Resident #2's Telephone Orders dated 08/24/12 reflected an order to increase the resident's [MEDICATION NAME] to 6 mg every day and to have a PT/INR drawn in one week. Resident #2's Telephone Orders dated 08/29/12 reflected an order to increase the resident's [MEDICATION NAME] to 7 mg daily and to have a PT/INR drawn in one week. Review of Resident #2's [MEDICATION NAME] administration schedule for August 2012 revealed the resident began receiving [MEDICATION NAME] 6 mg on 08/29/12 (five days late) and on 08/30/12, began receiving 7 mg of [MEDICATION NAME]. 2) Observation during initial tour on 08/21/12 at 10:45 AM revealed Resident #7 was in her room in bed. She was alert and pleasant and requested assistance from LVN C due to an episode of incontinence. Resident #7 was identified as alert and interviewable by LVN C. LVN C stated Resident #7 was currently utilizing a wheelchair for her means of locomotion around the facility but stated she used to walk on her own. LVN C stated Resident #7's health had recently declined. She became dehydrated and had stopped eating. She stated Resident #7 was incontinent of bowel and bladder. Resident #7 was observed at that time to be in her room in bed. Interview with Resident #7 on 08/22/12 at 9:55 AM revealed she had recently become ill and went to the hospital but she had no idea what was wrong with her. "No one ever told me why or what happened." She added she was doing better now and was trying to get her strength back. Resident #7 stated she liked the food and knew she needed to eat, because it would help her wound heal. Review of Resident #7's Annual MDS assessment dated [DATE] revealed the resident, a [AGE] year-old female, was readmitted to the facility on [DATE] from a hospital. [DIAGNOSES REDACTED]. The MDS assessment reflected she was cognitively intact, required supervision only for transfers, was independent for ambulation and locomotion on the unit. The MDS assessment further reflected Resident #7 required "limited assistance" for dressing and personal hygiene; she was "occasionally incontinent" of urine and "always continent" of bowel. Resident #7's Face Sheet dated 08/22/12 reflected an admission date of [DATE], and the resident was her own responsible party. The Comprehensive Care Plan dated 02/22/12 reflected Resident #2 was identified as being at a high risk for falls or had a history of [REDACTED].(two falls with no injury) and a review on 08/01/12 to continue with the Plan of Care. Further review revealed the following approaches: "...Review labs and medication for potentiating factors; Assess for change in condition and alerted (sic) staff to residents increased needs; Eval. (evaluate) for use of side rails, low bed or personal alarms; Assess for and implement if appropriate; Need for toileting schedule, or a BSC (bedside commode); Monitor for a pattern of risk factors, or tendency to fall; Analyze previous falls to determine causative factors, and implement changes; Monitor degree of disorientation to determine safety needs..." The Care Plan was reviewed by the facility on 07/02/12 and 08/01/12 and no changes were made to the interventions/approaches despite the resident continuing to fall. Resident #2's Comprehensive Plan of Care included a problem dated 02/22/12 for Hypertension. Approaches included: Monitor BP, increased swelling, dizziness, headache, chest pain, etc. and report abnormals to MD; Encourage oral fluid intake; Give meds as ordered and monitor labs and report abnormals to MD; Diet as ordered; and Encourage Resident #2 to restrict sodium intake if not ordered by MD. Resident #7's Nurse's Notes reflected the following entries: 06/03/12 at 11:00 AM: "(BP) 110/66, (pulse) 74, (respirations) 18, (temperature) 98.1 (degrees F)...Resident very weak, unable to bear own wt. (weight) needs assistance (with) transfers & ambulation. Confused. V/S/S (vital signs stable). ___ (MD. B) paged for change of condition and awaiting reply." 06/03/12 at 12:20 PM: "___ (MD. B) returned page & N.O. noted. UA with C&S and CBC. (Lab company) notified and Resident aware. Will cont (continue) to monitor. Awaiting resident to void (urinate)." Lab results dated 06/04/12 at 10:20 AM reflected Resident #7's urine was yellow and clear and was either "negative" or "absent" with the sedimentation rate, the pH, the presence of WBCs and RBCs well within normal limits. The culture reflected there was no growth within 24 hours and less than 10,000 of mixed flora at 48 hours. 06/04/12 at 8:30 PM: "Res (resident) lying in BR (bathroom) floor. Stated she sat down and laid in floor to keep from falling. Denies hitting head. No injuries noted. No distress noted. VS- (BP) 161/84, (pulse) 66, (respirations) 14, (temperature) 97.3 (degrees F)." (06/05/12) at 8:05 AM: "___ (MD B) notified of fall. No n.o. at this time...." 06/05/12 at 10:15 AM: "resident's L (left) side of mouth (with) pain, c/o (complains of) tooth pain, L cheek red, spoke (with) SW she said she would get resident appt (appointment with dentist)." 06/08/12 (untimed): "Resting - no c/o L cheek-gum tooth or mouth pain-no [MEDICAL CONDITION] noted at this time - will return with routine prn charting." 06/08/12 at 4:00 PM: "Becoming more dependent on assist (with) getting up & ADLs." 06/09/12 at 09:00 AM: "Resident not getting OOB (out of bed) except for bathroom can/does go alone - then wants her feet covered up after she has gotten into bed. She is needful of most ADL's now - getting more demanding and doing less for self." 06/09/12 at 10:00 AM: "needing assistance with putting deodorant on, covering up in bed, assist (with) getting up and toileting." 06/10/12 at 2:30 PM: "Needs assistance (with) ambulation, is staying in bed all day, ask for help (with) covering up." 06/09/12: "Late entry: At approximately 2300 (11:00 PM) noise was heard of someone banging on the wall...coming from (Resident #7's room). She stated she was coming from bathroom - fell all the way from her bathroom door to the door (entryway) of her room...discovered her (Resident #7) lying on her Rt. side on the floor. Examined her for injury, found none - VS taken, then assisted resident to her feet and helped her ambulate to her bed, positioned for comfort. It was noted that resident had used her rolling walker apparently - as the walker was turned over on it's side...Resident was placed in bed, position for comfort and reminded by myself that due to the nature of medication she was given prior to her getting out of bed without assistance to avoid this in the future to please use her nurse call and ask for assistance. Resident assured me she would do this." 06/11/12 at 7:30 PM: "...Assist X 1 needed stand-transfer ambulation to and from bathroom posture stooped - gait slow - shuffled, no delayed injuries from previous fall. Will continue to monitor." 06/12/12 at 10:15 AM: "Resident (#7) walking out of bathroom using cane and lost balance. Resident fell backwards. Denies hitting head but (Physical Therapy staff) was in room at time of incident and states resident hit head on sink. (No) bruising or hematoma noted to back of head. PT assisted resident back to bed. ___ (MD B) notified and orders monitor for fall precautions...neuro ? (checks) WNL. PT to eval and tx... will cont. to monitor." 06/13/12 at 11:30 PM: "2 X 2.5 cm raised area present lower Rt side back of head (with) yellow-purple discolor non-tender with touch, neuro WNL's - will monitor." 06/16/12 at 8:00 PM: "to room to answer call light - noted resident lying on her back at bedside between night stand and bed (with) call light in Rt hand - (with closer) exam, moderate amt (amount) bleeding noted at out head it (sic) shoulder - resident stated she fell backward hitting back of head on the floor...3 X 3 X 3 hematoma noted to base of skull (with) 1.5 cm laceration present - pressure applied to laceration to prevent excessive bleeding...." 06/16/12 at 8:10 PM: "911 called, notified of pending transfer to (hospital)...." 06/16/12 at 8:30 PM: "...ambulance here...resident transferred to hospital." Resident #7's hospital History and Physical dated 06/17/12 reflected the following: "Chief Complaint: the patient has been falling the last few days. The patient was feeling weak and fell again and had some skin lacerations, and that is why she was brought to the ER. She was found to have severe [MEDICAL CONDITION] (low sodium) and hypokalemia (low potassium) and was admitted here for further evaluation... Laboratory: ...Sodium is 122 (reference range is 140-148), potassium 3.5 (reference range 3.5-5.2) at the time of admission. BUN 22 (reference range 7-18), otherwise normal CMP. Today her sodium is 123, potassium is 3... Assessment and Plan: 1) Generalized debility with multiple recurrent falls status [REDACTED]. 2) Severe [MEDICAL CONDITION]. 3) Hypokalemia. 4) Dehydration." The facility's (Re)Admission Nursing Evaluation dated 06/22/12 at 2:45 PM for Resident #7 reflected an admission BP of 208/90 and pulse 68. The assessment further reflected Resident #7 was continent of bowel and bladder. There was nothing documented about Resident #7's laceration on her head. Resident #7's Daily Skilled Nurse's Note dated 06/22/12 DAY Shift reflected: "Res. returned from hospital. Full head to toe assessment complete. Two bruises noted one L hand from IV (intravenous line). One on L upper thigh - light yellow in color. Res c/o (complains of) still not feeling well but glad to be back...cont. to have difficulty with gait and balance. Will cont. to monitor. " Resident #7's Nurse's Notes dated 06/22/12 at 2:45 PM reflected: "Resident returned to facility, was assessed, VS WNL, (no) skin issues, generalized weakness, call light in place." Another entry on 06/22/12 at 6:45 PM reflected: "...has been on call light at least 50 times." Resident #7's Daily Skilled Nurse's Note dated 06/23/12 at 8:30 AM reflected: "Resident appears weaker ie. unable to stand. Incontinent of urine and feces this A.M. continues c/o of being cold even with multiple blankets applied. Voided incont X 3; BM soft X 2. Refuses breakfast BP 200/17, Pulse 78. Will monitor and rech (recheck) as medication for BP control has been given shortly ago. (sic)" Entry at 11:30 AM reflected: "Follow-up vital signs BP 149/87 P(pulse) 84. Comfortable. BM Lg X 3. " Resident #7's Daily Skilled Nurse's Note dated 07/01/12 at 10:00 AM reflected: "Assessed per flow sheet. Resting in bed. Alert. Speech unclear @ Xs. Weakness to all ext. (extremities). Assist X 2 with transfers. Incont. of B & B...(no) C/O pain or distress noted. Will cont. to monitor. PT cont as ordered & tol (tolerated) well." The Daily Skilled Nurse's Note for 07/01/12 for the evening shift reflected: "...resting - lethargic all motor function - assist X 1 (with) all ADL's - altered thought process present - having trouble expressing needs - wants...Incont B/B (with) prn incont care per staff - no s/s pain or burning with urination - will monitor. " Resident #7's Daily Skilled Nurse's Note dated 07/02/12 at 02:00 AM reflected: "...slowly responsive to verbal stimuli...cont. to be lethargic all motor f

Based on observation, interview, and record review, it was determined the facility failed to implement it's written policies and procedures that prohibit neglect of residents for one (Resident #2) of seven residents reviewed for abuse/neglect. 1. CNA F failed to have another staff member assist her, as the resident's care plan indicated, when she provided incontinent care to Resident #2 on 07/16/12. During the care, the unlocked bed rolled out from under the resident and CNA F lowered the resident to the floor. 2. The ADM failed to report to the State survey and certification agency when CNA F failed to have another staff member assist her with Resident #2's incontinent care and the resident was lowered to the floor. 3. The ADM and DON failed to investigate the bruising, which developed on 07/23/12, to Resident #2's breast area, which extended from her mid chest wall to her lateral left torso and the hematoma which also developed on her mid chest wall. 4. The ADM and DON failed to report the significant bruising to the State survey and certification agency. Resident #2 sustained a 5 inch abrasion to her thigh and a bruise on her abdomen, when she was lowered to the floor. These failures also resulted in a delay in care and treatment for [REDACTED]. 5. CNA E failed to have another staff member assist her when she provided incontinent care to Resident #2 on 08/22/12 and the resident almost rolled out of bed. CNA E's body prevented the resident from rolling off the bed. An Immediate Jeoparday (IJ) was identified on 08/23/12. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the 52 residents who were occasionally or frequently incontinent of bladder and the 40 residents who were occasionally or frequently incontinent of bowel, the 13 residents, who were dependent on staff for bathing, the one resident dependent on staff for tranfers, and the one resident dependent on staff for toileting, including Resident #2, by placing them at risk for neglect resulting in abrasions, lacerations, bruising, hematomas, fractures, and/or death. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. The facility's undated, current Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property reflected,"...If at any time abuse and neglect are reported the staff will follow the facility policy on reporting and investigating abuse...Staff are knowledgeable in recognizing suspicious bruising, swelling, pain...All allegations, no matter what types of incidents reported will be investigated fully...An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing...Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences...." The facility's undated, current Abuse/Neglect Prohibition Policy and Procedure reflected, "All employees are to report suspected abuse or neglect at any time it is identified...Any bruising on any resident will be documented upon discovery and all efforts will be made to determine if abuse/neglect could have occurred. The administrator or his designee will report the alleged abuse/neglect to the Texas Department of Aging and Disability Services and/or other appropriate agency and/or the appropriate law enforcement agency per regulation." The facility's undated, current, Resident Abuse Policy reflected, "The resident has the right to be free from...injury from an unknown source...In the event if any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility, or to state officials as posted in the facility. Upon report of any allegations or violations the administrator or his/her designated respresentative will thoroughly investigate the situation in accordance with Texas law. Any employee suspected of abuse or neglect will be removed from the direct care of the resident/residents while the investigation is in process. The investigation will include but not limited to the following facts...5. Any evidence of injury or abuse present on the resident's body...." Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Gastrostomy and [MEDICAL CONDITION] per the quarterly MDS assessment dated [DATE]. Further review of the MDS assessment revealed Resident #2 required two or more persons physical assistance for toileting, bed mobility and dressing. The MDS assessment reflected Resident #2 required one-person physical assistance for bathing. Further review of Resident #2's MDS assessment revealed she had long and short-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected Resident #2 was 68 inches tall and weighed 164 pounds. Review of Resident #2's Care Plan dated 03/29/12 revealed, "Problem Onset: 03/29/12 ... Toileting: Total dep (dependence).... X's 2 Staff (two-person assist)." The bathing portion of Resident #2's Care Plan reflected Resident #2 was totally dependent on staff for bathing. The number of staff required for assistance with bathing was blank. Resident #2's Care Plan was updated on 06/21/12 and 08/08/12. Review of a Care Summary, located in Resident #2's clinical record, dated 06/21/12 revealed, "...Toilet Use: 2+ persons physical assist...." On 08/24/12 at 12:10 PM, the DON was shown Resident #2's blank Care Plan for bathing and asked how many staff were required for assistance in bathing. The DON stated, "It's left up to interpretation." Review of the Incident/Accident Report dated 07/16/12 revealed, "...Time of incident/accident: 1600 (4:00 PM)...Findings: CNA was attempting to provide incont (incontinent) care to Resident and when the CNA turned Resident the bed was unlocked and slid out from underneath the Resident. CNA intercepted Resident from falling to the floor and eased her to the floor...Conclusion/Summary: ensure bed is locked prior to incont care...Recommendations/Interventions: ensure bed is locked prior to incont care. Always have 2 CNA's for care." Resident #2's Nurse's Note dated 07/16/12 at 4:00 PM reflected, "CNA was attempting to provide incont care to Resident & when the CNA turned the Resident, the bed was unlocked and slid out from underneath the Resident. CNA intercepted the Resident from falling to the floor, instead she caught the Resident and eased her to the floor. VS (vital signs) stable. 5 in (inch) scrape noted to R (right) leg and 2 in x 2 in bruise to abdomen.(No) pain according to FlACC (The Face, Legs, Activity, Cry, Consolability scale). MD paged. (Resident #2's family member) notified. Will cont to monitor." LVN K was then asked if Resident #2 showed signs of pain after her fall on 07/16/12. LVN K stated, "Yes. She would fight me when I changed her tube ([DEVICE] dressing) with two hands (prior to the fall on 07/16/12). After the fall (on 07/16/12), she would only move her right arm. This also happened during passive range of motion." LVN K stated Resident #2 showed signs of pain by facial grimaces from 07/17/12 through 07/22/12. A Care Plan for falls was not implemented after Resident #2 fell on [DATE]. An interview on 08/22/12 at 2:21 PM with CNA F revealed she provided incontinent care to Resident #2 on 07/16/12. CNA F stated she rolled Resident #2 onto her left side, facing the wall. She stated she then pulled the resident's bed away from the wall and stood in between the bed and the wall. CNA F said Resident #2 started rolling off the bed, towards the wall. She stated she grabbed Resident #2's gown to break her fall. CNA F said Resident #2 sustained a laceration to her leg and no other injuries were found. When asked if there was another CNA present during incontinent care, CNA F stated there was not. CNA F stated a large bruise on Resident #2's left shoulder and breast appeared approximately one week after the fall on 07/16/12. CNA F stated it was routine to use one CNA to provide incontinent care or to give Resident #2 a bed bath. CNA F was asked if any other residents required two people for assistance. CNA F identified two other residents. When CNA F was asked where to look or how to determine if a resident required required one or two persons assistance, the CNA said she did not know. When asked if she felt Resident #2 was safe, CNA F stated, "If they put a rail on the other side (of the bed) by the wall, she would be." During an interview on 08/22/12 at 5:15 PM with the Administrator, DON, Corporate Nurse and the facility's only ADON, the DON stated, following Resident #2's incident on 07/16/12, she "told everybody and probably yelled at them" to utilize two staff when providing care to the resident. The DON stated there was no documentation of the in-service. Resident #2's Nurse's Note dated 07/17/12 at 8:30 AM revealed, "2 + (plus) [MEDICAL CONDITION] & bruising noted to R (right) foot. Xray R foot ordered stat." Resident #2' s Nurse's Note dated 07/17/12 at 12:00 PM reflected, "NNO (no new order) r/t (related to) xray report of R foot. Will monitor. (No) further injuries noted." Resident #2's Nurse's Note dated 07/18/12 at 1:00 AM reflected, "Cont. to note [MEDICAL CONDITION] and discoloration to R ankle/foot. Foot up on pillow. Skin warm/dry to touch. No s/s (signs or symptoms) of pain or discomfort noted." Resident #2's Nurse's Note dated 07/18/12 at 11:00 AM reflected, "[MEDICAL CONDITION] & discoloration noted to Rt (right) ankle/foot...5 in (inch) abrasion to Rt thigh area...." Resident #2's Nurse's Note dated 07/23/12 at 9:00 PM reflected, "Large bruise noted to L (Left) breast, (No) apparent pain. Beefy red stoma protrusion noted from peg site. MD faxed." Review of the Incident/Accident Report dated 07/23/12 revealed, "...Time of incident/accident: 0900 (9:00) AM...Findings: Large bruise noted to L breast. Delayed injury from 7/16/12 fall. (No) apparent pain using Flacc. Incident Type: delayed injury from fall...Conclusion/Summary: Res (resident) (with) recent fall. She is on [MEDICATION NAME]. Area to breast (with) verying (sic) discoloration. No other incident area to breast seems to be from earlier fall...." An interview on 09/11/12 at 12:32 PM with LVN K revealed Resident #2's bruises appeared "several days" after she fell on [DATE]. LVN K stated she found the bruises on 07/23/12, but did not measure the size of the bruises, stating "No, or I would've written it down." LVN K stated she documented the size and color of the bruises when they were discovered. When asked if she completed incident reports when a bruise of unknown origin was found, LVN K stated, "It depends." LVN K said she followed normal procedure and faxed the information to the physician. LVN K then stated she observed Resident #2's bruise as it became larger and spread from her chest wall to her shoulder and then down the left side of her body. LVN K revealed she monitored Resident #2's bruising, but did not document her findings anywhere. LVN K stated, "If it was a critical lab, we would've called. I didn't feel this (bruising) warranted a phone call." When asked how the physician responded to faxes received, she stated the physician reported back by fax. LVN K was asked how nursing staff knew when a physician sent a fax regarding a resident's treatment or care. LVN K replied, "It prints out on our fax. Someone in the office (business office) checks it regularly, and I check it periodically." LVN K was asked if she documented in the resident's Nurse's Notes when a physician sent a fax communication. LVN K stated, "I usually do." When asked specifically about the communication with Resident #2's physician on 07/23/12, LVN K stated the physician responded via fax and ordered a referral to a surgeon regarding the resident's [DEVICE]. LVN K was asked if it concerned her that MD B's fax on 07/23/12 did not address Resident #2's newly discovered bruise. LVN K replied, "I guess from my notes and thought process, as the days went on, the bruise got worse. It started on her left breast then spread across her chest. I paged the doctor (on 07/26/12) to let him know." When asked if she thought Resident #2's [MEDICATION NAME] contributed to Resident #2's extensive bruising at the time, LVN K replied, "We knew she (Resident #2) was on [MEDICATION NAME]. That was a thought; that it could be the [MEDICATION NAME]." LVN K was asked if MD B knew Resident #2 was on [MEDICATION NAME]. LVN K replied, "Yes. He (MD B) remembers all his patients." LVN K was asked whose responsibility it was to prompt physicians and trigger their memory when a resident was on [MEDICATION NAME] and when extensive bruising occurred. LVN K stated, "We (nurses) do." When asked if she notified MD B Resident #2 was on [MEDICATION NAME] after the bruising appeared on 07/23/12, LVN K stated, "I don't remember." LVN K did not recall if she spoke to MD B prior to documenting Resident #2's [MEDICATION NAME] was to be held on 07/25/12. LVN K then stated MD B did not order Resident #2's PT/INR to be done STAT. LVN K stated, "I probably called him (MD B) back at 4 o'clock (4:00 PM on 07/25/12). I know my notes don't support that." LVN K said she usually called the doctor and completed an incident report when a resident on [MEDICATION NAME] had a bruise of unknown origin. When asked if she also checked labs in such a case, LVN K replied, "He'll (MD B) order one but usually not STAT." An interview on 09/11/12 at 1:53 PM with the facility ' s only ADON revealed, "Anytime they (nursing staff) find something new. We fax them (the physicians) and tell them about the bruise." The ADON was asked if it was common practice for a nurse to notify a physician a resident was on [MEDICATION NAME] when reporting a bruise of unknown origin. The ADON stated, "Yes, or if they're (the residents) on Aspirin. We let them (the physicians) know if they're (the residents) diabetic and taking insulin. He (MD B) usually faxes back; will initial and send it (fax) back to us. It depends on what nurses write." Resident #2's Nurse's Note dated 07/24/12 at 11:45 AM reflected, "...Lg (large) dk (dark) discoloration noted to Lt (left) breast...stoma beefy & red...." Resident #2's Nurse's Note dated 07/25/12 at 9:30 AM reflected, "Large bruise to mid chest wall extending to lateral L torso. 4 x 4 hematoma noted to L CW (chest wall). MD paged." Resident #2's Nurse's Note dated 07/25/12 at 3:00 PM reflected, "N.O. (new order) Check PT/INR, CBC and apply ice pack to hematoma. (x-ray company) called." Resident #2's Nurse's Note dated 07/25/12 at 4:00 PM reflected, "N.O. (new order) Hold [MEDICATION NAME] (blood thinner) until PT/INR results arrive." Resident #2's Nurse's Note dated 07/25/12 at 10:00 PM reflected, "Awaiting final report - Xray shows no fx (fracture) re (regarding) rib cage. No fx L shoulder, both Osteoporotic. Appears comfortable - facial expression or movement of hand or other s/s of restlessness." Resident #2's Nurse's Note dated 07/26/12 at 9:30 AM reflected, "...Bruise to L breast and chest cont to be purple and brown in color. Cont to show pain (with) movement of L arm...." Resident #2's laboratory report dated 07/26/12 reflected: Resident #2's lab results dated 07/26/12 reflected: WBC 16.9 K/ul, High (reference range of 4.0 - 11.0 K/ul); RBC 2.07 M/ul, Low (reference range 3.80 - 5.50 M/ul); HGB 6.5 g/dL, Critical Low (reference range 12.0 - 17.0 g/dL); and HCT 20.4%, Critical Low (reference range 37.0 - 50.4 %). Resident #2 s PT/INR results dated 07/26/12 reflected: PT 46.9, High (reference range 9.8 0 - 12.9) and INR 4.22, High (therapeutic range 2.00 - 3.00). Resident #2's Nurse's Note dated 07/26/12 at 11:50 AM reflected, "Critical labs faxed over (MD P)...." Resident #2's Nurse's Note dated 07/26/12 at 12:20 PM reflected, "(MD P) returned call N.O. to send to ER." An interview on 09/11/12 at 1:53 PM with the ADON revealed she was not aware of Resident #2's extensive bruises of unknown origin until she was sent to theER on [DATE]. The ADON stated Resident #2's bruises were not documented on the skin assessment sheet on 07/20/12. When asked if she was usually made aware of extensive bruising of unknown origin the ADON stated, "No. The DON was handling all of the skin. I took the critical (lab) call and had her sent out (to the ER)." The ADON revealed Resident #2's fall on 07/16/12 was mentioned during a morning stand-up meeting but not the extensive bruising that followed. When asked who monitored the Charge Nurses, the ADON stated, "I now have a daily list from (Interim DON). Before I worked the floor and didn't monitor, but I am now." Review of an SBAR (Situation-Background-Assessment-Recommendation), Physician/NP/PA Communication and Progress Note dated 07/26/12 revealed, "...Pain level/location/status: Grimaces when move L arm ...Progress Note: Lab results came back (with) critical labs...Res to be sent to ER (emergency room ). Bruising noted last wk (week) post fall...." Review of a hospital History and Physical dated 07/26/12 revealed, "...she (Resident #2) ended up having a large hematoma on the left breast, and now there is a significant drop in her H&H (hemoglobin and hematocrit) ...Laboratory...Sodium 115 mmol/L (Reference range: 140-148 mmol/L), BUN 40 (Reference range: 7-18 mg/dl) potassium 3.4 (Reference range: 3.5-5.2). When she came, her H&H was low at 6.5 g/dL and 19%. Left breast appears to be significantly enlarged with a subcutaneous hematoma. Assessment: 1) [MEDICAL CONDITION] probably secondary to blood loss in the left breast. No other evidence of blood loss from the history or the exam. She has been on [MEDICATION NAME] and probably that has made the bleeding or hematoma worse. 2) Coagulopathy...Plan...Transfuse packed cells and watch her potassium closely...." Review of hospital Physician's Admit Orders dated 07/26/12 revealed, "... Transfuse 2 units PRBC (packed red blood cells) today. (slowly each unit over 4 hours)...." Resident #2's facility's Nurse's Note dated 07/31/12 at 3:00 PM reflected she was readmitted to the facility with multiple bruises on her arms, leg, and chest wall, which was related to her fall on 07/16/12. The Note also reflected the resident had three plus [MEDICAL CONDITION] to left arm and three plus [MEDICAL CONDITION] to her left hand. Resident #2's Admission Nursing Evaluation dated 07/31/12 reflected admitting [DIAGNOSES REDACTED]. Resident #2's new Fall Risk Evaluation dated 07/31/12 reflected a total score of 21. The Fall Risk Evaluation reflected a score of 10 and above indicated the resident was at high risk for falls. Nurse's Notes dated 08/14/12 at 6:00 PM for Resident #2 reflected the [MEDICAL CONDITION] in the resident's left arm no longer remained. The physician was notified and orders were received to have lab drawn for a CBC and BMP in the morning. Nurse's Notes dated 08/17/12 at 1:00 PM reflected related to the lab results from the CBC and BMP, a new order was received to restart Resident #2's [MEDICATION NAME] 5 mg by mouth daily with a PT/INR scheduled to be drawn on 08/23/12. Review of a [MEDICATION NAME] administration schedule for August 2012 revealed Resident #2 began receiving [MEDICATION NAME] 5 mg at 4:00 PM on 08/17/12. Resident #2's Telephone Orders dated 08/24/12 reflected an order to increase the resident's [MEDICATION NAME] to 6 mg every day and to have a PT/INR drawn in one week. Resident #2's Telephone Orders dated 08/29/12 reflected an order to increase the resident's [MEDICATION NAME] to 7 mg daily and to have a PT/INR drawn in one week. Review of Resident #2's [MEDICATION NAME] administration schedule for August 2012 revealed the resident began receiving [MEDICATION NAME] 6 mg on 08/29/12 (five days late) and on 08/30/12, began receiving 7 mg of [MEDICATION NAME]. Observation on 08/22/12 at 10:53 AM revealed Resident #2 was lying in the middle of her bed, on her left side, and she was receiving a bed bath from CNA E. The resident's bed was against the wall and the resident was facing the wall at that time. The CNA tucked the clean linens beneath the resident and rolled the resident onto her back and then onto her right side. The resident's right shoulder and part of her upper back were off the mattress at that time. CNA E then reached over the top of the resident and pulled the linens out from under her to the other side. The resident's body was rolling further to her right at that time as though she were going to slide off the bed. CNA E's body prevented Resident #2 from falling off the bed. No side rail was up at that time. The CNA then rolled the resident onto her back and continued with care. The resident's left breast had purple and pale green bruising around the lower portion of the breast extending to her left arm pit and the inside of her upper left arm. Her left arm was swollen from her shoulder to her fingers. When CNA E was queried about the injuries, she stated, "I think they said it was from the medicine." When asked if she knew Resident #2 had fallen out of bed, CNA E replied, "Yes." When asked if she was there at the time of the fall, CNA E replied, "No. I was off. I think it happened on evening shift." When asked if she had received any training or new instructions about caring for Resident #2 since her fall, CNA E replied, "No. I've been working here [AGE] years." Review of the current facility policy "Falls and Fall Risk, Managing" dated December 2007 revealed: "Policy Statement - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling; Policy Interpretation and Implementation: ...1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified...." An IJ was identified on 08/23/11. The Administrator and the DON were informed of the IJ on 08/23/11 at 3:40 PM. The Administrator and the DON were requested to provide a Plan of Removal for the IJ at that time. The facility's Plan of Removal provided on 08/24/12 reflected, "...3. (DON) was terminated as facility Director of Nurses effective 8/24/12. (Corporate name) corporate RN supervisor will assume the responsibility of Nursing Director until a new qualified DON can be hired and oriented. Corporate Nursing team will continue to be responsible for the monitoring of this plan until substantial compliance is achieved. 4) The Accunurse documentation system reflects '2 person' assist for all transfers and ADL care. This is also reflective in the written nursing plan of care. In addition an alert page has been placed on (Resident #2) to remind all staff of the need for 2 persons to assist in all care. This was validated by the (corporate name) corporate RN supervisor(s)...6) On 8/22 at 7:00 PM the CNA's (sic) received a competency based in-service regarding this resident's ADL assistance needs by (ADON) was initiated. All nursing staff will receive this education by 8 AM on 8/24 or prior to the start of any shift. This education was be (sic) performed by DON and ADON under the supervision of (corporate name) corporate nurse supervisor(s). 7) A competency based in-service for all staff on abuse/neglect/misappropriation/injuries of unknown origin reporting will be completed. This will be completed by 8/24 by 5PM or prior to the start of any shift. Education material and education delivery will be validated and monitored by (corporate name) corporate nurse supervisor(s). On-going education for all employees on this practice will be done at the facility quarterly for the next 4 quarters through our online silverchair module...8. A competency based in-service for all licensed nurses including administrative nursing team on physician notification protocol will be done by (corporate name) corporate nurse staff. To be completed on 8/24 before 5 PM or prior to the start of any shift. 9. A competency based in-service for all licensed nurses including administrative nursing team on protocols for fall investigations, incident reporting, fall assessments, interventions, and monitoring. This education will be done by (corporate name) corporate nurse staff. To be completed on 8/24 before 5 PM or prior to the start of any shift. 10...a therapy referral was initiated (08/23/12)as well as initiated alarms as fall interventions. These updates were made to the resident written plan of care, the accunurse plan of care and a voice alert placed on this resident's accunurse system to communicate the change...11. All incidents including falls will be tracked, trended, and reviewed at the QA committee meeting, to be attended by the medical director, Administrator, and (corporate name) corporate nurse supervisor(s). QA meetings will be weekly for the next 8 weeks then monthly thereafter so long as substantial compliance is achieved...." Review of a Record of In-Service dated 08/23/12 revealed, "Abuse & Neglect. Define Abuse, Neglect and Injuries of Unknown Origin. Objectives of the In-Service: Make sure each CNA and nurse knows the difference between all kinds of abuse." The attached Abuse and Neglect Competency Exam reflected, "...6. If you transfer a resident alone when their plan of care indicates assistance of 2 it is considered neglect. True...9. What type of elder abuse involves inadequate care in activities of daily living? a. Neglect...." Review of a Record of In-Service dated 08/23/12 revealed, "Neuro Checks. Incident and accident report Falls & Investigation worksheet, Fall Risk Evaluation, Incident Accident Action Plan." Review of a Record of In-Service dated 08/23/12 revealed, "___ (Resident #2) will remain @ 75? - 90? while in bed & at all times 2 person assist with ADL's and transfer." Interviews on 08/25/12 at 8:30 AM with CNA N and at 9:00 AM with CNA J revealed they were able to verbalize the steps outlined in the facility's Plan of Removal regarding accessing AccuNurse in order to establish resident's care needs. CNAs N and J revealed the facility's process for reporting incidents to the Abuse Prohibition Coordinator as reflected in the Plan of Removal. Interviews with CNA EE and MA FF on 08/25/12 at approximately 8:00 AM revealed they had both received training in the last day or so on Abuse/Neglect and on Burnout. They both stated they knew who to report anything, which was unusual and occurred with the residents. And if their immediate supervisor did not report or do anything, they knew to report any incident to the Abuse Coordinator. They referred to the Silver Chair program regarding Staff Burnout, to notice a change in employee's personality such as being surly, irritable and to encourage the DON not to let those employees work double shifts of 16 hours. They were to attend Weekly Clinicals, ensure they received report from the previous shift, and to check for any incident, which may have occurred such as recent falls. CNA DD was interviewed on 08/25/12 at approximately 8:30 AM. She stated she had not received any inservice in the last day or so regarding Abuse and Neglect. CNA DD stated she was so new she was still learning the way the facility does things. During an interview on 08/25/12 at 8:45 AM, LVN D was asked if she had attended any in-services or training in the last two days. LVN D stated yes. LVN D was asked what the in-services were about. LVN D stated she received training regarding abuse, whom to report to (the DON, supervisor on duty, the Administrator and/or the Abuse Coordinator), how to recognize abuse and neglect, what to do if abuse or neglect was reported to her (report to her supervisor, initiate an Incident/Accident Report and investigation, get written statements, potentially suspend the perpetrator), answering call lights promptly and toileting procedures. LVN D revealed she had completed a test that covered the above mentioned topics. She stated the test had different scenarios and multiple choice answers. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 08/22/12 and signed by the DON reflected 52 residents were occasionally or frequently incontinent of bladder, 40 residents were occasionally or frequently incontinent of bowel, 13 residents were dependent on staff for bathing, one resident was dependent on staff for transferring and one resident was dependent on staff for toileting.

Based on observation, interview, and record review, it was determined the facility failed to implement the facility's policies and procedures that prohibit neglect of residents for one (Resident #2) of seven residents reviewed for abuse/neglect. 1. CNA F failed to have another staff member assist her, as the resident's care plan indicated, when she provided incontinent care to Resident #2 on 07/16/12. During the care, the unlocked bed rolled out from under the resident and CNA F lowered the resident to the floor. 2. The ADM failed to report to the State survey and certification agency when CNA F failed to have another staff member assist her with Resident #2's incontinent care and the resident was lowered to the floor. 3. The ADM and DON failed to investigate the bruising, which developed on 07/23/12, to Resident #2's breast area, which extended from her mid chest wall to her lateral left torso and the hematoma which also developed on her mid chest wall. 4. The ADM and DON failed to report the significant bruising to the State survey and certification agency. Resident #2 sustained a 5 inch abrasion to her thigh and a bruise on her abdomen, when she was lowered to the floor. These failures also resulted in a delay in care and treatment for [REDACTED]. 5. CNA E failed to have another staff member assist her when she provided incontinent care to Resident #2 on 08/22/12 and the resident almost rolled out of bed. CNA E's body prevented the resident from rolling off the bed. An Immediate Jeopardy was identified on 08/23/12. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the 52 residents who were occasionally or frequently incontinent of bladder and the 40 residents who were occasionally or frequently incontinent of bowel, the 13 residents, who were dependent on staff for bathing, the one resident dependent on staff for tranfers, and the one resident dependent on staff for toileting, including Resident #2, by placing them at risk for neglect resulting in abrasions, lacerations, bruising, hematomas, fractures, and/or death. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. 1) Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Gastrostomy and [MEDICAL CONDITION], per the quarterly MDS assessment dated [DATE]. Further review of the MDS assessment revealed Resident #2 required two or more persons physical assistance for toileting, bed mobility and dressing. The MDS assessment reflected Resident #2 required one-person physical assistance for bathing. Further review of Resident #2's MDS assessment revealed she had long and short-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected Resident #2 was 68 inches tall and weighed 164 pounds. Resident #2's Comprehensive Care Plan reflected the areas of concern (Problems) with the date they were identified and the approaches or interventions planned. These included: (a) ADL functions (03/29/12) including Bed Mobility; Transfers; Dressing; Eatuing; Toileting; Personal Hygeine; and Bathing. The resident was totally dependent with all functions and required 1-2 person's to accomplish the task. (Note: Bathing did not specify the number of persons needed to assist.) Approaches included "Assist with ADL's as needed." The Care Plan was updated on 06/21/12 and 08/08/12 but no apparent changes were made. The Care Plan did not address any the resident's use of blood thinners. Review of a Care Plan Meeting Summary, located in Resident #2's clinical record, dated 06/21/12 revealed, "...Toilet Use: 2+ persons physical assist...." On 08/24/12 at 12:10 PM, the DON was shown Resident #2's blank Care Plan for bathing and asked how many staff were required for assistance in bathing. The DON stated, "It's left up to interpretation." Review of the physician's orders [REDACTED]. Re(check) PT/INR on Monday...." laboratory results dated [DATE] reflected the PT was high at 24 seconds (reference range 9.8 0 - 12.9) and the INR (ratio) was low at 1.95 (reference range 2.00 - 3.00). Resident #2's BLOOD THINNERS administration record for July 2012 reflected the resident received [MEDICATION NAME] 10 mg daily. The July MAR further reflected, "Check skin for bruising or excessive bleeding...." Documentation reflected the resident was monitoring BID. Review of the Incident/Accident Report dated 07/16/12 revealed, "...Time of incident/accident: 1600 (4:00 PM)...Findings: CNA was attempting to provide incont (incontinent) care to Resident and when the CNA turned Resident the bed was unlocked and slid out from underneath the Resident. CNA intercepted Resident from falling to the floor and eased her to the floor...Conclusion/Summary: ensure bed is locked prior to incont care...Recommendations/Interventions: ensure bed is locked prior to incont care. Always have 2 CNA's for care." Resident #2's Nurse's Note dated 07/16/12 at 4:00 PM reflected, "CNA was attempting to provide incont care to Resident & when the CNA turned the Resident, the bed was unlocked and slid out from underneath the Resident. CNA intercepted the Resident from falling to the floor, instead she caught the Resident and eased her to the floor. VS (vital signs) stable. 5 in (inch) scrape noted to R (right) leg and 2 in x 2 in bruise to abdomen.(No) pain according to FlACC (The Face, Legs, Activity, Cry, Consolability scale). MD paged. (Resident #2's family member) notified. Will cont to monitor." An interview on 08/22/12 at 2:21 PM with CNA F revealed she provided incontinent care to Resident #2 on 07/16/12. CNA F stated she rolled Resident #2 onto her left side, facing the wall. She stated she then pulled the resident's bed away from the wall and stood in between the bed and the wall. CNA F said Resident #2 started rolling off the bed, towards the wall. She stated she grabbed Resident #2's gown to break her fall. CNA F said Resident #2 sustained a laceration to her leg and no other injuries were found. When asked if there was another CNA present during incontinent care, CNA F stated there was not. CNA F stated a large bruise on Resident #2's left shoulder and breast appeared approximately one week after the fall on 07/16/12. CNA F stated it was routine to use one CNA to provide incontinent care or to give Resident #2 a bed bath. CNA F was asked if any other residents required two people for assistance. CNA F identified two other residents. When CNA F was asked where to look or how to determine if a resident required required one or two persons assistance, the CNA said she did not know. When asked if she felt Resident #2 was safe, CNA F stated, "If they put a rail on the other side (of the bed) by the wall, she would be." A Care Plan for falls was not implemented after Resident #2 fell on [DATE]. During an interview on 08/22/12 at 5:15 PM with the Administrator, DON, Corporate Nurse and the facility's only ADON, the DON stated, following Resident #2's incident on 07/16/12, she "told everybody and probably yelled at them" to utilize two staff when providing care to the resident. The DON stated there was no documentation of the in-service. The Nurse's Notes dated 07/17/12 at 12:00 AM reflect, "No delayed injuries noted from previous incident" and at 8:30 AM, "2+ [MEDICAL CONDITION] & bruising noted to R foot. Xray R foot ordered stat. Review of the x-ray report dated 07/17/12 revealed "No dislocation or fracture." Nurse's Notes dated 07/18/12 at 11:00 AM reflected "[MEDICAL CONDITION] & discoloration noted to Rt ankle/foot. Rt. leg (elevated) on pillow...5 in (inch) abrasion to Rt. thigh area noted...." Nurse's Notes on 07/19/12 at 12:00 AM and 07/20/12 at 11:00 AM reflected no "delayed inuries" were noted from the incident. LVN K was then asked if Resident #2 showed signs of pain after her fall on 07/16/12. LVN K stated, "Yes. She would fight me when I changed her tube ([DEVICE] dressing) with two hands (prior to the fall on 07/16/12). After the fall (on 07/16/12), she would only move her right arm. This also happened during passive range of motion." LVN K stated Resident #2 showed signs of pain by facial grimaces from 07/17/12 through 07/22/12. Resident #2's Nurse's Note dated 07/17/12 at 8:30 AM revealed, "2 + (plus) [MEDICAL CONDITION] & bruising noted to R (right) foot. Xray R foot ordered stat." Resident #2' s Nurse's Note dated 07/17/12 at 12:00 PM reflected, "NNO (no new order) r/t (related to) xray report of R foot. Will monitor. (No) further injuries noted." Resident #2's Nurse's Note dated 07/18/12 at 1:00 AM reflected, "Cont. to note [MEDICAL CONDITION] and discoloration to R ankle/foot. Foot up on pillow. Skin warm/dry to touch. No s/s (signs or symptoms) of pain or discomfort noted." Resident #2's Nurse's Note dated 07/18/12 at 11:00 AM reflected, "[MEDICAL CONDITION] & discoloration noted to Rt (right) ankle/foot...5 in (inch) abrasion to Rt thigh area...." Resident #2's Nurse's Note dated 07/23/12 at 9:00 PM reflected, "Large bruise noted to L (Left) breast, (No) apparent pain. Beefy red stoma protrusion noted from peg site. MD faxed." Review of the Incident/Accident Report dated 07/23/12 revealed, "...Time of incident/accident: 0900 (9:00) AM...Findings: Large bruise noted to L breast. Delayed injury from 7/16/12 fall. (No) apparent pain using Flacc. Incident Type: delayed injury from fall...Conclusion/Summary: Res (resident) (with) recent fall. She is on [MEDICATION NAME]. Area to breast (with) verying (sic) discoloration. No other incident area to breast seems to be from earlier fall...." An interview on 09/11/12 at 12:32 PM with LVN K revealed Resident #2's bruises appeared "several days" after she fell on [DATE]. LVN K stated she found the bruises on 07/23/12, but did not measure the size of the bruises, stating "No, or I would've written it down." LVN K stated she documented the size and color of the bruises when they were discovered. When asked if she completed incident reports when a bruise of unknown origin was found, LVN K stated, "It depends." LVN K said she followed normal procedure and faxed the information to the physician. LVN K then stated she observed Resident #2's bruise as it became larger and spread from her chest wall to her shoulder and then down the left side of her body. LVN K revealed she monitored Resident #2's bruising, but did not document her findings anywhere. LVN K stated, "If it was a critical lab, we would've called. I didn't feel this (bruising) warranted a phone call." When asked how the physician responded to faxes received, she stated the physician reported back by fax. LVN K was asked how nursing staff knew when a physician sent a fax regarding a resident's treatment or care. LVN K replied, "It prints out on our fax. Someone in the office (business office) checks it regularly, and I check it periodically." LVN K was asked if she documented in the resident's Nurse's Notes when a physician sent a fax communication. LVN K stated, "I usually do." When asked specifically about the communication with Resident #2's physician on 07/23/12, LVN K stated the physician responded via fax and ordered a referral to a surgeon regarding the resident's [DEVICE]. LVN K was asked if it concerned her that MD B's fax on 07/23/12 did not address Resident #2's newly discovered bruise. LVN K replied, "I guess from my notes and thought process, as the days went on, the bruise got worse. It started on her left breast then spread across her chest. I paged the doctor (on 07/26/12) to let him know." When asked if she thought Resident #2's [MEDICATION NAME] contributed to Resident #2's extensive bruising at the time, LVN K replied, "We knew she (Resident #2) was on [MEDICATION NAME]. That was a thought; that it could be the [MEDICATION NAME]." LVN K was asked if MD B knew Resident #2 was on [MEDICATION NAME]. LVN K replied, "Yes. He (MD B) remembers all his patients." LVN K was asked whose responsibility it was to prompt physicians and trigger their memory when a resident was on [MEDICATION NAME] and when extensive bruising occurred. LVN K stated, "We (nurses) do." When asked if she notified MD B Resident #2 was on [MEDICATION NAME] after the bruising appeared on 07/23/12, LVN K stated, "I don't remember." LVN K did not recall if she spoke to MD B prior to documenting Resident #2's [MEDICATION NAME] was to be held on 07/25/12. LVN K then stated MD B did not order Resident #2's PT/INR to be done STAT. LVN K stated, "I probably called him (MD B) back at 4 o'clock (4:00 PM on 07/25/12). I know my notes don't support that." LVN K said she usually called the doctor and completed an incident report when a resident on [MEDICATION NAME] had a bruise of unknown origin. When asked if she also checked labs in such a case, LVN K replied, "He'll (MD B) order one but usually not STAT." An interview on 09/11/12 at 1:53 PM with the facility's only ADON revealed, "Anytime they (nursing staff) find something new. We fax them (the physicians) and tell them about the bruise." The ADON was asked if it was common practice for a nurse to notify a physician a resident was on [MEDICATION NAME] when reporting a bruise of unknown origin. The ADON stated, "Yes, or if they're (the residents) on Aspirin. We let them (the physicians) know if they're (the residents) diabetic and taking insulin. He (MD B) usually faxes back; will initial and send it (fax) back to us. It depends on what nurses write." Resident #2's Nurse's Note dated 07/24/12 at 11:45 AM reflected, "...Lg (large) dk (dark) discoloration noted to Lt (left) breast...stoma beefy & red...." Resident #2's Nurse's Note dated 07/25/12 at 9:30 AM reflected, "Large bruise to mid chest wall extending to lateral L torso. 4 x 4 hematoma noted to L CW (chest wall). MD paged." Resident #2's Nurse's Note dated 07/25/12 at 3:00 PM reflected, "N.O. (new order) Check PT/INR, CBC and apply ice pack to hematoma. (x-ray company) called." Resident #2's Nurse's Note dated 07/25/12 at 4:00 PM reflected, "N.O. (new order) Hold [MEDICATION NAME] (blood thinner) until PT/INR results arrive." Resident #2's Nurse's Note dated 07/25/12 at 10:00 PM reflected, "Awaiting final report - Xray shows no fx (fracture) re (regarding) rib cage. No fx L shoulder, both Osteoporotic. Appears comfortable - facial expression or movement of hand or other s/s of restlessness." Resident #2's Nurse's Note dated 07/26/12 at 9:30 AM reflected, "...Bruise to L breast and chest cont to be purple and brown in color. Cont to show pain (with) movement of L arm...." Resident #2's laboratory report dated 07/26/12 reflected: Resident #2's lab results dated 07/26/12 reflected: WBC 16.9 K/ul, High (reference range of 4.0 - 11.0 K/ul); RBC 2.07 M/ul, Low (reference range 3.80 - 5.50 M/ul); HGB 6.5 g/dL, Critical Low (reference range 12.0 - 17.0 g/dL); and HCT 20.4%, Critical Low (reference range 37.0 - 50.4 %). Resident #2 s PT/INR results dated 07/26/12 reflected: PT 46.9, High (reference range 9.8 0 - 12.9) and INR 4.22, High (therapeutic range 2.00 - 3.00). Resident #2's Nurse's Note dated 07/26/12 at 11:50 AM reflected, "Critical labs faxed over (MD P)...." Resident #2's Nurse's Note dated 07/26/12 at 12:20 PM reflected, "(MD P) returned call N.O. to send to ER." An interview on 09/11/12 at 1:53 PM with the facility's only ADON revealed she was not aware of Resident #2's extensive bruises of unknown origin until she was sent to theER on [DATE]. The ADON stated Resident #2's bruises were not documented on the skin assessment sheet on 07/20/12. When asked if she was usually made aware of extensive bruising of unknown origin the ADON stated, "No. The DON was handling all of the skin. I took the critical (lab) call and had her sent out (to the ER)." The ADON revealed Resident #2's fall on 07/16/12 was mentioned during a morning stand-up meeting but not the extensive bruising that followed. When asked who monitored the Charge Nurses, the ADON stated, "I now have a daily list from (Interim DON). Before I worked the floor and didn't monitor, but I am now." Review of an SBAR (Situation-Background-Assessment-Recommendation), Physician/NP/PA Communication and Progress Note dated 07/26/12 revealed, "...Pain level/location/status: Grimaces when move L arm ...Progress Note: Lab results came back (with) critical labs...Res to be sent to ER (emergency room ). Bruising noted last wk (week) post fall...." Review of a hospital History and Physical dated 07/26/12 revealed, "...she (Resident #2) ended up having a large hematoma on the left breast, and now there is a significant drop in her H&H (hemoglobin and hematocrit) ...Laboratory...Sodium 115 mmol/L (Reference range: 140-148 mmol/L), BUN 40 (Reference range: 7-18 mg/dl) potassium 3.4 (Reference range: 3.5-5.2). When she came, her H&H was low at 6.5 g/dL and 19%. Left breast appears to be significantly enlarged with a subcutaneous hematoma. Assessment: 1) [MEDICAL CONDITION] probably secondary to blood loss in the left breast. No other evidence of blood loss from the history or the exam. She has been on [MEDICATION NAME] and probably that has made the bleeding or hematoma worse. 2) Coagulopathy...Plan...Transfuse packed cells and watch her potassium closely...." Review of hospital Physician's Admit Orders dated 07/26/12 revealed, "... Transfuse 2 units PRBC (packed red blood cells) today. (slowly each unit over 4 hours)...." Resident #2's facility's Nurse's Note dated 07/31/12 at 3:00 PM reflected she was readmitted to the facility with multiple bruises on her arms, leg, and chest wall, which was related to her fall on 07/16/12. The Note also reflected the resident had three plus [MEDICAL CONDITION] to left arm and three plus [MEDICAL CONDITION] to her left hand. Resident #2's Admission Nursing Evaluation dated 07/31/12 reflected admitting [DIAGNOSES REDACTED]. Resident #2's new Fall Risk Evaluation dated 07/31/12 reflected a total score of 21. The Fall Risk Evaluation reflected a score of 10 and above indicated the resident was at high risk for falls. Nurse's Notes dated 08/14/12 at 6:00 PM for Resident #2 reflected the [MEDICAL CONDITION] in the resident's left arm no longer remained. The physician was notified and orders were received to have lab drawn for a CBC and BMP in the morning. Nurse's Notes dated 08/17/12 at 1:00 PM reflected related to the lab results from the CBC and BMP, a new order was received to restart Resident #2's [MEDICATION NAME] 5 mg by mouth daily with a PT/INR scheduled to be drawn on 08/23/12. Review of a [MEDICATION NAME] administration schedule for August 2012 revealed Resident #2 began receiving [MEDICATION NAME] 5 mg at 4:00 PM on 08/17/12. Resident #2's Telephone Orders dated 08/24/12 reflected an order to increase the resident's [MEDICATION NAME] to 6 mg every day and to have a PT/INR drawn in one week. Resident #2's Telephone Orders dated 08/29/12 reflected an order to increase the resident's [MEDICATION NAME] to 7 mg daily and to have a PT/INR drawn in one week. Review of Resident #2's [MEDICATION NAME] administration schedule for August 2012 revealed the resident began receiving [MEDICATION NAME] 6 mg on 08/29/12 (five days late) and on 08/30/12, began receiving 7 mg of [MEDICATION NAME]. Observation on 08/22/12 at 10:53 AM revealed Resident #2 was lying in the middle of her bed, on her left side, and she was receiving a bed bath from CNA E. The resident's bed was against the wall and the resident was facing the wall at that time. The CNA tucked the clean linens beneath the resident and rolled the resident onto her back and then onto her right side. The resident's right shoulder and part of her upper back were off the mattress at that time. CNA E then reached over the top of the resident and pulled the linens out from under her to the other side. The resident's body was rolling further to her right at that time as though she were going to slide off the bed. CNA E's body prevented Resident #2 from falling off the bed. No side rail was up at that time. The CNA then rolled the resident onto her back and continued with care. The resident's left breast had purple and pale green bruising around the lower portion of the breast extending to her left arm pit and the inside of her upper left arm. Her left arm was swollen from her shoulder to her fingers. Resident #2's [DEVICE] site was red with bloody drainage on the dressing. The site had a raw appearance. When asked about the swelling of Resident #2's arm and whether it was new, CNA E replied, "Kinda. Like it comes and goes." When CNA E was queried about the injuries, she stated, "I think they said it was from the medicine." When asked if she knew Resident #2 had fallen out of bed, CNA E replied, "Yes." When asked if she was there at the time of the fall, CNA E replied, "No. I was off. I think it happened on evening shift." When asked if she had received any training or new instructions about caring for Resident #2 since her fall, CNA E replied, "No. I've been working here [AGE] years." Review of the current facility policy "Falls and Fall Risk, Managing" dated December 2007 revealed: "Policy Statement - Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and to try to minimize complications from falling; Policy Interpretation and Implementation: ...1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls... 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the Attending Physician will help the staff reconsider possible causes that may not previously have been identified...." The facility's undated, current Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property reflected,"...If at any time abuse and neglect are reported the staff will follow the facility policy on reporting and investigating abuse...Staff are knowledgeable in recognizing suspicious bruising, swelling, pain...All allegations, no matter what types of incidents reported will be investigated fully...An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing...Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences...." The facility's undated, current Abuse/Neglect Prohibition Policy and Procedure reflected, "All employees are to report suspected abuse or neglect at any time it is identified...Any bruising on any resident will be documented upon discovery and all efforts will be made to determine if abuse/neglect could have occurred. The administrator or his designee will report the alleged abuse/neglect to the Texas Department of Aging and Disability Services and/or other appropriate agency and/or the appropriate law enforcement agency per regulation." The facility's undated, current, Resident Abuse Policy reflected, "The resident has the right to be free from...injury from an unknown source...In the event if any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility, or to state officials as posted in the facility. Upon report of any allegations or violations the administrator or his/her designated respresentative will thoroughly investigate the situation in accordance with Texas law. Any employee suspected of abuse or neglect will be removed from the direct care of the resident/residents while the investigation is in process. The investigation will include but not limited to the following facts...5. Any evidence of injury or abuse present on the resident's body...." An IJ was identified on 08/23/11. The Administrator and the DON were informed of the IJ on 08/23/11 at 3:40 PM. The Administrator and the DON were requested to provide a Plan of Removal for the IJ at that time. The facility's Plan of Removal provided on 08/24/12 reflected, "...3. (DON) was terminated as facility Director of Nurses effective 8/24/12. (Corporate name) corporate RN supervisor will assume the responsibility of Nursing Director until a new qualified DON can be hired and oriented. Corporate Nursing team will continue to be responsible for the monitoring of this plan until substantial compliance is achieved. 4) The Accunurse documentation system reflects '2 person' assist for all transfers and ADL care. This is also reflective in the written nursing plan of care. In addition an alert page has been placed on (Resident #2) to remind all staff of the need for 2 persons to assist in all care. This was validated by the (corporate name) corporate RN supervisor(s)...6) On 8/22 at 7:00 PM the CNA's (sic) received a competency based in-service regarding this resident's ADL assistance needs by (ADON) was initiated. All nursing staff will receive this education by 8 AM on 8/24 or prior to the start of any shift. This education was be (sic) performed by DON and ADON under the supervision of (corporate name) corporate nurse supervisor(s). 7) A competency based in-service for all staff on abuse/neglect/misappropriation/injuries of unknown origin reporting will be completed. This will be completed by 8/24 by 5PM or prior to the start of any shift. Education material and education delivery will be validated and monitored by (corporate name) corporate nurse supervisor(s). On-going education for all employees on this practice will be done at the facility quarterly for the next 4 quarters through our online silverchair module...8. A competency based in-service for all licensed nurses including administrative nursing team on physician notification protocol will be done by (corporate name) corporate nurse staff. To be completed on 8/24 before 5 PM or prior to the start of any shift. 9. A competency based in-service for all licensed nurses including administrative nursing team on protocols for fall investigations, incident reporting, fall assessments, interventions, and monitoring. This education will be done by (corporate name) corporate nurse staff. To be completed on 8/24 before 5 PM or prior to the start of any shift. 10...a therapy referral was initiated (08/23/12)as well as initiated alarms as fall interventions. These updates were made to the resident written plan of care, the accunurse plan of care and a voice alert placed on this resident's accunurse system to communicate the change...11. All incidents including falls will be tracked, trended, and reviewed at the QA committee meeting, to be attended by the medical director, Administrator, and (corporate name) corporate nurse supervisor(s). QA meetings will be weekly for the next 8 weeks then monthly thereafter so long as substantial compliance is achieved...." Review of a Record of In-Service dated 08/23/12 revealed, "Abuse & Neglect. Define Abuse, Neglect and Injuries of Unknown Origin. Objectives of the In-Service: Make sure each CNA and nurse knows the difference between all kinds of abuse." The attached Abuse and Neglect Competency Exam reflected, "...6. If you transfer a resident alone when their plan of care indicates assistance of 2 it is considered neglect. True...9. What type of elder abuse involves inadequate care in activities of daily living? a. Neglect...." Review of a Record of In-Service dated 08/23/12 revealed, "Neuro Checks. Incident and accident report Falls & Investigation worksheet, Fall Risk Evaluation, Incident Accident Action Plan." Review of a Record of In-Service dated 08/23/12 revealed, "___ (Resident #2) will remain @ 75? - 90? while in bed & at all times 2 person assist with ADL's and transfer." Interviews on 08/25/12 at 8:30 AM with CNA N and at 9:00 AM with CNA J revealed they were able to verbalize the steps outlined in the facility's Plan of Removal regarding accessing AccuNurse in order to establish resident's care needs. CNAs N and J revealed the facility's process for reporting incidents to the Abuse Prohibition Coordinator as reflected in the Plan of Removal. Interviews with CNA EE and MA FF on 08/25/12 at approximately 8:00 AM revealed they had both received training in the last day or so on Abuse/Neglect and on Burnout. They both stated they knew who to report anything, which was unusual and occurred with the residents. And if their immediate supervisor did not report or do anything, they knew to report any incident to the Abuse Coordinator. They referred to the Silver Chair program regarding Staff Burnout, to notice a change in employee's personality such as being surly, irritable and to encourage the DON not to let those employees work double shifts of 16 hours. They were to attend Weekly Clinicals, ensure they received report from the previous shift, and to check for any incident, which may have occurred such as recent falls. CNA DD was interviewed on 08/25/12 at approximately 8:30 AM. She stated she had not received any inservice in the last day or so regarding Abuse and Neglect. CNA DD stated she was so new she was still learning the way the facility does things. During an interview on 08/25/12 at 8:45 AM, LVN D was asked if she had attended any in-services or training in the last two days. LVN D stated yes. LVN D was asked what the in-services were about. LVN D stated she received training regarding abuse, whom to report to (the DON, supervisor on duty, the Administrator and/or the Abuse Coordinator), how to recognize abuse and neglect, what to do if abuse or neglect was reported to her (report to her supervisor, initiate an Incident/Accident Report and investigation, get written statements, potentially suspend the perpetrator), answering call lights promptly and toileting procedures. LVN D revealed she had completed a test that covered the above mentioned topics. She stated the test had different scenarios and multiple choice answers. While the IJ was removed on 08/25/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still implementing and monitoring the Plan of Removal. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 08/22/12 and signed by the DON reflected 52 residents were occasionally or frequently incontinent of bladder, 40 residents were occasionally or frequently incontinent of bo

Based on observation, interview, and record review, it was determined the facility failed to have evidence that significant bruising was thoroughly investigated and failed to report an allegation of neglect and the significant bruising were reported to the State survey and certification agency for one (Resident #2) of seven residents reviewed for abuse/neglect. 1. The ADM and DON failed to investigate the bruising, which developed on 07/23/12, to Resident #2's breast area, which extended from her mid chest wall to her lateral left torso. These failures resulted in a delay in care and treatment for [REDACTED]. 2. The ADM failed to report to the State survey and certification agency when CNA F failed to have another staff member assist her, as the care plan indicated, when she provided incontinent care to Resident #2 on 07/16/12. During the care, the unlocked bed rolled out from under the resident and CNA F lowered the resident to the floor. 3. The ADM and DON failed to report the significant bruising to the State survey and certification agency. These failures could affect the 52 residents who were occasionally or frequently incontinent of bladder and the 40 residents who were occasionally or frequently incontinent of bowel, the 13 residents, who were dependent on staff for bathing, the one resident dependent on staff for tranfers, and the one resident dependent on staff for toileting, including Resident #2, by placing them at risk for neglect resulting in abrasions, lacerations, bruising, hematomas, fractures, and/or death. Findings included: Per Administrative Review, it was determined more investigation was required and the survey team returned to the facility on [DATE]. Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Gastrostomy and [MEDICAL CONDITION] per the quarterly MDS assessment dated [DATE]. Further review of the MDS assessment revealed Resident #2 required two or more persons physical assistance for toileting, bed mobility and dressing. The MDS assessment reflected Resident #2 required one-person physical assistance for bathing. Further review of Resident #2's MDS assessment revealed she had long and short-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The MDS assessment also reflected Resident #2 was 68 inches tall and weighed 164 pounds. Review of Resident #2's Care Plan dated 03/29/12 revealed, "Problem Onset: 03/29/12 ... Toileting: Total dep (dependence).... X's 2 Staff (two person assist)." The bathing portion of Resident #2's Care Plan reflected Resident #2 was totally dependent on staff for bathing. The number of staff required for assistance with bathing was blank. Resident #2's Care Plan was updated on 06/21/12 and 08/08/12. Review of a Care Summary, located in Resident #2's clinical record, dated 06/21/12 revealed "...Toilet Use: 2+ persons physical assist..." On 08/24/12 at 12:10 PM the DON was shown Resident #2's blank Care Plan for bathing and asked how many staff were required for assistance in bathing. The DON stated, "It's left up to interpretation." Review of the Incident/Accident Report dated 07/16/12 revealed, "...Time of incident/accident: 1600 (4:00 PM)...Findings: CNA was attempting to provide incont (incontinent) care to Resident and when the CNA turned Resident the bed was unlocked and slid out from underneath the Resident. CNA intercepted Resident from falling to the floor and eased her to the floor...Conclusion / Summary: ensure bed is locked prior to incont care...Recommendations/Interventions: ensure bed is locked prior to incont care. Always have 2 CNA's for care." Resident #2's Nurse's Note dated 07/16/12 at 4:00 PM reflected, "CNA was attempting to provide incont care to Resident & (and) when the CNA turned the Resident, the bed was unlocked and slid out from underneath the Resident. CNA intercepted the Resident from falling to the floor, instead she caught the Resident and eased her to the floor. VS (vital signs) stable. 5 in (inch) scrape noted to R (right) leg and 2 in x 2 in bruise to abdomen. W (no) pain according to FlACC (The Face, Legs, Activity, Cry, Consolability scale). MD (medical doctor) paged. (Resident #2's family member) notified. Will cont (continue) to monitor." An interview on 08/22/12 at 2:21 PM with CNA F revealed she provided incontinent care to Resident #2 on 07/16/12. CNA F stated she rolled Resident #2 onto her left side, facing the wall. She stated she then pulled the resident's bed away from the wall and stood in between the bed and the wall. CNA F said Resident #2 started rolling off the bed, towards the wall. She stated she grabbed Resident #2's gown to break her fall. CNA F revealed Resident #2 sustained a laceration to her leg and no other injuries were found. When asked if there was another CNA present during incontinent care, CNA F stated there was not. CNA F stated a large bruise on Resident #2's left shoulder and breast appeared approximately one week after the fall on 07/16/12. CNA F stated it was routine to use one CNA to provide incontinent care or to give her a bed bath. CNA F was asked if any other residents required two people for assistance. CNA F identified two other residents. When asked if she felt Resident #2 was safe, CNA F stated, "If they put a rail on the other side (of the bed) by the wall she would be." Resident #2's Nurse's Note dated 07/23/12 at 9:00 PM reflected, "Large bruise noted to L (Left) breast, W apparent pain. Beefy red stoma protrusion noted from peg site. MD faxed." Review of the Incident/Accident Report dated 07/23/12 revealed, "...Time of incident/accident: 0900 AM...Findings: Large bruise noted to L breast. Delayed injury from 7/16/12 fall. W (no) apparent pain using Flacc (The Face, Legs, Activity, Cry, Consolability scale). Incident Type: delayed injury from fall...Conclusion/Summary: Res (resident) (with) recent fall. She is on [MEDICATION NAME]. Area to breast (with) verying (sic) discoloration. No other incident area to breast seems to be from earlier fall...." An interview on 09/11/12 at 12:32 PM with LVN K revealed Resident #2's bruises appeared "several days" after she fell on [DATE]. LVN K stated she found the bruises on 07/23/12, but did not measure the size of the bruises, stating "No, or I would've written it down." LVN K stated she documented the size and color of the bruises when they were discovered. When asked if she completed incident reports when a bruise of unknown origin was found, LVN K stated, "It depends." LVN K said she followed normal procedure and faxed the information to the physician. LVN K then stated she observed Resident #2's bruise as it became larger and spread from her chest wall to her shoulder and then down the left side of her body. LVN K revealed she monitored Resident #2's bruising, but did not document her findings anywhere. LVN K stated, "If it was a critical lab, we would've called. I didn't feel this (bruising) warranted a phone call." When asked how the physician responded to faxes received, she stated the physician reported back by fax. LVN K was asked how nursing staff knew when a physician sent a fax regarding a resident's treatment or care. LVN K replied, "It prints out on our fax. Someone in the office (business office) checks it regularly, and I check it periodically." LVN K was asked if she documented in the resident's Nurse's Notes when a physician sent a fax communication. LVN K stated, "I usually do." When asked specifically about the communication with Resident #2's physician on 07/23/12, LVN K stated the physician responded via fax and ordered a referral to a surgeon regarding the resident's [DEVICE]. LVN K was asked if it concerned her that MD B's fax on 07/23/12 did not address Resident #2's newly discovered bruise. LVN K replied, "I guess from my notes and thought process, as the days went on, the bruise got worse. It started on her left breast then spread across her chest. I paged the doctor (on 07/26/12) to let him know." When asked if she thought Resident #2's [MEDICATION NAME] contributed to Resident #2's extensive bruising at the time, LVN K replied, "We knew she (Resident #2) was on [MEDICATION NAME]. That was a thought; that it could be the [MEDICATION NAME]." LVN K was asked if MD B knew Resident #2 was on [MEDICATION NAME]. LVN K replied, "Yes. He (MD B) remembers all his patients." LVN K was asked whose responsibility it was to prompt physicians and trigger their memory when a resident was on [MEDICATION NAME] and when extensive bruising occurred. LVN K stated, "We (nurses) do." When asked if she notified MD B Resident #2 was on [MEDICATION NAME] after the bruising appeared on 07/23/12, LVN K stated, "I don't remember." LVN K did not recall if she spoke to MD B prior to documenting Resident #2's [MEDICATION NAME] was to be held on 07/25/12. LVN K then stated MD B did not order Resident #2's PT/INR to be done STAT. LVN K stated, "I probably called him (MD B) back at 4 o'clock (4:00 PM on 07/25/12). I know my notes don't support that." LVN K said she usually called the doctor and completed an incident report when a resident on [MEDICATION NAME] had a bruise of unknown origin. When asked if she also checked labs in such a case, LVN K replied, "He'll (MD B) order one but usually not STAT." An interview on 09/11/12 at 1:53 PM with the facility ' s only ADON revealed, "Anytime they (nursing staff) find something new. We fax them (the physicians) and tell them about the bruise." The ADON was asked if it was common practice for a nurse to notify a physician a resident was on [MEDICATION NAME] when reporting a bruise of unknown origin. The ADON stated, "Yes, or if they're (the residents) on Aspirin. We let them (the physicians) know if they're (the residents) diabetic and taking insulin. He (MD B) usually faxes back; will initial and send it (fax) back to us. It depends on what nurses write." Resident #2's Nurse's Note dated 07/24/12 at 11:45 AM reflected, "...Lg (large) dk (dark) discoloration noted to Lt (left) breast...stoma beefy & red...." Resident #2's Nurse's Note dated 07/25/12 at 9:30 AM reflected, "Large bruise to mid chest wall extending to lateral L torso. 4 x 4 hematoma noted to L CW (chest wall). MD paged." Resident #2's Nurse's Note dated 07/25/12 at 3:00 PM reflected, "N.O. (new order) Check PT/INR, CBC and apply ice pack to hematoma. (Mobile x-ray company) called." Resident #2's Nurse's Note dated 07/25/12 at 4:00 PM reflected, "N.O. (new order) Hold [MEDICATION NAME] until PT/INR results arrive." Resident #2's Nurse's Note dated 07/26/12 at 9:30 AM reflected, "...Bruise to L breast and chest cont to be purple and brown in color. Cont to show pain (with) movement of L arm...." Review of Resident #2's CBC laboratory report dated 07/26/12 revealed: WBC 16.9 High with a Reference Range of 4.0 - 11.0 K/ul; RBC 2.07 Low with a Reference Range of 3.80 - 5.50 M/ul; HGB 6.5 Critical Low with a Reference Range of 12.0 - 17.0 g/dL; and HCT 20.4 Critical Low with a Reference Range of 37.0 - 50.4 %. Resident #2's Nurse's Note dated 07/26/12 at 11:50 AM reflected, "Critical labs faxed over (MD P)...." Resident #2's Nurse's Note dated 07/26/12 at 12:20 PM reflected, "(MD P) returned call N.O. to send to ER." An interview on 09/11/12 at 1:53 PM with the ADON revealed she was not aware of Resident #2's extensive bruises of unknown origin until she was sent to theER on [DATE]. The ADON stated Resident #2's bruises were not documented on the skin assessment sheet on 07/20/12. When asked if she was usually made aware of extensive bruising of unknown origin the ADON stated, "No. The DON was handling all of the skin. I took the critical (lab) call and had her sent out (to the ER)." The ADON revealed Resident #2's fall on 07/16/12 was mentioned during a morning stand-up meeting but not the extensive bruising that followed. When asked who monitored the Charge Nurses, the ADON stated, "I now have a daily list from (Interim DON). Before I worked the floor and didn't monitor, but I am now." Review of a SBAR, Situation-Background-Assessment-Recommendation, Physician/NP/PA Communication and Progress Note dated 07/26/12 revealed, "...Pain level/location/status: Grimaces when move L arm ...Progress Note: Lab results came back (with) critical labs...Res to be sent to ER (emergency room ). Bruising noted last wk (week) post fall...." Review of a hospital History and Physical dated 07/26/12 revealed, "...she (Resident #2) ended up having a large hematoma on the left breast, and now there is a significant drop in her H&H (hemoglobin and hematocrit) ...Laboratory...Sodium 115 (Reference range: 140-148 mmol/L), BUN 40 (Reference range: 7-18 mg/dl) potassium 3.4 (Reference range: 3.5-5.2). When she came, her H&H was low at 6.5 and 19. Left breast appears to be significantly enlarged with a subcutaneous hematoma. Assessment: 1) [MEDICAL CONDITION] probably secondary to blood loss in the left breast. No other evidence of blood loss from the history or the exam. She has been on [MEDICATION NAME] and probably that has made the bleeding or hematoma worse. 2) Coagulopathy...Plan...Transfuse packed cells and watch her potassium closely...." Review of hospital Physician's Admit Orders dated 07/26/12 revealed "... Transfuse 2 units PRBC (packed red blood cells) today. (slowly each unit over 4 hours)...." Resident #2's facility's Nurse's Note dated 07/31/12 at 3:00 PM reflected she was readmitted to the facility with multiple bruises on her arms, leg, and chest wall, which was related to her fall on 07/16/12. The Note also reflected the resident had three plus [MEDICAL CONDITION] to left and three plus [MEDICAL CONDITION] to her left hand. Resident #2's Admission Nursing Evaluation dated 07/31/12 reflected an admitting [DIAGNOSES REDACTED]. Resident #2's new Fall Risk Evaluation dated 07/31/12 reflected a total score of 21. The Fall Risk Evaluation reflected a score of 10 and above indicated the resident was at high risk for falls. Review of Resident #2's August 2012 physician's orders [REDACTED]. During an interview on 08/25/12 at 11:00 AM with the Administrator it was revealed prior to the survey on 08/21/12, the facility's procedure for monitoring and reviewing resident injuries and ensuring nursing needs were being met included the review of incident/accident reports every morning during the morning staff meeting. The Administrator who identified himself as the facility's Abuse Prohibition Coordinator during the Entrance Conference on 08/21/12 at 10:05 AM revealed when he reviewed the incident/accident reports for Resident #2 he determined the incident was not reportable to DADS. The Administrator revealed when the DON informed him that Resident #2 had a "big, purple bruise on her breast" he immediately instructed her to send the resident to the hospital. During an interview on 08/24/12 at 12:35 PM with the DON the surveyor asked what procedure was in place prior to the start of the survey on 08/21/12 to determine when and what to report as neglect. The DON stated she was "flabbergasted" the incident involving Resident #2 even happened. The DON stated, "How does a resident who can't even move fall out of bed? I felt like it was witnessed so it was not reportable." The DON stated the incident was discussed during the facility's morning staff meeting and there was never any discussion about whether the incident was reportable or not. The DON revealed Resident #2's incident was not adequately addressed to prevent a re-occurrence because the resident's care plan in AccuNurse was not revised to reflect the change from one to two staff. She stated there was a "breakdown" in the facility's processes for care planning and AccuNurse. The DON revealed the nurse aide coordinator was not communicating with the MDS Coordinator regarding revisions to residents' plans of care. She stated she allowed things to "fall through the cracks" because she "lost her focus." The DON stated the facility had been without an Administrator for a period of two months and she was over-extended. The facility's undated Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property reflected,"...If at any time abuse and neglect are reported the staff will follow the facility policy on reporting and investigating abuse. Staff are knowledgeable in recognizing suspicious bruising, swelling, pain...All allegations, no matter what types of incidents reported will be investigated fully...An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the director of nursing. The Adm. will ensure that facility completes the appropriate investigated forms and forwards a copy of the investigation to DADS within 5 working days...Upon completion of an investigation, the director of nurses and administrator will analyze the occurrences and determine what changes, if any, are needed to prevent any further occurrences...." The facility's undated Abuse/Neglect Prohibition Policy and Procedure reflected, "All employees are to resport suspected abuse or neglect at any time it is identified...Any bruising on any resident will be documented upon discovery and all efforts will be made to determine if abuse/neglect could have occurred. The administrator or his designee will report the alleged abuse/neglect to the Texas Department of Aging and Disability Services and/or other appropriate agency and/or the appropriate law enforcement agency per regulation." The facility's undated Resident Abuse Policy reflected, "The resident has the right to be free from...injury from an unknown source...In the event if any evidence or cause to believe that a resident has suffered any of the above abuses, the employee, visitor, or family members are requested to report all allegations, suspicions, or incidents to the administrator of the facility, or to state officials as posted in the facility. Upon report of any allegations or violations the administrator or his/her designated respresentative will thoroughly investigate the situation in accordance with Texas law. Any employee suspected of abuse or neglect will be removed from the direct care of the resident/residents while the investigation is in process. The investigation will include but not limited to the following facts...5. Any evidence of injury or abuse present on the resident's body...." The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 08/22/12 and signed by the DON reflected 68 residents required assistance of one or two staff with toileting. The facility's Form CMS-672, Resident Census and Conditions of Residents, dated 08/22/12 and signed by the DON reflected 52 residents were occasionally or frequently incontinent of bladder, 40 residents were occasionally or frequently incontinent of bowel, 13 residents were dependent on staff for bathing, one resident was dependent on staff for transferring and one resident was dependent on staff for toileting.

Based on observation, interview and record review, it was determined the facility failed to implement its written policies regarding abuse/neglect/misappropriation, for one (Resident #1) of thirteen residents reviewed for abuse. - Resident #1 did not want male aides to provide care for him. - The ADM was aware of this on 03/03/12 and only two staff were informed not to assign a male aide to provide care for Resident #1. - On 03/08/12, CNA C provided incontinent care for Resident #1 despite the resident's vigorously telling the CNA to stop. - On 03/08/12, Resident #1 alleged CNA A hit him and cursed him. The resident had multiple bruises on both arms and a skin tear on the left arm. An Immediate Jeopardy (IJ) was identified on 03/08/12. While the IJ was lowered on 03/09/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures allowed CNA C to continue to provide care for Resident #1 for three nights resulting in the CNA providing incontinent care when the resident repeatedly told him no. This potentially contributed to Resident #1's skin tear and multiple bruising to both arms. These failures could affect the 59 residents residing on Halls 1, 2, 3 and 4, where CNA C was scheduled to work and placed them at risk for physical abuse, verbal abuse, lacerations, bruises and fractures. Findings included: Review of the undated "Senior Care Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property," provided by the ADM as the current policy, revealed: "Each resident has the right to be free from abuse...Residents will not be subjected to abuse by anyone, including...facility staff.... PREVENTION: ...each employee receives the 'Employee Standards of Conduct', which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a Resident... IDENTIFICATION: ...All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries; sudden changes in resident's behavior or personality; and resident fear and anxiety... INVESTIGATION: All staff in the nursing facility...have been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor...The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will them report the allegation to the director of nursing, and/or the administrator...." 1) Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of February 2012 consolidated physicians' orders for Resident #1 revealed he took the following medications: [REDACTED]. Review of a quarterly MDS assessment dated [DATE] for Resident #1 revealed the resident was able to recall three words after given to him, he was able to state the current year and he suffered signs of inattention and disorganized thinking. Resident #1 did not have any behaviors identified, but the assessment reflected the resident had [MEDICAL CONDITION]. He required two person physical assistance with bed mobility and toileting. Review of the Comprehensive Plans of Care for Resident #1 included the following: a. "Resident is currently taking [MEDICAL CONDITION] Medications," initiated on 05/09/11 and was last updated 01/25/12. "Approach:...7) Protect resident from self harm or harm to others...." b. "Resident has [DIAGNOSES REDACTED]...3) Remove resident from areas where there is over stimulation that agitates or confuses resident...." c. "Residents ADL functions," initiated on 05/09/11, "Toileting: one staff," (this was updated on 01/25/12 to state "assist of 2" needed for transfers & toileting). d. "Resident is verbally abusive to staff and others" initiated on 08/16/11, " ...Approach:...5) If resident is upset during care, stop and return later to allow resident to calm down. 6) Notify physician if behavior interferes with physical functioning...." e. "Resident is physically abusive to staff," initiated on 08/16/11, "...Approach: "...6) Notify physician if behavior interferes with physical functioning...8) If resident is upset during care, stop and return later to allow resident to calm down...." Review of a Social Service Review dated 07/08/11 for Resident #1 revealed, "...At times kicks hits & curses staff...." Review of Nurses' Notes from 12/10/11 through 03/08/12 revealed: 12/22/11 - 9:00 a.m. "Resident is refusing shower. When asking him again resident became agitated...." 01/14/12 - 12:00 a.m. "Res refusing care to be (changed), dried...." 01/27/12 - 8:30 a.m. "Resident refused all am meds offered by med aide offered again by nurse x2...refused...." 02/03/12 - 7:00 a.m. "...difficult resident in that he is trying to hit and curse NA when attempting to help-same he refused to let do care for him." 02/15/12 - 7:00 a.m. "...Abusive in attitude and language-Reported a CNA stated to me (Resident #1) had asked if (staff member) could 'suck' on her '(breast)'. She has not refused further help, but has asked he not speak to her this way. Will report behavior to appropriate personnel...." 02/20/12 - 12:00 a.m. "Refused care from CNA @ this time...." 2:00 a.m. "Resident (continues) to refuse care bed is wet & resident needs to be changed States come back @ 1 o'clock." 4:00 a.m. "Resident cont (continues) to refuse care from CNA again bed is wet & resident needs to be changed...." 02/25/12 - 10:30 p.m. "Resident refused to be (changed) or have any ADLs performed...." 02/26/12 - 12:15 a.m. "Resident refused ADLs, to be changed or cleaned up by any staff member." 02/26/12 - 5:00 a.m. "Resident refused care." 02/27/12 - 2:20 a.m. "Resident refused care." 03/08/12 - 9:30 a.m. "Called into res room by (ADM) and noted a skin tear on res (right) wrist 1cm (by) 1 cm. Cleanse (with) NS, apply TAO and bandaid. Res states '(CNA C) did this, he hit me in the chest and grabbed my arms.' Also noted multiple bruising . Has one on (left) arm measuring 5.5 cm (by) 3.5 cm. On (left) under arm 10.5 (by) 5 cm. And one on (right) forearm measuring 6.5 cm (by) 4 cm...." Review of Psychoactive Side Effect Monitoring for February 2012, for Resident #1, revealed he had no behaviors, or side effects for the entire month, except for 02/23/12, which was agitation/restlessness, verbal abuse and expressions of worry or general restlessness. Review of Psychoactive Side Effect Monitoring for March 2012, for Resident #1, revealed he had no behaviors, or side effects from 03/01/12 through 03/08/12. Interview on 03/09/12 at 11:16 a.m. with ADON O revealed Resident #1's behaviors should have been documented in the nurses notes and/or Social Services notes and on the behavior sheets. 2) Review of the Provider Investigation Report dated 03/08/12 revealed "Description of the Allegation: ___ (Resident #1) stated ___ (CNA C) came in his room at 5:30 am this morning and beat him up - stated he beat him in his chest with his fists and showed me a skin tear/stated CNA told him administrator and 3 others told him to do it...Investigation Summary ...Social Worker questioned resident on Halls 3 and 4 regarding treatment from ___ (CNA C). Head to toe assessment performed on all residents ___(CNA C) provided treatment to to determine if there were signs of abuse. fell ow staff members interviewed to determine if they had ever witnessed abuse from ___ (CNA C)...Investigation Findings: ___ (Confirmed was marked)...Provider Action Taken Post-Investigation: Staff in-serviced regarding recognizing and reporting abuse. Only 'female staff members' will provide care for resident in future - care plan updated, 'female'...." Review of a typed statement (attached to the Provider Investigation Report) dated 03/08/12 completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, that (Resident #1) had to be cared for. (LVN E) informed me at that point, (Resident #1) did not like males taking care of him and I said we have to see to it he receives care, and it was decided to have a female trade off and care for him. I called her the next morning and she said things had worked out fine. I called the other night charge nurse, (LVN H), on Monday night (03/05/12) her first night back and explained to her what was to be done. She voiced understanding and agreement." The statement was signed by the ADM. Review of a typed statement (attached to the Provider Investigation Report) undated, completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, She (sic) remembered the conversation and stated she had implemented the policy that night and explained to (CNA I) and (CNA C) that (CNA I) would have to come off the unit to care for (Resident #1) because he does not like males caring for him. (CNA C) understood he was not to care for (Resident #1). (LVN E) stated she thought everything had worked out fine and (CNA C) had stayed out of his room...." Review of the Hand Written Witness Statement received from CNA D on 03/09/12 at 5:43 p.m. revealed, "I have been employed at the Honey Grove Nursing Center for approximately 6 months. I have been an ordained minister for [AGE] years. A few days after February 20th on the night shift, while standing at or near the nursing station, ___ (CNA C) walked up at (sic) stated; 'I told ___ (Resident #1) he was gonna have to be changed whether he liked it or not. So turn your ass over.' ___ (LVN E) and ___ (LVN F) were at the nurses station at that time. On February 20th ___ (CNA A), ___ (CNA J), and myself went in to change ___ (Resident #1) and he refused to allow us to care for him. When I went in at 3:30 A.M. He told me to come back at 1:00. This was the first time I had attempted to care for him, and was later told he did not care for men taking (sic) of him. I reported to the nurse that he would not allow me to change him. I did not report or saying anything after ___ (CNA C's) comment because he used bad language and there were other staff around at the time. I have worked with ___ (CNA C) several times before and I felt that he was at times rough but not abusive with patients...." Review of the undated typed statement from the ADM revealed: "On March 8th, I took ___ (Resident #1) his breakfast tray. I asked him if he would like coffee and he stated he did not want anything from me. I could tell he was angry and I asked him what was wrong and he looked in the direction of his roommate and did not say anything. I assumed he was not getting along with his roommate, which is not unusual for ___ (Resident #1). When I came back with the coffee, I began asking ___ (Resident #1) questions and he finally began talking. He stated ___ (CNA C) had come in at 5:30 that morning and beat him up and showed me a skin tear on his arm (you could tell it was fresh), he also stated ___ (CNA C) had beat him in his chest with his fists. ___ (Resident #1) then said he did not know why I was looking so surprised as I had sent ___ (CNA C) into beat him up. I told ___ (Resident#1) I would never do that. ___ (Resident #1) said, 'well, he said you did - you and three other ladies'. ___ (Resident #1) said he did not want ___ (CNA C) back in his room, I informed him, ___ (CNA C) would probably not be back - that I would have to do an investigation. ___ (Resident #1) was happy about that. I told him I would be calling it into the state and that made him even happier - said he was also going to get an attorney. I asked ___ (Resident #3), ___ (Resident #1's) roommate who is very alert what happened and ___ (Resident #3) said ___ (CNA C) came into clean him and in the middle of cleaning him, ___ (Resident #1) started to fight. ___ (Resident #3) was able to confirm that ___ (CNA C) told ___ (Resident #1) that I had sent him in there. That evening when I asked ___ (CNA C) about the statement he denied it. I didn't push it but I knew he had said it because ___ (Resident #3) confirmed it earlier that day. Throughout the day, I kept ___ (Resident #1) abreast of what was going on. ___ (Resident #1) continued to talk about it and his story never changed once...." The statement was signed by the ADM. 3) Interview on 03/08/12 at 1:29 p.m. with RN B revealed she had been working with Resident #1 for about three days. RN B stated Resident #1 reported on the 10:00 p.m. - 6:00 a.m. shift on 03/08/12 a CNA had been "beating on him and shoving him against the wall." RN B stated Resident #1 had a skin tear. Resident #1 identified CNA C as the perpetrator. He (Resident #1) revealed CNA C had also been abusive to other people, but did not provide names of any specific residents. RN B stated Resident #1 had already talked to LVN L about CNA C, so RN B did not report the incident to anyone. RN B described Resident #1 to be "a little ornery when he first met and got to know someone." RN B stated Resident #1 had bruising up and down his arms. Resident #1 had reported having been hit in the chest but would not allow RN B to see his chest. RN B felt Resident #1 was worried about CNA C coming back that evening. During an interview on 03/08/12 at 1:50 p.m., LVN L was queried regarding Resident #1's allegations. LVN L replied, "Well, it's kind of under investigation." LVN L explained the ADM had called her and they went to Resident #1's room to talk to the resident between 9:30 a.m. and 10:30 a.m. on 03/08/12. LVN L stated Resident #1 had a lot of new, dark bruising on his arms and had a 1 cm by 1 cm skin tear. Resident #1 reported to LVN L CNA C grabbed his arms and punched him in the chest. LVN L stated she measured all of the bruises and did not see any bruises on his chest. Resident #1 told her the abuse had been going on for three days. LVN L stated she told Resident #1 this was unacceptable, and he had to let someone know if something like this was happening. Resident #1 again reported CNA C grabbed his arms and hit him in the chest, hard. LVN L stated Resident #1 was interviewable but could be "rowdy, and verbally abusive." LVN L stated Resident #1 verbalized the same story several times that day. LVN L stated she completed the Incident/Accident Report and the assessment. LVN L did not know how the ADM had found out about the incident but thought it was while she was delivering breakfast trays to the residents. LVN L stated Resident #1 needed assistance with transfers and was incontinent of bowel and bladder. LVN L had not received any similar complaints about CNA C and stated she knew CNA C worked on the hall the night before because she had already checked the assignment books. Interview on 03/08/12 at 2:04 p.m. with the ADM revealed she was working on an investigation involving Resident #1. The ADM stated Resident #1 reported CNA C had come into his room and beat him up around 5:30 a.m. on 03/08/12. Resident #1 showed her a skin tear and said CNA C had beat him in the chest with his fist. Resident #1 reported this when she delivered coffee to his room and picked up his breakfast tray. The ADM initially was under the impression Resident #1 was upset with his roommate. Resident #1 then stated to the ADM, "You told that guy to come and beat me up." Resident #1 explained CNA C had beat him and hit him in the chest. The ADM stated Resident #1 had not reported the incident to anyone else at that point. The ADM revealed CNA C worked nights and had worked on Hall 2, where Resident #1 resided, the night before (03/07/12). She stated she had been attempting to contact CNA C, but there was no answer. The ADM stated she did not know if CNA C was scheduled to work that night (03/08/12). The ADM stated she spoke with Resident #1's roommate, who revealed Resident #1 was fighting CNA C, who was providing care. The ADM stated even if Resident #1 was fighting, CNA C still did wrong because he should have left the room and not continued care. The ADM stated Resident #1 had repeatedly reported the same story to her (ADM) and other people all day long. The ADM stated Resident #1 had a court-appointed Guardian which meant, "He's not supposed to be that sharp." The ADM then explained Resident #1 had reported problems with his roommates before but later did not recall what he had said. The ADM stated the SW was interviewing residents to see if there were additional reports of problems with CNA C. The ADM stated the interviews with the other residents were "good" with no issues at that point. CNA C had reportedly been an employee at the facility for a long time. He was previously the van driver but was removed from that position for texting on a cell phone while he was driving. She stated she had no prior allegations against CNA C and had not had to conduct any investigation involving CNA C before. The ADM said the incident had already been reported to the State agency. Interview on 03/08/12 at 2:30 p.m. with CNA A revealed he was normally assigned to Hall 2 and had worked that day (03/08/12) on Hall 2, where Resident #1 resided. When asked if he was aware of any abuse happening in the facility, CNA A stated Resident #1 stated a staff member grabbed and twisted his arm early in the morning of 03/08/12. CNA A stated he reported this to RN B at approximately 6:30 a.m. on 03/08/12. When asked if Resident #1 had made an allegation of physical abuse in the past, CNA A stated he had not. CNA A added, "He is not a complainer...he doesn't like male aides." When asked to expand on Resident #1 not liking male aides, CNA A stated if a male aide came into the room, Resident #1 would be aggressive. CNA A stated when he was assigned to Resident #1's room, he took it upon himself to switch off with a female CNA so he would not have to care for Resident #1. Interview on 03/08/12 at 2:36 p.m. with LVN L revealed she did not make the CNAs' assignments so she was not aware of how it was determined who worked where and with which residents. She stated it depended "on the day" as to who was able to care of Resident #1, because the resident changed his mind frequently. She stated Resident #1 never allowed CNA A to care for him. LVN L stated Resident #1 did not want males cleaning him. Resident #1 would generally let women but not males into his room. LVN L stated if there was a male assigned to the hall, they would switch out with a female aide to provide care to Resident #1, then switch back after the care was provided. LVN L stated, "We don't put him through it for the heck of it. He has rights about who cares for him." Interview on 03/08/12 at 2:39 p.m. with CNA M revealed she had worked with Resident #1. She stated Resident #1 had always been sweet to her but used inappropriate language at times. CNA M stated Resident #1 had never reported anything to her about anyone that cared for him. She had seen him be rude to the male staff even when they were only there to bring him ice. CNA M was not aware of any male staff members who were not allowed in Resident #1's room. Observation and interview on 03/08/12 at 2:59 p.m. with Resident #1 revealed he "had a bad day since 5:00 this morning." Resident #1 explained he had been "beat on and cussed." Resident #1 showed the surveyor his arms. One arm had a band aid, and a scabbed area with dried blood and bruising. Both arms had multiple bruises. Resident #1 was observed in his room sitting in his wheelchair. Interview on 03/08/12 at 3:06 p.m. with HA N revealed he had worked with Resident #1. When queried about the resident, HA N responded, "He (Resident #1) doesn't like dudes." HA N stated it was "well known" Resident #1 did not like male staff doing anything for him. HA N stated if Resident #1 got upset, he just continued to do his job while Resident #1 cursed at him. Interview on 03/08/12 at 3:10 p.m. with ADON O, who also was the acting DON, revealed Resident #1 had a favorite aide and had even moved halls so he could be where she could take care of him. ADON O stated staff had not informed her Resident #1 did not want males to provide care or that it caused problems when males provided care. ADON O stated there were four male aides, and she was not aware of any male aides switching with the female aides to provide care. Interview on 03/08/12 at 3:40 p.m. with the SW revealed she was conducting interviews with residents specifically about the care they received from CNA C. Most of the residents had reported they felt safe with CNA C, but Resident #2 stated CNA C had been rough with him. Resident #2 stated when he reported CNA C to the nurse, CNA C came back and yelled at him. Resident #2 had stated that had been "a while ago." Resident #2 told the SW CNA C had also yelled at other residents. When the SW was asked if the ADM had been made aware of CNA C yelling at residents, she revealed she had not. The SW stated she had completed five resident interviews from residents on Halls 2 and 3. Interview on 03/08/12 at 4:16 p.m. with the ADM revealed since Resident #1 reported to her CNA C had beaten him, the ADM had made several unsuccessful telephone calls to CNA C, who worked the 10:00 p.m. to 6:00 a.m. shift. The ADM stated she had even attempted to call CNA I, who was close friends with CNA C. The ADM stated she had reported the allegation to the State agency and the local police. She stated she was to let the police know when CNA C came in, so they could interview him regarding the allegation. The ADM stated she had interviewed CNA D regarding CNA C's behavior. CNA D reported to the ADM CNA C was "hurried" and "a little rough." The ADM stated CNA D also told her CNA C stated, "I (CNA C) go in there to clean him up...I have to do it, whether you like it or not." The ADM stated the SW had told her she completed some resident interviews and one resident was not "favorable" of CNA C. On 03/08/12 at 4:35 p.m., Resident #1 was queried about the bruises on his arms. He stated, "I can remember it like my first name. ___ (CNA C)." Resident #1 was observed lying in bed, shaking and visibly upset. The surveyor requested permission from Resident #1 to take pictures of the bruising on his arms and he stated, "Yes." Resident #1 then asked the surveyor to sit down and talk with him a bit, because he was upset. Interview on 03/08/12 at 4:36 p.m. with CNA D revealed he had been employed at the facility for six months and was normally assigned to Hall 1 (secured unit) on the 2:00 p.m. to 10:00 p.m. shift. He stated he had recently been working overtime on the 10:00 p.m. to 6:00 a.m. shift in other parts of the facility. When asked if he was concerned about abuse in the facility, CNA D stated CNA C was "rough" at times, which had bothered him. CNA D stated Resident #1 had a problem with male aides assisting him. He (CNA D) was at the nurses' station with LVN E and LVN F when CNA C came toward the nurses' station and made the statement, "I told him, I'm gonna change you ass, turn over." CNA D stated one day last week, the ADM spoke to LVN E about Resident #1 not liking male assistance with care. CNA D stated the ADM told LVN E to switch out care with a female aide for Resident #1. When asked if it was well known Resident #1 did not like male aides caring for him, CNA D responded, "Oh yeah." When asked if the ADM was made aware of the statement CNA C made regarding Resident #1, CNA D stated he did not know. CNA D stated on another night, he was asked to attempt to change Resident #1 because the resident had refused two male CNAs, including CNA C. When he went in, Resident #1 refused again. Later, a female CNA from the secure unit was able to change him. Telephone interview on 03/08/12 at 4:55 p.m. with LVN E revealed she was aware Resident #1 was combative with male aides. She stated Resident #1 was nice to her, but he would not let a male aide assist him. LVN E denied hearing CNA C make the statement regarding Resident #1, as referenced in the interview on 03/08/12 at 4:36 p.m. with CNA D. When asked about CNA C, LVN E stated he was usually pretty good and most residents liked him. When asked which resident did not like CNA C, LVN E replied, "(Resident #1)." Interview on 03/08/12 at 8:56 p.m. with LVN F revealed she normally worked on Halls 4, 5, and 6 on the night shift. When asked if anything had been different when she arrived at work on 03/08/12, LVN F stated she had been inserviced on abuse and reporting abuse. LVN F stated she was not aware of any abuse,which had occurred and stated she had not received any complaints or reports of suspected abuse. LVN F stated she did know who CNA C was and denied overhearing CNA C make a comment like "I'm going to change your ass, so turn over" or anything else derogatory. LVN F stated she would have stopped him immediately had she heard this. LVN F reported she had heard CNA C curse but not at a resident. LVN F stated she had heard LVN E say, about a month ago, Resident #1 did not like males providing care to him. Interview on 03/08/12 at 4:47 p.m. with the ADM revealed she was not aware of any incidents or concerns involving CNA C prior to this allegation. The ADM only remembered disciplining him for texting and driving. The ADM stated she spoke with LVN E the past weekend (03/03/12) about Resident #1. The ADM told LVN E Resident #1 could not be left all night without being changed. Resident #3, who was Resident #1's roommate, had reported he went all night without being changed. The ADM stated she learned the reason Resident #1 had gone without being changed was because he did not like males providing him with care. The ADM informed LVN E a female needed to be the person who went into care for Resident #1 throughout the night. The ADM stated she was not sure why CNA C was still providing care, and shook her head saying "That's a problem." When asked specifically if anyone reported CNA C' statement to Resident #1, "I'm to going to change you ass, so turn over," (or anything similar), the ADM responded, "Really? Wow." The ADM stated she talked with CNA D who worked last night. The ADM stated she was unaware ADON O did not know about Resident #1 not wanting males to provide care to him. The ADM stated there were more males who worked the night shift than females and the ADM agreed it was the right of the residents to not have certain staff members care for them. The ADM stated, "This is a concern that should've been dealt with." Review of Daily Sign in Sheets, provided by the ADM, revealed on 03/03/12, 03/04/12 and 03/07/12 (all after the ADM was aware on 03/03/12 Resident #1 did not like male aides providing care to him ), CNA C was assigned to Halls 2 and 3. CNA C was assigned to Halls 2 and 3 on the night of 03/08/12 as well. Review of the ADL Coding Summary form dated 03/02/12 through 03/08/12 for Resident #1 revealed on 03/03/12 on the night shift, one staff person was provided for toileting due to the resident being totally dependent on one staff for toileting. On 03/04/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. On 03/07/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. During an interview on 03/08/12 at 5:10 p.m., the ADM revealed she told RN G and LVN H Resident #1 did not like male aides providing his care, on or about 03/03/12. The ADM confirmed she did not inform any additional staff of the behaviors exhibited by Resident #1. 4) On 03/08/12 at 5:40 p.m., the ADM and the ADON O were informed an Immediate Jeopardy was identified in the area of Resident Behavior and Facility Practices. A Plan of Removal for the IJ was requested. 5) Telephone interview on 03/08/12 at 8:00 p.m. with the Police Officer revealed he was unaware of the facility's plan to call and report if CNA C showed up at the facility. This information had not been passed on by his Police Chief. The Police Officer confirmed the facility had not called him at that point in the evening. Observation and interview on 03/08/12 at 8:35 p.m. revealed Resident #1 was in his bed, awake. There were multiple bruises and a skin tear to the right arm, and multiple bruises to the right arm. Resident #1 stated his ribs were very sore, and that it was uncomfortable to turn over. He added, "It's real sore on the inside." When asked if CNA C had done this to him in the past, Resident #1 stated it had never happened before. He stated, "He's been ugly before." When asked how he had been ugly, Resident #1 stated, "All kinds of different stuff." When asked why he preferred female staff to care for him, Resident #1 stated, "Women are more gentle." He added, "I prefer a woman for certain things." When asked to explain, he revealed for showers and toileting. Interview on 03/08/12 at 8:43 p.m. with LVN E revealed she normally worked the 6:00 p.m. to 6:00 a.m. on Halls 1, 2 and 3. When asked what happened when she arrived at the facility on 03/08/12, LVN E stated she talked with the ADM regarding CNA C. LVN E stated last Saturday (03/03/12), the ADM spoke to her regarding Resident #1. LVN E stated she was told by the ADM Resident #1 needed to have a female aide care for him. LVN E stated she told CNA C he was not supposed to provide care for Resident #1. When asked how she monitored Resident #1 to ensure CNA C did not provide care for him, LVN E stated she took his word for it and assumed CNA C did not provide care. LVN E added, "He (Resident #1) refuses to let males touch him...he is very abusive to staff." When asked if she had heard CNA C talk abusively to or about Resident #1, LVN E denied she had. When asked what CNA C's demeanor was at work, LVN E stated CNA C cursed a lot, but not directly to the residents. She added he used the "S" word and the "F" word. During an interview on 03/08/12 at 9:04 p.m. with the ADM and the RVP regarding the status of the investigation, the ADM stated she needed to interview the night staff. She added inservicing was being done regarding "females only" in Resident #1's room. She stated if staff were not working, they were being called on the phone, and staff were not to work until after they were inserviced. Also, care plan information was being added to the Accunurse system (computer system used by the aides and nurses to track resident ADLs) so all the nurses and aides had access to the information. The ADM stated she spoke with CNA D and LVN E. When asked about CNA C, the ADM stated CNA C had been to the facility and she interviewed him. When asked if she notified the police, as per her intention, the ADM stated she forgot. The ADM reported CNA C was not coming back to work at 10:00 p.m., because he had been suspended. The ADM stated CNA C revealed in the interview he told Resident #1 he was going to change him. Resident #1 responded saying no one was going to change him. Resident #1 then "swung" at CNA C. CNA C stated he still continued to provide care to Resident #1. CNA C denied abusing Resident #1, denied causing a skin tear to Resident #1, and denied being told by LVN E only females were supposed to be providing care to Resident #1. The ADM revealed at that point of the interview, she brought in LVN E. In the presence of LVN E, CNA C stated he remembered being told only females were to provide care to Resident #1. The ADM stated she felt it was abuse for CNA C to continue to provide care to Resident #1 after the resident was resisting. When asked about procedures in the event residents resisted care, the ADM stated they were trained to walk away, come back later, report to the charge

Based on observation, interview and record review, it was determined the ADM failed to administer the facility in a manner that enabled it to use its resources to effectively and efficiently attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of 13 residents reviewed for abuse. 1) The ADM failed to implement and follow the facility's Abuse and Neglect P/P. Staff did not immediately report or report allegations of abuse to him. 2) The ADM failed to implement protective measures for Resident #1 by ensuring a male aide was not assigned to provide care for the resident. - Resident #1 did not want male aides to provide care for him. - The ADM was aware of this on 03/03/12 and only two staff were informed not to assign a male aide to provide care for Resident #1. - On 03/08/12, CNA C provided incontinent care for Resident #1 despite the resident's vigorously telling the CNA to stop. - On 03/08/12, Resident #1 alleged CNA A hit him and cursed him. The resident had multiple bruises on both arms and a skin tear on the left arm. An Immediate Jeopardy (IJ) was identified on 03/08/12. While the IJ was lowered on 03/09/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that was not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures allowed CNA C to continue to provide care for Resident #1 for three nights resulting in the CNA providing incontinent care when the resident repeatedly told him no. This potentially contributed to Resident #1's skin tear and multiple bruising to both arms. These failures could affect the 59 residents residing on Halls 1, 2, 3 and 4, where CNA C was scheduled to work and placed them at risk for physical abuse, verbal abuse, lacerations, bruises and fractures. Findings included: 1) Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of February 2012 consolidated physicians' orders for Resident #1 revealed he took the following medications: [REDACTED]. Review of a quarterly MDS assessment dated [DATE] for Resident #1 revealed the resident was able to recall three words after given to him, he was able to state the current year and he suffered signs of inattention and disorganized thinking. Resident #1 did not have any behaviors identified, but the assessment reflected the resident had [MEDICAL CONDITION]. He required two person physical assistance with bed mobility and toileting. Review of the Comprehensive Plans of Care for Resident #1 included the following: a. "Resident is currently taking [MEDICAL CONDITION] Medications," initiated on 05/09/11 and was last updated 01/25/12. "Approach:...7) Protect resident from self harm or harm to others...." b. "Resident has [DIAGNOSES REDACTED]...3) Remove resident from areas where there is over stimulation that agitates or confuses resident...." c. "Residents ADL functions," initiated on 05/09/11, "Toileting: one staff," (this was updated on 01/25/12 to state "assist of 2" needed for transfers & toileting). d. "Resident is verbally abusive to staff and others" initiated on 08/16/11, " ...Approach:...5) If resident is upset during care, stop and return later to allow resident to calm down. 6) Notify physician if behavior interferes with physical functioning...." e. "Resident is physically abusive to staff," initiated on 08/16/11, "...Approach: "...6) Notify physician if behavior interferes with physical functioning...8) If resident is upset during care, stop and return later to allow resident to calm down...." Review of a Social Service Review dated 07/08/11 for Resident #1 revealed, "...At times kicks hits & curses staff...." Review of Nurses' Notes from 12/10/11 through 03/08/12 revealed: 12/22/11 - 9:00 a.m. "Resident is refusing shower. When asking him again resident became agitated...." 01/14/12 - 12:00 a.m. "Res refusing care to be (changed), dried...." 01/27/12 - 8:30 a.m. "Resident refused all am meds offered by med aide offered again by nurse x2...refused...." 02/03/12 - 7:00 a.m. "...difficult resident in that he is trying to hit and curse NA when attempting to help-same he refused to let do care for him." 02/15/12 - 7:00 a.m. "...Abusive in attitude and language-Reported a CNA stated to me (Resident #1) had asked if (staff member) could 'suck' on her '(breast)'. She has not refused further help, but has asked he not speak to her this way. Will report behavior to appropriate personnel...." 02/20/12 - 12:00 a.m. "Refused care from CNA @ this time...." 2:00 a.m. "Resident (continues) to refuse care bed is wet & resident needs to be changed States come back @ 1 o'clock." 4:00 a.m. "Resident cont (continues) to refuse care from CNA again bed is wet & resident needs to be changed...." 02/25/12 - 10:30 p.m. "Resident refused to be (changed) or have any ADLs performed...." 02/26/12 - 12:15 a.m. "Resident refused ADLs, to be changed or cleaned up by any staff member." 02/26/12 - 5:00 a.m. "Resident refused care." 02/27/12 - 2:20 a.m. "Resident refused care." 03/08/12 - 9:30 a.m. "Called into res room by (ADM) and noted a skin tear on res (right) wrist 1cm (by) 1 cm. Cleanse (with) NS, apply TAO and bandaid. Res states '(CNA C) did this, he hit me in the chest and grabbed my arms.' Also noted multiple bruising . Has one on (left) arm measuring 5.5 cm (by) 3.5 cm. On (left) under arm 10.5 (by) 5 cm. And one on (right) forearm measuring 6.5 cm (by) 4 cm...." Review of Psychoactive Side Effect Monitoring for February 2012, for Resident #1, revealed he had no behaviors, or side effects for the entire month, except for 02/23/12, which was agitation/restlessness, verbal abuse and expressions of worry or general restlessness. Review of Psychoactive Side Effect Monitoring for March 2012, for Resident #1, revealed he had no behaviors, or side effects from 03/01/12 through 03/08/12. Interview on 03/09/12 at 11:16 a.m. with ADON O revealed Resident #1's behaviors should have been documented in the nurses notes and/or Social Services notes and on the behavior sheets. 2) Review of the Provider Investigation Report dated 03/08/12 revealed "Description of the Allegation: ___ (Resident #1) stated ___ (CNA C) came in his room at 5:30 am this morning and beat him up - stated he beat him in his chest with his fists and showed me a skin tear/stated CNA told him administrator and 3 others told him to do it...Investigation Summary ...Social Worker questioned resident on Halls 3 and 4 regarding treatment from ___ (CNA C). Head to toe assessment performed on all residents ___(CNA C) provided treatment to to determine if there were signs of abuse. fell ow staff members interviewed to determine if they had ever witnessed abuse from ___ (CNA C)...Investigation Findings: ___ (Confirmed was marked)...Provider Action Taken Post-Investigation: Staff in-serviced regarding recognizing and reporting abuse. Only 'female staff members' will provide care for resident in future - care plan updated, 'female'...." Review of a typed statement (attached to the Provider Investigation Report) dated 03/08/12 completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, that (Resident #1) had to be cared for. (LVN E) informed me at that point, (Resident #1) did not like males taking care of him and I said we have to see to it he receives care, and it was decided to have a female trade off and care for him. I called her the next morning and she said things had worked out fine. I called the other night charge nurse, (LVN H), on Monday night (03/05/12) her first night back and explained to her what was to be done. She voiced understanding and agreement." The statement was signed by the ADM. Review of a typed statement (attached to the Provider Investigation Report) undated, completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, She (sic) remembered the conversation and stated she had implemented the policy that night and explained to (CNA I) and (CNA C) that (CNA I) would have to come off the unit to care for (Resident #1) because he does not like males caring for him. (CNA C) understood he was not to care for (Resident #1). (LVN E) stated she thought everything had worked out fine and (CNA C) had stayed out of his room...." Review of the Hand Written Witness Statement received from CNA D on 03/09/12 at 5:43 p.m. revealed, "I have been employed at the Honey Grove Nursing Center for approximately 6 months. I have been an ordained minister for [AGE] years. A few days after February 20th on the night shift, while standing at or near the nursing station, ___ (CNA C) walked up at (sic) stated; 'I told ___ (Resident #1) he was gonna have to be changed whether he liked it or not. So turn your ass over.' ___ (LVN E) and ___ (LVN F) were at the nurses station at that time. On February 20th ___ (CNA A), ___ (CNA J), and myself went in to change ___ (Resident #1) and he refused to allow us to care for him. When I went in at 3:30 A.M. He told me to come back at 1:00. This was the first time I had attempted to care for him, and was later told he did not care for men taking (sic) of him. I reported to the nurse that he would not allow me to change him. I did not report or saying anything after ___ (CNA C's) comment because he used bad language and there were other staff around at the time. I have worked with ___ (CNA C) several times before and I felt that he was at times rough but not abusive with patients...." Review of the undated typed statement from the ADM revealed: "On March 8th, I took ___ (Resident #1) his breakfast tray. I asked him if he would like coffee and he stated he did not want anything from me. I could tell he was angry and I asked him what was wrong and he looked in the direction of his roommate and did not say anything. I assumed he was not getting along with his roommate, which is not unusual for ___ (Resident #1). When I came back with the coffee, I began asking ___ (Resident #1) questions and he finally began talking. He stated ___ (CNA C) had come in at 5:30 that morning and beat him up and showed me a skin tear on his arm (you could tell it was fresh), he also stated ___ (CNA C) had beat him in his chest with his fists. ___ (Resident #1) then said he did not know why I was looking so surprised as I had sent ___ (CNA C) into beat him up. I told ___ (Resident#1) I would never do that. ___ (Resident #1) said, 'well, he said you did - you and three other ladies'. ___ (Resident #1) said he did not want ___ (CNA C) back in his room, I informed him, ___ (CNA C) would probably not be back - that I would have to do an investigation. ___ (Resident #1) was happy about that. I told him I would be calling it into the state and that made him even happier - said he was also going to get an attorney. I asked ___ (Resident #3), ___ (Resident #1's) roommate who is very alert what happened and ___ (Resident #3) said ___ (CNA C) came into clean him and in the middle of cleaning him, ___ (Resident #1) started to fight. ___ (Resident #3) was able to confirm that ___ (CNA C) told ___ (Resident #1) that I had sent him in there. That evening when I asked ___ (CNA C) about the statement he denied it. I didn't push it but I knew he had said it because ___ (Resident #3) confirmed it earlier that day. Throughout the day, I kept ___ (Resident #1) abreast of what was going on. ___ (Resident #1) continued to talk about it and his story never changed once...." The statement was signed by the ADM. 3) Interview on 03/08/12 at 1:29 p.m. with RN B revealed she had been working with Resident #1 for about three days. RN B stated Resident #1 reported on the 10:00 p.m. - 6:00 a.m. shift on 03/08/12 a CNA had been "beating on him and shoving him against the wall." RN B stated Resident #1 had a skin tear. Resident #1 identified CNA C as the perpetrator. He (Resident #1) revealed CNA C had also been abusive to other people, but did not provide names of any specific residents. RN B stated Resident #1 had already talked to LVN L about CNA C, so RN B did not report the incident to anyone. RN B described Resident #1 to be "a little ornery when he first met and got to know someone." RN B stated Resident #1 had bruising up and down his arms. Resident #1 had reported having been hit in the chest but would not allow RN B to see his chest. RN B felt Resident #1 was worried about CNA C coming back that evening. During an interview on 03/08/12 at 1:50 p.m., LVN L was queried regarding Resident #1's allegations. LVN L replied, "Well, it's kind of under investigation." LVN L explained the ADM had called her and they went to Resident #1's room to talk to the resident between 9:30 a.m. and 10:30 a.m. on 03/08/12. LVN L stated Resident #1 had a lot of new, dark bruising on his arms and had a 1 cm by 1 cm skin tear. Resident #1 reported to LVN L CNA C grabbed his arms and punched him in the chest. LVN L stated she measured all of the bruises and did not see any bruises on his chest. Resident #1 told her the abuse had been going on for three days. LVN L stated she told Resident #1 this was unacceptable, and he had to let someone know if something like this was happening. Resident #1 again reported CNA C grabbed his arms and hit him in the chest, hard. LVN L stated Resident #1 was interviewable but could be "rowdy, and verbally abusive." LVN L stated Resident #1 verbalized the same story several times that day. LVN L stated she completed the Incident/Accident Report and the assessment. LVN L did not know how the ADM had found out about the incident but thought it was while she was delivering breakfast trays to the residents. LVN L stated Resident #1 needed assistance with transfers and was incontinent of bowel and bladder. LVN L had not received any similar complaints about CNA C and stated she knew CNA C worked on the hall the night before because she had already checked the assignment books. Interview on 03/08/12 at 2:04 p.m. with the ADM revealed she was working on an investigation involving Resident #1. The ADM stated Resident #1 reported CNA C had come into his room and beat him up around 5:30 a.m. on 03/08/12. Resident #1 showed her a skin tear and said CNA C had beat him in the chest with his fist. Resident #1 reported this when she delivered coffee to his room and picked up his breakfast tray. The ADM initially was under the impression Resident #1 was upset with his roommate. Resident #1 then stated to the ADM, "You told that guy to come and beat me up." Resident #1 explained CNA C had beat him and hit him in the chest. The ADM stated Resident #1 had not reported the incident to anyone else at that point. The ADM revealed CNA C worked nights and had worked on Hall 2, where Resident #1 resided, the night before (03/07/12). She stated she had been attempting to contact CNA C, but there was no answer. The ADM stated she did not know if CNA C was scheduled to work that night (03/08/12). The ADM stated she spoke with Resident #1's roommate, who revealed Resident #1 was fighting CNA C, who was providing care. The ADM stated even if Resident #1 was fighting, CNA C still did wrong because he should have left the room and not continued care. The ADM stated Resident #1 had repeatedly reported the same story to her (ADM) and other people all day long. The ADM stated Resident #1 had a court-appointed Guardian which meant, "He's not supposed to be that sharp." The ADM then explained Resident #1 had reported problems with his roommates before but later did not recall what he had said. The ADM stated the SW was interviewing residents to see if there were additional reports of problems with CNA C. The ADM stated the interviews with the other residents were "good" with no issues at that point. CNA C had reportedly been an employee at the facility for a long time. He was previously the van driver but was removed from that position for texting on a cell phone while he was driving. She stated she had no prior allegations against CNA C and had not had to conduct any investigation involving CNA C before. The ADM said the incident had already been reported to the State agency. Interview on 03/08/12 at 2:30 p.m. with CNA A revealed he was normally assigned to Hall 2 and had worked that day (03/08/12) on Hall 2, where Resident #1 resided. When asked if he was aware of any abuse happening in the facility, CNA A stated Resident #1 stated a staff member grabbed and twisted his arm early in the morning of 03/08/12. CNA A stated he reported this to RN B at approximately 6:30 a.m. on 03/08/12. When asked if Resident #1 had made an allegation of physical abuse in the past, CNA A stated he had not. CNA A added, "He is not a complainer...he doesn't like male aides." When asked to expand on Resident #1 not liking male aides, CNA A stated if a male aide came into the room, Resident #1 would be aggressive. CNA A stated when he was assigned to Resident #1's room, he took it upon himself to switch off with a female CNA so he would not have to care for Resident #1. Interview on 03/08/12 at 2:36 p.m. with LVN L revealed she did not make the CNAs' assignments so she was not aware of how it was determined who worked where and with which residents. She stated it depended "on the day" as to who was able to care of Resident #1, because the resident changed his mind frequently. She stated Resident #1 never allowed CNA A to care for him. LVN L stated Resident #1 did not want males cleaning him. Resident #1 would generally let women but not males into his room. LVN L stated if there was a male assigned to the hall, they would switch out with a female aide to provide care to Resident #1, then switch back after the care was provided. LVN L stated, "We don't put him through it for the heck of it. He has rights about who cares for him." Interview on 03/08/12 at 2:39 p.m. with CNA M revealed she had worked with Resident #1. She stated Resident #1 had always been sweet to her but used inappropriate language at times. CNA M stated Resident #1 had never reported anything to her about anyone that cared for him. She had seen him be rude to the male staff even when they were only there to bring him ice. CNA M was not aware of any male staff members who were not allowed in Resident #1's room. Observation and interview on 03/08/12 at 2:59 p.m. with Resident #1 revealed he "had a bad day since 5:00 this morning." Resident #1 explained he had been "beat on and cussed." Resident #1 showed the surveyor his arms. One arm had a band aid, and a scabbed area with dried blood and bruising. Both arms had multiple bruises. Resident #1 was observed in his room sitting in his wheelchair. Interview on 03/08/12 at 3:06 p.m. with HA N revealed he had worked with Resident #1. When queried about the resident, HA N responded, "He (Resident #1) doesn't like dudes." HA N stated it was "well known" Resident #1 did not like male staff doing anything for him. HA N stated if Resident #1 got upset, he just continued to do his job while Resident #1 cursed at him. Interview on 03/08/12 at 3:10 p.m. with ADON O, who also was the acting DON, revealed Resident #1 had a favorite aide and had even moved halls so he could be where she could take care of him. ADON O stated staff had not informed her Resident #1 did not want males to provide care or that it caused problems when males provided care. ADON O stated there were four male aides, and she was not aware of any male aides switching with the female aides to provide care. Interview on 03/08/12 at 3:40 p.m. with the SW revealed she was conducting interviews with residents specifically about the care they received from CNA C. Most of the residents had reported they felt safe with CNA C, but Resident #2 stated CNA C had been rough with him. Resident #2 stated when he reported CNA C to the nurse, CNA C came back and yelled at him. Resident #2 had stated that had been "a while ago." Resident #2 told the SW CNA C had also yelled at other residents. When the SW was asked if the ADM had been made aware of CNA C yelling at residents, she revealed she had not. The SW stated she had completed five resident interviews from residents on Halls 2 and 3. Interview on 03/08/12 at 4:16 p.m. with the ADM revealed since Resident #1 reported to her CNA C had beaten him, the ADM had made several unsuccessful telephone calls to CNA C, who worked the 10:00 p.m. to 6:00 a.m. shift. The ADM stated she had even attempted to call CNA I, who was close friends with CNA C. The ADM stated she had reported the allegation to the State agency and the local police. She stated she was to let the police know when CNA C came in, so they could interview him regarding the allegation. The ADM stated she had interviewed CNA D regarding CNA C's behavior. CNA D reported to the ADM CNA C was "hurried" and "a little rough." The ADM stated CNA D also told her CNA C stated, "I (CNA C) go in there to clean him up...I have to do it, whether you like it or not." The ADM stated the SW had told her she completed some resident interviews and one resident was not "favorable" of CNA C. On 03/08/12 at 4:35 p.m., Resident #1 was queried about the bruises on his arms. He stated, "I can remember it like my first name. ___ (CNA C)." Resident #1 was observed lying in bed, shaking and visibly upset. The surveyor requested permission from Resident #1 to take pictures of the bruising on his arms and he stated, "Yes." Resident #1 then asked the surveyor to sit down and talk with him a bit, because he was upset. Interview on 03/08/12 at 4:36 p.m. with CNA D revealed he had been employed at the facility for six months and was normally assigned to Hall 1 (secured unit) on the 2:00 p.m. to 10:00 p.m. shift. He stated he had recently been working overtime on the 10:00 p.m. to 6:00 a.m. shift in other parts of the facility. When asked if he was concerned about abuse in the facility, CNA D stated CNA C was "rough" at times, which had bothered him. CNA D stated Resident #1 had a problem with male aides assisting him. He (CNA D) was at the nurses' station with LVN E and LVN F when CNA C came toward the nurses' station and made the statement, "I told him, I'm gonna change you ass, turn over." CNA D stated one day last week, the ADM spoke to LVN E about Resident #1 not liking male assistance with care. CNA D stated the ADM told LVN E to switch out care with a female aide for Resident #1. When asked if it was well known Resident #1 did not like male aides caring for him, CNA D responded, "Oh yeah." When asked if the ADM was made aware of the statement CNA C made regarding Resident #1, CNA D stated he did not know. CNA D stated on another night, he was asked to attempt to change Resident #1 because the resident had refused two male CNAs, including CNA C. When he went in, Resident #1 refused again. Later, a female CNA from the secure unit was able to change him. Telephone interview on 03/08/12 at 4:55 p.m. with LVN E revealed she was aware Resident #1 was combative with male aides. She stated Resident #1 was nice to her, but he would not let a male aide assist him. LVN E denied hearing CNA C make the statement regarding Resident #1, as referenced in the interview on 03/08/12 at 4:36 p.m. with CNA D. When asked about CNA C, LVN E stated he was usually pretty good and most residents liked him. When asked which resident did not like CNA C, LVN E replied, "(Resident #1)." Interview on 03/08/12 at 8:56 p.m. with LVN F revealed she normally worked on Halls 4, 5, and 6 on the night shift. When asked if anything had been different when she arrived at work on 03/08/12, LVN F stated she had been inserviced on abuse and reporting abuse. LVN F stated she was not aware of any abuse,which had occurred and stated she had not received any complaints or reports of suspected abuse. LVN F stated she did know who CNA C was and denied overhearing CNA C make a comment like "I'm going to change your ass, so turn over" or anything else derogatory. LVN F stated she would have stopped him immediately had she heard this. LVN F reported she had heard CNA C curse but not at a resident. LVN F stated she had heard LVN E say, about a month ago, Resident #1 did not like males providing care to him. Interview on 03/08/12 at 4:47 p.m. with the ADM revealed she was not aware of any incidents or concerns involving CNA C prior to this allegation. The ADM only remembered disciplining him for texting and driving. The ADM stated she spoke with LVN E the past weekend (03/03/12) about Resident #1. The ADM told LVN E Resident #1 could not be left all night without being changed. Resident #3, who was Resident #1's roommate, had reported he went all night without being changed. The ADM stated she learned the reason Resident #1 had gone without being changed was because he did not like males providing him with care. The ADM informed LVN E a female needed to be the person who went into care for Resident #1 throughout the night. The ADM stated she was not sure why CNA C was still providing care, and shook her head saying "That's a problem." When asked specifically if anyone reported CNA C' statement to Resident #1, "I'm to going to change you ass, so turn over," (or anything similar), the ADM responded, "Really? Wow." The ADM stated she talked with CNA D who worked last night. The ADM stated she was unaware ADON O did not know about Resident #1 not wanting males to provide care to him. The ADM stated there were more males who worked the night shift than females and the ADM agreed it was the right of the residents to not have certain staff members care for them. The ADM stated, "This is a concern that should've been dealt with." Review of Daily Sign in Sheets, provided by the ADM, revealed on 03/03/12, 03/04/12 and 03/07/12 (all after the ADM was aware on 03/03/12 Resident #1 did not like male aides providing care to him ), CNA C was assigned to Halls 2 and 3. CNA C was assigned to Halls 2 and 3 on the night of 03/08/12 as well. Review of the ADL Coding Summary form dated 03/02/12 through 03/08/12 for Resident #1 revealed on 03/03/12 on the night shift, one staff person was provided for toileting due to the resident being totally dependent on one staff for toileting. On 03/04/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. On 03/07/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. During an interview on 03/08/12 at 5:10 p.m., the ADM revealed she told RN G and LVN H Resident #1 did not like male aides providing his care, on or about 03/03/12. The ADM confirmed she did not inform any additional staff of the behaviors exhibited by Resident #1. 4) Review of the undated "Senior Care Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property," provided by the ADM as the current policy, revealed: "Each resident has the right to be free from abuse...Residents will not be subjected to abuse by anyone, including...facility staff.... PREVENTION: ...each employee receives the 'Employee Standards of Conduct', which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a Resident... IDENTIFICATION: ...All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries; sudden changes in resident's behavior or personality; and resident fear and anxiety... INVESTIGATION: All staff in the nursing facility...have been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor...The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will them report the allegation to the director of nursing, and/or the administrator...." 5) On 03/08/12 at 5:40 p.m., the ADM and the ADON O were informed an Immediate Jeopardy was identified in the area of Resident Behavior and Facility Practices. A Plan of Removal for the IJ was requested. 6) Telephone interview on 03/08/12 at 8:00 p.m. with the Police Officer revealed he was unaware of the facility's plan to call and report if CNA C showed up at the facility. This information had not been passed on by his Police Chief. The Police Officer confirmed the facility had not called him at that point in the evening. Observation and interview on 03/08/12 at 8:35 p.m. revealed Resident #1 was in his bed, awake. There were multiple bruises and a skin tear to the right arm, and multiple bruises to the right arm. Resident #1 stated his ribs were very sore, and that it was uncomfortable to turn over. He added, "It's real sore on the inside." When asked if CNA C had done this to him in the past, Resident #1 stated it had never happened before. He stated, "He's been ugly before." When asked how he had been ugly, Resident #1 stated, "All kinds of different stuff." When asked why he preferred female staff to care for him, Resident #1 stated, "Women are more gentle." He added, "I prefer a woman for certain things." When asked to explain, he revealed for showers and toileting. Interview on 03/08/12 at 8:43 p.m. with LVN E revealed she normally worked the 6:00 p.m. to 6:00 a.m. on Halls 1, 2 and 3. When asked what happened when she arrived at the facility on 03/08/12, LVN E stated she talked with the ADM regarding CNA C. LVN E stated last Saturday (03/03/12), the ADM spoke to her regarding Resident #1. LVN E stated she was told by the ADM Resident #1 needed to have a female aide care for him. LVN E stated she told CNA C he was not supposed to provide care for Resident #1. When asked how she monitored Resident #1 to ensure CNA C did not provide care for him, LVN E stated she took his word for it and assumed CNA C did not provide care. LVN E added, "He (Resident #1) refuses to let males touch him...he is very abusive to staff." When asked if she had heard CNA C talk abusively to or about Resident #1, LVN E denied she had. When asked what CNA C's demeanor was at work, LVN E stated CNA C cursed a lot, but not directly to the residents. She added he used the "S" word and the "F" word. During an interview on 03/08/12 at 9:04 p.m. with the ADM and the RVP regarding the status of the investigation, the ADM stated she needed to interview the night staff. She added inservicing was being done regarding "females only" in Resident #1's room. She stated if staff were not working, they were being called on the phone, and staff were not to work until after they were inserviced. Also, care plan information was being added to the Accunurse system (computer system used by the aides and nurses to track resident ADLs) so all the nurses and aides had access to the information. The ADM stated she spoke with CNA D and LVN E. When asked about CNA C, the ADM stated CNA C had been to the facility and she interviewed him. When asked if she notified the police, as per her intention, the ADM stated she forgot. The ADM reported CNA C was not coming back to work at 10:00 p.m., because he had been suspended. The ADM stated CNA C revealed in the interview he told Resident #1 he was going to change him. Resident #1 responded saying no one was going to change him. Resident #1 then "swung" at CNA C. CNA C stated he still continued to provide care to Resident #1. CNA C denied abusing Resident #1, denied causing a skin tear to Resident #1, and denied being told by LVN E only females were supposed to be providing care to Resident #1. The ADM revealed at that point of the inter

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident #1) of 13 residents reviewed for abuse was free from verbal, physical, and mental abuse. - Resident #1 did not want male aides to provide care for him. - The ADM was aware of this on 03/03/12 and only two staff were informed not to assign a male aide to provide care for Resident #1. - On 03/08/12, CNA C provided incontinent care for Resident #1 despite the resident's vigorously telling the CNA to stop. - On 03/08/12, Resident #1 alleged CNA A hit him and cursed him. The resident had multiple bruises on both arms and a skin tear on the left arm. An Immediate Jeopardy (IJ) was identified on 03/08/12. While the IJ was lowered on 03/09/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not Immediate Jeopardy" because all staff had not been trained, and the facility was still monitoring the plan of removal. These failures allowed CNA C to continue to provide care for Resident #1 for three nights resulting in the CNA providing incontinent care when the resident repeatedly told him no. This potentially contributed to Resident #1's skin tear and multiple bruising to both arms. These failures could affect the 59 residents residing on Halls 1, 2, 3 and 4, where CNA C was scheduled to work and placed them at risk for physical abuse, verbal abuse, lacerations, bruises and fractures. Findings included: 1) Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of February 2012 consolidated physicians' orders for Resident #1 revealed he took the following medications: [REDACTED]. Review of a quarterly MDS assessment dated [DATE] for Resident #1 revealed the resident was able to recall three words after given to him, he was able to state the current year and he suffered signs of inattention and disorganized thinking. Resident #1 did not have any behaviors identified, but the assessment reflected the resident had [MEDICAL CONDITION]. He required two person physical assistance with bed mobility and toileting. Review of the Comprehensive Plans of Care for Resident #1 included the following: a. "Resident is currently taking [MEDICAL CONDITION] Medications," initiated on 05/09/11 and was last updated 01/25/12. "Approach:...7) Protect resident from self harm or harm to others...." b. "Resident has [DIAGNOSES REDACTED]...3) Remove resident from areas where there is over stimulation that agitates or confuses resident...." c. "Residents ADL functions," initiated on 05/09/11, "Toileting: one staff," (this was updated on 01/25/12 to state "assist of 2" needed for transfers & toileting). d. "Resident is verbally abusive to staff and others" initiated on 08/16/11, " ...Approach:...5) If resident is upset during care, stop and return later to allow resident to calm down. 6) Notify physician if behavior interferes with physical functioning...." e. "Resident is physically abusive to staff," initiated on 08/16/11, "...Approach: "...6) Notify physician if behavior interferes with physical functioning...8) If resident is upset during care, stop and return later to allow resident to calm down...." Review of a Social Service Review dated 07/08/11 for Resident #1 revealed, "...At times kicks hits & curses staff...." Review of Nurses' Notes from 12/10/11 through 03/08/12 revealed: 12/22/11 - 9:00 a.m. "Resident is refusing shower. When asking him again resident became agitated...." 01/14/12 - 12:00 a.m. "Res refusing care to be (changed), dried...." 01/27/12 - 8:30 a.m. "Resident refused all am meds offered by med aide offered again by nurse x2...refused...." 02/03/12 - 7:00 a.m. "...difficult resident in that he is trying to hit and curse NA when attempting to help-same he refused to let do care for him." 02/15/12 - 7:00 a.m. "...Abusive in attitude and language-Reported a CNA stated to me (Resident #1) had asked if (staff member) could 'suck' on her '(breast)'. She has not refused further help, but has asked he not speak to her this way. Will report behavior to appropriate personnel...." 02/20/12 - 12:00 a.m. "Refused care from CNA @ this time...." 2:00 a.m. "Resident (continues) to refuse care bed is wet & resident needs to be changed States come back @ 1 o'clock." 4:00 a.m. "Resident cont (continues) to refuse care from CNA again bed is wet & resident needs to be changed...." 02/25/12 - 10:30 p.m. "Resident refused to be (changed) or have any ADLs performed...." 02/26/12 - 12:15 a.m. "Resident refused ADLs, to be changed or cleaned up by any staff member." 02/26/12 - 5:00 a.m. "Resident refused care." 02/27/12 - 2:20 a.m. "Resident refused care." 03/08/12 - 9:30 a.m. "Called into res room by (ADM) and noted a skin tear on res (right) wrist 1cm (by) 1 cm. Cleanse (with) NS, apply TAO and bandaid. Res states '(CNA C) did this, he hit me in the chest and grabbed my arms.' Also noted multiple bruising . Has one on (left) arm measuring 5.5 cm (by) 3.5 cm. On (left) under arm 10.5 (by) 5 cm. And one on (right) forearm measuring 6.5 cm (by) 4 cm...." Review of Psychoactive Side Effect Monitoring for February 2012, for Resident #1, revealed he had no behaviors, or side effects for the entire month, except for 02/23/12, which was agitation/restlessness, verbal abuse and expressions of worry or general restlessness. Review of Psychoactive Side Effect Monitoring for March 2012, for Resident #1, revealed he had no behaviors, or side effects from 03/01/12 through 03/08/12. Interview on 03/09/12 at 11:16 a.m. with ADON O revealed Resident #1's behaviors should have been documented in the nurses notes and/or Social Services notes and on the behavior sheets. 2) Review of the Provider Investigation Report dated 03/08/12 revealed "Description of the Allegation: ___ (Resident #1) stated ___ (CNA C) came in his room at 5:30 am this morning and beat him up - stated he beat him in his chest with his fists and showed me a skin tear/stated CNA told him administrator and 3 others told him to do it...Investigation Summary ...Social Worker questioned resident on Halls 3 and 4 regarding treatment from ___ (CNA C). Head to toe assessment performed on all residents ___(CNA C) provided treatment to to determine if there were signs of abuse. fell ow staff members interviewed to determine if they had ever witnessed abuse from ___ (CNA C)...Investigation Findings: ___ (Confirmed was marked)...Provider Action Taken Post-Investigation: Staff in-serviced regarding recognizing and reporting abuse. Only 'female staff members' will provide care for resident in future - care plan updated, 'female'...." Review of a typed statement (attached to the Provider Investigation Report) dated 03/08/12 completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, that (Resident #1) had to be cared for. (LVN E) informed me at that point, (Resident #1) did not like males taking care of him and I said we have to see to it he receives care, and it was decided to have a female trade off and care for him. I called her the next morning and she said things had worked out fine. I called the other night charge nurse, (LVN H), on Monday night (03/05/12) her first night back and explained to her what was to be done. She voiced understanding and agreement." The statement was signed by the ADM. Review of a typed statement (attached to the Provider Investigation Report) undated, completed by the ADM revealed, "I spoke with (LVN E) regarding our conversation Saturday, 3 March 2012, She (sic) remembered the conversation and stated she had implemented the policy that night and explained to (CNA I) and (CNA C) that (CNA I) would have to come off the unit to care for (Resident #1) because he does not like males caring for him. (CNA C) understood he was not to care for (Resident #1). (LVN E) stated she thought everything had worked out fine and (CNA C) had stayed out of his room...." Review of the Hand Written Witness Statement received from CNA D on 03/09/12 at 5:43 p.m. revealed, "I have been employed at the Honey Grove Nursing Center for approximately 6 months. I have been an ordained minister for [AGE] years. A few days after February 20th on the night shift, while standing at or near the nursing station, ___ (CNA C) walked up at (sic) stated; 'I told ___ (Resident #1) he was gonna have to be changed whether he liked it or not. So turn your ass over.' ___ (LVN E) and ___ (LVN F) were at the nurses station at that time. On February 20th ___ (CNA A), ___ (CNA J), and myself went in to change ___ (Resident #1) and he refused to allow us to care for him. When I went in at 3:30 A.M. He told me to come back at 1:00. This was the first time I had attempted to care for him, and was later told he did not care for men taking (sic) of him. I reported to the nurse that he would not allow me to change him. I did not report or saying anything after ___ (CNA C's) comment because he used bad language and there were other staff around at the time. I have worked with ___ (CNA C) several times before and I felt that he was at times rough but not abusive with patients...." Review of the undated typed statement from the ADM revealed: "On March 8th, I took ___ (Resident #1) his breakfast tray. I asked him if he would like coffee and he stated he did not want anything from me. I could tell he was angry and I asked him what was wrong and he looked in the direction of his roommate and did not say anything. I assumed he was not getting along with his roommate, which is not unusual for ___ (Resident #1). When I came back with the coffee, I began asking ___ (Resident #1) questions and he finally began talking. He stated ___ (CNA C) had come in at 5:30 that morning and beat him up and showed me a skin tear on his arm (you could tell it was fresh), he also stated ___ (CNA C) had beat him in his chest with his fists. ___ (Resident #1) then said he did not know why I was looking so surprised as I had sent ___ (CNA C) into beat him up. I told ___ (Resident#1) I would never do that. ___ (Resident #1) said, 'well, he said you did - you and three other ladies'. ___ (Resident #1) said he did not want ___ (CNA C) back in his room, I informed him, ___ (CNA C) would probably not be back - that I would have to do an investigation. ___ (Resident #1) was happy about that. I told him I would be calling it into the state and that made him even happier - said he was also going to get an attorney. I asked ___ (Resident #3), ___ (Resident #1's) roommate who is very alert what happened and ___ (Resident #3) said ___ (CNA C) came into clean him and in the middle of cleaning him, ___ (Resident #1) started to fight. ___ (Resident #3) was able to confirm that ___ (CNA C) told ___ (Resident #1) that I had sent him in there. That evening when I asked ___ (CNA C) about the statement he denied it. I didn't push it but I knew he had said it because ___ (Resident #3) confirmed it earlier that day. Throughout the day, I kept ___ (Resident #1) abreast of what was going on. ___ (Resident #1) continued to talk about it and his story never changed once...." The statement was signed by the ADM. 3) Interview on 03/08/12 at 1:29 p.m. with RN B revealed she had been working with Resident #1 for about three days. RN B stated Resident #1 reported on the 10:00 p.m. - 6:00 a.m. shift on 03/08/12 a CNA had been "beating on him and shoving him against the wall." RN B stated Resident #1 had a skin tear. Resident #1 identified CNA C as the perpetrator. He (Resident #1) revealed CNA C had also been abusive to other people, but did not provide names of any specific residents. RN B stated Resident #1 had already talked to LVN L about CNA C, so RN B did not report the incident to anyone. RN B described Resident #1 to be "a little ornery when he first met and got to know someone." RN B stated Resident #1 had bruising up and down his arms. Resident #1 had reported having been hit in the chest but would not allow RN B to see his chest. RN B felt Resident #1 was worried about CNA C coming back that evening. During an interview on 03/08/12 at 1:50 p.m., LVN L was queried regarding Resident #1's allegations. LVN L replied, "Well, it's kind of under investigation." LVN L explained the ADM had called her and they went to Resident #1's room to talk to the resident between 9:30 a.m. and 10:30 a.m. on 03/08/12. LVN L stated Resident #1 had a lot of new, dark bruising on his arms and had a 1 cm by 1 cm skin tear. Resident #1 reported to LVN L CNA C grabbed his arms and punched him in the chest. LVN L stated she measured all of the bruises and did not see any bruises on his chest. Resident #1 told her the abuse had been going on for three days. LVN L stated she told Resident #1 this was unacceptable, and he had to let someone know if something like this was happening. Resident #1 again reported CNA C grabbed his arms and hit him in the chest, hard. LVN L stated Resident #1 was interviewable but could be "rowdy, and verbally abusive." LVN L stated Resident #1 verbalized the same story several times that day. LVN L stated she completed the Incident/Accident Report and the assessment. LVN L did not know how the ADM had found out about the incident but thought it was while she was delivering breakfast trays to the residents. LVN L stated Resident #1 needed assistance with transfers and was incontinent of bowel and bladder. LVN L had not received any similar complaints about CNA C and stated she knew CNA C worked on the hall the night before because she had already checked the assignment books. Interview on 03/08/12 at 2:04 p.m. with the ADM revealed she was working on an investigation involving Resident #1. The ADM stated Resident #1 reported CNA C had come into his room and beat him up around 5:30 a.m. on 03/08/12. Resident #1 showed her a skin tear and said CNA C had beat him in the chest with his fist. Resident #1 reported this when she delivered coffee to his room and picked up his breakfast tray. The ADM initially was under the impression Resident #1 was upset with his roommate. Resident #1 then stated to the ADM, "You told that guy to come and beat me up." Resident #1 explained CNA C had beat him and hit him in the chest. The ADM stated Resident #1 had not reported the incident to anyone else at that point. The ADM revealed CNA C worked nights and had worked on Hall 2, where Resident #1 resided, the night before (03/07/12). She stated she had been attempting to contact CNA C, but there was no answer. The ADM stated she did not know if CNA C was scheduled to work that night (03/08/12). The ADM stated she spoke with Resident #1's roommate, who revealed Resident #1 was fighting CNA C, who was providing care. The ADM stated even if Resident #1 was fighting, CNA C still did wrong because he should have left the room and not continued care. The ADM stated Resident #1 had repeatedly reported the same story to her (ADM) and other people all day long. The ADM stated Resident #1 had a court-appointed Guardian which meant, "He's not supposed to be that sharp." The ADM then explained Resident #1 had reported problems with his roommates before but later did not recall what he had said. The ADM stated the SW was interviewing residents to see if there were additional reports of problems with CNA C. The ADM stated the interviews with the other residents were "good" with no issues at that point. CNA C had reportedly been an employee at the facility for a long time. He was previously the van driver but was removed from that position for texting on a cell phone while he was driving. She stated she had no prior allegations against CNA C and had not had to conduct any investigation involving CNA C before. The ADM said the incident had already been reported to the State agency. Interview on 03/08/12 at 2:30 p.m. with CNA A revealed he was normally assigned to Hall 2 and had worked that day (03/08/12) on Hall 2, where Resident #1 resided. When asked if he was aware of any abuse happening in the facility, CNA A stated Resident #1 stated a staff member grabbed and twisted his arm early in the morning of 03/08/12. CNA A stated he reported this to RN B at approximately 6:30 a.m. on 03/08/12. When asked if Resident #1 had made an allegation of physical abuse in the past, CNA A stated he had not. CNA A added, "He is not a complainer...he doesn't like male aides." When asked to expand on Resident #1 not liking male aides, CNA A stated if a male aide came into the room, Resident #1 would be aggressive. CNA A stated when he was assigned to Resident #1's room, he took it upon himself to switch off with a female CNA so he would not have to care for Resident #1. Interview on 03/08/12 at 2:36 p.m. with LVN L revealed she did not make the CNAs' assignments so she was not aware of how it was determined who worked where and with which residents. She stated it depended "on the day" as to who was able to care of Resident #1, because the resident changed his mind frequently. She stated Resident #1 never allowed CNA A to care for him. LVN L stated Resident #1 did not want males cleaning him. Resident #1 would generally let women but not males into his room. LVN L stated if there was a male assigned to the hall, they would switch out with a female aide to provide care to Resident #1, then switch back after the care was provided. LVN L stated, "We don't put him through it for the heck of it. He has rights about who cares for him." Interview on 03/08/12 at 2:39 p.m. with CNA M revealed she had worked with Resident #1. She stated Resident #1 had always been sweet to her but used inappropriate language at times. CNA M stated Resident #1 had never reported anything to her about anyone that cared for him. She had seen him be rude to the male staff even when they were only there to bring him ice. CNA M was not aware of any male staff members who were not allowed in Resident #1's room. Observation and interview on 03/08/12 at 2:59 p.m. with Resident #1 revealed he "had a bad day since 5:00 this morning." Resident #1 explained he had been "beat on and cussed." Resident #1 showed the surveyor his arms. One arm had a band aid, and a scabbed area with dried blood and bruising. Both arms had multiple bruises. Resident #1 was observed in his room sitting in his wheelchair. Interview on 03/08/12 at 3:06 p.m. with HA N revealed he had worked with Resident #1. When queried about the resident, HA N responded, "He (Resident #1) doesn't like dudes." HA N stated it was "well known" Resident #1 did not like male staff doing anything for him. HA N stated if Resident #1 got upset, he just continued to do his job while Resident #1 cursed at him. Interview on 03/08/12 at 3:10 p.m. with ADON O, who also was the acting DON, revealed Resident #1 had a favorite aide and had even moved halls so he could be where she could take care of him. ADON O stated staff had not informed her Resident #1 did not want males to provide care or that it caused problems when males provided care. ADON O stated there were four male aides, and she was not aware of any male aides switching with the female aides to provide care. Interview on 03/08/12 at 3:40 p.m. with the SW revealed she was conducting interviews with residents specifically about the care they received from CNA C. Most of the residents had reported they felt safe with CNA C, but Resident #2 stated CNA C had been rough with him. Resident #2 stated when he reported CNA C to the nurse, CNA C came back and yelled at him. Resident #2 had stated that had been "a while ago." Resident #2 told the SW CNA C had also yelled at other residents. When the SW was asked if the ADM had been made aware of CNA C yelling at residents, she revealed she had not. The SW stated she had completed five resident interviews from residents on Halls 2 and 3. Interview on 03/08/12 at 4:16 p.m. with the ADM revealed since Resident #1 reported to her CNA C had beaten him, the ADM had made several unsuccessful telephone calls to CNA C, who worked the 10:00 p.m. to 6:00 a.m. shift. The ADM stated she had even attempted to call CNA I, who was close friends with CNA C. The ADM stated she had reported the allegation to the State agency and the local police. She stated she was to let the police know when CNA C came in, so they could interview him regarding the allegation. The ADM stated she had interviewed CNA D regarding CNA C's behavior. CNA D reported to the ADM CNA C was "hurried" and "a little rough." The ADM stated CNA D also told her CNA C stated, "I (CNA C) go in there to clean him up...I have to do it, whether you like it or not." The ADM stated the SW had told her she completed some resident interviews and one resident was not "favorable" of CNA C. On 03/08/12 at 4:35 p.m., Resident #1 was queried about the bruises on his arms. He stated, "I can remember it like my first name. ___ (CNA C)." Resident #1 was observed lying in bed, shaking and visibly upset. The surveyor requested permission from Resident #1 to take pictures of the bruising on his arms and he stated, "Yes." Resident #1 then asked the surveyor to sit down and talk with him a bit, because he was upset. Interview on 03/08/12 at 4:36 p.m. with CNA D revealed he had been employed at the facility for six months and was normally assigned to Hall 1 (secured unit) on the 2:00 p.m. to 10:00 p.m. shift. He stated he had recently been working overtime on the 10:00 p.m. to 6:00 a.m. shift in other parts of the facility. When asked if he was concerned about abuse in the facility, CNA D stated CNA C was "rough" at times, which had bothered him. CNA D stated Resident #1 had a problem with male aides assisting him. He (CNA D) was at the nurses' station with LVN E and LVN F when CNA C came toward the nurses' station and made the statement, "I told him, I'm gonna change you ass, turn over." CNA D stated one day last week, the ADM spoke to LVN E about Resident #1 not liking male assistance with care. CNA D stated the ADM told LVN E to switch out care with a female aide for Resident #1. When asked if it was well known Resident #1 did not like male aides caring for him, CNA D responded, "Oh yeah." When asked if the ADM was made aware of the statement CNA C made regarding Resident #1, CNA D stated he did not know. CNA D stated on another night, he was asked to attempt to change Resident #1 because the resident had refused two male CNAs, including CNA C. When he went in, Resident #1 refused again. Later, a female CNA from the secure unit was able to change him. Telephone interview on 03/08/12 at 4:55 p.m. with LVN E revealed she was aware Resident #1 was combative with male aides. She stated Resident #1 was nice to her, but he would not let a male aide assist him. LVN E denied hearing CNA C make the statement regarding Resident #1, as referenced in the interview on 03/08/12 at 4:36 p.m. with CNA D. When asked about CNA C, LVN E stated he was usually pretty good and most residents liked him. When asked which resident did not like CNA C, LVN E replied, "(Resident #1)." Interview on 03/08/12 at 8:56 p.m. with LVN F revealed she normally worked on Halls 4, 5, and 6 on the night shift. When asked if anything had been different when she arrived at work on 03/08/12, LVN F stated she had been inserviced on abuse and reporting abuse. LVN F stated she was not aware of any abuse,which had occurred and stated she had not received any complaints or reports of suspected abuse. LVN F stated she did know who CNA C was and denied overhearing CNA C make a comment like "I'm going to change your ass, so turn over" or anything else derogatory. LVN F stated she would have stopped him immediately had she heard this. LVN F reported she had heard CNA C curse but not at a resident. LVN F stated she had heard LVN E say, about a month ago, Resident #1 did not like males providing care to him. Interview on 03/08/12 at 4:47 p.m. with the ADM revealed she was not aware of any incidents or concerns involving CNA C prior to this allegation. The ADM only remembered disciplining him for texting and driving. The ADM stated she spoke with LVN E the past weekend (03/03/12) about Resident #1. The ADM told LVN E Resident #1 could not be left all night without being changed. Resident #3, who was Resident #1's roommate, had reported he went all night without being changed. The ADM stated she learned the reason Resident #1 had gone without being changed was because he did not like males providing him with care. The ADM informed LVN E a female needed to be the person who went into care for Resident #1 throughout the night. The ADM stated she was not sure why CNA C was still providing care, and shook her head saying "That's a problem." When asked specifically if anyone reported CNA C' statement to Resident #1, "I'm to going to change you ass, so turn over," (or anything similar), the ADM responded, "Really? Wow." The ADM stated she talked with CNA D who worked last night. The ADM stated she was unaware ADON O did not know about Resident #1 not wanting males to provide care to him. The ADM stated there were more males who worked the night shift than females and the ADM agreed it was the right of the residents to not have certain staff members care for them. The ADM stated, "This is a concern that should've been dealt with." Review of Daily Sign in Sheets, provided by the ADM, revealed on 03/03/12, 03/04/12 and 03/07/12 (all after the ADM was aware on 03/03/12 Resident #1 did not like male aides providing care to him ), CNA C was assigned to Halls 2 and 3. CNA C was assigned to Halls 2 and 3 on the night of 03/08/12 as well. Review of the ADL Coding Summary form dated 03/02/12 through 03/08/12 for Resident #1 revealed on 03/03/12 on the night shift, one staff person was provided for toileting due to the resident being totally dependent on one staff for toileting. On 03/04/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. On 03/07/12 on the night shift, two staff were provided for toileting due to the resident's total dependence on staff for toileting. During an interview on 03/08/12 at 5:10 p.m., the ADM revealed she told RN G and LVN H Resident #1 did not like male aides providing his care, on or about 03/03/12. The ADM confirmed she did not inform any additional staff of the behaviors exhibited by Resident #1. 4) Review of the undated "Senior Care Policy to Prohibit the Mistreatment, Neglect, and Abuse of Residents and the Misappropriation of Resident Property," provided by the ADM as the current policy, revealed: "Each resident has the right to be free from abuse...Residents will not be subjected to abuse by anyone, including...facility staff.... PREVENTION: ...each employee receives the 'Employee Standards of Conduct', which outlines the standard for refraining from abuse or neglect of a resident and the reporting of any suspected abuse or neglect of a Resident... IDENTIFICATION: ...All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff are knowledgeable in recognizing suspicious bruising, swelling, pain or other injuries; sudden changes in resident's behavior or personality; and resident fear and anxiety... INVESTIGATION: All staff in the nursing facility...have been properly notified through facility policy that any abuse will not be tolerated at all. All allegations, no matter what types of incidents reported will be investigated fully...All employees who suspect abuse at any time it is identified are to report it to their immediate supervisor...The charge nurse receiving the allegation shall immediately contact either one of the following: the nurse on call, who will them report the allegation to the director of nursing, and/or the administrator...." 5) On 03/08/12 at 5:40 p.m., the ADM and the ADON O were informed an Immediate Jeopardy was identified in the area of Resident Behavior and Facility Practices. A Plan of Removal for the IJ was requested. 6) Telephone interview on 03/08/12 at 8:00 p.m. with the Police Officer revealed he was unaware of the facility's plan to call and report if CNA C showed up at the facility. This information had not been passed on by his Police Chief. The Police Officer confirmed the facility had not called him at that point in the evening. Observation and interview on 03/08/12 at 8:35 p.m. revealed Resident #1 was in his bed, awake. There were multiple bruises and a skin tear to the right arm, and multiple bruises to the right arm. Resident #1 stated his ribs were very sore, and that it was uncomfortable to turn over. He added, "It's real sore on the inside." When asked if CNA C had done this to him in the past, Resident #1 stated it had never happened before. He stated, "He's been ugly before." When asked how he had been ugly, Resident #1 stated, "All kinds of different stuff." When asked why he preferred female staff to care for him, Resident #1 stated, "Women are more gentle." He added, "I prefer a woman for certain things." When asked to explain, he revealed for showers and toileting. Interview on 03/08/12 at 8:43 p.m. with LVN E revealed she normally worked the 6:00 p.m. to 6:00 a.m. on Halls 1, 2 and 3. When asked what happened when she arrived at the facility on 03/08/12, LVN E stated she talked with the ADM regarding CNA C. LVN E stated last Saturday (03/03/12), the ADM spoke to her regarding Resident #1. LVN E stated she was told by the ADM Resident #1 needed to have a female aide care for him. LVN E stated she told CNA C he was not supposed to provide care for Resident #1. When asked how she monitored Resident #1 to ensure CNA C did not provide care for him, LVN E stated she took his word for it and assumed CNA C did not provide care. LVN E added, "He (Resident #1) refuses to let males touch him...he is very abusive to staff." When asked if she had heard CNA C talk abusively to or about Resident #1, LVN E denied she had. When asked what CNA C's demeanor was at work, LVN E stated CNA C cursed a lot, but not directly to the residents. She added he used the "S" word and the "F" word. During an interview on 03/08/12 at 9:04 p.m. with the ADM and the RVP regarding the status of the investigation, the ADM stated she needed to interview the night staff. She added inservicing was being done regarding "females only" in Resident #1's room. She stated if staff were not working, they were being called on the phone, and staff were not to work until after they were inserviced. Also, care plan information was being added to the Accunurse system (computer system used by the aides and nurses to track resident ADLs) so all the nurses and aides had access to the information. The ADM stated she spoke with CNA D and LVN E. When asked about CNA C, the ADM stated CNA C had been to the facility and she interviewed him. When asked if she notified the police, as per her intention, the ADM stated she forgot. The ADM reported CNA C was not coming back to work at 10:00 p.m., because he had been suspended. The ADM stated CNA C revealed in the interview he told Resident #1 he was going to change him. Resident #1 responded saying no one was going to change him. Resident #1 then "swung" at CNA C. CNA C stated he still continued to provide care to Resident #1. CNA C denied abusing Resident #1, denied causing a skin tear to Resident #1, and denied being told by LVN E only females were supposed to be providing care to Resident #1. The ADM revealed at that point of the interview, she brought in LVN E. In the presence of LVN E, CNA C stated he remembered being told only females were to provide care to Resident #1. The ADM stated she felt it was abuse for CNA C to continue to provide care to Resident #1 after the resident was resisting. When asked about procedures in the event residents resisted care, the ADM stated they were trained to walk away, come back later, report to the charge nurse and not to force