Every finding on record at Jacinto Nursing and Rehabilitation Center

Based on observations, interviews, and record reviews, the facility failed to ensure each resident was free from abuse for 2 of 6 residents (Residents #1 and #3) reviewed for abuse. The facility failed to ensure Resident #1, who had cognitive impairment, was free from sexual abuse when Resident #3 inserted his finger into Resident #1's vagina on 8/28/26. The facility failed to ensure Resident #3 was free from physical abuse when LVN B hit Resident #3 on the top of his head on 8/28/26. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. The findings included:Record review of Resident #1's admission Record generated on 8/31/26 revealed she was admitted to the facility on [DATE] and resided on the secured unit (a specialized, enclosed residential environment designed to protect and support individuals with Alzheimer's disease or other forms of dementia). She had diagnoses of metabolic encephalopathy (a temporary or progressive brain dysfunction caused by an underlying medical condition or chemical imbalance in the blood that deprives the brain of vital energy), spontaneous ecchymoses (flat, large discolored skin patches-essentially bruises-that form without any known injury or trauma), other Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks) and major depressive disorder (a common and serious mood disorder that causes a lasting feeling of sadness, emptiness, and a loss of interest in activities). She was [AGE] years old. Record review of Resident #1's Care Plan Report dated 10/9/25 and revised on 10/21/25 revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia diagnosis. Interventions included, Administer medications as ordered. ask yes/no questions in order to determine the resident's needs. cue, reorient and supervise as needed. Record review of Resident #1's Care Plan Report dated 10/9/25 and revised on 12/10/25 revealed Resident #1 was at risk for eloping and wandering related to being disoriented to place and impaired safety awareness. Interventions included, Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Monitor location on rounds and document wandering behavior and attempted diversional interventions in resident's chart. Record review of Resident #1's Care Plan Report dated 10/21/25 and revised on 8/31/26 revealed Resident #1 required limited assistance of one staff for dressing, required limited to extensive assistance by one staff for personal hygiene, and required supervision for transfers. Record review of Resident #3's admission Record generated on 8/31/26 revealed he was admitted to the facility on [DATE] and had diagnoses of tinea unguium (a common fungal infection of the fingernails or toenails), neurosyphilis (Neurosyphilis is a serious bacterial infection of the brain or spinal cord that occurs when a syphilis infection spreads to the central nervous system), heart failure (a chronic condition where the heart muscle cannot pump blood and oxygen well enough to meet the body's needs) and history of transient ischemic attack (a temporary blockage of blood flow to a part of the brain that causes stroke-like symptoms without leaving permanent damage). He was [AGE] years old. Record review of Resident #3's Care Plan Report dated 7/24/26 revealed there were no behaviors listed. Record review of Resident #3's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 15, indicating he had no cognitive impairment. No behaviors were noted. He had no functional limitations in range of motion and required supervision or touching assistance for activities of daily living including dressing, personal hygiene, transfers, bed mobility and walking.Record review of Resident #1's Nurse Progress Note dated 8/28/26 at 9:30pm, LVN B wrote, Resident was assessed following a resident to resident intervention in a male resident's room. Resident has a base line cognitive impairment and unable to provide account of event. A head to toe physical assessment was completed. Resident shows no sign of pain or signs of distress at time of assessment. Resident is separated from other resident and placed under direct staff supervision. EMS contracted to transfer resident to the hospital for further evaluation. Necessary authorities notified, Administrator, DON, ADON, physician and family member. Record review of Resident #3's Progress Note dated 8/28/26 at 10:06pm, LVN B wrote, Resident was assessed following a reported resident to resident interaction. Resident is alert and oriented x 3 (a person is awake and aware of three specific things: who they are, where they are, and what time it is). Head to toe assessment completed, vitals are normal.Resident is separated from other residents and placed under supervision. Authorities notified, Administrator, DON, ADON, family. Record review of Resident #1's local acute care hospital After Visit Summary dated 8/29/26 revealed she arrived at the emergency department needing a SANE exam and decreased activity/lethargy and generalized weakness. Resident #1 was unable to answer questions or follow commands. Per nursing home- male resident was found in patient's room- unknown of sexual activity or assault or report of patient being naked.Pt presents to EC for concern of abuse in nursing home. Record review of a witness statement dated 8/30/26 and signed by Resident #3 revealed, [Resident #3] was questioned by DON and ADM concerning incident that happened on 8-28-26. [Resident #3] was able to give us his name and age but unable to give us information concerning anything else. When questioned about incident resident was quiet but after prompting resident stated [Resident #1] walked into his room, and he thought was (sic) having a date. He states she sat on the bed beside him. Resident stated [Resident #1] started pulling her clothes off and she grabbed him and he then layed (sic) back and put his finger in her vagina. Resident says he did not tell the nurse that night. However, he told the police. Record review of Resident #3's Care Plan Report dated 8/30/26 revealed he had a behavior problem related to sexually inappropriate behavior. It indicated on 8/28/26, resident alleged to be (sic) sexually inappropriate behavior with/toward female resident. Interventions included, Administer medications as ordered. if reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Record review of Resident #3's Nurse Progress Notes dated 8/30/26 revealed the following: -A note written at 5:51am by LVN J read, Resident remained in room resting well throughout shift, no changes in behavior or condition noted. Residents safety and privacy maintained. -A note written at 9:56am by LVN I read, Resident moved to main dining room pending transfer to [local behavioral hospital]. 15 min monitoring and report handed over to nurse of that unit. Plan of care continues. In an interview on 8/30/26 at 11:02am, the Administrator stated on the night of 8/28/26, she received a call that Resident #1 was found in Resident #3's room and she had her clothes off, and Resident #3 was seen walking out of the room. She said out of precaution, they sent her to the hospital to see if anything happened. She said Resident #3 was recently diagnosed with a brain tumor. She said he had no behavioral problems until recently when he started exit seeking. She said afterwards they decided to place him on the secure unit.In an observation on 8/30/26 at 11:25am, revealed the secure unit was shaped like the letter L. The dining room/common area was adjacent to the female resident rooms, and the long hallway housed the male resident rooms. CNA T was seated where the two hallways intersected observing residents in the halls and CNA F was in the dining room. In an observation on 8/30/26 at 11:42am, Resident #3 was sitting in a hallway outside of the secure unit with a CNA. Resident #3 stood up and walked down the hallway and the CNA followed him. In an interview on 8/30/26 at 1:38pm, CNA F said Resident #1 had a behavior of wandering and getting on other residents' beds to sleep. When asked if Resident #1 had other behaviors, CNA F said Resident #1 would take off her socks or pull down her pants in the common areas at times. She said Resident #3 required supervision and she was unsure if he had memory impairments. She said on 8/28/26, she worked the 2pm-10pm shift. She said she was assigned to the female residents on the memory care unit. She said she saw Resident #1 before a 30-minute break and she was walking in the hall heading toward the female rooms. She said when she returned from break, she completed her last rounds. She said she noticed Resident #1 was not in her room. She said she checked all the female residents' rooms to search for Resident #1. She said she notified CNA E. She said CNA E found Resident #1 in Resident #3's room. She said when she walked into Resident #3's room, she saw Resident #1 lying horizontally on her back with her brief and pants off of her body, and Resident #3 was lying next to her. She said Resident #3 stood up and pulled up his pants. She said when she tried to talk to Resident #1, she appeared weaker than normal. She said CNA E told the nurse while CNA F assisted Resident #1 with dressing. She said she did not want to compromise any evidence and did not clean her up. She said the nurse assessed Resident #1 then she was sent to the hospital. She said to prevent incidents of abuse or any accidents, the facility staff kept men and woman separate. She said for example, in the dining room, the men are seated by the television and the woman were seated at the dining room tables on the other side of the dining room. She said she supervised the residents and watched for signs of aggression, fighting or other behaviors and intervened when necessary. In an interview on 8/30/26 at 2:05pm, Resident #3 said on the night of the incident, Resident #1 walked into his room, sat down next to him on his bed, then pulled down her pants. He said he put his finger in her vagina. He said she was not upset at the physical contact. He said he had seen Resident #1 a few times and thought they had a good relationship. She said then, a man walked in, stood above him and was asking about the girl. He said the man hit him with a closed fist to the left side of his head. He said he did not know the name of the man but gave a description of him and stated he was on the nursing staff. He could not state how he felt about the incidents. In an interview on 8/30/26 at 2:10pm, the Administrator was informed of an allegation of abuse between Resident #3 and a male staff member, and the Administrator said it was the first time learning of the allegation. The Administrator was provided the description that was reported and the Administrator stated the staff member who was working who met the description was LVN B. In an interview on 8/30/26 at 4:00pm, LVN C said Resident #3 had no disruptive behaviors and was usually calm. He said Resident #1 had behaviors of wandering and hitting surfaces with her hands. He said he was not aware of any other allegations of sexual abuse or sexual contact between residents. In an interview on 8/30/26 at 4:50pm, CNA R said residents on the secure unit could not consent to sexual activity, so they prevented it from occurring. He said they had two CNAs and one nurse supervising the residents on the secure unit. He said they were aware of the residents who had behaviors affecting others and watched closely. He said Resident #3 had no incidents or behaviors and Resident #1 wandered and drummed on surfaces. He said he was not aware of any other allegations of sexual abuse or sexual contact between residents. In an interview on 8/31/26 at 1:13pm, CNA F said she had not witnessed any resident mistreatment or abuse on 8/28/26. She said she was unsure if LVN B was alone with Resident #3 after they found Resident #1 in Resident #3's room. She said she left with Resident #1 and did not return to the male side of the secure unit during her shift. In an interview on 8/31/26 at 12:41pm, LVN I said Resident #3 had no behaviors and was quiet with minimal interactions with other residents. She said Resident #1 had behaviors of wandering and walking into the common area with some of her clothing removed. She said she wandered daily and only removed her clothing about once a week. She said she was not aware of any other allegations of sexual abuse or sexual contact between residents. She said to keep residents safe, they provided supervision and redirected Resident #1 from entering other resident's rooms. In an observation and attempted interview on 8/31/26 at 1:05pm, revealed Resident #1 was walking quickly around the common area and tapping on hard surfaces with her hands, including tables and walls. She was not interviewable and did not respond to conversations. In an interview on 8/31/265 at 3:51pm, LVN W, she said she worked in the memory care unit on 8/29/26. She said Resident #1 returned from the hospital around 2:00pm on 8/29/26. She said Resident #3 was in his room in the morning and was in the dining room between 11:00am and 12:00pm. She said Resident #1 and Resident #3 did not interact with each other on 8/29/26. She said she was provided no specific instructions regarding interventions or monitoring for the residents. She said the facility staff could not leave residents unsupervised in the common areas and they prevented female residents from entering the hallway that housed the male resident rooms. In an interview on 8/31/26 at 4:13pm, CNA E said Resident #3 was a high-functioning resident and was aware of everything. He said Resident #3 did not have any prior behaviors. He said Resident #1 wandered around the secure unit, slept in other residents' beds, and did not talk much. He said they supervised the residents in the common areas closely and tried to keep female residents in the female area of the secure unit. He said on 8/28/26, he started his last round around 8:30pm. He said he was in the common area when CNA F informed him that she could not find Resident #1. He said he walked into Resident #3's room and saw both residents on their backs in bed. He said Resident #1 had her pants and brief down and stated he could not remember what Resident #3 was wearing. He said he immediately informed LVN B. He said they separated the residents and CNA E kept an eye on Resident #3. He said he was present when LVN B assessed Resident #3. He said LVN B asked Resident #3 what happened and why he did what he did. He said he did not see or hear any mistreatment or abuse. He said when LVN B left the room, Resident #3 started packing his belongings, washing his hands, walking around in circles and did not look at CNA E. He said he worked on 8/29/26 between 2pm-10pm. He said he was not provided with any instructions for monitoring or interventions, but increased supervision of Residents #1 and #3 because he did not want anything to happen. In an interview on 8/31/26 at 4:30pm, the Social Worker stated she spoke to Resident #3 on the morning of 8/30/26 about the incident that occurred on 8/28/26 with Resident #1. She said she explained to Resident #3 that next time a resident wandered into his room, he needed to turn on his call light or alert a staff member. She said he explained to Resident #3 that a resident wandering into his room does not give Resident #3 the right to touch them. She said Resident #3 could follow instructions and seemed to have understood the conversation. She said after she spoke to Resident #3 on 8/30/26, she moved Resident #3 off the secure unit to another room. She said he was placed on 1:1 supervision (A staff member stays within direct line of sight or a short physical distance) and she had referred him to a hospital to get him some help and have an evaluation for his new behaviors. She said she updated Resident #1 and Resident #3's care plans and educated staff regarding ensuring a staff member was supervising the common areas/hallways at all times. In an interview on 8/31/26 at 5:30pm, LVN B said on the evening of 8/28/26, he came back from a break, and CNA E told him a resident was naked in Resident #3's room and he was suspected some foul play. He said he walked into Resident #3's room and saw Resident #1 was naked with her back on the bed and Resident #3 was sitting next to her. He said he asked Resident #3 to stand up but he refused. He said he asked Resident #3 what happened, then pulled him by his arm to stand him up. He said he knew he was alert enough to answer questions, so he continued to ask Resident #3 what happened and what he did to Resident #1. He said Resident #3 responded, I don't know. and looked down. He said he thought maybe Resident #3 felt that LVN B was confrontational. He said he did not hit him at any point during the evening. He said he notified the Administrator, ADON and the DON. He said he completed a head-to-toe assessment of Resident #1 and Resident #1 appeared tired, weak or worn out. He said she had no injuries or bleeding. He said she had not seen her like that. He said Resident #1 was sent to the hospital. He said he worked during the overnight shift on 8/28/26 and he directed a CNA to sit in front of Resident #3's room during the night. He said he was surprised that the incident happened. He said Resident #1 typically wandered in the common areas but was easily redirected. He said when Resident #1 wandered, they provided direct supervision to prevent accidents or incidents. In an interview on 8/31/26 at 5:40pm, the ADON stated Resident #1 resided in the memory care unit due to wandering behaviors. She said they monitored and provided supervision to prevent accidents and falls. She said they kept the female and male room assignments separate and kept residents from wandering into other resident rooms by providing supervision. She said they assigned one CNA on the male side and one CNA on the female side and the nurse was assigned the secure unit to step in when needed to supervise the residents. In an interview on 8/31/26 at 5:53pm, Resident #1's Family Member stated that Resident #1 was found nude in a male resident's room and stated due to Resident #1's mental condition and dementia, the Family Member was not shocked. The Family Member stated Resident #1 was very modest.In an interview on 8/31/26 at 6:30pm, the Administrator said facility staff were aware that Resident #1 had wandering behaviors. She said to prevent accidents or abuse, they provided supervision to the residents on both sides of the secure unit, including the male side and the female side. She said she was not aware of any complaints or concerns related to LVN B's work performance. She stated they were investigating the incident regarding LVN B and Resident #3. Record review of a witness statement dated 9/1/26 and signed by CNA F revealed, I [CNA F] did witness Nurse [LVN B] hitting [Resident #3] upside the head after calling in the room to attest (sic) the situation on August 28th [2026]. I witness [LVN B] hitting him with an opened hand. In an interview on 9/2/26 at 2:39pm, CNA F said she wrote a statement regarding LVN B and Resident #3 and said she was fully honest with the Administrator. She said when she spoke to the State Surveyor on 8/31/26, she was not in the right mindset. She said on 8/28/26 when CNA F and CNA E found Resident #1 in Resident #3's room, CNA E left to get LVN B. She said LVN B was really pissed off and angry. She said she saw LVN B hit Resident #3 on the top of the head with an open hand. She said she saw a little glimpse of it because at the time she was pulling up Resident #1's pants. She said CNA E was not in the room at the time LVN B hit Resident #3. She said she could not say why she did not report it to the Administrator immediately. Record review of the Provider Investigation Report dated 9/2/26 revealed on 8/30/26, Resident #3 reported an allegation of physical abuse that occurred on 8/28/26 at 9:36pm. Description of the Allegation reflected that the state was on-site investigating a resident-to-resident sexual incident when Resident #3 disclosed to the State Surveyor that a nurse had hit him. The report indicated that Resident #3 was assessed on 8/30/26 at 12:30pm and noted no injuries and there were no concerns revealed during a psychosocial assessment. Record review of the facility's policy regarding Identifying Sexual Abuse and Capacity to Consent dated September 2022 revealed , A resident's capacity to consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent. 'sexual abuse' is non-consensual sexual contact of any type with a resident.sexual abuse includes, but is not limited to: a. unwanted intimate touching of any kind especially of breasts or perineal area (the diamond-shaped region of soft tissue located at the bottom of the pelvis between the thighs ). Generally, sexual contact is non-consensual if the resident either: a. appears to want the contact to occur, but lacks the cognitive ability to consent; or b. does not want the contact to occur. Record review of the facility's policy regarding Abuse Prevention Program dated December 2016 revealed, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but it not limited to free from.sexual or physical abuse. As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: Facility staff, other residents.

Based on interview and record view the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #1 and #3) reviewed for abuse and neglect.The facility failed to report an allegation of abuse within 2 hours when Resident #1 was found naked below the waist in Resident #3's room on 08/28/26 and she was sent to the hospital for a sexual assault examination. CNA F failed to report an allegation of abuse to the Administrator on 8/28/26 when she witnessed LVN B hit Resident #3 on the top of his head. The failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.Findings included: Record review of Resident #1's admission Record generated on 8/31/26 revealed she was admitted to the facility on [DATE] and resided on the secured unit. She had diagnoses of metabolic encephalopathy, spontaneous ecchymoses, other Alzheimer's disease and major depressive disorder. She was [AGE] years old. Record review of Resident #1's Care Plan Report dated 10/9/25 and revised on 10/21/25 revealed Resident #1 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, dementia diagnosis. Interventions included, Administer medications as ordered. ask yes/no questions in order to determine the resident's needs. cue, reorient and supervise as needed. Record review of Resident #3's admission Record generated on 8/31/26 revealed he was admitted to the facility on [DATE] and had diagnoses of tinea unguium, neurosyphilis, heart failure and history of transient ischemic attack. He was [AGE] years old. Record review of Resident #1's Nurse Progress Note dated 8/28/26 at 9:30pm, LVN B wrote, Resident was assessed following a resident to resident intervention in a male resident's room. Resident has a base line cognitive impairment and unable to provided account of event. A head to toe physical assessment was completed. Resident shows no sign of pain or signs of distress at time of assessment. Resident is separated from other resident and placed under direct staff supervision. EMS contracted to transfer resident to the hospital for further evaluation. Necessary authorities notified, Administrator, DON, ADON, physician and family member. Record review of Resident #3's Progress Note dated 8/28/26 at 10:06pm, LVN B wrote, Resident was assessed following a reported resident to resident interaction. Resident is alert and oriented x 3. Head to toe assessment completed, vitals are normal.Resident is separated from other residents and placed under supervision. Authorities notified, Administrator, DON, ADON, family. Record review of a witness statement dated 8/28/26 signed by CNA F revealed, Around 9:20-9:25ish, I was going to [Resident #1's] room to change her. I saw she was not there. I went to each room looking for her. [CNA E] informed me where she was and what he saw. I then went into the room. I witnessed [Resident #1] lying on her back with her brief & pants off. I saw [Resident #3] pulling up his pants. [CNA E] went to inform the Nurse. I put her pants back on and I guided her back to bed. Record review of a witness statement dated 8/28/26 signed by CNA E revealed, Around 9 to 9:25ish I was doing my last round for the day and my fellow CNA [CNA F] was looking for [Resident #1] but she was not in her room so we went to each room to go to looking for her until I saw [Resident #1] in [Resident #3's] room laying on her back with [Resident #3] in the same position with both brief (sic) down and I went to go inform the nurse [LVN B] what happened.Record review of Resident #1's local acute care hospital After Visit Summary dated 8/29/26 revealed she arrived at the emergency department needing SANE exam and decreased activity/lethargy and generalized weakness. Resident #1 was unable to answer questions or follow commands. Per nursing home- male resident was found in patient's room- unknown of sexual activity or assault or report of patient being naked.Pt presents to EC for concern of abuse in nursing home. In an interview on 8/30/26 at 10:12am, the Social Worker stated she was working on an investigation regarding Resident #1 and Resident #3. In an interview on 8/30/26 at 11:02am, the Administrator stated on the night of 8/28/26, she received a call that Resident #1 was found in Resident #3's room and she had her clothes off, and Resident #3 was seen walking out of the room. She said out of precaution, they sent her to the hospital to see if anything happened. She said it was not reported to HHSC because they were not aware that anything happened. She said on 8/30/26, the Social Worker interviewed Resident #3 and he said he inserted his finger into Resident #1's vagina. She said she was going to report to HHSC. In an interview on 8/31/26 at 1:13pm, CNA F said she had not witnessed any resident mistreatment or abuse on 8/28/26. She said she was unsure if LVN B was alone with Resident #3 after they found Resident #1 in Resident #3's room. She said she left with Resident #1 and did not return to the male side of the secure unit during her shift. In an interview on 8/31/26 at 4:30pm, the Social Worker stated she first learned of the incident between Resident #1 and Resident #3 on 8/30/26 when she checked in at the nurse's station and LVN I shared with her what happened. She said on 8/30/26, she interviewed Resident #3 and he reported that he put his finger in her vagina. She said she notified the Administrator, provided Resident #3 with direct supervision and began an investigation. In an interview on 8/31/26 at 5:30pm, LVN B said on the evening of 8/28/26, he came back from a break and CNA E told him a resident was naked in Resident #3's room and he was suspected some foul play. He said he walked into Resident #3's room and saw Resident #1 was naked with her back on the bed and Resident #3 was sitting next to her. He said he notified the Administrator, ADON and the DON. He said Resident #1 appeared tired, weak or worn out. He said she had not seen her like that. He said Resident #1 was sent to the hospital. In an interview on 8/31/26 at 6:30pm, the Administrator stated on the night of the incident between Resident #1 and Resident #3, LVN B called her and explained that situation and was a little hysterical. She said LVN B reported that Resident #1 was in Resident #3's room, Resident #1 did not have clothes on, and Resident #3 was messing with his zipper. She said they did not know if there was any sexual activity. She said the police were notified and they filed a police report. She said she asked the staff to write statements and they monitored the residents. She said on 8/29/26, she told LVN W to call her when Resident #1 returned from the hospital. She said LVN W called her later on 8/29/26 and told the Administrator that the discharge notes indicated no sexual assault occurred. She said she read the witness statements on 8/30/26. She stated she was not feeling well on 8/29/26. She said she did not want to report something to HHSC that was not confirmed. Record review of a witness statement dated 9/1/26 and signed by CNA F revealed, I [CNA F] did witness Nurse [LVN B] hitting [Resident #3] upside the head after calling in the room to attest (sic) the situation on August 28th [2026]. I witness [LVN B] hitting him with an opened hand. In an interview on 9/2/26 at 2:39pm, CNA F said she wrote a statement regarding LVN B and Resident #3 and said she was fully honest with the Administrator. She said when she spoke to the State Surveyor on 8/31/26, she was not in the right mindset. She said on 8/28/26 when CNA F and CNA E found Resident #1 in Resident #3's room, CNA E left to get LVN B. She said LVN B was really pissed off and angry. She said she saw LVN B hit Resident #3 on the top of the head with an open hand. She said she saw a little glimpse of it because at the time she was pulling up Resident #1's pants. She said CNA E was not in the room at the time LVN B hit Resident #3. She said she could not say why she did not report it to the Administrator immediately. Record review of the Provider Investigation Report dated 9/2/26 revealed on 8/30/26, Resident #3 reported an allegation of physical abuse that occurred on 8/28/26 at 9:36pm. Description of the Allegation reflected that the state was on-site investigating a resident-to-resident sexual incident when Resident #3 disclosed to the State Surveyor that a nurse had hit him. The report indicated that Resident #3 was assessed on 8/30/26 at 12:30pm and noted no injuries and there were no concerns revealed during a psychosocial assessment. Record review of the facility's policy regarding Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022 revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation. are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.If resident abuse, neglect, exploitation. is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility.'Immediately' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury.

Based on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by providing care including assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for 1 (Resident #1) of 7 residents reviewed for nursing services. The facility failed to ensure that skin assessments were completed completely and correctly for Resident #1. This failure could place residents at risk of worsening skin conditions or infection. Findings included: Record review of Resident #1's face sheet dated 4/28/26, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including aphasia following cerebral infarction (inability to comprehend or communicate following a stroke) and anemia (deficiency of red blood cells) in chronic kidney disease. Record review of Resident #1's Entry MDS on 4/24/26 revealed admission date of 4/24/26. Record review of Resident #1's Medication Review Report revealed a physician order for weekly skin assessments with order date of 4/24/26 and start date of 4/25/26. Record review of Daily Sign In Sheets revealed the following staff members were assigned to Resident #1: on 4/24/26 from 2 p.m. to 10 p.m. was LVN A and CNA A, on 4/24/26 from 10 p.m. to 6 a.m. was LVN B and CNA B, and on 4/25/26 from 6 a.m. to 2p.m. was LVN C and CNA C. Record review of Resident #1's admission Clinical Evaluation - V2 dated 4/24/26 revealed description of redness to sites of front and rear right thigh. Section K (Skin) states Complete a thorough head to toe skin assessment. Identify any abnormalities and indicate on the diagram below. (e.g. pressure injuries, non-pressure injuries, skin tears, arterial ulcers, redness, bruises, senile purpura (benign skin condition in older adults characterized by purplish bruises on sun-exposed areas due to fragile blood vessels and thinning skin) , scabs, swelling, corns, bunions, callouses, rashes, dryness). Record review of Resident #1's Progress Note dated 4/24/26 at 8:04 p.m. revealed Resident #1 was admitted to the facility. Record review of Resident #1's Progress Note dated 4/25/26 at 8:25 a.m. revealed Resident #1 was to go to a local hospital for feeding tube replacement. Record review of Resident #1's Daily Skilled Documentation - V 4.0 - V 1 dated 4/25/26 completed by LVN C revealed under section J. Skin no was documented for question Note skin issues new and old. A. Does the resident have any skin conditions?Record review of Resident #1's documentation from a local hospital dated 4/25/26 at 1:10 p.m. revealed skin integrity was positive for redness and bruising to right hip, back and leg. Record review of Resident #1's Progress Note dated 4/25/26 at 7:26 p.m. revealed the DON spoke with a doctor from a local hospital where Resident #1 was transferred to regarding bruising that was getting progressively worse on Resident #1's leg. The progress note said the DON discussed in detail with the doctor that this bruising was present on admission to the facility but not as large. During interview on 4/26/26 at 5:07 p.m., LVN C said she cared for Resident #1 on 4/25/26 from 6 a.m. to 2 p.m. shift and transferred him to a local hospital around 10:30 to 11 a.m. but could not remember the exact time. LVN C said Resident #1 had some excoriation (condition where skin becomes red and painful) on his bottom and groin and a healed great toe amputation but no large bruising when asked regarding Resident #1's skin conditions. LVN C said Resident #1 did not have any large bruises that she saw. During interview on 4/26/26 at 9:54 a.m., RN A who worked at local hospital where Resident #1 currently resided said they did not have any measurements regarding the bruising to Resident #1's right hip and thigh but he would assist the surveyor to observe the bruise. Observation on 4/26/26 at 10:08 a.m. of Resident #1 at a local hospital revealed red and purplish bruising starting above Resident #1's right hip and extending down his right thigh that measured 15 inches in length. Resident #1 was not interviewable. During interview on 4/27/26 at 4:13 p.m., CNA C said she had changed Resident #1's brief during the 10 p.m. to 6 a.m. on 4/24-4/25/26 and did not see any bruising when changing Resident #1. CNA C said Resident #1 did not make any noises like he was in pain when she turned Resident #1 from side to side when changing him. On 4/28/26 at 10:24 a.m., surveyor left LVN A a message via phone with request to call surveyor. On 4/28/26 at 10:33 a.m., surveyor left CNA B a message via phone with request to call surveyor. During interview on 4/28/26 at 11:18 a.m., LVN B said she had Resident #1 during her shift on 4/24/26 from 10 p.m. to 6 a.m. and was received as a new admission from the previous nurse. LVN B said she frequently checked on Resident #1 as he was confused and had checked on him more than five times during her shift and last checked him at 5 a.m. LVN B said Resident #1 had a previous injury that was on the leg and said she thought it was a bruise or discoloration and did not remember which side the leg was on. LVN B said she only used the light from the door that was open from the bathroom to not disturb the resident so did not see the bruise well to see if the bruise was large or small when asked to describe Resident #1's bruise. LVN B said the morning and afternoon nurses did the skin assessment because they do not want to wake residents up at night to do skin assessments because if they wake them up they do not go back to sleep and it increases their risk of falling. LVN B said the nurse who admitted Resident #1 had completed a skin assessment. During interview on 4/28/26 at 11:38 a.m., CNA A said she did not really remember Resident #1 and did not remember anything specifically about his care. CNA A said she did not remember anything regarding Resident #1's skin condition. CNA A said if she noticed a large bruise or a wound on a resident she would report it to the charge nurse. During interview on 4/28/26 at 11:58 a.m., the ADON said she did see Resident #1 briefly when he was admitted to the facility and the nurse was in the room with him. The ADON said she did not see the skin on Resident #1's bottom or legs. The ADON said the charge nurse that admits the resident was responsible for doing a skin assessment on residents when they were first admitted before their shift was over. The ADON said if the charge notices a new skin condition, they document it. The ADON answered yes when asked if a bruise that was getting larger was something that should be documented. The ADON said they did not measure a bruise and just described what they were seeing. The ADON said if skin conditions were not documented the effect it could have on the resident was that it could get worse or turn into a pressure sore or anything. During interview on 4/28/26 at 12:11 p.m., the DON said Resident #1 had come to the facility the evening of 4/24/26 and left by noon the next day and she knew from the review of the paperwork that Resident #1 had a couple of skin conditions, but she did not observe his skin because he was gone before she came back to work on 4/26/26. The DON said she spoke to a doctor from the transferring local hospital on 4/25/26 from her home. The DON said the doctor from the transferring local hospital had spoken to a nurse at the facility and said there was a bruised area that was present from admission at the facility but was getting worse. The DON said the nurses generally did not measure skin conditions and normally just describe what they were seeing as the wound care doctor comes on Monday and they did measurements and staging if it was a pressure ulcer. The DON said previously the documentation asked if there were any new skin issues. The DON said they were under a different company now as of April 7th so the staff were still getting used to the new system, so the answer would have been no previously because he had the skin conditions on admission. The DON said they were still using their previous assessments until the system got integrated on April 7th . The DON said the effect it would have on a resident if skin assessment documentation was not accurate was it would depend on what the skin issue was and if it was a pressure ulcer then it could get worse, infection, sepsis (life-threatening condition caused by the body's extreme response to an infection), and would depend on the nature and extent of the wound. The DON said if redness was documented regarding skin assessment, then it could mean excoriation or skin color and it would tell them there was some kind of skin impairment. The DON said the effect it could have on the resident if a bruise was getting larger but not documented would depend on which stage the bruise was as it starts off as red and goes to purple and would depend on where they are at in the healing process. During interview on 4/28/26 at 1:01 p.m., the Administrator said they changed computer charting systems recently with their company change and have had to add onto the electronic medical record system and tell them there were features that they need so as they go along they were having to add on new features that they need and this was probably one of the features they need and they just need to educate the nursing staff regarding the new features and programs. Record Review of facility's policy Skin Management dated June 2022 revealed Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes.

Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13 %, based on 4 errors out of 29 opportunities, which involved 2 of 7 residents (Resident #59, Resident #58) and one of five staff (MA V) observed during medication administration.1. MA V failed to administer Resident #59's Gabapentin 100 mg (used in treatment for neuropathy) and Pentoxifylline Extended Release 400 mg (used in treatment for peripheral vascular disease) according to physician orders, the medication was administered over one hour after the prescribed time. 2. MA V failed to administer Gabapentin 100 mg to Resident #59 from Resident #59's own supply of medications. MA V administered a Gabapentin capsule taken from a supply belonging to CR #10.3. MA V failed to administer Resident #48's Divalproex sodium Delayed Release 125 mg (used in treatment for bipolar disorder) according to physician orders, the medication was administered over one hour after the prescribed time.These failures could place residents at risk of not receiving the desired therapeutic effect of their medications, a depleted supply of the medication, missed dose and undue financial hardship.1. Record review of Resident #59's face sheet, dated 02/17/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and initially admitted on [DATE]. Resident #59 had diagnoses which included: dementia (a general term for a group of symptoms that cause a loss of cognitive functioning), diabetes (a chronic condition that occurs when blood glucose levels are too high), heart disease (a range of conditions that affect the heart often leading to heart attacks or other serious complications), COPD (a lung condition caused by damage to the airway), and PVD (a disorder of blood vessels outside the heart that affects blood flow to the limbs).Record review of Resident #59's annual MDS, dated [DATE], revealed a BIMS score of 11 out of 15, which indicated moderate cognitive impairment. Resident #59 required moderate assistance with most ADLs.Record review of Resident #59's, undated, Care Plan revealed, focus- Resident #59 had diabetes, Interventions included - give medications as ordered. Focus- Resident #59 had PVD. Interventions included - give medications for improved blood flow or anticoagulants as ordered.Record review of Resident #59's Order Summary Report, dated 02/17/26 at 2:45 PM, revealed an active order for Gabapentin 100 mg, give one capsule by mouth three times a day r/t type 2 Diabetes with diabetic polyneuropathy (a condition affecting peripheral nerves leading to symptoms like pain and numbness). Pentoxifylline ER 400mg, one tablet three times a day for PVD.An observation on 02/17/26 at 2:15 PM revealed MA V prepared medications for administration for Resident #59. MA V removed a 100 mg Gabapentin capsule from a blister pack that had a different resident name. Then MA V removed the Pentoxifylline tablet from Resident #59's blister pack. Resident #59 was alert and cooperative and in her room. MA V administered Gabapentin 100 mg oral capsule and Pentoxifylline ER 400 mg, one oral tablet to Resident #59.In an interview on 02/27/26 at 2:15 PM, MA V, who was assigned to the 2-front sections of the resident rooms, stated she was passing out 12:00 PM medications at 2:00 PM which was late and the DON and ADON told her she must help with passing out meal trays and not give medications during mealtimes because the State Surveyors told them to. MA V stated she received an in-service the other day to this effect. MA V showed the state surveyor the written in-service. When asked if administering medications 2 hours after the prescribed time was following physician orders MA V stated the residents still received their medication and it was not her responsibility, but it was the nurse's responsibility to change the administration times for medications ordered multiple times per day. MA V did not state whether she would notify the assigned nurse the medications were administered 2 hours late.2. Record review of Resident #48's face sheet, dated 02/03/26, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #48 had diagnoses which included: dementia and bipolar disorder (a mental illness characterized by mood swings and depressive episodes).Record review of Resident #48's annual MDS, dated [DATE], revealed a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. Resident #48 required supervision with most ADLs.Record review of Resident #48's, undated, Care Plan revealed focus- Resident #48 used psychotropic medications. Interventions included - administer psychotropic medications as ordered by physician. Focus- Resident #48 was on anticonvulsant therapy r/t mood stabilizer. Interventions included - administer medication per orders. Focus - Resident #48 had risk for mood impairment r/t diagnosis of bipolar disorder. Interventions included - administer medications as ordered. Record review of Resident #48's Order Summary Report, dated 02/17/26, revealed an active order for Divalproex Sodium DR 125mg one tablet three times per day r/t bipolar disorder.An observation on 02/17/26 at 2:20 PM revealed, MA V prepared medications for administration to Resident #48. Resident #48 was alert, pleasant and sitting on the edge of her bed. MA V gave Divalproex Sodium DR 125mg tablet to Resident #48 for administration.In an interview on 02/17/26 at 3:40 PM, LVN P, who was assigned to the 2-back section of resident rooms, stated there was a one-hour window for administering medications: one hour before or one hour after the prescribed time. LVN P stated if a medication was given outside the parameters, she would notify the physician and would write a nurse note. LVN P stated she expected any medication aide she was working with to notify her so she could address a medication that was administered late. LVN P stated if she was not notified then, the late medication issue would fall back onto the charge nurse responsibility. In an interview on 02/17/26 at 3:44 PM, MA V stated she made a mistake and grabbed the wrong blister pack for Resident #59 and Resident #59 had her own medication blister pack for Gabapentin. MA V stated the 5 rights for medication administration were: right name, right dose, right drug, right time and right documentation. MA V stated she had one hour before or one hour after the prescribed time to give medications and was just trying to do the right thing by making sure the residents received their medication when she gave medications two hours late. MA V stated she did not know the policy for when medications were given late and she would have to ask the Administrator. MA V stated she could not recall the last time she received an in-service on medication administration.In an interview on 02/17/26 at 4:25 PM, the DON stated the 5 rights for medication administration were: right patient, right dose, right route, right time, and right medication. The DON stated her expectation was that medication aides and nurses always followed the 5 rights. The DON stated medications could be given one hour before or one hour after the scheduled time of administration. The DON stated how a resident may be affected by a late dose of Gabapentin depending on the reason for the medication and there may not be any ramifications for giving late. The DON stated Divalproex should be given on time for therapeutic reasons and the resident may experience behaviors if given too late but if only one dose was late, there may not be adverse effects. The DON stated BP medications and anticoagulants were the most important to not miss or be late for administration. The DON expected the medication aide to ask for help if running behind as there were more than enough staff to help. The DON stated breakfast was at 7:00 AM and lunch in the dining room was served from 11:30 AM to 12:00 PM. The DON stated the nursing staff had an in-service on medication administration when the State Surveyors were in the building recently. The DON stated she expected nursing staff to complete medication passes then help with meal trays if the time had been managed properly. The DON stated once the medication popped up with a red alert in the electronic health record system, she expected the medication aide to stop and notify the nurse who would then address the medication that was administered late. The DON stated she did not expect nursing staff to borrow medication from other residents' supply d/t Medicare paying for the medication in 30-day increments, therefore carrying undue hardship for the resident if the medication pack would come up short.Record review of the facility's policy and procedure for Administering Medications, revised in April 2019, read in part: .Medications are administered in a safe and timely manner, and as prescribed.3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience.7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.Record review of the facility's in-service report, dated 02/04/26, submitted by MA V and conducted by the ADON read in part: .All med aides that work 2-front med cart are to be on 2-back during breakfast, lunch and dinner to assist with trays at mealtimes. All med aids that work Memory Care unit are to assist with trays during breakfast, lunch and dinner.

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 9 of 12 resident rooms and public areas reviewed for environment.1. The facility failed to ensure the floors were clean and not tacky, in the hallways where the following resident rooms were located: 202, 203, 204, 205, 206, 207, 222, 223 and 224.2. The facility failed to ensure the floor in the public restroom was clean and not tacky.These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Observation on 02/18/26 at 1:00 PM revealed the hallway floors were tacky where the occupied rooms numbered: 202, 203, 204, 205, 206, 207, 222, 223 and 224. The restroom used by staff and visitors had brown/black splatters on the walls and baseboards. The floor had black spots and was tacky when stepped on.In a telephone interview on 02/19/26 at 8:22 AM, the RP for CR #6 stated overall the facility was not clean, the floors were dirty, and she did not like it when she would have to be the one to pick up and clean CR #6's room.In an interview on 02/19/26 at 10:40 AM, the Laundry/Housekeeping Supervisor stated, when cleaning resident rooms she would use Virex (a disinfectant cleaner and deodorant) and add water but did not know the ratio of Virex to water. When asked questions, she did not know which germs Virex killed or the contact time used to kill germs. She stated if too much cleaner was used the floors would get sticky. She stated the floors were cleaned using the cleaner-Pinalen (a multi-surface cleaner) and for large urine spills she would use a capful of Odoban (a disinfectant and air freshener). She stated honestly, she would just guess on how much water to add to the cleaning solutions. She stated all she had for housekeeping procedures was the Safety Data Sheet which listed the cleaning products being used.In an interview and observation on 02/19/2026 at 2:45 PM, Laundry Staff E, was working as a housekeeper stated she would add 4 oz of floor cleaner solution into a spray bottle, add water then use on floors. The spray bottle held 32 fluid ounces. The bottle read: Dirt-destroying Floor Cleaner and the instructions were to squirt and mop. Further review of the product label revealed no instructions to dilute the cleaning solution and no EPA registration numbers. She stated she would use Virex to clean resident rooms and when deep cleaning rooms but not on floors.Record review of the Laundry/Housekeeping Supervisor's job description for Housekeeper, signed by Laundry/Housekeeping Supervisor, on 01/23/2025, read in part: .The Housekeeper is responsible to keep the facility clean daily in accordance with established schedules and procedures.Record review of the Laundry/Housekeeping Supervisor's electronic training transcript included: Bloodborne Pathogens and use of Standard Precautions, completed on 01/30/26, Infection Control: Enhanced Barrier Precautions, completed on 08/28/25.Record review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces read in part: .Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard.1(c)(1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors.2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. a. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. b. by law, all applicable label instructions on EPA-registered products must be followed.9. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.Record review of the facility's Material Safety Data Sheet, revised on 12/04/2025, revealed a list of cleaners and disinfectants: Virex, Distilled [NAME] Vinegar 5%, hand sanitizer, LA's Totally Awesome Window(glass)-blue Cleaner, Professional Cleaner-Pinalen Floral Delight, Odoban, Non-acid bowl cleaner. Further review of the Safety Data Sheet did not include Better Life-Dirt destroying Floor Cleaner.Record review of the facility's Homelike Environment policy dated February 2021 read in part, .Residents are provided with a safe, clean, comfortable and homelike environment.2. The facility staff management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Theses characteristics include: a. clean, sanitary and orderly environment.

Based on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #1) of 6 residents (Resident #1) reviewed for foot care.The facility failed to obtain treatment orders and monitor the status of Resident #1's skin impairment to her toe. The facility failed to monitor and document the blood-tinged gauze present on Resident #1's toe on 2/17/26-2/18/26.This failure could result place residents at risk of in discomfort and/or infection.Findings include: Record review of Resident #1's admission record, dated 2/19/26, revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included type 2 diabetes (a chronic condition that happens when you have constant high blood sugar), reduced mobility, mild cognitive impairment, pneumonia (an infection that inflames the air sacs in one or both lungs), and heart failure. Record review of Resident #1's quarterly MDS assessment, dated 1/6/26, revealed a BIMS score of 9 out of 15, which indicated moderate cognitive impairment. She required assistance from staff with ADL care.Record review of Resident #1's Order Summary Report revealed an order for Podiatry, dental, and eye care PRN , order date 12/11/25. Record review of Resident #1's Podiatry visit, dated 2/11/26 and signed by the Podiatrist, revealed she was on anticoagulants. Her treatment included reduced nails only to patient tolerance. Bleeding due to nail fragment piercing distal flesh 3rd toe right. Cleaned with normal saline. Applied antibiotic ointment and light dressing for 1-2 days.Record review of Resident #1's Skin Monitoring: Comprehensive CNA Shower Review paper record, dated 2/13/26 signed by LVN T, revealed the skin assessment (in the electronic system) was not triggering, DON not available. Resident refused to have dressing removed on right foot 3rd toe.Record review of Resident #1's Weekly Skin Review/Assessment, completed 2/19/26 (effective 2/13/26), revealed the resident refused to allow the nurse to remove dressing on her right foot 3rd toe. The skin issue was not noted on the 24-hour report.Record review of Resident #1's Nursing notes, from 12/11/26 - 2/18/26, revealed there was no documentation of the skin area or gauze to Resident #1's right foot, 3rd toe.In an observation and interview on 2/17/26 at 10:27 a.m. of Resident #1 revealed there was a gauze with dark colored spots present on Resident #1's her right foot, 3rd toe. She said a few days the Podiatrist trimmed her toenails (her toe started bleeding) and the Podiatrist applied a pressure bandage. She said a nurse removed the pressure bandage yesterday . In an interview on 2/19/26 at 8:45 a.m., Resident #1 said the facility really needed to take the gauze off her toe because it had been on for a week and a half. She said a few days ago a nurse took off the pressure bandages but left the gauze in place . In an interview on 2/19/26 at 9:02 a.m., CNA N said she had not noticed a gauze on Resident #1's toe and had not needed to report anything to the nurse. In an observation and interview on 2/19/26 at 9:06 a.m., LVN F who was assigned to Resident #1, said no information about a gauze on Resident #1's toe was passed on to her during report. She said she normally did not work in the section with Resident #1 and was unfamiliar with her toe. LVN F entered Resident #1's room and observed her right foot, third toe and said the gauze appeared to have dry, dark, old blood or dirt on it. Resident #1 informed LVN F that the Podiatrist cut her toenail a week and a half or more ago. LVN F said this would normally be reported to the doctor and the Podiatrist would normally leave an order. She said she would report it .In an interview on 2/19/26 at 9:21 a.m. LVN T, who worked with Resident #1 on 2/18/26, said no one reported Resident #1's toe to her and if the resident had expressed concerns about it yesterday, she would have looked at it . Record review of Resident #1's nursing note dated 2/19/26 at 9:45 a.m. by the Regional Nurse Consultant read, .Resident noted with taped, dry dressing to right 3rd toe. Resident states that the podiatrist had put the dressing on during a visit where her toenail was clipped and there was some residual bleeding. Because of her bleeding tendencies, she states that the podiatrist told her to leave the dressing on for a few days but that she likes to leave them on for additional days because in her past when she resided in the community, she had issues with recurring bleeding where she had to have EMS come and rebandage to control the bleeding. Dressing was softened with normal saline and then removed. Noted with a scabbed area to the top of the toe measuring approximately 0.3 cm which is consistent with the trauma that resident indicated was caused from the toenail clipping. No active bleeding noted. Area free of drainage or any sign of infection. Resident denies any pain or discomfort related to the area. In an interview on 2/19/26 at 10:15 a.m. the ADON said she found out about Resident #1's toe when I (the State Surveyor) found out. She said Resident #1 normally told the staff everything. She said the Podiatrist should have left an order or let someone know about the bandage. She said someone should have seen the area and reported it.In an interview on 2/19/26 at 10:55 a.m. the Regional Nurse Consultant said she spoke with the Podiatrist (today) and received orders to remove Resident #1's dressing and leave it open to air. She removed the dressing and left it open to air. She said Resident #1 requested the dressing from the Podiatrist because she was very particular about the bleeding. She said Resident #1's weekly skin assessment (scheduled 2/13/26) was not triggering in the computer system and a nurse documented the toe on the skin sheet. She said the area was originally an open area and staff should have been made aware, she said the Podiatrist apologized and assumed the bandage would have been removed. She said if the nurses had known they would have checked the area. She said nurses should be aware of the skin area to monitor and know when to remove the bandage to ensure there were no changes to the skin.In an interview on 2/19/26 at 11:26 a.m., LVN T said she was aware of the area to Resident #1's right 3rd toe. She said last Friday, 2/13/26, she did a skin assessment about the toe. She notified the DON, but she was out of town and notified the MD but did not provide the name of the MD. She said she verbally informed the other nurses about the toe but might not have put it in the chart.In an interview on 2/19/26 at 12:11 p.m., the DON said she was not aware of Resident #1's toe because she was out of the building. She said the area should have been discovered on skin assessment or through the Podiatrist who should have reported orders for a pressure dressing for 24 hours. She said when staff found it, they should have reported it to the MD for guidance and/or orders. Staff should notify the MD and family about refusals but said she was unsure if that was done. She said there was a care path sheet at every nurses station that showed what to do in the event of skin impairment. In an interview on 2/19/26 at 2:16 p.m. revealed Resident #1's Podiatrist said Resident #1 had contracted digits and her nails pierced the flesh. When she clipped the nails, it started bleeding. She said she normally placed a temporary bandage, applied an ointment and removed the bandage. The resident had poor circulation and to be safe they left it on, and she communicated to the resident it should be left on approximately 1-2 days. She said she did not leave a treatment order and assumed the bandage would be removed during bathing, but she should have notified the staff to remove it. She said the risk of leaving the bandage on could lead to laceration and set up infection but that was a low probability. She did not feel the facility was negligent and said Resident #1 liked the bandage. In an interview on 2/19/26 at 2:52 p.m., Resident #1's NP said the facility was not made aware of the provider's accidental clipping and should not be at fault . She said the facility notified her today and a nurse attempted to remove the dressing prior to today but Resident #1 refused to. She said she did not recall the facility reaching out to her at the time but if they did it would be documented. She said if the patient refused more than once, the facility would reach out to her and let her know. She said Resident #1 was at high risk for bleeding and the skin was typically assessed every 7 days.In an interview on 2/19/26 at 3:09 p.m., Resident #1 said when the nurse removed the pressure bandage (around 2/16/26) the resident did not request that the gauze stay on. She said the nurse suggested leaving the gauze in place to ensure no additional bleeding which Resident #1 said she agreed with. She said 3-4 days passed and she was going to see if someone could remove it. She said she started asking staff to remove it because it needed to come off and it looked really dirty. She said the facility did a good job removing the gauze today. It stuck for a little bit when they tried to remove it, they wet it to soften it. Resident #1 said she did not experience any pain. In an interview on 2/19/26 at 3:25 p.m. with Resident #1's RP, he said he was not notified by the facility of a refusal to remove the gauze or of the incident. He said Resident #1 told him that she was nicked by the Podiatrist. He said Resident #1 did like to keep the gauze in place for a few days.In an attempted interview on 2/19/26 at 3:40 p.m. with LVN M, who Resident #1 said might have removed the pressure bandage, was unsuccessful.Record review of Resident #1's nursing note, dated 2/19/26 at 9:45 a.m. by the Regional Nurse Consultant, read, .Resident noted with taped, dry dressing to right 3rd toe. Resident states that the podiatrist had put the dressing on during a visit where her toenail was clipped and there was some residual bleeding. Because of her bleeding tendencies, she states that the podiatrist told her to leave the dressing on for a few days but that she likes to leave them on for additional days because in her past when she resided in the community, she had issues with recurring bleeding where she had to have EMS come and rebandage to control the bleeding. Dressing was softened with normal saline and then removed. Noted with a scabbed area to the top of the toe measuring approximately 0.3 cm which is consistent with the trauma that resident indicated was caused from the toenail clipping. No active bleeding noted. Area free of drainage or any sign of infection. Resident denies any pain or discomfort related to the area.Record review of the facility's Prevention of Pressure Injuries policy, dated April 2020, read in part, .Skin Assessment. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Monitoring: 1. Evaluate, report and document potential changes in the skin.Record review of the facility's Wound Care policy, dated October 2010, read in part, .Reporting.1.notify the supervisor if the resident refuses the wound care. 2. Report other information in accordance with facility policy and professional standards of practice.Record review of the facility's Charting and Documentation policy, dated July 2017, read in part, Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Documentation in the medical record may be electronic, manual or a combination. 2.The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #12) reviewed for tube feeding.The facility failed to ensure Resident #12 received her enteral feeding, Jevity 1.5, at the rate assigned by the MD on 2/17/26 and 2/18/26.This failure could result in weight loss and dehydration.Findings include: Record review of Resident #12's admission record, dated 2/18/26, revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included dementia, moderate protein-calorie malnutrition (occurs when there is a deficiency of protein and calories in the diet), anemia (a blood disorder that affects red blood cells and oxygen delivery), and gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus). Record review of Resident #12's annual MDS assessment, dated 12/12/25, revealed her cognitive skills for daily decision making were severely impaired. She was totally dependent on staff for ADL care, and she received 51% or more total calories through the feeding tube.Record review of Resident #12's care plan, revised on 12/25/25, revealed she had a potential nutritional problem related to NPO, getting all nutritional needs via peg tube due to dysphagia (difficulty swallowin) also noted with diagnoses of protein/calorie malnutrition, anemia, and legally blind. Interventions were to provide enteral feeding/flush as ordered.Record review of Resident #12's order summary report revealed an order for Jevity 1.5 cc at 55 cc/hr x 22 hours via kangaroo pump, order date 2/7/25. (a kangaroo pump is a medical device used to deliver enteral nutrition and hydration directly into a patient's gastrointestinal tract).In an observation on 2/17/26 at 12:13 p.m. revealed Resident #12 was lying in bed and did not respond to the State Surveyor greeting. Her g-tube feeding, Jevity 1.5 cal, was running at 50 cc/hr.In an observation on 2/18/26 at 8:57 a.m. Resident #12's g-tube feeding (Jevity) was running at 50 cc/hr. The feeding was dated 2/18/25 at 3:30 a.m. and 50 mL (cc)/hr was handwritten on the formula bottle.In an observation and interview on 2/18/26 at 12:40 p.m. revealed LVN T entered Resident #12's room and said the enteral feeding was set at 50 cc/hr, but should be at 55 cc/hr. She said the 10 p.m. - 6 a.m. nurse hung the feeding for Resident #12. She said she checked the rate of the formula during her shift but had not checked it yet.In an interview on 2/18/26 at 1:37 p.m., LVN T said Resident #12 was not receiving the ordered amount and a possible risk could be not getting proper nutrition. She said the resident was well balanced and was informed by the previous nurse during shift change that she had no adverse effects.In a telephone interview on 2/18/26 at 6:00 p.m., LVN R said he hung the enteral feeding for Resident #12 overnight. He said he believed the rate was 50 cc but was not 100% sure because he did not have the order in front of him. He said the rate was provided to him by his trainer approximately 1 and 1/2 months ago and was also passed down through shift report. He said he did not need to reference the MD order every night for the enteral rate because he already knew the rate and it remained the same to his knowledge. He said he would also take note of the rate that was written down on the formula bottle when he came on shift. He was made aware of changes to the enteral rate through shift change, but no one informed him of any changes. He had not noticed any changes in Resident #12's weight. He said the risk of Resident #12 not receiving the enteral feeding at the rate ordered by the MD could affect her nutrition over the long run. He said he did not recall if he was trained to check the order for the rate prior to administering the enteral feeing but said there was a lot of information provided during training. In an interview on 2/18/26 at 3:36 p.m., the DON said the night shift nurses changed the syringes and formula bags at midnight. She said nurses were trained on hire and quarterly on g-tubes. The enteral feedings should be labeled at the cart and nurses should use the computer to verify the rate. She said the dietitian might have changed Resident #12's rate and the nurse might have gone by memory instead of verifying the order. She said Resident #12 could have weight loss or not receive the number of calories calculated for her. Record review of the facility's Enteral Nutrition policy, dated 11/2018, read in part, .Policy Statement: adequate nutritional support through enteral nutrition is provided to resident as ordered. 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include. e. volume and rate of administration.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of three medication carts (Medication Aide Cart 2-Front) reviewed for medication storage.1. The facility failed to keep residents' eye drop medications in their original containers/packaging. There was one box of Simbrinza 1%/0.2% (an eye drop used to treat glaucoma and high eye pressure) that had two resident name labels.2. The facility failed to label and identify the specific resident for whom the Artificial Tears-lubricant eye drops (designed for multiple administrations) were prescribed. These failures could place residents at risk of receiving the wrong medication, adverse side effects and hospitalization. During an observation and interview on 02/19/2026 at 9:13 AM, the medication aide cart for 2-front, which was assigned to MA U had a box for Simbrinza 1%/0.2% ophthalmic eye drops. The box had a pharmacy label with the name of a resident and the bottle inside the box had a pharmacy label with the name of a different resident. The two names did not match.A box for Artificial Tears was not identified with a resident name. The box was labeled with the opened date of 02/03/26. The bottle inside the box did not have a sealed cap. MA U stated she could tell the Artificial Tears bottle had been opened because it no longer had the plastic seal. MA U denied opening, labeling or using Artificial Tears for any of her assigned residents because it would be an infection control problem. MA U stated the Artificial Tears should have a resident's name for identification and she would never use a bottle that did not have the proper identification. MA U denied using the Simbrinza for the resident whose name was on the box. MA U stated she did not know why the name labels on the Simbrinza did not match. MA U stated the eye drops should not be in the cart and would remove them. MA U stated all the medication aides were responsible for cleaning and auditing the cart and she had just returned from having days off. In an interview on 02/19/2026 at 12:14 PM, the DON stated a new OTC box of Artificial Tears should be labeled with identifiers for the resident it will be used for including date and room number. The DON stated the Nurse administering the medication would be responsible for proper labeling. The DON stated whoever was responsible for the two different name labels was probably not paying attention, did not follow through by putting the Simbrinza eye drops in the right box. The DON stated the risks to residents would be the spreading of an eye infection from resident to resident.Record review of the facility's policy for Medication Labeling and Storage, revised in February 2023, read in part: .Medication Storage 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.5.Each resident's medications are assigned to an individua cubicle, drawer or other holding areas to prevent the possibility of missing medications of several residents. Medication Labeling. 2. The medication label includes, at a minimum: a. medication name.b. prescribed dose; c. strength; d. expiration date, when applicable; e. resident's name; f. route of administration; and g. appropriate instructions and precautions.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen pantry and refrigerator located in the kitchen area that was reviewed for food procurement. The facility failed to ensure food items stored in the refrigerator were properly identified and dated when opened. The facility failed to train staff in identifying the importance of the sanitizing strips. The facility failed to discard expired food items found in the refrigerator. The facility failed to clean and sanitize the kitchen. The facility failed to repair a malfunctioning dishwasher temperature, resulting in inaccurate readings and the inability to verify proper sanitation of dishes. These failures could place residents at risk of foodborne illness, disease, and hospitalization.Findings include:Observation of the facility's kitchen and interview with the Dietary Supervisor on 02/17/26 between 8:45 AM and 9:30 AM revealed the kitchen area was not clean with paper and food debris on the floor, which was sticky, and did not appear to have been swept or mopped. There was a dead roach on the pantry area floor; no light fixture on the electrical socket, the stove was not cleaned as there was a buildup of crusty black unidentified dark matter; an uncovered stainless-steel f6canister with butter, unidentified white matter and a food spreader inside, and the hood of the stove had grease build-up. Behind the stove on the floor was buildup of dirt on the floor and grease on the pipe and wall area. The inside of the stove appeared to have built up grease, unidentified white particles and food in the crevices between the inside of the stove and the door. The temperature knobs on the stove handles were [NAME] and yellowish.Observation on the counter in the kitchen area revealed:Cane Sugar placed in a Ziploc bag with no date.Observation in the Refrigerator:Puree in a jar was sitting in the refrigerator and had no date placed in the refrigeratorOpened BBQ sauce in the Refrigerator was dated 1/5/26A package of Chocolate in the refrigerator was dated 1/27/26Observation of the Freezer revealed:Whip cream in a Ziploc bag was not identified in writing on its package2 pkg of hashbrowns were not properly identified by writing on its packageBag of what appeared to be Okra was not properly identified on the bagObservation in the Pantry area revealed:Liquid in bottle had no datePudding and Jello were not in the refrigerator and sitting uncovered on the counterLarge mustard container was opened with no date or year.Ziploc bag of whip cream was dated 11/28 and had no yearObservation of the facility's malfunctioning dishwasher gauge that showed 120 degrees while not in operation. According to the color-coded sanitizing test strip the dishwashing machine should show 400 ppm, which was a dark purple color when placed in the dishwasher while in operation. This sanitizing test strip ensures the dishes are being properly sanitized while washing. The dietary supervisor stated the dishwasher was operating properly; however, when he tested the strip there was no color, which indicated the dishes were not being sanitized. Under the sink was unidentified black matter on the wall, pipes and base boards.Observation of the Dish Machine Temperatures & Sanitation Log revealed:In October & November (No year noted), January 2026, February 2026, The AM wash temp (120 degrees), Noon wash final temp (140 degrees), and PM wash temp (100) were completed and initialed by staff each day, which was based on the sanitation strip and the dishwasher temperature gauge.Test strip log for the water temp for February 2026 showed Water temp at 120 degrees, PPM at 400 (this matches the color on the sanitizing strip).In an interview on 02/17/26 at 9:10 AM with the Dietary Supervisor, he stated all items should be marked (identified) with the date opened and received. If not marked (Identified), then there was no way to determine when an item was received or how long the items were in the refrigerator and the risk could very well cause residents to be sick and other negative pathogens. When asked for in-service training records on employees who were trained in proper storage, he stated he could not find the records. The dietary supervisor stated the staff that opened the package to place in refrigerator should have labeled and dated it.In an interview on 2/18/26 at 8:55am with the Dietary Supervisor & Administrator, the Dietary Supervisor stated the Dishwasher tester strips (verification of chlorine in the dishwasher rinse cycle to sanitize dishes) identify the amount of chloride in the dishwater to ensure sanitation. The dietary supervisor stated the gauge is what the staff observe and record on their daily log. He stated if the gauge on the dishwasher failed, then there was no way to determine if the dishwasher was operating at an acceptable capacity because his staff completes the dish washer temp log based on the gauge. The dietary supervisor stated the dishwasher temp form is very important because it is used to ensure the hot water is hot enough to wash and rinse the dishes. The dietary supervisor performed a demonstration to show the dishwasher temperature gauge, even though it showed 120 degrees prior to the startup of the dishwasher, would move and show the actual temperature. The gauge did not move. During the rinse, the Dietary Supervisor used the chlorine strip, which would turn a deep purple color in one second after being placed in the rinse water of the dishwashing machine to measure the level of chloride. He tested the strip on 4 occasions, and the strip was colorless. The administrator suggested allowing more time for the strip to turn colors to identify the temperature of the rinse water (400 degrees). The administrator was shown the directions on the strip bottle that indicated the strip should turn colors within one second. Both the Dietary Supervisor and Administrator acknowledged and stated the dishwasher was not working properly and the dishes were not being sanitized appropriately, which could cause contamination and bacteria that could affect the residents and make them sick. The Dietary Supervisor stated that when there is no sanitation on resident dishes the risk is that residents are exposed to contamination that can make them sick.In an interview on 2/18/26 at 1:00pm with Maintenance Supervisor, she stated just a few moments ago she increased the water temperature by 5 degrees more and the chlorine strip is now 400 PPM (Used as a disinfectant and decontamination agent), and the temperature for the dishwashing machine is 180 . She stated she was not notified that there was an issue with water temperature for the dishwasher and rinse.In an interview on 2/18/26 at 1:25pm with Dietary Aid-A, she stated that she completed the Dish machine temp & sanitizing log and inputs the appropriate numbers as instructed to by the current Dietary Supervisor. She stated that the temperature gauge has always shown 120 because it does not work. She stated she has informed the Dietary Supervisor of this on several occasions for at least within last two weeks or more. She stated he told her to continue to fill out the sheets and he would call someone later. She stated later had never arrived. She stated that without the gauge operating properly there is no way to know if the dishes have been sanitized or not and could affect the residents.In an interview on 2/18/26 at 1:40pm with Service Manager stated the contract with the facility is he maintenance the equipment in the kitchen every 28 days, unless called by the facility to come sooner. He stated the contract includes servicing the dishwasher, replacing dispenser & dropping off chemicals. He stated there is no invoice unless there are costly parts for the equipment. The service manager stated he has been servicing the dishwashing machine for some time now. He states that he's typically here every month, however it feels like it's every day because the dishwashing machine always has an issue. The Service Manager stated that the dishwashing machine does not make a lot of water or has a lot of pressure. The Service Manager stated staff should wait at least five minutes after the start of the dishwasher before putting the dishes in it for a better and sanitized wash. The Service Manager stated that he has informed the Dietary Supervisor of this procedure. The Service Manager stated that if someone is in the sink area washing dishes and using that hot water, this will diminish the water temperature (heat), and the water pressure on the dishwasher. The Service Manager stated the plumbing is a problem in the facility. The Service Manager stated the temperature gauge has not been reported to him for being broken. He stated when the gauge is working properly, it is set to zero (0) when the washer is not running. It should not be set to 120 when dishwasher is not operating. The Service Manager stated he will replace it.In a follow-up interview on 2/19/26 at 7:40am with the Service Manager he stated he has repaired the temperature gauge, and it is working properly. The gauge was observed to be set at zero. At this time the Kitchen Manager turned the dishwasher on, and the gauge moved to 120 degrees. The chlorine strip showed 400 in accordance with the color contrast. In an interview on 2/19/26 at 8:30 AM with Cook-A, she stated when washing the dishes she did not initial the dishwashing log because she forgot and another coworker would complete it for her and place her initials in the appropriate area. She stated the logs were on the wall. Cook-A stated the temperature for dishes was 120 degrees and PPM 400. Cook-A stated she thought the 400ppm was related to the chemicals in the water, but she was not sure because she had not received in-service training. Cook-A stated she believed she received in-service training about a month ago but could not say what it was about. Cook-A stated there was deep cleaning overnight about 2 months ago in the kitchen area. Cook-A stated there was a set schedule to clean each area for dining staff, but she cleaned daily.In an interview on 2/19/26 at 1:15pm with Dietary Aide-D, she stated that she uses the strip tester then she indicated that she's been informed by the previous Dietary Supervisor just to fill in the numbers of 120 /140/100 PPM. She stated that she does not know what the numbers mean and she has not had any in-service training. She stated she assumed that the temperatures on the dish washer are important, but she doesn't know why because she hasn't been trained. In a follow-up interview on 2/19/26 at 1:55pm with Dietary Aide-A, she initially stated she didn't receive in-service training; however, then she stated she remembered the Dietary Supervisor had brought around a piece of paper and told her to sign it. She stated she asked what she was signing and the dietary supervisor told her it was about the temperature on the washing machine. She stated she signed it but didn't understand.In an interview on 2/19/26 @2:04pm Follow Interview with Dietary Supervisor stated he believes the most important part of his job is making sure residents get their daily nutrition; while eating utensils and surfaces are clean and sanitary to ensure sanitary environment and the residents don't get sick. He stated he completed a sanitation daily cleaning schedule that included chlorine testing the dishwasher, proper food storage with dates and times, dining room expectations, and the importance of sanitation to eliminate cross contamination. He stated the in-service training with staff was completed yesterday (2.18.26). The dietary supervisor stated he has 8 employees working under his supervision. He stated he was trained by the previous administrator on how to do in-service training. The dietary supervisor stated kitchen staff never informed him that the temperature gauge on the dishwasher was not working. He stated the dishwasher gauge would work after starting the dishwasher 5 times, but there is no written instructions for staff to know this procedure. The dietary supervisor stated he never instructed staff to complete the operator's paperwork with signatures without observation. The dietary supervisor stated the negative result with temperature gauge not operating properly is possible contamination and possible disease for the residents. The dietary supervisor stated the stove is cleaned once a week or whenever there is visible spill. The dietary supervisor stated, the stove is important to be kept clean, because if you're cooking on an unclean stove dirt may get into food and the food could be contaminated. This could make residents sick. In an interview on 2/19/26 at 4:30pm Interview with the Administrator she stated the kitchen is dirty and she has spoken with the dietary supervisor about this on several occasions. She stated she told him if state (survey team) comes to the building during survey and if there is any issues with the kitchen that she has previously addressed with him, there will be disciplinary actions. The administrator stated due to the issues surveyors have addressed in that kitchen were issues she addressed prior to the survey. She stated the dietary supervisor received a written discipline yesterday. The administrator stated she and the dietary supervisor and a few other facility staff members were hired 6 months ago. She stated a lot of the issues in that kitchen were inherited by the current dietary supervisor. The administrator stated she came to the facility on one occasion and assisted the dietary supervisor in deep cleaning all areas of the kitchen. She stated the building is old and if you mop the floor, within an hour it looks as if it wasn't mopped at all. She stated yesterday and today the staff received in-service on kitchen cleanliness, the dishwasher maintenance log, accountability, and the importance of ensuring the food is dated when in the pantry areas after its opened and placed in the refrigerator and being left uncovered on counters. She stated this could cause contamination and make the residents sick.Record reviews of the facility's tracking and trending infection control, found there has not been any GI bugs (an inflammation of the stomach and intestines caused by viral, bacterial, or parasitic infections) or outbreaks among the residents.Record review of the facility's Policy & Procedure Manual 2024, dated 2/28/2024_Food & Nutrition Services Manual read:Food Storage Procedure (page 32) revealed: It is recommended that food items are to be dated upon receipt with the month, day and year (00/00/00). All opened and partially used foods shall be dated, labeled and sealed before being returned to thestorage area.Dry food containers revealed:Date, label if not identifiable, and seal all opened packages.Keep shelving and floor clean and dry. c. Refrigerated items revealed:Enclose all cooked food or other products removed from original containers in clean, sanitized, covered containers with proper label and date. No food should be stored in open cans.Label all cooked and opened items with open and use by dates (00/00/00), unless the item already includes an expiration date. Follow state regulatory guidelines.Discard all TCS (time and temperature control for safety) food which has been at room temperature for more than 2 hours.C. Dishwasher Temperatures - Required Records Policy:The temperatures of the dish machine will be recorded three times a day. Temperatures out of specified range will be reported to the Nutrition Services Manager (NSM).Mechanical Washing Reads,Low temp machine:120-140 F with chemical sanitizer, for further specifications, see manufacturer's recommendations.Rinse must provide 50 to 100 ppm hypochlorite (chlorine) on the dish surface. Verify with a test strip prior to washing dishes for each meal.The machine must have a visual or audio alarm to indicate when the sanitizing chemical is low.5. Certified Dietary manager, Director of Staff Development, Dietician or designated individual should in-service dietary staff annually or more frequently as needed on how to prevent infectious diseases in the kitchen.13. Infection Prevention:Record Review of the Texas Food Establishment Rules (TFER) dated August 2021(c) Labeling. Donated foods transported offsite shall be labeled with the name of the food, the source of the food, and the date of preparation.(d) A food specified in Food Code, Paragraphs 3-501.17(A) or (B) or S3-501.18 shall be discarded if it: (1) exceeds the temperature or time specified in Food Code, Paragraphs 3- 501.17(A) and (B), except time that the product is frozen; (2) is in a container or package that does not bear an expiration date or day; or (3) is not appropriately marked with a date or day that exceeds the temperature and time combination as specified in Food Code, Paragraphs 3-501.17(A) and (B).

Based on observation, interview, and record review, the facility failed to provide housekeeping and the maintenance services necessary to maintain a clean, sanitary, safe, and comfortable environment for 7 of 10 resident rooms (Rooms #215, #216, #309, #311, #312, #313, and #314) reviewed for the environment. This failure could affect the health, safety and the dignity of the residents and other residents in the facility. Findings include: On 1/22/2026 at 9:05 a.m., an observation of resident room [ROOM NUMBER] was conducted. The bed was observed to be positioned close to a torn window blind. The floor of the room was observed to have thick, dark, dirty stains along the edges and corners. The walls were observed to be in poor condition with paint visibly peeling off in multiple areas. On 1/22/2026 at 9:08 a.m., an observation of resident room [ROOM NUMBER] was conducted. The floor of the room was observed to be dirty and sticky, dirty stains along the edges and corners. The walls were observed to be in poor condition with paint visibly peeling off in multiple areas. On 1/22/2026 at 9:10 a.m., an observation of resident room [ROOM NUMBER] was conducted. There was multiple dirty resident clothing on the floor near a full dirty trashcan. The floor of the room was observed to be sticky and have dark, dirty stains along the edges and corners. The window blind was observed to be torn and damaged. On 1/22/2026 at 9:29 a.m., an observation of resident room [ROOM NUMBER] was conducted. The observation reflected the room floor had thick dark dirt stains along the edges and corners of the floor. On 1/22/2026 at 9:32 a.m., an observation of resident room [ROOM NUMBER] was conducted. The observation reflected the room floor had thick dark dirt stains along the edges and corners of the floor. On 1/22/2026 at 9:35 a.m., an observation of resident room [ROOM NUMBER] was conducted. There was no window blind and no privacy curtain in the room. The floor of the room was dirty and sticky. The wall by the window had brown stains on the bottom. The room floor had thick, dark, dirty stains along the edges and corners of the floor. A part of the ceiling had holes and opens, the air vent had thick black dirt on the vents. The bathroom floor had dark stains along the corners of the floor and behind the toilet. On 1/22/2026 at 9:40 a.m., an observation of resident room [ROOM NUMBER] was conducted. The observation reflected the floor was filthy, sticky, and thick dark dirty stains along the edges near the bed. The base of the wall toward the right entrance of the room has peeled off and has brown liquid around it. In an interview with the Maintenance Director on 01/22/26 at 9:48 a.m. resident room [ROOM NUMBER], the Maintenance Director said there was black stuff on the vent and it should not look like that. The gap (hole) in the ceiling needed to be covered to prevent roaches and rats from entering the room. The facility was in the process of painting the walls and repairing the baseboards. The resident rooms and environment should be homelike, clean, nice, and organized. The resident rooms (#215, #216, #309, #311, #312, #313, and #314) did not feel like a homelike environment. She checked each room daily for hazards, but any staff could check for environmental hazards/concerns, and if reported, she would address it. When resident rooms are not free from hazards, and not cleaned, it will be unsanitary for the residents. She stated that maintaining clean resident rooms is important for resident health and safety. In an interview with LVN J on 1/22/2026 at 10:50 a.m., LVN J stated that the housekeeping staff make daily rounds and provide cleaning services daily and as needed. She noted that there is only one housekeeping staff member assigned to the memory care unit. She conducts room rounds daily and as needed. If any hazardous conditions are identified, she documents them in the maintenance log and notifies the administrator. Additional cleaning should be done as needed in all the rooms. For room [ROOM NUMBER], she had not noticed any damage to the base of the wall or brown liquid around it. She would address the issue immediately. She confirmed that it is her responsibility to ensure residents are safe within their rooms and environment. CNAs are responsible for monitoring and cleaning after housekeeping has already made their round for the day, and they are also responsible for picking up dirty laundry. The resident rooms should be safe, clean, and homelike environment. She confirmed that if resident rooms are not cleaned properly, the environment will be unsanitary for the residents and could affect their health condition. In an interview with Administrator on 1/22/2026 at 12:35 p.m., she stated that one of her roles is to ensure resident safety within the facility. She conducts daily observations to ensure residents have a safe environment. Safety concerns are identified and addressed as promptly as possible. The resident environment should be homelike, clean and safe. The environmental issues remain due to the age of the building and competing priorities, but efforts are ongoing to address outstanding concerns. The resident rooms (#215, #216, #309, #311, #312, #313, and #314) did not feel like a homelike environment. The facility had two housekeeping staff members per day to provide housekeeping services throughout the facility. The housekeeping and maintenance staff are responsible for cleaning and room maintenance for resident safety and well-health being. She acknowledged that there have been instances where cleaning duties were not completed as expected. If the resident rooms are not cleaned, it will be unsanitary for the residents. She stated that maintaining clean resident rooms is important for resident well-being and safety. In an interview with CNA H on 1/22/26 at 2:55 p.m., she stated that housekeeping and maintenance staff are responsible for ensuring resident rooms are clean and maintained in a home-like environment. She reported that if she enters a resident room and identifies housekeeping concerns, she reports them to housekeeping staff for cleaning. If maintenance concerns are identified she documents the issue in the maintenance log for follow-up. The resident rooms are expected to be maintained in safe condition. She reported that she had not observed any environmental concerns in the units or resident rooms. She acknowledged that some window blinds in the resident rooms needed replacement. Most of the resident rooms need to be painted, due to the paint peeling off. Additional cleaning needs to be done in the residents' rooms. If the resident rooms are not cleaned, it will be unsanitary for the residents. She stated that maintaining clean resident rooms is important for resident well-being and safety. In an interview on 01/22/2026 at 2:58 p.m., the DON stated housekeeping is responsible for cleaning the resident rooms. The facility had 2 housekeeping staff, and the resident rooms are cleaned once daily. Resident rooms need more frequent cleaning, and additional cleaning should be done as needed. The resident rooms are expected to be cleaned daily and as needed by housekeeping, however she was unsure why some resident rooms were observed to be unclean and unsanitary. CNAs are responsible for monitoring and cleaning after housekeeping has already made their round for the day, and they are also responsible for picking up dirty laundry. She confirmed that if resident rooms are not cleaned adequately, the environment will be unsanitary for the residents and could affect their health. In an interview with LVN O on 01/22/2026 at 4:12 p.m., LVN O stated that the resident rooms require attention from housekeeping and maintenance. Many resident rooms have window blinds that are torn and need replacement. The base of the wall in some resident rooms is peeling off, and wall paints are peeling off in some areas. The facility management is aware of the issue but was unsure why the repairs have not been completed. The resident rooms are expected to be maintained in a clean, safe and homelike manner. LVN O confirmed that if resident rooms are not cleaned adequately, the environment will be unsanitary and can affect the health of the residents. Record review of the facility's policy revised on February 2021 on Homelike environment Residents are Provided with a safe, clean, comfortable, and home like environment and encouraged to use their personal belongings to the extent possible. Staff provide person - centered care that emphasizes the residents comfort, independence, and the personal needs and preferences. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include a) clean, sanitary, and orderly environment.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet per resident for 2 of 6 multiple occupancy resident rooms (Rooms #311 and #314) reviewed for room size.Rooms #311 and #314 did not have the required 80 square feet per resident.These failures could place residents at risk of reduced living space and could affect their activities of daily living (ADLs).The findings were:Record review of Form 3740 Bed Classifications, signed by the Administrator on 1/15/26, revealed rooms #311, #312, #313, #314, #315, and #316 was classified to have 3 resident beds in each room.In an interview on 1/21/26 at 1:02 p.m., the Administrator said she did not have documentation to show that 3 beds were allowed in the room. She said the corporate office informed her in the past that they did not need a waiver. In an observation on 1/21/26 at 2:12 p.m., the Maintenance Director measured rooms #311 and #314 in the secure unit. Room size measurements were as follows:1. room [ROOM NUMBER] (3-person room - 3 residents in room) 20 ft x 11 ft = 220 sq ft / 3 residents = 73.3 sq. ft per resident2. room [ROOM NUMBER] (3-person room - 3 residents in room) 20 ft x 10.25 ft = 221.3 sq ft / 3 residents = 73.77 sq. ft/residentIn an interview on 1/21/26 at 2:18 p.m., the Maintenance Director said she was unsure of the amount of space needed per resident and needed to verify. She said there was no concerns brought to her about the size of the room and the number of beds but risks for the inappropriate amount of space could include falls, trips, clutter, and not enough space for evacuation.In an interview on 1/21/26 at 2:56 p.m., the Administrator said each resident needed 80 square feet. She said she would make the rooms a two-person room to ensure enough space. She said she could not find a waiver but would continue to look.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 hallways, (Hall 200), conference room, and Resident #1 and #2's shared room. The facility had live flies in the room of Resident #1 and #2 located on Hall 200. The facility had live gnats in and outside the conference room located on Hall 200. This failure has the potential to place residents at risk for disease and a decline in their physical health. Findings included: Record review of Resident #1's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of Unspecified Psychosis not due to a substance or known psychological condition (when an individual exhibits psychotic symptoms such as hallucinations, delusions, or disorganized thinking, but the underlying cause is not attributable to substance use or a known physiological condition). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicates a severe cognitive impairment. Record review of Resident #2's Electronic Health Record revealed an [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of Chronic Obstructive Pulmonary Disease (a term for lung and airway diseases that restrict breathing). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicates a severe cognitive impairment. In an observation on 11/18/2025 at 8:45 am, 2 gnats were observed in the conference room located on the 200 hall. In an observation on 11/18/2025 at 8:50am, 1 gnat was observed in the hallway of 200 hall outside of the conference room. In an observation on 11/18/2025 at 1:46pm of room [ROOM NUMBER] shared by Resident#1 and #2 located on the 200 hall there were 2 flies flying in the room. One fly was observed to fly above both residents and to land on Resident#2's linen, and the second fly was observed on the bedside table of Resident#2. In an effort to interview on 11/18/2025 at 1:46pm, Resident#1 decline to be interviewed. In an interview and observation on 11/18/2025 at 1:50pm, Resident #2 said he saw one fly in his room. Resident#2 pointed to his bedside table where a fly was located. He said that he saw flies all the time but had not told anyone about the flies. In an interview on 11/18/2025 at 1:55pm, the ADON said that she saw a fly on the bedside table of Resident#2. She said that a pest control company came to the facility monthly, and she thought the facility's pest control was effective. She said that she would report the fly she observed in the room of Resident#1 and #2 to the Administrator. In an interview on 11/18/2025 at 3:15pm with the Administrator and DON, both were made aware of observation of flies in room [ROOM NUMBER] and gnats in the conference room. The Administrator said that the facility's pest control company was scheduled to service the facility each month, and the pest control company was scheduled to return to the facility on [DATE] for targeted concerns. In an observation on 11/20/2025 at 1:17pm, 1 gnat was seen to fly in the conference room. In an interview on 11/20/2025 at 1:17pm with the Maintenance Director, she said that when there is a sighting for a pest control problem it should be reported to her. She said she then goes to assess the area of concerns, and she notifies the pest control company to schedule a visit to address the targeted area. She said that the pest control company is scheduled to service the facility monthly to maintain effective pest control. She said that she does not feel that pest control is effective, and she frequently has seen gnats and roaches. She said that she started at the facility on 08/28/2025, and she requested that the pest control company increase the monthly visits to twice each month, but the pest control company declined with no reason provided. She said that she had been working with the Administrator to get a new contract for pest control, but it had not been approved. She said that she had not been told that gnats were seen in the conference room, and she only saw gnats in the conference room on 11/20/2025 while being interviewed. She said that she would request that pest control to return on 11/21/2025 to address the concern for gnats. She said that an effective pest control system was needed as insects like flies and gnats can carry bacteria and cause residents to become sick. In an interview on 11/21/2025 at 11:51am with the DON, she said that the facility should have an effective pest control system. She said that the pest control company comes to service the facility monthly. She said that there had been an issue with flies, gnats, and roaches. She said that the Administrator has been trying to get a new contract for pest control. She said that an ineffective pest control system can cause illness and problems with infection control. In an interview on 11/21/2025 at 12:05pm with the Administrator, she said that the facility has had an issue with gnats since she started on 08/25/2025. She said that she had not been aware of roaches to be an issue, and she was only aware of there to be an issue with flies on 11/18/2025. She said that she is in the process of getting a new contract for pest control, and the corporate office is getting quotes, but it had not been finalized. She said that the facility should have an effective pest control system, and the facility's environment should be pest free. She said that an ineffective pest control system can cause illness and problems with infection control. Record review of the facility's pest control invoices revealed the facility received monthly pest control services on 11/05/2025, 10/01/2025, and 09/03/2025 for ant, spider, and roach prevention. Record review of a pest control invoice dated 11/19/2025 that did not detail the treatment provided on 11/19/2025. Record review of the facility's policy titled pest control dated 2001 read in part, .Our facility shall maintain an effective pest control program. 1. This facility will maintain an on-going pest control program to ensure that the building is kept free of insects and rodents .

Based on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. CR #1 eloped from the facility on 03/23/2025 while in the secured unit, through the window. CR #1 was found at a previous residence on 03/24/2025 and refused to return to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/23/2025 and ended on 03/24/2025. The facility corrected the non-compliance before the investigation, began on 10/14/2025. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included:Record review of CR #1's previous facility note text, dated 01/01/2025 stated staff went to the resident's room and noted the window was open in the secured unit, resident was not found in the room. Staff immediately initiated their elopement protocol.Record review of CR #1's previous facility note text, dated 01/01/2025 stated resident was found by staff and escorted back to the facility and placed into the secured unit where his room was. CR #1 stated the reason why he left out the window is wanting to go shopping. CR #1 was placed on 1:1 supervision until transfer to another facility for further evaluation. Record review of CR #1 face sheet, unknown date revealed a [AGE] year-old male who was admitted to the facility on , 01/17/2025. CR #1 had diagnosis which included lack of coordination, dementia, depressive disorder, mild cognitive impairment, and persistent mood disorders. Record review of CR #1's Social Services Note by SW L dated 01/17/2025 met with Social Worker from previous facility who shared general information regarding CR #1 to include, the resident is polite and no behaviors at this time. However, residents attempted escape through the window at previous facility. The family desired for the resident to be moved to Houston area to be close to family. Record review of CR #1's Nurses Note by LVN S dated 01/17/2025 met with new resident in the lobby. CR #1 was able to independently walk. Vision and hearing is within normal limits. Secured unit has assessed his belongings and documented. MD was notified and has reconciled medications for the resident. Record review of CR #1's Care Plan dated 01/22/2025 revealed an elopement risk/wanderer with history of attempts to leave prior facility unattended, impaired safety awareness. Presently admitted to the memory care/secured unit. Interventions included distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. To also include monitor location during rounds and document wandering behavior and attempted diversional interventions in behavior log. Record review of CR #1's Wandering Risk Scale dated 02/17/2025 stated the resident has been at the facility for 1 month and had no episodes of wandering in the past 3 months, with a high-risk wanderer rating of 13(rating above 11 is considered high risk). Record review of CR #1's Quarterly MDS, dated [DATE] revealed a BIMS score of 14 of 15, which indicated no significant signs of cognitive impairment. CR #1 coded 0 for behaviors not exhibited for wandering; rejection of care, verbal behavioral symptoms, and physical behavioral symptoms directed toward others. CR #1 did not require assistance for ADL care and at the time of this assessment, CR #1 was not at risk for elopement. Record review of CR #1's Progress Note dated 03/13/2025 written by MD stated, resident unable to obtain due to cognitive impairment/dementia/inability to cooperate. Psychiatric alert and oriented x1. A discussion was assisted with SW L with the resident stated, patient surrogate decision maker was family, and the patient does not have the capacity to make decisions for himself at this time and needs assistance with decisions. With the diagnosis of mood disorder with psychosis, consult behavioral health services, patient to remain in secured unit and monitor for any agitation or aggression. Record review of the facility's undated self-report read in part, .Incident Details: Date/Time you first learned of incident: Reported to Administrator . patient (CR #1) went through the window from the secure unit. Approxiametly (sic) at 5:30 - 5:45 pm. Police have been called . Date/Time the incident occurred: approximately Sunday March 23rd approximately 5:30 - 5:45. Record review of Reporting to HHSC Complaint and Incident Intake dated 03/23/2025 at 7:33pm by ADMN stated, at this time, CR #1 eloped from the secure unit, via e-mail. Record review of Reporting to HHSC Complaint and Incident Intake dated 03/23/2025 at8L27 pm by ADMN stated, at this time, CR #1 is found safe, approximately 8:20pm near his home. Follow up with Ombudsman and family has been done, via e-mail. Record review of CR #1's Nurses Note dated 03/23/2025 at 10:55pm written by LVN W stated the on-call supervisor was contacted and dispatch was notified of Resident #9 eloping from the facility. Record review of CR #1's Social Service Note dated 03/23/2025 written by SW L stated resident has eloped from the facility and police were notified. The family was contacted, and SW L received an address for where CR #1 lived prior to being admitted to the previous facility. Record review of CR #1's Alert Note dated 03/23/2025 written by SW L stated resident was spotted at his old address by a neighbor who provided the resident with $40.00 and a bike. Staff were unable to locate the residents by this time. Record review of Secured Unit schedule for 03/23/2025 revealed, 1 LVN, 2 CNA's, and 1 CMA were assigned for 2pm-10pm. Record review of CR #1's Social Service Note dated 03/24/2025 written by SW L went to the residence of CR #1 and spoke face to face regarding the signature of an AMA. CR #1 was asked if he wanted to return to the facility and he stated he did not want to come back. During the time of speaking with CR #1, the Ombudsman was called where CR #1 stated again he did not want to return to the facility. The administrator was also contacted via telephone with the DON on the line CR #1 also stated that he did not wish to return to the facility and signed the AMA at that time. CR #1 was not assessed prior to the SW L leaving the premises nor was he screened for BIMS. Record review of corrective actions' facility implemented beginning on 03/24/2025.The facility had CR #1 sign an AMA form to be discharged from the facility to home. Increased staffing on the secured unit by 1 CNA for monitoring. Staff were re-educated on elopement prevention with in-services on 03/24/2025 and 03/27/2025. The window and screen was were replaced by Maintenance and screws were placed in the windowpane to prevent future elopements. Record review of facility in-service on 03/24/2025 for elopement brief outline of contents: If an employee observes a resident leaving the premises he/she should; 1. Attempt to prevent the resident from leaving. 2. Seek help from staff nearby. 3. Inform another member to inform the Charge Nurse, Administrator, Social Worker, and ADON's. Conducted by LVN S and signed by staff. Record review of Secured Unit schedule for 03/24/2025 revealed, 2 LVN's, 2 CNA's, and 1 CMA were assigned for 2pm-10pm. Record review of in-service on 03/27/2025 for elopement brief outline of contents: If an employee or family member sees or reports a resident leaving or attempting to leave the premises, he/she should attempt to prevent the resident from leaving in a courteous manner, notify nursing staff, administrator, director of nursing, and social worker immediately. Do not leave the resident alone. Notify Medical Director and Responsible Party. Complete the following: incident report, wandering assessment, call police for case #, and 15-minute monitoring for 72 hours. Conducted by LVN S and signed by all nursing staff. During an interview with the ADMN on 10/14/2025 at 10:56am, she stated CR #1 had a history of elopements from the window while in secured unit. The ADMN stated the resident wanted to go see the mother of his kids and the next day he eloped. She stated the resident signed an AMA form after eloping because he did not want to return to the facility. The ADMN did state they were not present when the residents eloped, so they were only informed of what took place via telephone by the DON. Once it was verified CR #1 was no longer at the facility or surrounding areas, the incident was reported to HHSC and followed through with an investigation to locate CR #1. The ADMN stated the reason for the resident being in the secured unit was based off family and what information was provided at admission. She stated the reason are based off the residents diagnosis or if the family's input. The ADMN stated she did not recall specifically why the resident was placed into the secured unit but does know it was for a reason, and it would be based on their BIMS score. During an interview with DON on 10/14/2025 at 12:06pm, she stated she was contacted by nursing staff the resident eloped, and a perimeter search would need to be started, and she also contacted the family. After speaking with the family, she was told the resident was at his previous home and contacted his RP who provided him with $40.00 and a bike. The resident was not found the night he eloped from the facility, but the social worker did go to the previous home of the resident the next morning. The ombudsman called and stated the resident was able to sign himself out by using the AMA form. The DON was unsure of how the resident eloped from the facility and stated she was unsure because it was so long ago and could not remember. The secured unit does not have an alarm on the windows, or any other windows at the facility. The DON stated the next day, she does remember the window had to be replaced and they were informed by someone from the state they are able to put nails on the windows, but the window could not be raised greater than 3 inches, so that's what they did to every window at the facility. The DON stated this was the first time a resident had eloped out of the window from the secured unit. The resident did not give any indication of exit seeking behaviors before he eloped and appeared to be a very pleasant guy, quiet. The DON stated the reason why the resident was put into secured unit was due to him attempting an elopement at a previous facility and it was recommended for the resident to remain in the secured unit, as that was where he was at in previous facility. The DON stated the resident could not sign himself out due to him being in the secured unit, but he was evaluated on 02/17/2025, where it revealed the resident was a high-risk wanderer, which was why he remained in secured unit. The DON stated it would be considered a restraint for the resident to be placed on the secured unit based on his BIMS solely, but because had had an history, it was not considered a restraint. The resident's family member also wanted him to stay in the secured unit because the family knew he was at high risk for wandering. The DON stated she did not know how the resident was able to elope from the facility and get to his previous home. The facility had since done elopement in-services to educate staff on what to do in case of an elopement. In the case of an elopement, staff are to checking any and all closed doors, anywhere a resident could be hiding, immediate location of the facility and surrounding areas, teams are broken out and the perimeter is searched until the resident is found. If the resident is not found within 15-30 minutes Law Enforcement will need to be contacted. The facility hired a third CNA to the secured unit for greater monitoring and to prevent elopement. The DON stated the risk of the resident eloping was being killed because the facility was on a main highway. The resident could have also been hurt because the facility was also in a dark crime area. The DON was not present when the resident was found, therefore he was never accessed for possible injury. In an interview with CR #1's family member on 10/14/2025 at 12:35pm stated the reason the resident was in the secured unit was he left out of the window at a prior facility was successful, although he was found shortly. The family member stated the resident was living on his own before going to the hospital, and it was recommended that he did not live alone. The family member stated they did keep the lights and water on, should the resident ever return. The family member stated the resident could not be in a nursing home and not be secured because he would try to leave. The day the resident eloped; it was unsure of how the resident got back to his previous address but stated that it was within 9 miles of the facility. Observation of facility windows on 10/14/2025 at 1:15ppm with LVN P for the following rooms: room [ROOM NUMBER] measured at opening no more than 2.5 inches on the right and 3.5 inches on the left (secured unit). room [ROOM NUMBER] measured at opening no more than 5 inches to the left and unable to measure the window to the right due to a resident in bed (secured unit). room [ROOM NUMBER] measured at opening no more than approximated 6 inches. room [ROOM NUMBER] measured at opening 5.5 inches. LVN P stated in case of emergency or fire, in the secured unit there are 5 emergency exits that can be used to ensure residents are out of the facility safely. The only risk would be if the residents could possibly catch fire if in proximity and the windows not being able to open entirely. During an interview with MD on 10/14/2025 at 2:38pm stated she was notified by the DON of the resident eloping from the window. MD stated if the resident has exit seeking behaviors it has been an understanding the resident should be in a secure unit and use clinical judgment, not based on the BIMS score. The MD stated if there was a risk of elopement, the recommendation was for the resident to be in the secured unit. She stated with a diagnosis of dementia, if the residents scored well on the BIM's, ADL wise the resident may not be able to care for themselves. The MD stated they can contradict each other but if the resident was in the secured unit he was not competent enough to sign himself out. The MD recalled the resident being able to make decisions but could not recall the specifics of decision making. The MD was not aware of CR #1 signing the AMA form, as she stated that would not have been necessary because the resident had already left the facility. The MD stated she was under the impression the family wanted the resident to be back home but did not question their reasoning or who was to care for the resident. The MD stated she was also informed the resident did not want to return to the facility. The risk of elopement was ultimate and could cause harm to the resident or injury, which would be the worst-case scenario. During an interview with LVN W on 10/14/2025 at 4:08pm, she stated she was present the day CR#1 eloped from the facility. She stated the resident was acting normal all day with no signs of wandering/elopement and as trays were being passed out, that was when it was noticed the resident escaped from the window. There were no witnesses to the resident leaving the facility. The resident pushed the window screen out and she was unsure if the resident being injured as he eloped. Record review on 10/15/2025 of In-Service Education on 09/24/2025 for Virtual Dementia Tour with a brief outline of; examine his or her current perception of dementia, experience the virtual dementia tour environment while attempting to complete five activities of daily living such as dressing, eating, or setting a dinner table, compare pre and post virtual tour perceptions during a post tour debriefing session, and propose a strategy for how to effectively interact with individuals with dementia. This in-service was facilitated by RD M and signed by 38 facility staff members. Record review on 10/15/2025 of policy for Discharging a Resident without a Physician's Approval (revised October 2022) .3. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will treat this situation similarly to refusal of care, and will:a. discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location;b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed;c. document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; andd. determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. Record review on 10/15/2025 of policy for Wandering and Elopements (Revised March 2019).The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safetyIf an employee observes a resident leaving the premises, he/she should:- Attempt to prevent the resident from leaving in a courteous manner;- Get help from other staff members in the immediate vicinity, if necessary; and- Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises.If a resident is missing, initiate the elopement/missing resident emergency procedure:1. Determine if the resident is out on an authorized leave or pass;- If the resident was not authorized to leave, initiate a search of the building(s) and premises; and- If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.).When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:1. Examine the resident for injuries;2. Contact the Attending Physician and report findings and conditions of the resident;3. Notify the resident's legal representative (sponsor);4. Notify search teams that the resident has been located;5. Complete and file an incident report; and6. Document relevant information in the resident's medical record During an interview on 10/30/2025 between 9:17am and 11:13am CNA P, LVN W, CNA C, CNA V, HSK B, AA L, LVN G, LVN, M and CNA H and between 11:56am and 1:48pm CM M, CNA A, CNA W, LVN M, were able to state they were in-services on elopement. Staff stated once it is announced that a resident has eloped from the facility they immediately begin checking all areas in the facility, to include all closed off spaces. If the resident is not found inside the facility, teams are formed to monitor the inside and a thorough search is conducted outside of the facility by a team. If the resident is not located within a perimeter of 5-10 minutes from the facility, Law Enforcement must be contacted, along with ADMN and DON to start an official investigation and file an incident report with State. During an interview with Ombudsman R on 10/30/2025 at 11:26am he stated he was unaware of any resident eloping from the secured unit from a window and he could not provide any information regarding the elopement. Observation of Elopement Drill on 10/30/2025 at 11:28am revealed the announcement of a missing resident over the intercom and to follow elopement procedure to locate the resident safely.

Based on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extend possible for 1 of 5 residents (Resident #1) reviewed for incontinent care. CNA A failed to place the urine collection bag of the indwelling urinary catheter below Resident #1's bladder after transferring from bed to chair.The failure could place residents with indwelling urinary catheters at risk for infection from potential backflow of urine into the bladder. Findings included:Record review of Resident #1's face sheet dated 10/16/25 revealed a [AGE] year old admitted to the facility on [DATE]. Resident #1's diagnoses included chronic kidney disease, and retention of urine.Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate impaired cognition. Resident #1 was dependent on staff for most ADLs and had an indwelling urinary catheter.Record review of Resident #1's undated care plan included the following: * Resident #1 had renal insufficiency r/t acute kidney disease and acquired absence of kidney. Goal included: The resident will be free from infection through the review date, target date was 11/29/25. Interventions included: monitor for signs and symptoms (s/sx) of acute renal failure. *Resident#1 had a foley catheter d/t obstructive uropathy and urinary retention. Goal: The resident will show no s/sx of urinary infection through the review date. Interventions did not include keep urinary foley bag at a level below the resident's bladder.Record review of Resident #1's active order summary report dated 10/16/25 revealed and order for Cefdinir 300 mg capsules by mouth two times a day for urinary tract infection (UTI) for 7 days. Start date was 10/11/25.Observation on 10/15/25 at 1:35PM, Resident #1 was asleep in a recliner inside the resident's room. The urine collection bag was hooked on the armrest of the recliner which was at a level above Resident #1's bladder. In an interview and observation on 10/15/25 at 1:35 PM, LVN B stated the urine collection bag was higher than Resident #1's bladder and it should not be at or above the bladder d/t risk of infection as the urine could back up into the bladder. LVN B stated Resident #1 was being treated for a UTI. LVN B repositioned the urine collection bag below the level of the bladder.In an interview on 10/15/25 at 1:45PM, CNA A stated she and another CNA transferred Resident #1 from the bed to the recliner at 10:15 AM and said the collection bag should be below the bladder. CNA A stated the risk would be infection. CNA A asked the surveyor if she left the bag in the wrong place. CNA A stated she was rushing to get to another resident after transferring Resident #1.In an interview on 10/15/25 at 1:57 PM, the DON stated urinary collection bags should be below the level of the bladder for drainage and the risks were infection such as UTI. The DON stated Resident #1 gets UTI's frequently due to refusals of care. The DON stated the CNA's were responsible to ensure the urine collection bag was placed properly.Record review of the facility policy for Urinary Catheter Care revised on August 2022 read in part: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Maintaining Unobstructed Urine Flow.3. Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 (Resident #1) of 7 residents reviewed for reporting abuse. -The facility failed to implement their written policy of abuse when facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. -The facility failed to implement their written policy of abuse when the facility failed to notify the state agency of the allegation of abuse. This deficient practice could place residents at risk of continued and/or unrecognized abuse, neglect, exploitation, or mistreatment. Findings included: Record review of Resident #1's Face sheet dated 12/27/2024, he was a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. He was discharged from the facility on 12/26/2024. His medical diagnoses included stroke), Type 2 Diabetes Mellitus without complications, Hypertension (high blood pressure), Hyperlipidemia (high fat content in blood), iron deficiency, chronic pain syndrome, Dementia (unspecified without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), sleep terrors, history of falling, Major Depressive Disorder (recurrent severe without psychotic features), Anxiety Disorder, Alzheimer's Disorder, and Metabolic Encephalopathy (a brain dysfunction due to the body's metabolism which can cause confusion, memory loss and loss of consciousness). Record review of Resident #1's Quarterly MDS (a resident assessment tool) dated 12/16/2024 revealed the resident had a BIMS score of 14, indicating cognitive intactness. Resident #1 had symptoms of feeling down, depressed, or hopeless several days in a week. Further review reflected he required maximal assistance with showering and bathing and required setup only for eating and supervision with oral hygiene. Record review of Resident #1's care plan last captured 12/27/2024 revealed: -Date Initiated: 06/19/2024 -Resident #1 was at risk for mood impairment r/t admitted with diagnosis of major depressive disorder, anxiety, Alzheimer's disease, dementia, night/sleep terrors and insomnia, with interventions including monitoring/documenting/reporting PRN any risk for harm to self, including suicidal plan and past attempt at suicide, monitoring/recording/reporting mood patterns of s/sx of depression, anxiety. -Date Initiated: 12/27/2024 - Resident #1 was at risk for suicidal impulsive/ideations of self-harm related to a recent suicide attempt, found on his room with call light around his neck, was sent out to the hospital right away, with interventions including: monitoring and reporting any behavior changes (like appetite/expression, excessive crying), provide Social Service support visits as needed, Immediately reporting if resident verbalizes thoughts of hurting themselves, and for Licensed Staff Member to perform suicide assessment if suicidal ideation is identified. Assess suicidal thoughts by asking the Resident/Patient to share suicidal history, feelings, plans and behavior. Record review of Resident #1's psychological notes revealed he was seen twice per week from 10/28/2024 to 11/25/2024. Resident #1 expressed concerns regarding a lack of adequate nursing care, feeling neglected and lonely. Resident #1 requested help finding social support and was educated on coping skills such as engaging in his environment and reframing negative feelings and experiences. There was no mention of suicidal ideation in the notes. Record review of Resident #1's SBAR (an incident report) done on 12/26/2024 by LVN B revealed Resident #1 had an altered level of consciousness, he had other types of skin condition, and did not have pain. The SBAR reflected a CNA called the nurse to Resident #1's room around 1:33am. The resident was in bed with the call light wrapped around his neck. Resident #1 was lethargic, and his breathing was even and unlabored. His call light was removed from his neck, his vital signs were stable and he was given oxygen at 2L via nasal canula as a precaution. Resident #1 was noted briefly opening his eyes, he responded to verbal and touch stimuli but would not talk. 911 was called at 1:36am; the DON was notified at 1:38am; his RP was notified at 1:42am and the MD was notified. Resident #1 was transported to the hospital by EMS. Record review of Resident #1's pain assessment completed 12/26/2024 at 5:40am by LVN B revealed he had ligature marks to the front and rear of his neck, and he was not in pain according to the faces scale (a range of faces showing no pain to severe pain). The pain assessment also noted the resident had a self-injury and was transferred to the ER. Record review of the intake online portal revealed HHSC received a self-reported intake related to Resident #1's incident on 12/27/2024 at 1:30pm. Record review of CNA C's witness statement dated and signed 12/26 (no year), reflected, at 1:15am, I saw [Resident #1], [Resident #1] had his call light on, I went in his room he wanted me to pull his blankets up on him and he went back to sleep. Interview with Resident #1's RP on 12/27/2024 at 11:28am, he stated he regularly received updates on Resident #1. The RP stated the resident had really good periods where he liked the facility and the people there and that he didn't want to leave, but when his dementia symptoms came, the resident would get suspicious of everyone and express wanting to leave. The RP said Resident #1 had a history of attempting suicide, but he was never told of any suicide attempts by the facility until 12/26/2024. Interview with CNA A on 12/27/2024 at 12:45pm, revealed she worked with Resident #1 and described him as quiet and usually in a good mood with her. She stated Resident #1 was out and about a few days ago, talking and laughing with other residents. She denied any signs of possible suicidal ideation or anything unusual, and she did not think he would have done what he did because staff could tell when he was feeling well or not. Interview with LVN A on 12/27/2024 at 1:26pm, she stated that she worked on Resident #1's hall. She read his chart which reflected he had ligatures around his neck caused by his call light. She denied him having symptoms of suicidal ideation, and that he never expressed loneliness or depressive symptoms. Resident #1 was quiet, polite and very nice. LVN A said Resident #1's roommate discharged recently so he was in his room by himself. She was aware he had a prior suicide attempt at his last facility, but that he never expressed any concerns to her. Interview with the Social Worker on 12/27/2024 at 1:43pm, she said that she was not at the facility during the incident but heard that Resident #1 had a call light wrapped around his neck and a CNA removed it and afterward the resident was conscious and responded to verbal and physical stimuli. She said he did not seem like he would attempt what he did and denied Resident #1 making an attempt at this facility. The Social Worker said he did not talk to a lot of people and did not go to activities such either. The resident and his previous roommate did not talk to each other, but the resident appeared comfortable with the room. swelling on his face, but he denied pain. Attempted to interview with CNA C on 12/27/2024 at 2:41pm, but she did not answer the phone call, and a voicemail was left. Interview with CNA B on 12/27/2024 at 2:59pm, revealed she witnessed and removed the call light around Resident #1's neck. CNA B stated she changed Resident #1's brief at 10:00pm and he was doing fine. At 11:00pm the resident was in bed. When she went back around 1:00am, his call light came on and she walked into the room where CNA B saw Resident #1 with his cord around his throat and pulling it tight. CNA B said Resident #1 was making choking sounds and his eyes looked like they were gonna pop off; she started yelling for help. CNA B was unable to pull the cord from Resident #1's hand because he held onto it tight, so she pulled the cord from the outlet and was able to go in the opposite direction and remove the cord from his neck, but the resident continued to hold onto the cord. Resident #1 did not say anything and laid in bed. The two nurses came to assess and stayed with the resident. CNA B said Resident #1 was nice and sweet, did not ask for a lot and was dependent on staff for brief changes. She said one of the nurses called 911 and Resident #1 left around 20 minutes later. CNA B denied Resident #1 mentioning suicide or wanting to commit suicide to her. Interview with LVN B on 12/27/2024 at 3:31pm, she was the charge nurse for Resident #1's hall during the incident. She said when she started her shift on 12/26/2024 at 6:00pm, the resident was sitting at the side of his bed and there were no concerns. At 1:10am , CNA B had answered Resident #1's call light but LVN B did not remember what the resident needed at that time. About 15 minutes later, LVN B heard CNA B call out. When LVN B arrived to Resident #1's room, CNA B told her that Resident #1 had a cord around his neck and was choking himself so she removed it. LVN B and LVN C were the two nurses during the night shift, so LVN C assessed Resident #1's vitals and oxygen and LVN B called 911 at 1:36am. At the time, Resident #1 did not say anything, and from what she remembered his vitals were pretty good. Resident #1's only skin abnormality was his obvious ligature marks around his neck. Resident #1e retracted when a sternum rub was performed but was not otherwise responsive, and he was not asleep. 911 arrived at 1:42am, they did assessments, questioned staff, and discussed if Resident #1 needed to be transferred or not. LVN B said she told them he needed to be transferred because it was an active suicide attempt, and they went ahead and took him. LVN B said EMS' assessments revealed normal pupil dilation, but when they attempted a blood sugar check, Resident #1 snatched his hands away. LVN B notified the DON who responded right away. Interview with the DON on 12/27/2024 at 3:41pm, she said LVN B notified her of Resident #1's incident on 12/26/2024 around 1:30am to 2:30am. The DON told LVN B to do a total assessment including a skin and pain assessment. LVN B told her she sent Resident #1 to the ER and notified the MD and family and completed a Change in Condition assessment. The DON began her investigation and found that during medication review, Resident #1 was placed on Zyrtec on 12/20/2024 which could cause suicidal ideation. The DON said Resident #1 was rolling through the hallway and she did not see any symptoms of suicidal ideation from him. She said Resident #1 was care-planned for suicidal ideation because he came to the facility from a behavioral hospital for a suicide attempt, but he never had an attempt at the facility. The family did not share his previous suicide attempt. The DON said no residents showed signs of suicidal ideation. The DON said she did not report the abuse to the State because according to the new State guidelines, Resident #1 did not have an injury of unknown origin and that he did not expire at the facility and that the facility got Resident #1 help immediately. She said that the Administrator reported when she found out today. The DON did not suspect foul play since Resident #1 was found in his room alone. Interview with the Administrator on 12/27/2024 at 4:15pm, she stated that she first heard of the incident on 12/27/2024 around 1:00pm. She stated she was concerned that no one told her because that was something she needed to report. She conducted interviews, looked at his skin and pain assessments, called the Ombudsman, and notified the family. The Administrator said from her investigation, Resident #1 was happy, and the facility did not know what happened in the 15 minutes between his call light being answered the first and second time. The Administrator said that if she knew about the incident, she would have reported it immediately, and that anything out of the ordinary should be reported. She said reporting in a timely manner was to protect the residents. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy statement revised September 2022 revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Record review of the facility's Identifying Neglect policy revised September 2022, the facility's employees, volunteers and contractors are expected to be able to identify neglect as it may occur against residents, and that staff and service providers are expected to report deficiencies in processes or practices that may lead to resident neglect.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1) of 7 residents reviewed for reporting. -The facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. -The facility failed to report within the required time frame to the state agency when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. This deficient practice could place residents at risk of continued and/or unrecognized neglect. Findings included: Record review of Resident #1's Face sheet dated 12/27/2024, he was a [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. He was discharged from the facility on 12/26/2024. His medical diagnoses included stroke), Type 2 Diabetes Mellitus without complications, Hypertension (high blood pressure), Hyperlipidemia (high fat content in blood), iron deficiency, chronic pain syndrome, Dementia (unspecified without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), sleep terrors, history of falling, Major Depressive Disorder (recurrent severe without psychotic features), Anxiety Disorder, Alzheimer's Disorder, and Metabolic Encephalopathy (a brain dysfunction due to the body's metabolism which can cause confusion, memory loss and loss of consciousness). Record review of Resident #1's Quarterly MDS (a resident assessment tool) dated 12/16/2024 revealed the resident had a BIMS score of 14, indicating cognitive intactness. Resident #1 had symptoms of feeling down, depressed, or hopeless several days in a week. Further review reflected he required maximal assistance with showering and bathing and required setup only for eating and supervision with oral hygiene. Record review of Resident #1's care plan last captured 12/27/2024 revealed: -Date Initiated: 06/19/2024 -Resident #1 was at risk for mood impairment r/t admitted with diagnosis of major depressive disorder, anxiety, Alzheimer's disease, dementia, night/sleep terrors and insomnia, with interventions including monitoring/documenting/reporting PRN any risk for harm to self, including suicidal plan and past attempt at suicide, monitoring/recording/reporting mood patterns of s/sx of depression, anxiety. -Date Initiated: 12/27/2024 - Resident #1 was at risk for suicidal impulsive/ideations of self-harm related to a recent suicide attempt, found on his room with call light around his neck, was sent out to the hospital right away, with interventions including: monitoring and reporting any behavior changes (like appetite/expression, excessive crying), provide Social Service support visits as needed, Immediately reporting if resident verbalizes thoughts of hurting themselves, and for Licensed Staff Member to perform suicide assessment if suicidal ideation is identified. Assess suicidal thoughts by asking the Resident/Patient to share suicidal history, feelings, plans and behavior. Record review of Resident #1's psychological notes revealed he was seen twice per week from 10/28/2024 to 11/25/2024. Resident #1 expressed concerns regarding a lack of adequate nursing care, feeling neglected and lonely. Resident #1 requested help finding social support and was educated on coping skills such as engaging in his environment and reframing negative feelings and experiences. There was no mention of suicidal ideation in the notes. Record review of Resident #1's SBAR (an incident report) done on 12/26/2024 by LVN B revealed Resident #1 had an altered level of consciousness, he had other types of skin condition, and did not have pain. The SBAR reflected a CNA called the nurse to Resident #1's room around 1:33am. The resident was in bed with the call light wrapped around his neck. Resident #1 was lethargic, and his breathing was even and unlabored. His call light was removed from his neck, his vital signs were stable and he was given oxygen at 2L via nasal canula as a precaution. Resident #1 was noted briefly opening his eyes, he responded to verbal and touch stimuli but would not talk. 911 was called at 1:36am; the DON was notified at 1:38am; his RP was notified at 1:42am and the MD was notified. Resident #1 was transported to the hospital by EMS. Record review of Resident #1's pain assessment completed 12/26/2024 at 5:40am by LVN B revealed he had ligature marks to the front and rear of his neck, and he was not in pain according to the faces scale (a range of faces showing no pain to severe pain). The pain assessment also noted the resident had a self-injury and was transferred to the ER. Record review of the intake online portal revealed HHSC received a self-reported intake related to Resident #1's incident on 12/27/2024 at 1:30pm. Record review of CNA C's witness statement dated and signed 12/26 (no year), reflected, at 1:15am, I saw [Resident #1], [Resident #1] had his call light on, I went in his room he wanted me to pull his blankets up on him and he went back to sleep. Interview with Resident #1's RP on 12/27/2024 at 11:28am, he stated he regularly received updates on Resident #1. The RP stated the resident had really good periods where he liked the facility and the people there and that he didn't want to leave, but when his dementia symptoms came, the resident would get suspicious of everyone and express wanting to leave. The RP said Resident #1 had a history of attempting suicide, but he was never told of any suicide attempts by the facility until 12/26/2024. Interview with CNA A on 12/27/2024 at 12:45pm, revealed she worked with Resident #1 and described him as quiet and usually in a good mood with her. She stated Resident #1 was out and about a few days ago, talking and laughing with other residents. She denied any signs of possible suicidal ideation or anything unusual, and she did not think he would have done what he did because staff could tell when he was feeling well or not. Interview with LVN A on 12/27/2024 at 1:26pm, she stated that she worked on Resident #1's hall. She read his chart which reflected he had ligatures around his neck caused by his call light. She denied him having symptoms of suicidal ideation, and that he never expressed loneliness or depressive symptoms. Resident #1 was quiet, polite and very nice. LVN A said Resident #1's roommate discharged recently so he was in his room by himself. She was aware he had a prior suicide attempt at his last facility, but that he never expressed any concerns to her. Interview with the Social Worker on 12/27/2024 at 1:43pm, she said that she was not at the facility during the incident but heard that Resident #1 had a call light wrapped around his neck and a CNA removed it and afterward the resident was conscious and responded to verbal and physical stimuli. She said he did not seem like he would attempt what he did and denied Resident #1 making an attempt at this facility. The Social Worker said he did not talk to a lot of people and did not go to activities such either. The resident and his previous roommate did not talk to each other, but the resident appeared comfortable with the room. swelling on his face, but he denied pain. Attempted to interview with CNA C on 12/27/2024 at 2:41pm, but she did not answer the phone call, and a voicemail was left. Interview with CNA B on 12/27/2024 at 2:59pm, revealed she witnessed and removed the call light around Resident #1's neck. CNA B stated she changed Resident #1's brief at 10:00pm and he was doing fine. At 11:00pm the resident was in bed. When she went back around 1:00am, his call light came on and she walked into the room where CNA B saw Resident #1 with his cord around his throat and pulling it tight. CNA B said Resident #1 was making choking sounds and his eyes looked like they were gonna pop off; she started yelling for help. CNA B was unable to pull the cord from Resident #1's hand because he held onto it tight, so she pulled the cord from the outlet and was able to go in the opposite direction and remove the cord from his neck, but the resident continued to hold onto the cord. Resident #1 did not say anything and laid in bed. The two nurses came to assess and stayed with the resident. CNA B said Resident #1 was nice and sweet, did not ask for a lot and was dependent on staff for brief changes. She said one of the nurses called 911 and Resident #1 left around 20 minutes later. CNA B denied Resident #1 mentioning suicide or wanting to commit suicide to her. Interview with LVN B on 12/27/2024 at 3:31pm, she was the charge nurse for Resident #1's hall during the incident. She said when she started her shift on 12/26/2024 at 6:00pm, the resident was sitting at the side of his bed and there were no concerns. At 1:10am , CNA B had answered Resident #1's call light but LVN B did not remember what the resident needed at that time. About 15 minutes later, LVN B heard CNA B call out. When LVN B arrived to Resident #1's room, CNA B told her that Resident #1 had a cord around his neck and was choking himself so she removed it. LVN B and LVN C were the two nurses during the night shift, so LVN C assessed Resident #1's vitals and oxygen and LVN B called 911 at 1:36am. At the time, Resident #1 did not say anything, and from what she remembered his vitals were pretty good. Resident #1's only skin abnormality was his obvious ligature marks around his neck. Resident #1e retracted when a sternum rub was performed but was not otherwise responsive, and he was not asleep. 911 arrived at 1:42am, they did assessments, questioned staff, and discussed if Resident #1 needed to be transferred or not. LVN B said she told them he needed to be transferred because it was an active suicide attempt, and they went ahead and took him. LVN B said EMS' assessments revealed normal pupil dilation, but when they attempted a blood sugar check, Resident #1 snatched his hands away. LVN B notified the DON who responded right away. Interview with the DON on 12/27/2024 at 3:41pm, she said LVN B notified her of Resident #1's incident on 12/26/2024 around 1:30am to 2:30am. The DON told LVN B to do a total assessment including a skin and pain assessment. LVN B told her she sent Resident #1 to the ER and notified the MD and family and completed a Change in Condition assessment. The DON began her investigation and found that during medication review, Resident #1 was placed on Zyrtec on 12/20/2024 which could cause suicidal ideation. The DON said Resident #1 was rolling through the hallway and she did not see any symptoms of suicidal ideation from him. She said Resident #1 was care-planned for suicidal ideation because he came to the facility from a behavioral hospital for a suicide attempt, but he never had an attempt at the facility. The family did not share his previous suicide attempt. The DON said no residents showed signs of suicidal ideation. The DON said she did not report the abuse to the State because according to the new State guidelines, Resident #1 did not have an injury of unknown origin and that he did not expire at the facility and that the facility got Resident #1 help immediately. She said that the Administrator reported when she found out today. The DON did not suspect foul play since Resident #1 was found in his room alone. Interview with the Administrator on 12/27/2024 at 4:15pm, she stated that she first heard of the incident on 12/27/2024 around 1:00pm. She stated she was concerned that no one told her because that was something she needed to report. She conducted interviews, looked at his skin and pain assessments, called the Ombudsman, and notified the family. The Administrator said from her investigation, Resident #1 was happy, and the facility did not know what happened in the 15 minutes between his call light being answered the first and second time. The Administrator said that if she knew about the incident, she would have reported it immediately, and that anything out of the ordinary should be reported. She said reporting in a timely manner was to protect the residents. Record review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy statement revised September 2022 revealed if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Record review of the facility's Identifying Neglect policy revised September 2022, the facility's employees, volunteers and contractors are expected to be able to identify neglect as it may occur against residents, and that staff and service providers are expected to report deficiencies in processes or practices that may lead to resident neglect.

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 90 days (9/21/24, 9/29/24, and 10/20/24) reviewed for RN coverage. The facility failed to ensure they had RN coverage for at least 8 consecutive hours on 9/21/24, 9/29/24, and 10/20/24. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Record review of the staffing sign in sheets for 9/21/24, 9/29/24, and 10/20/24 revealed no RN signed in or on the schedule. Record review of the DON's electronic clock in sheet revealed she worked 4.6hrs on 9/21/24, she didn't work on 9/29/24, and worked 6.93hrs on 10/20/24. In an interview with the DON on 12/4/24 at 10:00am she said an RN must be at the facility for 8 consecutive hours a day. She said the RNs provided direct supervision, filled out incident reports, ran IVs and PICC (thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein above the heart) lines, and ensured everyone was practicing inside their scope of practice. She said that she was usually the nurse who covered if they did not have an RN, but she was not sure what happened on the days in question. In an interview with the Administrator on 12/4/24 at 4:00pm, she said an RN must be in the facility for 8 consecutive hours a day. She said the DON had been working every weekend to provide that coverage, but they just hired an RN for the weekend position. She said the RN started IV lines, provided care for the PICC lines, and provided education. She said if an RN was not at the facility, one of those services would not be able to be performed. The Administrator said there were not any residents who did not receive care that she knew of. Record review of the facility's policy and procedure on Departmental Supervision, Nursing (revised August 2022) read in part: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times .A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident .

Based on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 17% based on 5 errors out of 29 opportunities which involved 2 of 9 residents (Resident #34 and #20) and 2 of 4 staff (MA A and LVN B) reviewed for medication administration. MA A crushed and administered Divalproex DR (a delayed release medication used to treat seizure disorders and mental/mood conditions) and Oxybutynin ER (an extended-release medication used to reduce bladder spasms and treats overactive bladder) to Resident #34 on 12/4/24. Delayed and Extended-release formulations should not be crushed. MA A administered Resident #48's Sertraline (used to treat depression) to Resident #34 on 12/4/24. MA A administered chewable Aspirin instead of enteric coated Aspirin to Resident #34 as ordered by the Physician on 12/4/24. LVN B administered Heparin lock flush (an anticoagulant that prevents blood clots in IV catheters) instead of normal saline flush (used to help prevent IV catheters from becoming blocked) to Resident #20 as ordered by the Physician on 12/4/24. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #34's face sheet dated 12/5/24 revealed a [AGE] year old male who admitted on [DATE]. His diagnosis included Alzheimer's disease, major depressive disorder, overactive bladder, other neuromuscular dysfunction of bladder, and persistent mood disorder. Record review of Resident#34's quarterly MDS assessment dated [DATE] revealed a BIMS score of 3 out of 15, which indicated severe cognitive impairment. He required assistance from staff with ADL care. Record review of Resident #34's care plan dated 9/19/24 revealed he was on anticonvulsant therapy related to mood stabilizer. Interventions were to administer medication per orders. The care plan also indicated resident was at risk for mood impairment related to recent admission, noted with diagnosis of anxiety, bipolar, Alzheimer's, major depressive disorder, persistent mood affective disorder, and insomnia disorder. Interventions were to administer medications as ordered, dated 8/16/24. Record review of Resident #34's Physician orders for December 2024 revealed orders for: Aspirin 81 Delayed Release give 1 tablet by mouth one time a day for anticoagulant ***do not crush**, order date 8/14/24. Divalproex Delayed Release 125 mg give 1 capsule by mouth three times a day for mood, order date 8/14/24. Oxybutynin Extended Release 10 mg give 1 tablet by mouth one time a day for overactive bladder, order date 8/14/24. Sertraline 25 mg give 1 tablet by mouth one time a day related to anxiety disorder, order date 8/14/24. May crush and cocktail medications as necessary unless contraindicated, order date 8/14/24. In an observation on 12/4/24 at 8:41 a.m. MA A prepared Resident #34's medication for administration. She prepared chewable Aspirin 81 mg, Divalproex DR 125 mg, Oxybutynin ER 10 mg (the pharmacy label read do not crush), and the remainder of his medications. MA A retrieved Resident #48's Sertraline 50 mg and said she would use it for Resident #34. MA A asked LVN C to cut the Sertraline 50 mg in half. LVN C looked at the eMAR and cut the Sertraline 50 mg in half to equal 25 mg and MA A placed it in the cup with Resident #34's medications. MA A said the resident required crushed pills, she crushed all the medication and administered them to the resident. In an interview on 12/4/24 at 9:12 a.m. MA A said she used Resident #48's Sertraline for Resident #34 because she could not find his Sertraline. She said she could use another resident's medication for one time only and then call the pharmacy. She said she was taught in school to never leave a resident without their medication. She said she should check the medication room first for the medication. She said she knew which medication could or could not be crushed because she was experienced. MA A said some medications had permission to be crushed from the MD and that some of the medications did not have an alternative. She said enteric coated medications could not be crushed but she should check with the nurse prior to switching the medication. She said when preparing medication for administration she had to check the 7 rights which included the right patient, dose, time, route, and if the medication could be crushed. In an interview on 12/4/24 at 9:20 a.m. LVN C said she cut the Zoloft (Sertraline) 50 mg in half to equal 25 mg. She said she looked at the eMAR and checked the mg but could not remember if the resident's name on the eMAR matched the name on the blister pack. In an interview on 12/4/24 at 3:57 p.m. the DON said she discussed misappropriation of property with MA A. She said MA A informed her that the pharmacist who trained her said it was better to borrow another resident's medication to ensure the resident received a medication instead of not giving it. The DON said the process at the facility was to notify the nurse, call the MD, put the medication on hold, and see if the medication could be changed to something else. She said MA A could have retrieved the medication from the resident's overstock in the medication room, but she got nervous. She said staff needed to verify the right patient, dose, time, and medication. She said she educated the medication aide on medications that could be crushed and printed out the do not crush list. She said the pharmacy normally sent a label that would indicate if the medication could not be crushed. She said ER and DR formulations were meant to absorb over a specified time and could not be as effective if crushed. She said the medication aide should not decide to change medications, she should notify the nurse who could fix the order. She said medications were paid by the resident's insurance and that could be affected if someone borrowed their medicine. In an interview on 12/5/24 at 2:17 p.m. the Administrator said it was common sense in training for staff to review the directions that were on the MAR and read the information. She said a medication aide was not the physician and she had to follow policy and procedures. She said it was not tolerable to borrow other residents' medications. She said the MA was educated and her expectation was for staff to read and follow the physician orders. 2. Record review of Resident #20's face sheet dated 12/5/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnosis included bipolar disorder, major depressive disorder, mild cognitive impairment, violent behavior, and pain. Record review of Resident #20's quarterly MDS assessment, dated 10/14/2024, reflected the resident had a BIMS score of 15 out of 15 which indicated intact cognition. He required ADL assistance from staff. Record review of Resident #20's care plan, dated 11/24/24, revealed he had a current acute infection and was on IV antibiotics due to positive UA. Interventions were to provide treatments as ordered by MD/NP. Record review of Resident #20's Physician Orders for December 2024 indicated an order for: Sodium Chloride 0.9% flush 10 mL every shift for maintenance, order date 11/30/24. There were no orders for Heparin lock flush. In an observation and interview on 12/4/24 at 4:48 p.m. in the main hallway LVN B administered heparin lock flush 5 mL to one of Resident #20's lumens (a port through which IV treatments and blood transfusions can be given). LVN B attempted to flush the other lumen with Heparin lock flush but was unable to because it was clogged. LVN B placed one full flush in her pocket and discarded the empty one in the trash. LVN B said the resident was prescribed normal saline flush and did not realize the flushes were heparin lock flush. She retrieved the full flush from her pocket and this Surveyor retrieved the empty flush from the trash and both flushes were verified as Heparin flush lock 50 USP units/5 mL with LVN B. She said the ADON gave her the flushes from her pocket. She said the difference between the heparin lock and saline flush was that heparin was used for cardiac patients. She said she was pretty sure there were risks to administering heparin lock flush, but she would have to familiarize herself with them. She said she would monitor Resident #20 for side effects. In an interview on 12/4/24 at 5:01 p.m. the ADON said she did not give LVN B heparin lock flushes. Record review of LVN B's statement dated 12/4/24 at 5:54 p.m. read in part, I, [LVN B], in haste, accidentally administered 5 mL of Heparin lock flush to one port of his PICC line to left upper arm. Resident was immediately reassessed and PICC line was flushed with 10 mL of saline flush. Vital signs were within normal limits and resident reported no signs or symptoms cardiac issues. In an interview on 12/5/24 at 8:56 a.m. Resident #20 said he did not have any bleeding or bruising, and the facility removed his IV access. In an interview on 12/5/24 at 9:04 a.m. the DON said she notified Resident #20's MD about the heparin lock flush incident. She said the MD said the heparin lock flush was ok to give and there was no harm done. The MD informed her to observe for signs of bleeding and remove the PICC line. She said there was no direct scientific correlation that was harmful because heparin and saline lock were interchangeable. In an interview on 12/5/24 at 9:06 a.m. the ADON said LVN B informed her that she obtained the heparin lock flush from the back of the nursing cart. In an interview on 12/5/24 at 12:06 p.m. Resident #20's MD said it was the standard of care in the hospital to flush PICC lines with heparin. He said it was considered acceptable in the nursing home to flush with saline, but the heparin lock flush had a minute dose and would not cause anything. He said it would keep the line open but had no systemic effect. He said it was a medical error and the resident was originally prescribed normal saline flush, but the error caused no harm or risk to the patient. He said the facility notified him and he ordered for the picc line to be removed and there was no deviation from normal care. In an interview on 12/5/24 at 1:17 p.m. the DON said LVN B should have check the name of the flush against the MAR. She said the nurse should also know that heparin was blue, or orange and the normal saline was black. She said she did not know where the nurse retrieved the heparin flush from, and they could not find any more in the facility. She said nursing staff should verify the 5 rights of medication administration which included the right patient, dose, time, and medication. She said there was no risk of using heparin instead of the saline because all IVs in the hospital were flushed with heparin. She said it could be used interchangeably if there was a Physicians order. She said the LVN should have pulled the correct flush and could not answer why she pulled the heparin. She said the DON was ultimately responsible for ensuring the resident received the right medication, but the administering staff was immediately responsible for accuracy. She said she completed skills check off with LVN B. (A skills check is a practical list that details the skills an employee is required to perform and the level of performance that is expected for each skill). In an interview on 12/5/24 at 2:17 p.m. the Administrator said nursing staff should be able to check for the proper medication, right patient, and right process. Record review of the facility's Crushing Medications policy dated April 2018 read in part, .Medication shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .2. The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example, long acting or enteric coated medications) . Record review of Medication Crushing Guidelines dated 2001 provided by the facility read in part, .the rationale for not crushing some medications include: .D. Timed Release Tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations are utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed Record review of the undated document Medications not to be crushed provided by the facility revealed Divalproex Sodium: DR, ER and Oxybutynin ER were listed. Record review of the facility's Administering Medications policy dated April 2019 read in part, .Medications are administered in a safe and timely manner and as prescribed .4. Medications are administered in accordance with prescriber orders, including any required time frame . 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications . 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication . 26. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #20 and #56) reviewed for infection control. -LVN A did not wear appropriate PPE when administering medication via peg-tube care (PEG tubes allow you to receive nutrition through your stomach) to Resident #56 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 12/4/24. -LVN A de-clogged (remove or clear a blockage) Resident #56's g-tube using an oxygen key that was retrieved from her pocket on 12/4/24. -LVN B did not wear appropriate PPE when administering an IV picc line flush to Resident #20 on 12/4/24 who was on enhanced barrier precautions per facility protocol and care plan. These failures could place residents at risk of infections. Findings included: 1.Record review of Resident #56's face sheet dated 12/5/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included gastrostomy infection (complication of gastrostomy tube placement), gastrostomy status (presence of an artificial opening to the stomach), type 2 diabetes, cerebral infarction (stroke), unspecified dementia, altered mental status, post-traumatic stress disorder, and hemiplegia affecting right nondominant side (paralysis of one side of the body). Record review of Resident #56's quarterly MDS assessment, dated 10/14/2024, reflected the resident had a BIMS score of 0 out of 15 which indicated she had severe cognitive impairment. She had a feeding tube and was dependent on staff for ADL care. Record review of Resident #56's care plan revised on 8/10/24 revealed she required enhanced barrier precautions due to IV antibiotics (resolved) peg tube feedings. Interventions included: staff will wear gloves and gown (per protocol) to provide high contact care activity to include dressing, bathing/showering, transferring, hygiene, changing linens, changing briefs, assist with toileting, device care or use (PICC/central line, catheter, feeding tube, trach, vent), wound care. Her care plan revealed she required tube feeding related to dysphagia. Interventions/Tasks were that the resident was dependent with tube feeding and water flushes. See MD orders for current feeding orders, dated 7/16/24. In an observation and interview on 12/4/24 at 11:44 a.m. LVN A prepared and began the medication administration process for Resident #56's via g-tube. She donned (put on) gloves but did not don a gown. There was a sign on Resident #56's door that read, STOP Enhanced Barrier Precautions, everyone must: clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and gown for the following high contact resident care activities . device care or use . feeding tube .' There was also PPE on the door. LVN A said the PPE had been on the resident's door for a while, but she did not have wounds or MRSA. LVN A checked for placement and residual and then started administration via g-tube with a water flush. The water flush would not drain through the tube, LVN A used the syringe to push the water into the tube to try to declog it. After that she retrieved her keys from her pocket and used an oxygen key to strip (stretch the tube and try to dissolve the pieces) the g-tube plastic multiple times. After alternating between stripping the tube with the oxygen key and pushing the water with the syringe, LVN A was able to declog Resident #56's tube and proceed with administering the medications. In an interview on 12/4/24 at 12:06 p.m. LVN A said Resident #56 used to have a roommate with wounds who passed away and that was why the enhanced barrier precaution sign was on her door. She said the hospice providers would come in and wear PPE when providing the resident with a shower. She said gowns were not required when caring for g-tubes. She said she was in serviced on enhanced barrier precautions one month ago and the information provided on the door sign was new. She said she used an oxygen key to strip and declog Resident #56's g-tube. She said she was unsure if using the oxygen key was allowed but that was how she unclogged the tube. She said to maintain infection control she only used the key on the plastic portion on the outside of the tube, not near the resident ports. In an interview on 12/4/24 at 4:14 p.m. the DON said enhanced barrier precautions (EBP) required staff to use gloves and gown and was like contact isolation. She said she educated staff that EBP was for residents with g-tube, a wound, and was to prevent passing infections on to another resident. In an interview on 12/5/24 at 1:17 p.m. the DON said an oxygen key retrieved from the pocket should not be used on a g-tube because it could be infected with anything. She said infection or bacteria could be introduced to the patient. 2.Record review of Resident #20's face sheet dated 12/5/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnosis included bipolar disorder, major depressive disorder, mild cognitive impairment, violent behavior, and pain. Record review of Resident #20's quarterly MDS assessment, dated 10/14/2024, reflected the resident had a BIMS score of 15 out of 15 which indicated intact cognition. He required ADL assistance from staff. Record review of Resident #20's care plan, dated 11/24/24, revealed he had a current acute infection and was on IV antibiotics due to positive UA. Interventions were to provide treatments as ordered by MD/NP, Enhanced Barrier Precautions (Novel MDRO)(per protocol): use gloves and gown to provide high-contact care. Use face mask if there is a risk of splash or spray. Infection control precautions per CDC guidelines for acute infection. In an observation and interview on 12/4/24 at 4:48 p.m. in the main hallway revealed LVN B administered Resident #20 an IV flush. She donned gloves but did not have on a gown. She said the resident did not require any special PPE, only standard gloves. She said EBP was for high-risk residents who had infections such as MRSA and CDIFF. She said Resident #20 was not on precautions. In an interview on 12/5/24 at 1:17 p.m. the DON said full PPE including a face mask, gown, and gloves were required for Resident #20 because of his IV site. She said the resident had an EBP sign on his doorway. In an interview on 12/5/24 at 2:17 p.m. the Administrator said the facility provided monthly training on enhanced barrier precautions and it should have been honored by using the proper PPE and protocol. Record review of the facility's Enhanced Barrier Precautions policy revised August 2022 read in part, .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. A. gloves and gown are applied prior to performing the high contact resident activity . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: .g.device care or use (central line, urinary catheter, feeding tube, .) 5. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Record review of the facility's Administering Medications policy revised April 2019 read in part, .25. Staff follows established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable .

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 8 residents (Resident #56 and Resident #20) reviewed for privacy in that: 1. LVN A failed to provide privacy while administering medications via g-tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) to Resident #56 by not closing her privacy curtain on 12/04/2024. 2. LVN B failed to provide privacy while administering an IV flush to Resident #20 by administering his IV flush in the middle of the hallway on 12/04/2024. This failure could place residents at-risk of loss of dignity due to lack of privacy. The findings included: 1.Record review of Resident #56's face sheet dated 12/5/24 revealed a [AGE] year-old female who admitted on [DATE]. Her diagnosis included gastrostomy infection (complication of gastrostomy tube placement), gastrostomy status (presence of an artificial opening to the stomach), type 2 diabetes, cerebral infarction (stroke), unspecified dementia, altered mental status, post-traumatic stress disorder, and hemiplegia affecting right nondominant side (paralysis of one side of the body). Record review of Resident #56's quarterly MDS assessment, dated 10/14/2024, reflected the resident had a BIMS score of 0 out of 15 which indicated she had severe cognitive impairment. She had a feeding tube and was dependent on staff for ADL care. Record review of Resident #56's care plan, dated 7/16/24, revealed she required tube feeding related to dysphagia. Interventions/Tasks were that the resident was dependent with tube feeding and water flushes. See MD orders for current feeding orders. In an observation and interview on 12/4/24 at 11:44 a.m. revealed LVN A prepared to administer Resident #56's medication via g-tube. She pulled the curtain to block the open doorway but did not close the privacy curtain between Resident #56 and her roommate. LVN A raised the Resident #56's shirt and began medication administration. The resident's roommate was in the room. LVN A said she forgot to pull the privacy curtain between the residents because Resident #56's roommate gets anxious when the curtain was pulled. In an interview on 12/4/24 at 4:21 p.m. the DON said nursing staff should close the door and pull the privacy curtain to provide privacy to the residents. She said privacy was provided for the residents' dignity. 2.Record review of Resident #20's face sheet dated 12/5/24 revealed a [AGE] year-old male who admitted on [DATE]. His diagnosis included bipolar disorder, major depressive disorder, mild cognitive impairment, violent behavior and pain. Record review of Resident #20's quarterly MDS assessment, dated 10/14/2024, reflected the resident had a BIMS score of 15 out of 15 which indicated intact cognition. He required ADL assistance from staff. Record review of Resident #20's care plan, dated 11/24/24, revealed he had a current acute infection and was on IV antibiotics due to positive UA. Interventions were to provide treatments as ordered by MD/NP. In an observation and interview on 12/4/24 at 4:48 p.m. in the main hallway revealed LVN B administered Resident #20 an IV flush. There was another resident and staff in the hallway. LVN B said she administered flushes in the hallway or near the nursing station with no problem. She said she did educate the resident on privacy. In an interview on 12/5/24 at 1:17 p.m. the DON said she 99% of the time it was not ok to flush an IV in the hallway. She said the resident should be taken to the room because of privacy and dignity. She said staff should ensure they are in the right environment with no distractions. In an interview on 12/5/24 at 2:17 p.m. the Administrator said it was basic resident rights and dignity for staff to pull the curtain. She also said staff should not provide IV flushes in the hallway for dignity purposes. Record review of facility's policy titled Dignity revised February 2021 revealed Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem .11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .

Based on observation and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable, physical, mental, and psychosocial well-being of each resident for 1 (Resident #3) of 18 residents reviewed for Administration. - The Administrator failed to ensure nursing staff were performing weekly skin assessments on Resident #3 and other residents at the facility, causing Resident #3 to get facility acquired Stage 2 (wounds extends through skin and looks like a blister or ulcer but does not extend through deeper tissue) and Stage 3 (wound extends through deep tissue and fat but does not expose bone) pressure wounds. - The Administrator failed to ensure staff were performing showers and daily hygiene care on Resident #3 and other residents at the facility, causing Resident #3 to go a week without a shower which can cause skin breakdown. - The Administrator failed to ensure wounds were being identified and communicated to the physician for Resident #3, which lead to late treatment of his pressure wounds. - The Administrator failed to ensure full-time DON coverage which caused lack of nursing supervision and oversight. - The Administrator failed to ensure the EMR system notified staff to perform skin assessments on Resident #3 and other residents, causing missed skin assessments and pressure wounds to Resident #3. An Immediate Jeopardy (IJ) was identified on 9/5/2023. The IJ template was provided to the facility on [DATE] at 12:40pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy. with a scope of isolated. due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for receiving substandard care, missed care, skin break down, wounds developing, and infections. Findings include: Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of dementia with other behavioral disturbance (dementia with agitation, depression, or psychosis), COPD (group of diseases that cause airflow blockage and breathing problems), seizures, major depression, schizoaffective bipolar (mental illness that can affect thoughts, mood, and behavior), cataracts (cloudy area in eye making it hard to see), right and left-hand contractures, obstructive and reflux uropathy (obstructed urinary flow), borderline intellectual functioning (below average cognition), C6 Cervical spinal cord injury (spinal cord injury near the base of the neck), acquired absence of right and left leg (amputation of the right and left leg). Record review of Resident #3's Quarterly MDS dated [DATE] revealed, a BIMS score of 15 which indicated normal cognition. According to the MDS, Resident #3 required extensive assistance with personal hygiene, toilet use, eating, dressing, transferring, and bed mobility. He also required 1-2+ people physical assistance with the activities. The resident was wheelchair bound and had limitation in ROM for both his upper and lower extremities. He also was totally dependent for shower/baths and required 2+ people physical assistance. The MDS revealed the resident had an indwelling catheter and was always incontinent of bowel. According to the MDS, the resident was at risk for pressure ulcers/injuries but had none. He was using a pressure reducing device for his bed and application of ointment/medication other than to his feet. Record review of Resident #3's care plan dated 7/14/23, had a Focus: Resident #3 experienced bowel incontinence r/t severe impaired physical mobility. Interventions: Check me every two hours and assist with toileting as needed . Focus: Resident #3 had bilateral AKAs. Interventions: Change position frequently. Alternate periods of rest with activity out of bed in order to [prevent] respiratory complications, prevent dependent edema [swelling], [prevent] flexion deformity and skin pressure areas . Focus: Resident #3 had a (Moderate) risk for skin breakdown per Braden scale. Interventions: .Implement weekly skin checks .Turn schedule every 1-2 hours while in bed. Focus: Resident #3 had an ADL self-care performance deficit r/t amputation .Interventions: BATHING/SHOWERING: The resident requires 1-2 staff with showers/bathing. BED MOBILITY: The resident requires 2 staff to turn and reposition in bed .TOILET USE: The resident is totally dependent on (1-2) staff for toilet use .CONTRACTURES: The resident has contractures of the (admitted with bilateral hands contractures). Provide skin care (q shift) to keep clean and prevent skin breakdown .TRANSFER: The resident is totally dependent on (X2) staff for transferring. The resident requires Mechanical Lift with (X2) staff assistance for transfers . Focus: Resident #3 had a behavior problem (refused ADLs assistance .wound care . Interventions: .Document refusals of ADLs assistance, e.g., repositioning assistance, toileting assistance .wound care . Focus: Resident #3 refused to take protein supplements r/t does not like the taste of any of it. Interventions: .Weekly skin care assessment. Wound care as ordered. The 2-posterior thigh/buttock wounds were not care planned. Record review of Resident #3's physician orders revealed an order for Weekly Skin checks (Monday/AM), one time a day, every Mon. Ordered on 5/27/21 by MD A. The physician orders did not reveal any wound treatment orders. Record review of Resident #3's Weekly Skin Review/Assessments, performed by different nurses, from 4/24/23 through 8/28/23 revealed No new skin issues noted. Record review of Resident #3's August 2023 TAR revealed weekly skin checks were not documented on 8/14/23 and 8/21/23. Record review of Resident #3's August 2023 and September 2023 shower sheets revealed documentation of showers/baths only on 8/8/23, 8/19/23, and 9/2/23. In an observation and interview with Resident #3 on 8/30/23 at 10:02am, he was laying on his back in bed with both legs amputated and a wheelchair next to his bed. He stated the staff put him into his wheelchair in the morning about 8:00am or 9:00am via a Hoyer lift and then left him in it all day long, until about 8:00pm. He stated he was only supposed to be in his chair for 3-4hrs, but he was unable to find anyone to put him back into bed with the Hoyer lift in the evening. He said by the time staff put him back into bed, he would be in a lot of pain. He also said staff did not perform skin assessments on him and he had a wound that they did not check on. He also said he had not been receiving showers 3 x week like he was supposed to, and he had not had a shower in over a week. In the Resident Council meeting on 8/31/23 at 10:30am, it was revealed by the 6 residents that showers were not being given, especially on the 2-10pm shift. They stated that the odd number rooms got showers on Tue/Thu/Sat and the even number rooms got showers on Mon/Wed/Fri. They also stated that the A beds got showers in the morning and the B beds got showers at night. In an interview with RN AA on 8/31/23 at 2:48pm, she stated she was the part-time DON, then she said Interim DON. She said she did not start full time until 9/10/23 or 9/11/23. Her badge stated DON and she stated the employees called her the DON. She said she had already identified skin assessments as an issue at the facility. She had already done a PIP on it. She stated she ran a report on skin assessments in their EMR and it showed skin assessments were not being completed. She also stated there was an issue in the EMR with the skin assessment tasks not popping up and alerting staff to perform them. She said she planned on doing chart audits to ensure skin assessments were being completed and if they were not done, residents could have an ulcer/wound which could lead to infection, sepsis, and could die. She stated she was not going to start as the full time DON until 9/10/23 or 9/11/23. She stated she had already identified showers as a concern at the facility also. She stated she planned to pull a CNA to be the shower tech once she started as the full time DON. She said she was also going to ensure the documentation in the chart was clear if the resident refused a shower, and make sure staff notified the resident's RP and notified the DON if they refused. RN AA stated the reason why the 2pm-10pm shift was not getting showers was due to lack of accountability, since management was not there. In an interview with LPN N on 9/1/23 at 10:30am he stated Resident #3 had no skin concerns to his buttocks or sacrum (triangular bone above the tailbone). He stated if the resident had anything, it was just some redness to his groin from the Foley catheter tubing. He stated he never noticed any wounds on Resident #3 but had not performed a skin assessment on him before. He stated that Resident #3 had mentioned he was in pain, but the resident always had pain and exaggerated on things. In an interview on 9/1/23 at 11:00am, CNA HH said on MWF, A-Bed residents in even numbered rooms were to be showered by 6-2pm staff; B-Bed residents were showered by 2-10pm staff. On TTS, A-Bed residents in odd numbered rooms were to be showered by 6-2pm staff; B-Bed residents were showered by 2-10pm staff. In an interview with the Administrator on 9/1/23 at 1:35pm, it was revealed showers had already been identified as a concern and they were not being performed. She stated the plan was to hire a shower tech to assist with giving showers. In an interview with the RN AA on 9/1/23 at 3:55pm she stated there was not a wound care nurse and the wounds were handled in house since there were only 4. She stated she walked with MD B on Thursdays and helped assess and enter orders, and the nursing staff were responsible for wound care when she was not assisting with MD B. In an observation and interview on 9/1/23 at 4:26pm with CNA CC, CNA BB, and Resident #3, resident was observed to have a Stage III (wound extends through deep tissue and fat but does not expose bone) pressure wound to his right posterior thigh/buttock area and a Stage II (wound extends through skin and looks like a blister or ulcer but does not go through deeper tissue) pressure wound to his left posterior thigh/buttock area. Both CNAs stated they had not seen and did not know about the wounds until that day. CNA CC stated she had not worked with Resident #3 in a while. She did say that the resident had had a Stage II or III to the same area on the right side several months ago that had healed, and it looked like it had re-opened again in the same place. CNA BB stated she had been working with the resident but had not noticed the wounds. She stated she must have not turned him far enough to see it when she changed him. CNA BB stated now that she knew about the wounds, she was going to inform the nurse on duty which was LPN H. Record review of the facility's wound documentation list on 9/2/23, revealed there were 6 residents with wounds that were all facility acquired. Resident #3 was not listed as a resident with a wound. In an interview with CNA Z on 9/2/23 at 2:27pm, he stated residents received showers on alternating days. He said A beds got them in the morning and B beds got them at night. He said they documented showers in the computer and on shower sheets in a binder at the nurse's station. He also stated he felt like they had enough staff to provide adequate showers. CNA Z said RN AA was the DON and identified herself as the DON to all the staff. There were not any shower sheets in the shower binder for Resident #3 for August 2023 or September 2023. In an interview with LPN H on 9/2/23 at 2:30pm she stated she had only been at the facility for 10days. She knew skin assessments were done weekly but she did not know what day because she only did them when the task popped up in the EMR. She said she had never checked off the skin assessment task, without actually performing a skin assessment. She said if a skin assessment was missed, a wound could be missed. LPN H stated the DON was RN AA and that she identified herself as the DON to all the staff. In an interview with Resident #3 on 9/3/23 at 10:34am he said, he finally had received a shower the night before (9/2/23) and he felt much better. Record review of Resident #3's Skin/Wound Note by LPN H on 9/3/23 at 10:34am revealed, Area to right hip has reopened [MD A] notified and orders given to consult with [MD B], area cleansed with NS patted dry and covered with dry dressing, until new orders are received. In an interview with LPN H on 9/3/23 at 10:38am she stated she did not perform a head-to-toe assessment on all residents, only when the skin assessment task popped up. She stated today (9/3/23) was the first day she saw Resident #3's wound and was informed of it. She stated she had been his nurse before but had not done a skin assessment on him. In an interview with LPN N on 9/3/23 at 10:51am, he stated he had no problems with the skin assessments and had not noticed any not popping up. He also stated there were only a few wounds at the facility and he felt comfortable and had plenty of time to perform skin assessments and wound care. LPN N stated the DON was RN AA and she identified herself as such to the employees. He said he never noticed any wounds on Resident #3, but he had not performed a skin assessment on him in a long time. In an interview with the Administrator, the Regional Nurse Consultant, and RN AA on 9/3/23 at 11:23am, it was revealed RN AA was not the acting DON, even though staff identified her as such, and DON was on her name tag. Per the Administrator, RN A was the acting DON at night, and worked on the floor as an RN on the night shift. It was revealed RN A oversaw the nursing department but was not following through with oversight, which was why RN AA was going to be taking over as the DON. However, RN AA was not taking over until 9/10/23. RN AA stated a skin assessment was performed on 8/28/23 and there were no wounds on Resident #3. Per the Regional Nurse Consultant, it was possible his old wound to his right buttock/ischium (curved bone at base of pelvis) opened back up in 4 days. The Regional Nurse Consultant stated Resident #3 had an old wound in the same area that used to be a Stage 3 (wound extends through deep tissue and fat but does not expose bone) or 4 (wound extends through deep tisse/fat and muscle or bone is shown) and it could have been developing from the inside before it opened back up and it was not found on the last skin assessment. The Regional Nurse Consultant stated Resident #3 never told anyone he was having any pain or had any wounds. The Regional Nurse Consultant agreed Resident #3 was a paraplegic (no movement/feeling from waist down) and was unable to feel a lot, and it was not up to him to tell staff he had a wound. The Administrator, the Regional Nurse Consultant, and RN AA agreed staff should have been doing skin assessments and noticed the wounds during showers, brief changes, or pericare. Per the Administrator, RN A oversaw the skin assessments and accuracy of staff documentation, even though she was working as a floor nurse at night. The Administrator said the nurses had competencies that were continual and ongoing. Per RN AA, on hire the nurses had a competency sheet they had to fill out with their preceptor. Per the Regional Nurse Consultant, if issues were identified with new employees, they were re-educated, and if it seemed to be a system wide issue, they provided an in-service for the whole facility. Per the Administrator, the Regional Nurse Consultant, and RN AA, they had an issue with their EMR not popping up the skin assessment task. They said if the nurse did not do her skin assessment task, it would turn red and then the assessment would not pop up for any other later shifts. They were trying to address the problem. RN AA stated MD B would call her and ask her if there were any new residents with wounds. He would see those residents with her on Thursdays. RN AA stated she left face sheets in MD B's box at the nurse's station, for him to round on when he came. On 9/3/23 at 12:15pm, a message was left for the acting DON (RN A) to call back. On 9/3/23 at 12:49pm, a message was left for MD B to call back. In an interview with the Administrator on 9/3/23 at 1:45pm, she stated RN A oversaw the nurses. The Administrator said RN A was not providing adequate supervision of the nurses and there was a complete system breakdown in the nursing department. The Administrator stated RN A was the RN 8hr coverage at night and also the acting DON at night. The Administrator stated she did not have a full time DON who supervised the nursing staff during the day. She stated the last time there was a full time DON was for 2 weeks back in July and the previous ADON had been taking care of everything, but she left on 8/4/23. In an interview with the Medical Director on 9/4/23 at 12:23pm, she stated there were some failures with oversight since they did not have a DON during the day. She stated the last time they had a full time DON was for 2 weeks in July. She said primarily the previous ADON took care of everything, but she quit 8/4/23. In an observation and interview with Resident #64 and RN AA on 9/4/23 at 3:30pm, it was revealed the resident had a fitted sheet soaked with, what appeared to be urine, from his head all the way down to his legs. There was a foul smell in the room that got worse when his brief was opened. RN AA was there with 2 CNAs while performing a skin assessment. RN AA stated the resident had just been changed about 30min ago. She was unsure how the sheet was soaked and stated the CNA who changed him must have placed a new cloth chuck on top of the soiled sheet, without changing it. She stated it was unacceptable for them to not have changed the sheet and would investigate it. In an interview with Resident #3 on 9/6/23 at 1:30pm, he stated he had not had a shower since 9/2/23, and he was supposed to have received one on 9/5/23 but did not get one. He stated he did not receive a shower on 9/4/23, and the documentation was wrong that he had received a shower on 9/4/23. In an interview on 9/6/23 at 1:40pm, CNA W said if a resident declined to have ADLs performed, the CNA was to report it to the charge nurse who would follow up with the resident. In an interview on 9/6/23 at 1:42pm, LPN L said if a resident declined to have ADLs performed, the CNA reported it to the charge nurse. She said the charge nurse would follow up with the resident to see if the nurse could encourage the resident to accept care. She said if the resident continued to decline care, the care would be offered again later, and the nurse would document the refusal and notify the resident's RP. Record review of the facility's policy and procedure for Charting and Documentation (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations .c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward of changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Record review of the facility's policy and procedure for Change in a Resident's Condition of Status (Revised February 2021) read in part: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): .b. discovery of injuries of an unknown source .d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly .2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting) c. requires [IDT] review and/or revisions to the care plan . Record review of the facility's policy and procedure on CNA Expectations (undated) read in part: .Daily hygiene needed on ALL resident EVERYDAY AM/PM: Brush Hair and Teeth- Shave all facial hair unless resident requests otherwise. Trim/File Nails- clean under nails. Fresh Clothing- Morning: Fresh clothing, Night: Pjs, Skid resistant socks/footwear at all times. Rounds should be Q2H and as needed with assistance provided timely Turning and Repositioning Q2H and as needed for ALL BED BOUND residents: Heels should be offloaded on pillow (hanging off) when in bed. Wheelchair Cushions need to be provided for all resident without one .Get Up List- ALL residents should be OUT OF BED for ALL meals and Activities as tolerated: Night Shift- get up 50% of all abled residents. Day Shift- get up all abled residents .Showers: All residents showers to be completed daily as scheduled day/evening shifts- All skin abnormalities to be reported to nurse on duty. Record review of the facility's policy and procedure on Prevention of Pressure Injuries (revised April 2020) read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Skin Assessment: 2. During the skin assessment, inspect: a. Presence of erythema [redness]; b. Temperature of skin and soft tissues; and c. Edema [swelling]. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. A. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema [skin that does not turn white when pushed]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum [triangular bone above tailbone], heels, buttocks, coccyx [tailbone], elbows, ischium [curved bone at base of pelvis], trochanter [hip bone], etc.); c. Wash the skin after any episodes of incontinence, using pH balanced skin cleanser; d. Moisturize dry skin daily; and e. Reposition resident as indicated on the care plan. Prevention: 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence .4. Use a barrier product to protect skin from moisture .Mobility/Repositioning: 1. Repositioning all residents with or at risk of pressure injuries on an individualized schedule, as determined by the [IDT] care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines .Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility's policy and procedure on Pressure Ulcers/Skin Breakdown-Clinical Protocol (Revised April 2018) read in part: Assessment and Recognition: .2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .d. Current treatments .4. The physician will assist the staff to identify the type .of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .2. The physician will clarify the status of relevant medical issues .and the impact of comorbid conditions on healing an existing wound. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement [removing skin] approaches, dressings .and application of topical agents. 2. The physician will help identify medical interventions related to wound management .Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Record review of the facility's policy and procedure for Department Supervision, Nursing (Revised August 2022) read in part: The nursing services department shall be under the direct supervision of a registered or licensed practical/vocational nurse at all times. 1. A licensed nurse (RN/LPN/LVN) is on duty twenty-four hours per day, seven (7) days per week, to provide resident care services and supervise the nursing services activities provided by unlicensed staff. A licensed nurse is designated as a charge nurse on each shift .b. A charge nurse is a licensed nurse with designated responsibilities that may include staff supervision, emergency coordination, provider or physician support and direct resident care. c. The director of nursing services (DNS) may serve as the charge nurse only when the average daily occupancy of the facility is 60 or fewer residents .3. Licensed nurses are required to supervise nurse aides/nursing assistants and are scheduled in such a way that permits adequate time to do so. 4. A registered nurse (RN) is employed as the director of nursing services (DNS). The DNS is on duty a minimum of 40 hours per week. 5. During the absence of the DNS, a nurse supervisor/charge nurse is responsible for the supervision of all nursing department activities including supervision of direct care staff . An Immediate Jeopardy (IJ) was identified on 9/5/2023. The IJ template was provided to the facility on [DATE] at 12:40pm. The Plan of removal was accepted on 9/6/2023 at 12:38pm. The plan of removal reflected the following: Immediate action: A plan has been created to ensure full time Director of Nursing coverage until the part time DON is able to start full time on 9/7/2023. The RN Clinical Nurse Resource will assume DON duties, including reviewing weekly skin check assessments, ADL documentation, wound care, and physician communication. Signage will be posted throughout the facility to assist staff to know who to contact with clinical concerns. The Chief Nursing Officer provided training with the RN Clinical Nurse Resource and the facility Administrator about Director of Nursing responsibilities 09/5/23. Resident 3 had a skin check performed by the Medical Director on 9/4/2023. The physician identified wound present in sacral/coccyx area and instructed to continue with current treatment order in place for identified skin breakdown. The resident's Care Plan/Kardex was updated on 9/4/2023 with individualized interventions to address/prevent skin breakdown, including turning/repositioning him at least every two hours. Resident 3 was assessed for pain/discomfort. The resident's physician reviewed his pain management interventions. The resident's Care Plan/Kardex was updated on 9/4/2023 with individualized interventions to address/prevent pain, including turning/repositioning him at least every two hours. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/4/2023 of all residents to validate a skin check has been completed in the past 7 days. Any resident who has not had a documented skin check will have a skin check completed by 9/5/2023. Facilities Plan to ensure compliance quickly: An Ad-Hoc QAPI was conducted on 9/3/2023 when the missing skin check issue was brought up to the facility. Facility interventions were implemented: The facility skin assessment schedule was reviewed on 9/3/2023 and adjustments were made. An audit was completed on 9/3/2023 of every resident's skin check schedule in [EMR] and updates were made as needed to validate the skin check would pop up in the EMAR on the date/shift that was s cheduled. Education was initiated for the facility nursing staff on 9/3/2023 regarding the new skin assessment schedule. Education was initiated for Nursing Assistants on 9/4/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours and who to notify if skin breakdown is identified. Education to be initiated by DON/Designee on 9/4/2023 with all Licensed Nurses regarding the importance of completing a thorough weekly skin assessment with return demonstration and reporting immediately when a resident has incurred a skin impairment. Training to also include proper technique to perform the skin check and how to document the skin check. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. Education to be initiated by Administrator/Designee on 9/4/2023 with all facility staff on the conditions that lead to neglect and who/when to report suspicion of neglect to. Education to be completed with all nursing staff working 9/5/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. Administrator and Clinical Nurse Resource to create a schedule to validate that facility has sufficient oversight of clinical systems to attain the highest, practicable physical, mental, and psychosocial well-being of each resident while the new Director of Nursing is in training. Administrator and facility administrative nursing team educated by Regional Nurse Consultant on 9/5/23 related to their responsibilities in clinical oversight, clinical audits, and skin program. From 9/6/23-9/7/23 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed: On 9/6/23 at 11:20am in an interview with the Regional Nurse Consultant she said she was the Interim DON for the next 24hrs and had started as the Interim DON yesterday (9/5/23) after the Administration IJ was called. She stated RN AA would move up her start date and start full time on 9/7/23. On 9/6/23 at 11:47am in an interview with RN AA, she stated she would take over as the full time DON tomorrow 9/7/23. She said she decided to not take a vacation and moved up her start date and will actually be the full time DON starting at 12:01am on 9/7/23. On 9/6/23 at 1:00pm in an interview with the Interim DON (Regional Nurse Consultant), she said she had started in-services/trainings on 9/5/23 regarding skin assessments, skin assessment schedule (with a quiz), showers, and abuse/neglect. She stated most of the staff had been trained. On 9/6/23 at 2:00pm in an interview with CNA CC she stated the facility had training on abuse/neglect on 9/5/23 and training on skin assessments was on 9/4/23. She stated

Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 1 (Resident #3) of 18 residents reviewed for pressure ulcers. - The facility failed to perform adequate skin assessments to identify pressure injuries for Resident #3, who was non-ambulatory and wheelchair bound. - The facility failed to identify and treat Resident #3's stage 2 (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues ) and stage 3 (wound goes through deep tissue and fat but does not expose bone) pressure injuries. An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on [DATE] at 1:00pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of developing pressure ulcers/wounds, worsening pressure ulcers/wounds, and could cause pain, infection, hospitalization , or death. Findings include: Record review of Resident #3's undated face sheet revealed he was a [AGE] year-old male, who admitted to the facility on [DATE] with diagnoses of dementia with other behavioral disturbance (dementia with agitation, depression, or psychosis), COPD (group of diseases that cause airflow blockage and breathing problems), seizures, major depression, schizoaffective bipolar (mental illness that can affect thoughts, mood, and behavior), cataracts (cloudy area in eye making it hard to see), right and left-hand contractures (fixed tightening of muscle, tendons, ligaments, or skin), obstructive and reflux uropathy (obstructed urinary flow), borderline intellectual functioning (below average cognition), C6 Cervical spinal cord injury (spinal cord injury near the base of the neck), and acquired absence of right and left leg (amputation of the right and left leg). Record review of Resident #3's Quarterly MDS dated [DATE] revealed, a BIMS score of 15 which indicated normal cognition. According to the MDS, Resident #3 required extensive assistance with personal hygiene, toilet use, eating, dressing, transferring, and bed mobility. He also required 1-2+ people physical assistance with the ADL's. The resident was wheelchair bound and had limitation in ROM for both his upper and lower extremities. He also was totally dependent for shower/baths and required 2+ people physical assistance. The MDS revealed the resident had an indwelling catheter and was always incontinent of bowel. According to the MDS, the resident was at risk for pressure ulcers/injuries but had none. He was using a pressure reducing device for his bed and application of ointment/medication other than to his feet. Record review of Resident #3's care plan dated 7/14/23, had a Focus: Resident #3 experienced bowel incontinence r/t severe impaired physical mobility. Interventions: Check me every two hours and assist with toileting as needed . Focus: Resident #3 had bilateral [both sides] AKAs. Interventions: Change position frequently. Alternate periods of rest with activity out of bed in order to [prevent] respiratory complications, prevent dependent edema [swelling], [prevent] flexion deformity [inability to fully straighten or extend] and skin pressure areas . Focus: Resident #3 had a (moderate) risk for skin breakdown per the Braden scale. Interventions: .Implement weekly skin checks .Turn schedule every 1-2 hours while in bed. Focus: Resident #3 had an ADL self-care performance deficit r/t amputation .Interventions: BATHING/SHOWERING: The resident requires 1-2 staff with showers/bathing. BED MOBILITY: The resident requires 2 staff to turn and reposition in bed .TOILET USE: The resident is totally dependent on (1-2) staff for toilet use .CONTRACTURES: The resident has contractures of the (admitted with bilateral hands contractures). Provide skin care (q shift) to keep clean and prevent skin breakdown .TRANSFER: The resident is totally dependent on (X2) staff for transferring. The resident requires Mechanical Lift with (X2) staff assistance for transfers . Focus: Resident #3 had a behavior problem (refused ADLs assistance .wound care . Interventions: .Document refusals of ADLs assistance, e.g., repositioning assistance, toileting assistance .wound care . Focus: Resident #3 refused to take protein supplements r/t does not like the taste of any of it. Interventions: .Weekly skin care assessment. Wound care as ordered. The 2-posterior (back) thigh/buttock wounds were not care planned. Record review of Resident #3's physician's orders revealed an order for Weekly Skin checks (Monday/AM), one time a day, every Mon. Ordered on 5/27/21 by MD A. The physician's orders did not reveal any wound treatment orders. Record review of Resident #3's Weekly Skin Review/Assessment by LPN MM dated 4/18/23 revealed Woundcare D/C'ed to R Ischium (curved bone at base of pelvis). No new skin issues noted at this time. Record review of Resident #3's Wound Treatment Note by MD B on 4/21/23, revealed the resident was being treated for a Stage III (wound goes through deep tissue and fat but does not expose bone) pressure wound to his right ischium that initially started 6/6/19, and then started again on 2/17/22. According to MD B, on 4/21/23 the right ischium pressure ulcer had resolved; however, MD B documented the resident was at increased risk of wound incidence due to his many comorbidities. Record review of Resident #3's Weekly Skin Review/Assessments, performed by different nurses, from 4/24/23 through 8/28/23 revealed No new skin issues noted. Record review of Resident #3's August 2023 TAR revealed weekly skin checks were not documented as completed on 8/14/23 and 8/21/23. Record review of Resident #3's medical record on 8/28/23 revealed no documentation indicating he refused to be turned every 2hrs, or refeused weekly skin checks. In an observation and interview with Resident #3 on 8/30/23 at 10:02am, it was revealed he was lying on his back in bed, he had both legs amputated, and there was a wheelchair next to his bed. He stated the staff put him into his wheelchair in the morning at about 8:00am or 9:00am via a Hoyer lift and then left him in it all day long, until about 8:00pm. He stated he was only supposed to be in his chair for 3-4hrs, but he was unable to find anyone to put him back into bed with the Hoyer lift in the evening. He said by the time staff put him back into bed, he would be in a lot of pain. He also said staff were not performing skin assessments on him and he had a wound they did not check on (he did not say where the wound was). In an interview with RN AA on 8/31/23 at 2:48pm, she stated she had already identified skin assessments as an issue at the facility and had already done a PIP on it. She stated she ran a report on skin assessments in their EMR and it showed skin assessments were not being completed. She also stated there was an issue in the EMR with the skin assessment tasks not popping up and alerting staff to perform them. She said she planned on doing chart audits to ensure skin assessments were being completed and if they were not done, residents could have an ulcer/wound which could lead to infection, sepsis (infection through whole body), or could die. She stated she was not going to start as the full time DON until 9/10/23 or 9/11/23. In an interview with LPN N on 9/1/23 at 10:30am, he stated Resident #3 did not have any skin issues to his buttocks or sacrum (triangular bone above the tailbone). He stated if the resident had any skin issues, it was redness to his groin area from the Foley catheter tubing rubbing him. In an interview with the RN AA on 9/1/23 at 3:55pm she stated there was not a wound care nurse and the wounds were handled in house since there were only 4. She stated she walked with MD B on Thursdays and helped assess and enter orders, and the nursing staff were responsible for wound care when she was not assisting with MD B. In an observation and interview on 9/1/23 at 4:26pm with CNA CC, CNA BB, and Resident #3, the resident was observed to have a Stage III pressure wound (wound goes through deep tissue and fat but does not expose bone) about the size of an egg, to his right posterior thigh/buttock, without a dressing. It was also observed that he had a Stage II pressure wound (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues) about the size of a quarter, to his left posterior thigh/buttock area, without a dressing. Both CNAs stated they had not seen and did not know about the wounds until that day. CNA CC stated she had not worked with Resident #3 in a while. She did say that the resident had had a Stage II (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues) or III (wound goes through deep tissue and fat but does not expose bone) to the same area on the right side several months ago when she last worked with him that had healed, and it looked like it had opened again in the same place. CNA BB stated she had been working with the resident but had not noticed the wounds. She stated she must have not turned him far enough to see it when she changed him. CNA BB stated now that she knew about the wounds, she was going to inform the nurse on duty which was LPN H. Record review of the facility's wound documentation list on 9/2/23, revealed there were 6 residents with wounds that were all facility acquired. Resident #3 was not listed as a resident with a wound. In an interview with LPN H on 9/2/23 at 2:30pm she stated she had only been at the facility for 10days. She said she knew skin assessments were done weekly but she did not know what day because she only did them when the task popped up in the EMR. She said she had never checked off the skin assessment task, without actually performing a skin assessment. She said if a skin assessment was missed, a wound could be missed. In an interview with LPN H on 9/3/23 at 10:38am, she stated there were concerns with the skin care system. She said sometimes the skin assessments would not pop up to tell you to perform the assessment, but she knew from being a former manager where to go in the EMR to see the task. She said something was broken with the system, but she could not put her finger on it, and she had not told anyone about it. Record review of Resident #3's Skin/Wound Note by LPN H on 9/3/23 at 10:34am revealed, Area to right hip has reopened [MD A] notified and orders given to consult with [MD B], area cleansed with NS patted dry and covered with dry dressing, until new orders are received. In an interview with the Administrator, the Regional Nurse Consultant, and RN AA on 9/3/23 at 11:23am, it was revealed RN A had been the acting DON and worked on the floor as an RN on the night shift. It was revealed RN A oversaw the nursing department but was not following through, which was why RN AA was going to be taking over as the DON. RN AA stated a skin assessment was performed on 8/28/23 and there were no wounds on Resident #3. Per the Regional Nurse Consultant, it was possible his old wound to his right buttock/ischium (curved bone at base of pelvis) opened back up in 4 days. The Regional Nurse Consultant stated Resident #3 had an old wound in the same area that used to be a Stage 3 (wound goes through deep tissue and fat but does not expose bone) or 4 (wound that goes through deep tissue and fat and exposes bone/muscle) and it could have been developing from the inside before it opened back up and it was not found on the last skin assessment. The Regional Nurse Consultant stated Resident #3 never told anyone he was having any pain or had any wounds. The Regional Nurse Consultant agreed Resident #3 was a paraplegic (no movement/feeling from waist down) and was unable to feel a lot, and it was not up to him to tell staff he had a wound. The Administrator, the Regional Nurse Consultant, and RN AA agreed staff should have been doing skin assessments and noticed the wounds during showers, brief changes, or pericare. Per the Administrator, RN A oversaw the skin assessments and accuracy of staff documentation, even though she was working as a floor nurse at night. The Administrator said the nurses had competencies that were continual and ongoing. Per RN AA, on hire the nurses had a competency sheet they had to fill out with their preceptor. Per the Regional Nurse Consultant, if issues were identified with new employees, they were re-educated, and if it seemed to be a system wide issue, they provided an in-service for the whole facility. Per the Administrator, the Regional Nurse Consultant, and RN AA, they had an issue with their EMR not popping up the skin assessment task. They said if the nurse did not do her skin assessment task, it would turn red and then the assessment would not pop up for any other later shifts. They were trying to address the problem. RN AA stated MD B would call her and ask her if there were any new residents with wounds. He would see those residents with her on Thursdays. RN AA stated she left face sheets in MD B's box at the nurse's station, for him to round on when he came. On 9/3/23 at 12:15pm, a message was left for RN A, the acting DON to call back. On 9/3/23 at 12:49pm, a message was left for MD B to call back. In an interview with the Administrator on 9/3/23 at 1:45pm, she stated RN A oversaw the nurses. The Administrator said RN A was not providing adequate supervision of the nurses and there was a complete system breakdown in the nursing department. The Administrator stated RN A was the RN 8hr coverage at night and the acting DON at night. The Administrator stated she did not have a full time DON who supervised the nursing staff during the day. In an interview with the Medical Director on 9/4/23 at 12:23pm, she stated there were some failures with oversight with the nursing staff since they did not have a DON during the day. She stated the last time they had a full time DON was for 2 weeks in July 2023. She said primarily the previous ADON took care of everything, but she quit 8/4/23. Record review of the facility's policy and procedure for Charting and Documentation (revised July 2017) read in part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record: a. Objective observations .c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward of changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .7. Documentation of procedures and treatments will include care-specific details, including: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; and g. The signature and title of the individual documenting. Record review of the facility's policy and procedure on Prevention of Pressure Injuries (revised April 2020) read in part: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable .Skin Assessment: 2. During the skin assessment, inspect: a. Presence of erythema [redness]; b. Temperature of skin and soft tissues; and c. Edema [swelling]. 3. Inspect the skin on a daily basis when performing or assisting with personal care of ADLs. A. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema [redness that does not turn white when pushed]). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum [triangular-shaped bone above the tailbone], heels, buttocks, coccyx [tailbone], elbows, ischium, trochanter [hip bone], etc.) .e. Reposition resident as indicated on the care plan .Mobility/Repositioning: 1. Repositioning all residents with or at risk of pressure injuries on an individualized schedule, as determined by the [IDT] care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines .Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. Record review of the facility's policy and procedure on Pressure Ulcers/Skin Breakdown-Clinical Protocol (Revised April 2018) read in part: Assessment and Recognition: .2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates [secretion] or necrotic [black/dead] tissue .d. Current treatments .4. The physician will assist the staff to identify the type .of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Cause Identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown .2. The physician will clarify the status of relevant medical issues .and the impact of comorbid conditions on healing an existing wound. Treatment/Management: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement [removing skin] approaches, dressings .and application of topical agents. 2. The physician will help identify medical interventions related to wound management .Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. 2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on [DATE] at 1:00pm. The Plan of removal was accepted on 9/6/2023 at 12:38pm. The plan of removal reflected the following: Immediate: Resident 3 had a skin check performed by the Medical Director on 9/4/2023. The physician identified a wound present in sacral/coccyx area and instructed to continue with current treatment order in place for identified skin breakdown. The resident's Care Plan/Kardex was updated on 9/4/2023 with individualized interventions to address/prevent skin breakdown, including turning/repositioning him at least every two hours. A facility audit of all residents to be completed by the Director of Nursing/Designee by 9/4/2023 of all residents to validate a skin check has been completed in the past 7 days. Any resident who has not had a documented skin check will have a skin check completed by 9/5/2023. Facilities Plan to ensure compliance quickly: An Ad-Hoc QAPI was conducted on 9/3/2023 when the missing skin check issue was brought up to the facility. Facility interventions were implemented: The facility skin assessment schedule was reviewed on 9/3/2023 and adjustments were made. An audit was completed on 9/3/2023 of every resident's skin check schedule in [EMR] and updates were made as needed to validate the skin check would show up in the EMAR on the date/shift that was scheduled. Education was initiated for the facility nursing staff on 9/3/2023 regarding the new skin assessment schedule. Education was initiated for Nursing Assistants on 9/4/2023 on ensuring residents at high risk for skin breakdown are turned and repositioned at least every two hours and who to notify if skin breakdown is identified. Education to be initiated by DON/Designee on 9/4/2023 with all Licensed Nurses regarding the importance of completing a thorough weekly skin assessment and reporting immediately when a resident has incurred a skin impairment. Training to also include proper technique to perform the skin check and how to document the skin check in the EMAR. This training to Licensed Nurses will be validated by completion of a post-training test, to be dated and signed by each nurse. Education to be completed with all nursing staff working 9/5/2023. Staff who did not receive the training will receive this training prior to their next shift and will not be allowed to provide direct resident care until they have completed the trainings. From 9/6/23-9/7/23 a monitoring visit was conducted to ensure the facility was following its POR. The visits revealed: On 9/6/23 at 1:00pm in an interview with the Interim DON (Regional Nurse Consultant), she said she had started in-services/trainings on 9/5/23 regarding skin assessments, and skin assessment schedule (with a quiz). She stated most of the staff had been trained. On 9/6/23 at 2:00pm in an interview with CNA CC she stated the facility had training on skin assessments on 9/4/23. She was able to re-iterate what she had learned from the skin assessment in-service. She stated it was important to monitor for skin breakdown, turn every 2 hrs, and to notify the nurse if any redness or skin breakdown was noticed. Record review of Resident #3's Wound Treatment documentation by MD B on 9/7/23, revealed the resident had a R Ischium wound that was 4.5 x 3.6 x .1 cm and a L Ischium wound that was .2 x 1.2 x .1 cm, that had reopened. He wrote orders on the paper to limit sitting to < 2hrs/time and to reposition/offload. On 9/7/23 at 11:20am in an interview with RN AA, she said she initiated a whole new skin assessment calendar by room, instead of by resident. She said, if a resident moved, the skin assessment would still be due by room and not by resident. She stated they were also starting chart audits where they would go into a resident's chart and pick a random day in the last week, to ensure the nurses were documenting the skin assessments. Also, she said every morning she would go into the EMR and see if the assessment was in red, because when it was not done it would be triggered in red. RN AA stated the facility performed a skin sweep of the facility, so every resident had a new skin assessment as of 9/6/23 and then she was going to start checking the assessments today (9/7/23). She also said she checked the shower sheets, and the staff would bring them to her if they identified something on a resident. RN AA stated she would compare the shower sheets to what she had identified on the residents in the computer. RN AA also said they were hiring a treatment nurse, so once they got a treatment nurse all the identified areas would be funneled through them, and they would only have one person looking at it. On 9/7/23 at 11:52am in an interview with the Interim DON (The Regional Nurse Consultant), she said the plan was to follow up and monitor now. She stated all the training had been completed on skin assessments, showers, shower sheets, ADLs, checking and turning the resident every 2hrs, and ANE. She stated with the skin assessments, she trained on when to do them, where to find them, what to look for, what to do if something is found, and the Stop and Watch notification. She said she also took them to the kiosk and showed them how to perform the Stop and Watch notification, and then had them perform a return demonstration. The Interim DON (The Regional Nurse Consultant) also stated staff were not allowed to work unless they had been trained, and she had gone through next week's schedule and staff that were scheduled to work had already been in-serviced. She said the PRN staff would not be allowed to work until they were in-serviced also. On 9/7/23 at 11:55am in an interview with CNA W, he said they had in-services on showers and were informed to make sure and tell the nurse if any skin concerns were found during the shower, and to document them on the shower sheet and in the EMR. CNA W said staff were in-serviced on skin assessments as well and staff needed to make sure and document anything they saw, and to fill out a Stop and Watch which would also trigger a notification. He said after filling out the Stop and Watch the staff also needed to tell the nurse verbally about any skin issues. On 9/7/23 at 12:10pm in an interview with CNA X, she said they received training on the EMR and where to go to document things, and the Stop and Watch for skin findings. She said if she were to find any skin irregularity on a resident, she was supposed to document it, enter a Stop and Watch that triggered the nurse, and verbally report it to the nurse. She stated, even if the skin irregularity was old, it was important to document it because the other staff may have not seen it before. The CNA said they were supposed to have the nurse come in and assess the resident when they were showering also, to ensure nothing was missed on the resident. She said once the shower sheets were filled out, the ADON checked them to ensure everything was filled out and there were no questions. On 9/7/23 at 2:36pm in an interview with Resident #3, he said that MD B came and saw him today. He said the doctor ordered new treatments for his wounds and staff were going to start treating his wounds. He stated that his pain was ok. He also stated that staff were not leaving him in his wheelchair for as long and putting him back in bed. Record reviews performed by the Surveyor on 9/7/23: - Record of training provided by the Interim DON (Regional Nurse Consultant) to the Nursing staff regarding new skin assessment schedule, performing a head-to-toe skin assessment with return demonstration. - Record of training provided by the Interim DON (Regional Nurse Consultant) to the CNA's regarding skin breakdown prevention, turning and repositioning for residents with high risk for skin breakdown, reporting to nurse if resident refuses to turn/reposition, and reporting to nurse any alteration in skin integrity. - Record of training provided by the ADON to the Nursing staff and CNA's regarding filling out a Stop and Watch in the EMR, for nurses to check their dashboard multiple times a shift for updates from CNA's and updating the DON/ADON about any alerts triggered in the EMR. - Record of re-education provided by the ADON on the resident's Kardex, following it, and where to find it. - Record of the staff's Skin Assessment Post Test. - Record of Resident #3's assessment and orders from MD B. - Record of training provided by the Regional Nurse Consultant regarding nursing oversite and skin program monitoring, including: - Reviewing 24hr report - Reviewing for incidents of abuse/neglect - Monitoring/performing chart audits - Following up on areas of concern - Holding nurses accountable - Maintaining clear, concise, open communication with regional support staff - Monitoring UDA schedules, ensuring assessments are being completed, and intervening when they are not completed - Monitoring for trends - Utilizing root cause analysis and QA process - Continual/ongoing in-services and training of staff An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on [DATE] at 1:00pm. While the IJ was removed on 9/7/2023 at 2:10pm, the facility remained out of compliance at a severity of actual harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practical and physical, mental and psychosocial well-being for 1 of 8 residents (Residents #1) reviewed for behavioral health services, in that: The facility failed to ensure Resident #1 had behavioral health interventions in place to prevent physical and verbal aggression towards other residents and staff. Resident #1 was physically abusive towards other residents on separate occasions, once resulting in bodily injury. Staff were not aware of prevention measures for Resident #1's behaviors. An Immediate Jeopardy (IJ) was identified on 1/31/2020. While the IJ was lowered on 2/1/2020, 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 continued to train staff and monitor the effectiveness of the Plan of Removal. This failure could affect any resident with psychosocial needs, behaviors and mental health disorders and placed them at risk for increased anger and behaviors, inflicting harm on others, anxiety and decreased quality of life. Findings include: Resident #1 Record review of face sheet for Resident #1 revealed he was a [AGE] year-old male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's history and physical, dated 3/14/2019, revealed for [DIAGNOSES REDACTED].continue present medications and psychiatry see the patient. Record review of Resident #1's PASRR evaluation, dated 3/25/19, revealed resident was assessed for mental illness. Record review of Denial of PASRR Specialized Services, dated 3/25/19, revealed that Resident #1 was deemed ineligible for specialized services. Record review of current physician's orders [REDACTED]. disorder starting 3/29/2019. Record review revealed order for resident to have psychiatric evaluation and treatment for [REDACTED]. Record review of care plan for Resident #1, dated 1/15/19, revealed goals to reduce episodes of verbally aggressive behaviors, starting 7/23/2019, and socially inappropriate/disruptive behaviors by 50% with interventions to remove (resident) from public area when behavior is disruptive and unacceptable, refer to social services, monitor and document target behaviors, don't argue with resident, discuss options for appropriate channeling of anger, and administer medications as ordered by physician. To reduce episodes of physically aggressive behaviors, starting 11/14/19, by 50% with interventions including to remove from public area when behavior is disruptive and unacceptable, praise for demonstrating desired behaviors, talk in calm voice when behavior is disruptive, reinforce unacceptability of verbal abuse and refer to socials services for evaluation. Record review of nursing notes revealed Resident #1 was involved in multiple altercations with residents and staff. Nursing notes revealed the following: On 4/10/19, resident was seen trying to take another resident's money while sitting in front of the nurse's station. Resident stated he needed the money to buy cigarettes. On 4/12/19, target behaviors seen for [MEDICATION NAME] 0.5 mg, resident yelling during all shift. On 6/15/19, nurse was notified by second nurse that resident was arguing with a 2nd resident about a sitting spot at the dining room. Upon asking resident about the event. Resident states 'he was taking my spot and did not wanted to move' resident redirected for behavior at this point . Q15min monitoring initiated. On 6/28/19, resident observed going through roommate belongings . resident began to curse at staff as he was being removed from roommate area. On 6/29/19, during rounds resident observed in another resident room with their belongings in hand and wc. On 7/2/19, another resident notified (former DON) that resident had been his room and he went through his things and stole from him . spoke to Resident #1 and discussed this behavior. He stated he did go in the other resident's room and did take my box back. Discussed that it is wrong to take other's things. If he continues this behavior, he could have the police called as this is theft. He stated he would not do it any longer. On 8/30/19, resident brought to nurses station via (former DON). Resident observed in hallway arguing with another resident per 2 front (location) nurse. Per (former DON) the two residents were hitting each other. (Resident #1) stated he did not hit the other resident but she hit him on the head & it did not hurt . (Resident #1) observed stated 'she hit me & I'm going to get my lick back'. Note was written by LVN C. On 9/14/19, resident had an altercation with (Resident #4) in the hallway .As he was passing by (Resident #4), she claimed that the resident hit her in the face. On 9/15/19. RSC approached nurse with resident, stating resident hit (Resident #7) while sitting in the dining room. House supervisor was notified. Per resident the female resident hit him first in the head & he hit her back during a argument while passing .resident apologized to the female resident .Q15min monitoring in progress. Note was written by LVN C. On 9/18/19, (facility), (facility) and (facility) all denied resident admission. (former social worker) sent resident medical records to (multiple facilities) for discharge placement. On 9/23/19, resident .wheeled self to nurse's station to ask for cigarette right hand raise in attempt to strike resident saying that the resident touched his wc and hit him first. Resident redirected and assisted back to room . (Physician) called (Resident #1) to be transferred to (facility) . Note was written by LVN B. Record review of the MDS assessment for Resident #1, dated 11/19/2019, revealed a BIMS score of 12, indicating he had moderate cognitive impairment. He used a wheelchair for mobility. Behaviors were coded as a 1 for verbal behavior symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (hitting, scratching self, pacing, rummaging, public sexual acts, screaming, disruptive sounds etc.) indicating that behaviors occurred for 1 to 3 days of the week. Further record review of Resident #1's nursing notes revealed the following: On 11/19/19, resident is been having screaming/yelling/hitting staff and residents behaviors, able to be re-directed at times. Note was written by MDS Nurse. On 11/22/19, reported to nurse by staff that resident has been throwing items all over his room when he is upset. Resident reeducated about keeping room clutter free for his safety. Note was written by LVN [NAME] On 11/25/19, resident was seen swinging at another resident while the other resident involved was also swinging at him. This nurse then stood in between the two and removed residents from hallway and away from each other. Resident assess with no apparent injuries noted. No redness or swelling noted. On 11/27/19, resident attempted to stab other resident with a fork while in the dining room. Note was written by LVN [NAME] Record review of Resident #1's progress note, dated 11/27/2019, revealed for [DIAGNOSES REDACTED].continue present medications and psychiatry see the patient. Further record review of Resident #1's nursing notes revealed the following: On 11/30/19, resident was heard in dining room yelling and cursing to 2nd resident . spilled hot sauce was observed by resident's table and on the floor. According to 2nd person involved, resident attempted to throw the hot sauce at her without success. On 12/3/19, resident was constantly redirected at intervals without success this shift as he kept cursing and wanting to strike out at staff and residents . resident had an altercation with nurse at 7:45pm in from of the nurses station . Nurse held 7 pack case (of soda) close to her chest and without warning, resident use fist and hit nurse on her chest. In the process of the (sodas) burst open and spilled all over nurses station. Nurse was still trying to recover her composure and resident hit her again on the chest and then on the left arm. On 12/4/19, (Resident #1) attend activities by his choice he enjoys bingo, TV and he is a resident that don't get (along) very well with others, he (goes) into other resident room and take other people things. Note was written by the Activity Coordinator. Record review of Resident #1's physician's orders [REDACTED].#1 was referred to receive, .psychological services and (medication) management may provide psychiatric services. Further record review of Resident #1's nursing notes revealed the following: On 12/9/19, resident had an altercation with another resident (Resident #2) on the hallway and contact was made, head to toe assessment done no apparent injury noted, (patient) denies pain and discomfort at this time. On 12/13/19, resident and (Resident #2) got into an argument this morning as noted by staff in the dining room. (Resident #2) was propelling self in the dining room when he mistakenly touch (Resident #1) (wheelchair) and he immediately turned with a fork in his hand ready to after (sic) Resident #1 and the staff immediately intervened and no one was hurt. Note was written by RN [NAME] Record review of Resident #1's psychiatric initial assessment, dated 12/19/2019, revealed resident was referred for psychiatric evaluation with a psychiatric history of anxiety, dementia, depression and [MEDICAL CONDITION], and no previous psychiatric history. Assessment/Plan stated, increase [MEDICATION NAME] to 20mg po q daily and, [MEDICATION NAME] needs to be (discontinued) since there is no apparent [MEDICAL CONDITION]- will re-evaluate at next visit. Further record review of Resident #1's nursing notes revealed the following: On 1/3/20, resident seen purposely run (wheelchair) into other resident from 2 back's (wheelchair). (Note: 2 back is a location). Staff asked resident to stop but resident continued to push into other resident. Staff pulled resident away while resident cursed at staff. Resident kept screaming at other resident from 2 back even while staff was wheeling resident away. Also, on 1/3/20, Resident reported to nurse by RSC that she seen (sic) resident strike resident from 2 back in the face. Per RSC resident was passing by other resident in hallway and resident stuck hand out and striked (sic) resident from 2 back in the face, RSC immediately separated residents . new orders received to send resident out to (facility) for psych (evaluation). Both notes were written by LVN [NAME] On 1/15/20, resident hit another resident with a cup. Cup hit other resident on left shoulder. Resident blamed the resident he hit . guardian notified of resident's behavior. Note was written by DON. In an interview with CNA A on 1/15/20 at 10:35AM, she stated Resident #1 got combative because other residents antagonize him and make comments based on his history of hitting people. She said when residents provoke him, it led him to act out. She said she knew that Resident #1 specifically got into it with Resident #2. CNA A also stated that she had never been trained on abuse prevention with a focus on Resident #1 and his behaviors. She knew to move the resident out once there was a sign of an altercation. In an interview with Resident #2 on 1/15/20 at 10:44AM, Resident #2 stated Resident #1 got upset with him after he almost bumped into his wheelchair and he punched him in the face. Resident #2 stated he thought Resident #1 just talked a lot. He said he could not go by him or near him. He said Resident #1 has gotten into altercations with other residents before but he was not aware if he has hit anyone else. In an interview with Receptionist A on 1/15/20 at 11:45AM, she stated she was told to watch Resident #1 for today and she usually did not watch over residents. She said Resident #1 usually sat in the dining room with other residents without one-on-one supervision. In an interview with the Activity Coordinator on 1/15/20 at 1:10PM, the Activity Coordinator stated Resident #1 attended activities all the time. She said every day, he came to the dining hall and sat by himself or mingled with other residents in the presence of a direct care staff. She said, many times, she has had to redirect Resident #1 when he became unhappy. She said most of the times, Resident #1 was quiet and not combative but it would not hurt to increase supervision over the resident. In an interview with CNA C on 1/15/20 at 2:00PM, she stated on 1/3/20, she stated Resident #1 had the tendency to dig in other resident's personal belongings and throw stuff. She said when he gets caught, he curses staff out. She stated she believed Resident #1 needed one-on-one supervision. In an interview with LVN A on 1/29/20 at 12:45PM, she stated she was aware Resident #1 hit other residents. Other residents don't like (Resident #1) because he is disruptive and sometimes they instigate to rile him up. She said she saw Resident #1's actions as physical abuse because he was the only resident that actually hits (becomes physical). She said when an altercation occurs, the staff know to separate Resident #1 from the resident and report him to the DON. LVN A stated she was not aware of the interventions necessary to reduce the frequency of Resident #1's aggressive behaviors listed on the care plan. However, she redirected him and administered medication to the resident, as well as uses smoke breaks as incentive for resident to behave or calm aggression. In an interview with LVN B on 1/29/20 at 12:58PM, she stated she has worked with Resident #1 before. She said he was an angry resident that flicks people off, spits at people, swings at residents, both male and female, and once threw water on her during med pass. She said she saw his physical and verbal aggressions as abuse and sees the resident as a threat to other residents. She also stated she believed that Q15 minute monitoring was not enough and that one person needed to keep an eye on Resident #1. In an interview with LVN C on 1/29/20 at 1:14PM, she stated upon admission, Resident #1 curses, steals from residents and swings at both residents and staff. She said following resident's altercations, he would typically be placed on Q15 minute monitoring for 72 hours. She said she did not believe Q15 minute monitoring was enough because the resident moves quickly and can get into altercations as soon as you turn your back . She said she was aware that residents sometimes pick on him and it causes him to act out, but rarely does it happen that way. She said the resident usually tried to hit other residents that accidentally bump into his wheelchair. In an interview with Resident #1 on 1/29/20 at 4:20PM, the resident stated he disliked being on one-on-one supervision and would like to get off of it. He said he did not like the facility because they were too restrictive and there were too many rules. He also stated Resident #3 and Resident #8 sit by him because they want to be his friend. He said Resident #3 is his friend but not Resident #8 because Resident #8 liked to fight him and has tried to stab him with a fork. Resident #1 stated he hit Resident #4 in the past because she was getting on his nerves but he eventually apologized to her. He said he also hit Resident #7 in the past because she hit him first. In an interview with Receptionist B on 1/29/20 at 4:20PM, she said Resident #1 and Resident #8 were allowed to sit together sometimes because on their good days they have no issues. In an interview with the Psychiatric PA on 1/30/20 at 2:03PM, she stated that Resident #1's issues seems to be a personality issues because he is not aggressive everyday and he knows what he is doing. You can't treat personality. She said he struggles to communicate and that makes him become agitated. His behaviors were horrible also at the previous facility he resided in. No other facilities want him. Her initial move with Resident #1 was to adjust his medication regimen. Resident #1 has expressed to her concerns over medication regimen as well as made requests for specific medications. She stated she has not seen any real signs of [MEDICAL CONDITION] in the resident; he neither reports seeing things or hearing voices. She said because he does not elaborate so she was unable to see or assess his thought process. She believed the facility was unfit to manage his behaviors and that they have tried all they can to do so, but it hasn't worked. However, she said she believes that the facility should do a better job at preventing residents from provoking Resident #1 by keeping them separated. She said she tends to notice that the residents that he has gotten into altercations with are often the ones sitting close by him during the day. She also stated she questions the timing of the referral made to psychiatric services and thinks it may have been due to their lack of a social work staff. In an interview with RN A on 2/1/20 at 12:05PM, she said that if an altercation is witnessed, as the weekend charge nurse, she was to separate the residents, redirect them, monitor them, report to the DON, Administrator, physician and guardian and write an incident report. She believed that one-on-one supervision was necessary for Resident #1 due to repeated incidents although interventions in place following incidents usually called for Q15 minute monitoring for up to 72 hours. In an interview with the Administrator on 1/15/20 at 1:45PM, the Administrator stated facility staff monitor and watch for behaviors of Resident #1 during meals and generally keeps an eye on him and Resident #2. He said has tried to send out Resident #1 to a behavioral health facility after the incident on 1/3/20, but the facility sent him back. He said the resident's guardian also visited him to convince him to behave, but the resident returned to his normal self afterwards. The Administrator stated he felt that there was not much they could do. He said they could not give him more medication, and they could not restrict him. Most of the time, Resident #1 was fine but they do not know what sparks his behaviors. He said Resident #1 could not receive one-on-one supervision at this facility. He also stated he heard about what had happened between Resident #1 and Resident #3 in the morning but has not yet talked to Resident #3 about it. In an interview with the DON and Regional Nurse on 1/15/20 at 3:45PM, The DON stated when Resident #1 roamed around, she sometimes tells staff to redirect him in order to keep Resident #1 away from Resident #2, and he tended to gets irritated when other residents make remarks towards him. They have tried to have him sent out to a behavioral health facility but they brought him back, and she does not know what else they can do. The Regional Nurse stated she helped remove Resident #1 from the altercation he had this morning and interviewed him. When asked about sufficiency of current supervision for Resident #1, she stated Resident #1 was calm most of the times and at time of impulse supervision was increased. She ordered the receptionist to supervise him one-on-one following the incident and he has not had an outburst since. One-on-one supervision will cease whenever the receptionist leaves for the day at 4pm. In an interview with the Medical Director on 1/29/20 at 2:18PM, she identified herself as Resident #1's physician and stated she was aware of Resident #1's psychiatric problems and about his past incidents. She said he was verbally abusive to staff and has had altercations with specific residents. She said the altercations start usually in Resident #1's response to things such as being bumped in the hallway. She stated Resident #1 and Resident #2 used to be roommates and they had to separate them. She said she believes the facility has made efforts to remove Resident #1 but the transfer was unsuccessful. She was not sure why it took the time it did for Resident #1 to receive a psychiatry evaluation on 12/16/19, though it was ordered back in 9/18/19. She said until she referred the resident for an evaluation in September, the facility's staff were capable of managing his behaviors by redirecting, physically separating and observing residents involved. Although Resident #1's behaviors are abusive towards staff, she does not believe that Resident #1's behaviors can be considered abuse due to his cognitive deficits. In an interview with the Administrator on 1/29/20 at 3:36PM, he stated he saw any resident-to-resident altercations as abuse. He did think it was not necessary to send Resident #1 out the first time he witnessed him abuse Resident #2 on 12/9/19 because it was unpredictable. Who knew it was going to happen. He stated Q15 monitoring was the intervention that worked until the following incident on 1/3/20. He said Resident #1 was unpredictable and has no precursor behaviors to his aggression and, you can't predict human nature. He said he did not know what more they could do for this resident besides one-on-one supervision other than find another facility for him to be transferred to. He also does not know why the former staff at this facility waited for his psych evaluation. If it were him, he would ensure that the evaluation was performed by psychiatry services sooner. He also would have not accepted this resident into the facility considering his history of behaviors. In an interview with the DON on 1/29/20 at 3:54PM, she stated she was not sure that Resident #1's care plan needs revision because they have tried so many things for him already. She said the methods staff used included redirection, medication, removal from the situation, but other than that, she does not know what can be done to prevent behaviors. She said his behaviors are not constant, and they are unpredictable. She believes that his behaviors are his defense mechanism and that he does not intend to punch anyone. She said she believed that the Q15 monitoring was sufficient at the time it was ordered until the aggressive behavior he displayed on 12/9/19, when he successfully struck someone. Now the resident was on one-on-one supervision. She said she was not sure why psychiatry services were delayed until (MONTH) 2019, but at the same time, she did not believe they could meet his behavioral needs. She said that she got psychiatric services involved once she witnessed Resident #1 swing at another resident.She said she was looking forward to putting the resident in a program that will keep him out of the facility for longer periods of time. The Administrator, DON and Regional Nurse were notified of Immediate Jeopardy (IJ) on 1/31/2020 at 1:00 PM due to the above failures. A Plan of Removal was requested. The final plan of removal was accepted on 1/31/2020 at 5:47 PM after revisions were made. The Plan of Removal included the following: Plan of Removal The facility will ensure that resident will receive services to meet his behavioral and mental health needs, including ensuring nursing staff are trained and competent to address the resident's behaviors and physical aggression and to have interventions in place for the resident and the residents he is having altercations with. Resident will be one on one at all times, including meal service times, permanently as long as he remains in the facility or until he is deemed to no longer be a threat to other residents by Interdisciplinary Team, including the physician. One on one supervision will be provided by the facility CNAs between the times the resident is out of his bed in the morning, 8:00am, until he goes to bed in the evening, 9:00pm. All CNAs providing one-on-one supervision will be inserviced prior to beginning their assigned shifts starting on Friday, (MONTH) 31, 2020. All staff will inserviced prior to working a shift at the facility by the DON/Corporate Nurse/designee on this and on incident prevention methods including but not limited to ensuring he has a clear path for his wheelchair, does not sit near residents he has had altercations with, ensuring he has desired snacks beginning on Friday, (MONTH) 31,2020. The preventative interventions will be placed in the electronic health record for staff to view and sign each shift. Corporate Nurse/DON/designee will monitor at least 2 times daily for 8 weeks then randomly to ensure the one on one is in place per plan of care. All nursing and CNA staff will be interviewed to ensure they are aware of constant one on one, aware of preventive measures, and aware where to find the preventive measure in the health records. The resident will be taken to the (emergency room ) for medical clearance to be placed a the (facility) unit today, (MONTH) 31, 2020. The facility will continue to seek optional placement for this resident. Other resident affected by this resident's behavior will have a decrease in their own agitation as a result of removal of the resident from the facility. Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 10/05/19 at 1:40 PM. Facility staff from the morning, evening and night shift were inserviced by the Administrator and Regional Nurse. Record review of the training revealed that CNAs assigned to one-on-one supervision are to stay by resident's side, provide snacks, keep him away from resident's known to provoke him, ensure he is supervised from time he is out of bed until he goes to sleep at nights, and find another CNA as a replacement during break times. Record review of staff schedules revealed staff assigned to one-on-one duty with Resident #1. Observation of Resident #1 revealed resident being transferred out of the facility to an emergency room . Resident remained out of the facility through 2/1/2020. Observations of Resident #1 on 2/13/20 revealed he was on 1:1 supervision at the facility. Record review of staff schedules revealed staff assigned to one-on-one duty with Resident #1. Interview of 4 CNAs and 1 LVN on 2/1/20 and 2/13/20 revealed that they were trained on one-on-one supervision procedures, which include keeping resident by their side, keeping him separated from other troublesome residents, and giving resident snacks at his request. The Administrator, DON, and MDS Nurse were notified IJ was lowered on 2/1/2020 at 4:45PM. However, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern due to the facility continued to monitor the plan of correction for effectiveness.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse for 5 of 8 residents (Residents #2, #3, #4 , #7 and #8) reviewed for abuse in that: Resident #1, who had a history of [REDACTED].#2, #3, #4, #7 and #8, on separate occasions, once resulting in bodily injury. Residents #3 and #4 did not feel safe around Resident #1. An Immediate Jeopardy (IJ) was identified on 1/31/2020. While the IJ was lowered on 2/1/2020, 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 continued to train staff and monitor the effectiveness of the Plan of Removal. This failure could affect any resident in the facility and placed them at risk of fear, anxiety, injury and physical harm. Findings include: Resident #1 Record review of face sheet for Resident #1 revealed he was a [AGE] year-old male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of care plan for Resident #1 dated 1/15/2019, revealed goals to reduce episodes of verbally aggressive behaviors, starting 7/23/2019, and socially inappropriate/disruptive behaviors, starting 11/26/19, by 50% with interventions to remove (resident) from public area when behavior is disruptive and unacceptable, refer to social services, monitor and document target behaviors, don't argue with resident, discuss options for appropriate channeling of anger, and administer medications as ordered by physician. To reduce episodes of physically aggressive behaviors, starting 11/14/2019 by 50% with interventions including to remove from public area when behavior is disruptive and unacceptable, praise for demonstrating desired behaviors, talk in calm voice when behavior is disruptive, reinforce unacceptability of verbal abuse and refer to socials services for evaluation. Record review of nursing notes revealed Resident #1 was involved in multiple altercations with residents and staff. Nursing notes revealed the following: On 8/30/19, resident brought to nurses station via (former DON). Resident observed in hallway arguing with another resident per 2 front (location) nurse. Per (former DON) the two residents were hitting each other. (Resident #1) stated he did not hit the other resident but she hit him on the head & it did not hurt . (Resident #1) observed stated 'she hit me & I'm going to get my lick back'. Note was written by LVN C. On 9/14/19, resident had an altercation with (Resident #4) in the hallway .As he was passing by (Resident #4), she claimed that the resident hit her in the face. On 9/15/19. RSC approached nurse with resident, stating resident hit (Resident #7) while sitting in the dining room. House supervisor was notified. Per resident the female resident hit him first in the head & he hit her back during a argument while passing .resident apologized to the female resident .Q15min monitoring in progress. Note was written by LVN C. On 9/18/19, (facility), (facility) and (facility) all denied resident admission. (former social worker) sent resident medical records to (multiple facilities) for discharge placement. On 9/23/19, resident .wheeled self to nurse's station to ask for cigarette right hand raise in attempt to strike resident saying that the resident touched his wc and hit him first. Resident redirected and assisted back to room . (Physician) called (Resident #1) to be transferred to (facility) . Note was written by LVN B. Record review of physician's orders [REDACTED]. Record review of the MDS assessment for Resident #1, dated 11/19/2019, revealed a BIMS score of 12, indicating he had moderate cognitive impairment. He used a wheelchair for mobility. Behaviors were coded as a 1 for verbal behavior symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (hitting, scratching self, pacing, rummaging, public sexual acts, screaming, disruptive sounds etc.) indicating that behaviors occurred for 1 to 3 days of the week. Record review of nursing notes revealed Resident #1 was involved in multiple altercations with residents and staff. Nursing notes revealed the following: On 11/19/19, resident is been having screaming/yelling/hitting staff and residents behaviors, able to be re-directed at times. Note was written by MDS Nurse. On 11/22/19, reported to nurse by staff that resident has been throwing items all over his room when he is upset. Resident reeducated about keeping room clutter free for his safety. Note was written by LVN [NAME] On 11/25/19, resident was seen swinging at another resident while the other resident involved was also swinging at him. This nurse then stood in between the two and removed residents from hallway and away from each other. Resident assess with no apparent injuries noted. No redness or swelling noted. On 11/27/19, resident attempted to stab other resident with a fork while in the dining room. Note was written by LVN [NAME] On 11/30/19, resident was heard in dining room yelling and cursing to 2nd resident . spilled hot sauce was observed by resident's table and on the floor. According to 2nd person involved, resident attempted to throw the hot sauce at her without success. On 12/3/19, resident was constantly redirected at intervals without success this shift as he kept cursing and wanting to strike out at staff and residents . resident had an altercation with nurse at 7:45pm in from of the nurses station . Nurse held 7 pack case (of soda) close to her chest and without warning, resident use fist and hit nurse on her chest. In the process of the (sodas) burst open and spilled all over nurses station. Nurse was still trying to recover her composure and resident hit her again on the chest and then on the left arm. On 12/4/19, (Resident #1) attend activities by his choice he enjoys bingo, TV and he is a resident that don't get (along) very well with others, he (goes) into other resident room and take other people things. Note was written by the Activity Coordinator. On 12/9/19, resident had an altercation with another resident (Resident #2) on the hallway and contact was made, head to toe assessment done no apparent injury noted, (patient) denies pain and discomfort at this time. On 12/13/19, resident and (Resident #2) got into an argument this morning as noted by staff in the dining room. (Resident #2) was propelling self in the dining room when he mistakenly touch (Resident #1) (wheelchair) and he immediately turned with a fork in his hand ready to after (sic) Resident #1 and the staff immediately intervened and no one was hurt. Note was written by RN [NAME] On 1/3/20, resident seen purposely run (wheelchair) into other resident from 2 back's (wheelchair). (Note: 2 back is a location). Staff asked resident to stop but resident continued to push into other resident. Staff pulled resident away while resident cursed at staff. Resident kept screaming at other resident from 2 back even while staff was wheeling resident away. Also, on 1/3/20, Resident reported to nurse by RCS that she seen (sic) resident strike resident from 2 back in the face. Per RCS resident was passing by other resident in hallway and resident stuck hand out and striked (sic) resident from 2 back in the face, RSC immediately separated residents . new orders received to send resident out to (facility) for psych (evaluation). Both notes were written by LVN [NAME] On 1/15/20, resident hit another resident with a cup. Cup hit other resident on left shoulder. Resident blamed the resident he hit . guardian notified of resident's behavior. Note was written by DON. In an interview with Receptionist A on 1/15/20 at 11:45AM, she stated she was told to watch Resident #1 for today and she usually did not watch over residents. She said Resident #1 usually sat in the dining room with other residents without one-on-one supervision. In an interview with the Activity Coordinator on 1/15/20 at 1:10PM, the Activity Coordinator stated Resident #1 attended activities all the time. She said every day, he came to the dining hall and sat by himself or mingled with other residents in the presence of a direct care staff. She said, many times, she has had to redirect Resident #1 when he became unhappy. She said most of the times, Resident #1 was quiet and not combative but it would not hurt to increase supervision over the resident. In an interview with LVN A on 1/29/20 at 12:45PM, she stated she was aware Resident #1 hit other residents. Other residents don't like (Resident #1) because he is disruptive and sometimes they instigate to rile him up. She said she saw Resident #1's actions as physical abuse because he was the only resident that actually hits (becomes physical). She said when an altercation occurs, the staff know to separate Resident #1 from the resident and report him to the DON. LVN A stated she was not aware of the interventions necessary to reduce the frequency of Resident #1's aggressive behaviors listed on the care plan. However, she redirected him and administered medication to the resident, as well as uses smoke breaks as incentive for resident to behave or calm aggression. In an interview with LVN B on 1/29/20 at 12:58PM, she stated she has worked with Resident #1 before. She said he was an angry resident that flicks people off, spits at people, swings at residents, both male and female, and once threw water on her during med pass. She said she saw his physical and verbal aggressions as abuse and sees the resident as a threat to other residents. She also stated she believed that Q15 minute monitoring was not enough and that one person needed to keep an eye on Resident #1. In an interview with LVN C on 1/29/20 at 1:14PM, she stated upon admission, Resident #1 curses, steals from residents and swings at both residents and staff. She said following resident's altercations, he would typically be placed on Q15 minute monitoring for 72 hours. She said she did not believe Q15 minute monitoring was enough because the resident moves quickly and can get into altercations as soon as you turn your back . She said she was aware that residents sometimes pick on him and it causes him to act out, but rarely does it happen that way. She said the resident usually tried to hit other residents that accidentally bump into his wheelchair. In an interview with Resident #1 on 1/29/20 at 4:20PM, the resident stated he disliked being on one-on-one supervision and would like to get off of it. He said he did not like the facility because they were too restrictive and there were too many rules. He also stated Resident #3 and Resident #8 sit by him because they want to be his friend. He said Resident #3 is his friend but not Resident #8 because Resident #8 likes to fight him and has tried to stab him with a fork. Resident #1 stated he hit Resident #4 in the past because she was getting on his nerves but he eventually apologized to her. He said he also hit Resident #7 in the past because she hit him first. In an interview with Receptionist B on 1/29/20 at 4:20PM, she said Resident #1 and Resident #8 were allowed to sit together sometimes because on their good days they have no issues. In an interview with RN A on 2/1/20 at 12:05PM, she revealed that if an altercation is witnessed, as the weekend charge nurse, she was to separate the residents, redirect them, monitor them, report to the DON, Administrator, physician and guardian and write an incident report. She believes that one-on-one supervision was necessary for Resident #1 due to repeated incidents although interventions in place following incidents usually on called for Q15 minute monitoring for up to 72 hours. Resident #2 Record review of face sheet for Resident #2 revealed a [AGE] year-old male, admitted into the facility on [DATE], diagnosed with [REDACTED]. Record review of MDS for Resident #2, dated 10/16/2019, revealed a BIMS score of 13, indicating no cognitive impairment. Record review of care plan for Resident #2, revealed goal to reduce physically aggressive behaviors by 50% with interventions to remove (resident) from public area when behavior is disruptive and unacceptable and identify causes for behavior and reduce factors that may provoke aggressive behaviors. Record review of Resident #2's resident incident report, dated 11/13/19 at 8:45PM, it revealed Resident #2 made contact with (Resident #1). The narrative noted, (CNA) walking down the hallway saw resident and resident in (room) 235 hitting each other with their fist. (CNA) separated both residents. No witness observed what started the altercation. There were no apparent injuries and immediate actions taken were monitoring every 15 minutes for 3 days each shift and educating on importance of using a more constructive approach instead of hitting or fighting. The Medical Director and family member were notified. Record review of facility investigation report, dated 11/25/19, revealed, (Resident #2) hit (Resident #1) and (Resident #1) hit (Resident #2) back in the hallway near the nursing station. No injuries to either resident and neither showed any adverse effect. Both residents were assessed by the Charge Nurse . The provider response to the incident included separation of two residents by staff, placement of Resident #2 on Q15 monitoring rounds, and a staff in-service on abuse and neglect. Record review of facility investigation report, dated 12/16/19, revealed on 12/9/19, (Resident #2) was propelling down the hallway and was passing (Resident #1) when (Resident #1) started throwing punches at (Resident #2), who defended himself and (Resident #2) received a bloody nose and was noted with an abrasion to the left side of his face. The provider response to the incident included separation of two residents and placement on Q15 monitoring to ensure no further incidents occur. Record review of facility investigation report, dated 1/8/20, revealed on 1/3/20, (Resident #2) was passing by (Resident #1) in the hallway on the way to his room when (Resident #1) reached out and slapped (Resident #2) across the face. The provider response to incident included separation of residents and placement on Q15 monitoring. It was also noted that Resident #1 was sent out of the facility for a behavioral evaluation and returned two days later with no changes to medication. In an interview with Resident #2 on 1/15/20 at 10:44AM, Resident #2 stated Resident #1 got upset with him after he almost bumped into his wheelchair and he punched him in the face. Resident #2 stated he thought Resident #1 just talked a lot. He said he could not go by him or near him. He said Resident #1 has gotten into altercations with other residents before but he was not aware if he had hit anyone else. In an interview with CNA A on 1/15/20 at 10:35AM, she stated Resident #1 got combative because other residents antagonize him and make comments based on his history of hitting people. She said when residents provoke him, it led him to act out. She said she knew that Resident #1 specifically got into it with Resident #2. CNA A also stated that she had never been trained on abuse prevention with a focus on Resident #1 and his behaviors. She knew to move the resident out once there was a sign of an altercation. In an interview with CNA C on 1/15/20 at 2:00PM, she stated on 1/3/20, she was pushing Resident #2 down the hall towards the dining room. Resident #1, who was seated by the nurses station, reached out his arm and hit Resident #2. She reported it to the Administrator, and wrote a statement about the case. She said Resident #2 has been the only resident that Resident #1 has physically fought. She stated Resident #1 also has the tendency to dig in other resident's personal belongings and throw stuff. She said when he gets caught, he curses staff out. She stated she believed Resident #1 needed one-on-one supervision. In an interview with CNA [NAME] on 1/30/20, she revealed that she witnessed the fight between Resident #1 and Resident #2. She said they were throwing punches at each other and Resident #1 almost hit him with a wet floor sign too, but she helped break up the fight before he had the chance to. She said Resident #2 ended up with a bloody nose and they had to be kept separate from each other. She said she often saw Resident #2 try to instigate a fight by coming to sit next to Resident #1. She said she tried to redirect Resident #2 away from Resident #1 when that happens. She said as a CNA, she gets updates on matters, such as changes of resident care and updates on resident's moods or involvement in incidents, by word of mouth from unit nurses or other CNAs during her shift. She said she can only get point of care information including, showers, toileting and changing from the computer kiosk she worked on. Resident #3 Record review of face sheet for Resident #3 revealed a [AGE] year-old male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of MDS for Resident #3, dated 10/16/2019, revealed a BIMS score of 15, indicating no cognitive impairment. Record review of care plan, dated 1/15/2020, for Resident #3, revealed goal to reduce episodes of refusing/aggressive (hitting staff, cursing and yelling at staff) behaviors, starting 7/17/2019, by 50% with interventions to identify causes for behavior and reduce factors that may provoke aggressive behaviors and monitor and document target behaviors. Observations of Resident #1 and Resident #3 in dining room area on 1/15/20 at 10:00AM, revealed both residents sitting at the same dining table across from each other in a conversation exchanging curse words. Resident #1 was observed raising his middle finger, Resident #3 then knocked his empty coffee cup on the floor, and Resident #1 threw his empty coffee cup at Resident #3. Resident #3 then left the dining table as a nurse was observed to come in and take Resident #1 away from the dining area. CNA B was present in dining room during altercation. In an interview with Resident #3 on 1/15/20 at 10:20AM, Resident #3 stated that Resident #1 was a bad influence, and he cursed at people, flicks people off, and fights with the 2-10p nurse. He said Resident #1 threw a cup at his shoulder earlier in the dining room and the staff did not do anything about it. He said Resident #1 took things out of residents' rooms and throws it out into the hallway. He said once when had complained about Resident #1's anger problem, he noticed afterward that Resident #1 was out of the facility for 3 days, but he came back. Resident #3 said that he did not feel safe because he never knew what the resident would throw at him and he was physically abusive. In an interview with CNA B on 1/15/20 at 12:45PM, she stated she worked with Resident #1. She said Resident #1's behavior varies, and he got agitated and sometimes lashed out at some employees and residents. She stated, for example, if a resident was talking too much and requested for that resident to be moved, if the resident was not moved he would start to lash out at them. She said she was present to see the altercation Resident #1 had with Resident #3. She said she believed the altercation started because Resident #1 disliked residents sitting in his preferred seat. She said he needed behavior supervision, but not all the time. She said Resident #1 had his good days and he lashed out on average of twice a week. CNA B said she usually tried to de-escalate the situation when she notices changes in his behavior. She said overall, it was difficult to predict when the resident was going to lash out. She said more supervision for Resident #1 would be more helpful. Resident #4 Record review of face sheet for Resident #4 revealed a [AGE] year-old female, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's nursing progress note revealed the following: on 9/14/19, resident had an altercation with (Resident #4) in the hallway .As he was passing by (Resident #4), she claimed that the resident hit her in the face. Record review of MDS assessment for Resident #4, dated 11/4/2019, revealed a BIMS score of 4, indicating she had severe cognitive impairment. In an interview with Resident #4 on 1/15/20, the resident stated she did not feel safe around Resident #1 and could not trust him. She said he has cussed her out and a staff had to take him away. She said she did not like that Resident #1 was allowed to eat in the dining room with everyone else. Resident #8 Record review of face sheet for Resident #8 revealed a [AGE] year-old male, admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #8's resident incident report, dated 9/15/19, revealed Resident #1 made contact with Resident #8. Incident was non-witnessed. Immediate actions were to separate residents and only a family member was notified. Record review of MDS assessment for Resident #8, dated, 11/7/2019, revealed a BIMS score of 3, indicating she had severe cognitive impairment. Record review of care plan, dated 1/31/2020, for Resident #8, revealed goal to behaviors associated with [MEDICAL CONDITION], mood affective disorder, conduct disorder, delusional disorder, adjustment disorder, impulse disorder, emotional liability, unspecified mental disorder, starting 10/28/2019, will not interfere with others, with the intervention to assess hallucinations, report onset or increase in behaviors to physician, provide honest consistent feedback in non-threatening manner and monitor and document target behaviors. Observations on 1/29/20 at 11:40am, of Resident #1 and Resident #8 sitting at same dining table, revealed residents arguing and cursing at each other while Resident #8 raised a fork and pointed it towards Resident #1's face as residents continue cursing. Resident #1 was removed by from table by LVN A and relocated to different table to finish eating his lunch. In an interview with the Administrator on 1/15/20 at 1:45PM, the Administrator stated facility staff monitor and watch for behaviors of Resident #1 during meals and generally keeps an eye on him and Resident #2. He said has tried to send out Resident #1 to a behavioral health facility after the incident on 1/3/20, but the facility sent him back. He said the resident's guardian also visited him to convince him to behave, but the resident returned to his normal self afterwards. The Administrator stated he felt that there was not much they could do. He said they could not give him more medication, and they could not restrict him. Most of the time, Resident #1 was fine but they do not know what sparks his behaviors. He said Resident #1 could not receive one-on-one supervision at this facility. He also stated he heard about what had happened between Resident #1 and Resident #3 in the morning but has not yet talked to Resident #3 about it. In an interview with the Administrator on 1/29/20 at 3:36PM, he stated he saw any resident-to-resident altercations as abuse. He did think it was not necessary to send Resident #1 out the first time he witnessed him abuse Resident #2 on 12/9/19 because it was unpredictable. Who knew it was going to happen. He stated Q15 monitoring was the intervention that worked until the following incident on 1/3/20. He said Resident #1 was unpredictable and has no precursor behaviors to his aggression and, you can't predict human nature. He said he did not know what more they could do for this resident besides one-on-one supervision other than find another facility for him to be transferred to. In an interview with the DON and Regional Nurse on 1/15/20 at 3:45PM, The DON stated when Resident #1 roamed around, she sometimes tells staff to redirect him in order to keep Resident #1 away from Resident #2, and he tended to get irritated when other residents make remarks towards him. They have tried to have him sent out to a behavioral health facility but they brought him back, and she does not know what else they can do. The Regional Nurse stated she helped remove Resident #1 from the altercation he had this morning and interviewed him. When asked about sufficiency of current supervision for Resident #1, she stated Resident #1 was calm most of the times and at time of impulse supervision was increased. She ordered the receptionist to supervise him one-on-one following the incident and he has not had an outburst since. One-on-one supervision will cease whenever the receptionist leaves for the day at 4pm. In an interview with the DON on 1/29/20 at 3:54PM, she stated she was not sure that Resident #1's care plan needs revision because they have tried so many things for him already. She said the methods staff used included redirection, medication, removal from the situation, but other than that, she does not know what can be done to prevent behaviors. She said his behaviors are not constant, and they are unpredictable. She believes that his behaviors are his defense mechanism and that he does not intend to punch anyone. She said she believed that the Q15 monitoring was sufficient at the time it was ordered until the aggressive behavior he displayed on 12/9/19, when he successfully struck someone. Now the resident was on one-on-one supervision. In an interview with the Medical Director on 1/29/20 at 2:18PM, she identified herself as Resident #1's physician and stated she was aware of Resident #1's psychiatric problems and about his past incidents. She said he was verbally abusive to staff and has had altercations with specific residents. She said the altercations start usually in Resident #1's response to things such as being bumped in the hallway. She stated Resident #1 and Resident #2 used to be roommates and they had to separate them. She said she believes the facility has made efforts to remove Resident #1 but the transfer was unsuccessful. She was not sure why it took the time it did for Resident #1 to receive a psychiatry evaluation on 12/16/19, though it was ordered back in 9/18/19. She said until she referred the resident for an evaluation in September, the facility's staff were capable of managing his behaviors by redirecting, physically separating and observing residents involved. Although Resident #1's behaviors are abusive towards staff, she does not believe that Resident #1's behaviors can be considered abuse due to his cognitive deficits. Record review of the facility's Accident/Incident Reports policy, revealed for resident-to-resident incidents, 1) .staff should quickly intervene by taking residents to separate areas at least until the immediate situation is resolved and provide any immediate care needed. 2) The Administrator or Director of Nursing will be notified as soon as is practical and will make the necessary decisions to help ensure all residents are safe .4)If the resident do not present a danger to themselves or each other, they may both be allowed to return to their rooms and regular routines. If appropriate, the charge nurse should assign staff to monitor the residents. For corrective action, the charge nurse shall take any immediate action necessary to prevent further accidents or injuries, such as assigning an employee to monitor residents . Record Review of the facility's Abuse Prevention and Investigation policy read in part, The facility defines resident abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical Abuse includes hitting, slapping, pinching and kicking. Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Misappropriation of Resident Property means the deliberate misplacement, exploitation or wrongful, temporary or permanent use of a resident's belongings or money without resident's consent. The facility will monitor for and identify the incidents and/or patterns of incidents, as well as specific resident signs, symptoms, and outcomes that may indicate the need for further investigation. All employees are required to report any observed, known, or suspected instance of resident abuse or neglect to their supervisors, the Administrator or the Director of Nursing. The Administrator, DON and Regional Nurse were notified of Immediate Jeopardy (IJ) on 1/31/2020 at 1:00 PM due to the above failures. A Plan of Removal was requested. The final plan of removal was accepted on 1/31/2020 at 5:47 PM after revisions were made. The Plan of Removal included the following: Plan of Removal The facility will ensure that resident will receive services to meet his behavioral and mental health needs, including ensuring nursing staff are trained and competent to address the resident's behaviors and physical aggression and to have interventions in place for the resident and the residents he is having altercations with. Resident will be one on one at all times, including meal service times, permanently as long as he remains in the facility or until he is deemed to no longer be a threat to other residents by Interdisciplinary Team, including the physician. One on one supervision will be provided by the facility CNAs between the times the resident is out of his bed in the morning, 8:00am, until he goes to bed in the evening, 9:00pm. All CNAs providing one-on-one supervision will be inserviced prior to beginning their assigned shifts starting on Friday, (MONTH) 31, 2020. All staff will inserviced prior to working a shift at the facility by the DON/Corporate Nurse/designee on this and on incident prevention methods including but not limited to ensuring he has a clear path for his wheelchair, does not sit near residents he has had altercations with, ensuring he has desired snacks beginning on Friday, (MONTH) 31,2020. The preventative interventions will be placed in the electronic health record for staff to view and sign each shift. Corporate Nurse/DON/designee will monitor at least 2 times daily for 8 weeks then randomly to ensure the one on one is in place per plan of care. All nursing and CNA staff will be interviewed to ensure they are aware of constant one on one, aware of preventive measures, and aware where to find the preventive measure in the health records. The resident will be taken to the (emergency room ) for medical clearance to be placed a the (facility) unit today, (MONTH) 31, 2020. The facility will continue to seek optional placement for this resident. Other resident affected by this resident's behavior will have a decrease in their own agitation as a result of removal of the resident from the facility. Monitoring of Plan of Removal Monitoring of the facility plan of removal began on 10/05/19 at 1:40 PM. Facility staff from the morning, evening and night shift were inserviced by t

Based on observation, interview and record review; the facility failed to implement a comprehensive person-centered care plan for 1 of 6 residents reviewed for transfers. (Resident #1). Certified Nursing Assistant (CNA) B failed to transfer Resident #1 using two staff members as per her plan of care. This resulted in a hairline fracture of Resident #1's right knee. These failures affected 1 resident and placed 18 residents who were dependent on staff for transfers at risk for falls, skin tears and fractures Findings include: Resident #1 Record review of Resident #1 ' s face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Care Plan dated 3/1/2017 revealed Resident #1 required Mechanical Lift transfers with two staff assist. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment, she required total assistance with two staff on transfers, she was not steady with surface to surface transfers and only able to stabilize with staff assistance and she had impairments on her bilateral lower extremities Record review of nursing note dated 4/20/17 read, Resident c/o pain to the lower right leg. Resident was assessed for injuries. Slight swelling noted. An x-ray of the lower right leg was ordered. Resident leg was elevated, will continue to monitor for any changes in condition. Record review of nursing note dated 4/20/17 read, During shower RCS (resident care specialist) stated resident leg became stuck on shower chair and right knee bumped against GC (gerichair). No bruising or swelling noted. ROM (range of motion) WNL (within normal limits). No complaints of pain was noted. Record review of nursing note dated 4/21/17 read in part, Tib fib x-ray conclusion: normal right tibia and fibula . Record review of nursing note dated 4/21/17 read in part, Received call from MD. New order to repeat right knee x-ray . new order to place knee brace or immobilizer to right knee . Record review of the Radiology Report dated 4/24/17 read in part, Examination: Knee . Right - Results: There is a subtle recent hairline fracture involving right posterior distal femur with no displacement. The joint shows no dislocation. There is associated joint effusion. Conclusion: Recent right knee fracture . In an interview on 5/9/2017 at 11:15 AM with CNA A, she stated when transferring a resident who required a mechanical lift, you were to use two staff members at all times. She stated Resident #1 was a mechanical lift transfer, dependent on two staff members. Observations on 5/9/2017 at 2:15 PM revealed Resident #1 lying in bed, with a pillow under her right knee and a brace on her right knee. In an interview on 5/9/2017 at 2:15PM with Resident #1, she stated she was going to get a shower and CNA B transferred her from the bed to the shower chair by herself. She stated once she was in the shower and was finished, CNA B attempted to transfer Resident #1 to her wheelchair, but her legs were stuck under the bars of the shower chair. Resident #1 stated she screamed when CNA B tried to transfer her because her leg was twisted and informed the CNA that her leg was stuck. Resident #1 stated CNA B got her legs from being stuck and then transferred her to the wheelchair by herself. In an interview on 5/9/2017 at 3PM with the Director of Nursing (DON), she stated the facility had in-serviced staff on how to transfer residents and she has placed little stick figures on the doors, indicating the number of people needed to transfer a resident. The DON stated the staff has been made aware of the importance of using the proper amount of staff for a transfer. A phone interview attempt was made on 5/9/2017 at 3:15PM to interview CNA B, but was unsuccessful. The facility's CMS 672 form listed 19 residents who were dependent on two staff members for transfers.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for one of six residents (Resident #1) reviewed for accidents. Certified Nursing Assistant (CNA) B failed to transfer Resident #1 using two staff members as per her plan of care. This resulted in a hairline fracture of Resident #1's right knee. These failures affected 1 resident and placed 18 residents who were dependent on staff for transfers at risk for falls, skin tears and fractures Findings include: Resident #1 Record review of Resident #1 ' s face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Care Plan dated 3/1/2017 revealed Resident #1 required Mechanical Lift transfers with two staff assist. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) of 11 which indicated moderate cognitive impairment, she required total assistance with two staff on transfers, she was not steady with surface to surface transfers and only able to stabilize with staff assistance and she had impairments on her bilateral lower extremities Record review of nursing note dated 4/20/17 read, Resident c/o pain to the lower right leg. Resident was assessed for injuries. Slight swelling noted. An x-ray of the lower right leg was ordered. Resident leg was elevated, will continue to monitor for any changes in condition. Record review of nursing note dated 4/20/17 read, During shower RCS (resident care specialist) stated resident leg became stuck on shower chair and right knee bumped against GC (gerichair). No bruising or swelling noted. ROM (range of motion) WNL (within normal limits). No complaints of pain was noted. Record review of nursing note dated 4/21/17 read in part, Tib fib x-ray conclusion: normal right tibia and fibula . Record review of nursing note dated 4/21/17 read in part, Received call from MD. New order to repeat right knee x-ray . new order to place knee brace or immobilizer to right knee . Record review of the Radiology Report dated 4/24/17 read in part, Examination: Knee . Right - Results: There is a subtle recent hairline fracture involving right posterior distal femur with no displacement. The joint shows no dislocation. There is associated joint effusion. Conclusion: Recent right knee fracture . In an interview on 5/9/2017 at 11:15 AM with CNA A, she stated when transferring a resident who required a mechanical lift, you were to use two staff members at all times. She stated Resident #1 was a mechanical lift transfer, dependent on two staff members. Observations on 5/9/2017 at 2:15 PM revealed Resident #1 lying in bed, with a pillow under her right knee and a brace on her right knee. In an interview on 5/9/2017 at 2:15PM with Resident #1, she stated she was going to get a shower and CNA B transferred her from the bed to the shower chair by herself. She stated once she was in the shower and was finished, CNA B attempted to transfer Resident #1 to her wheelchair, but her legs were stuck under the bars of the shower chair. Resident #1 stated she screamed when CNA B tried to transfer her because her leg was twisted and informed the CNA that her leg was stuck. Resident #1 stated CNA B got her legs from being stuck and then transferred her to the wheelchair by herself. In an interview on 5/9/2017 at 3PM with the Director of Nursing (DON), she stated the facility had in-serviced staff on how to transfer residents and she has placed little stick figures on the doors, indicating the number of people needed to transfer a resident. The DON stated the staff has been made aware of the importance of using the proper amount of staff for a transfer. A phone interview attempt was made on 5/9/2017 at 3:15PM to interview CNA B, but was unsuccessful. The facility's CMS 672 form listed 19 residents who were dependent on two staff members for transfers.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided consistent to the plan of care for one of 18 residents reviewed for pain management. (Resident #10) - The facility failed to provide pain relief for Resident #10 when she experienced severe pain during a transfer. - The facility failed to provide pain relief for Resident #10 when she experienced pain during Stage 4 sacral pressure sore treatment. -Pain management was not provided for Resident #10 per physician orders. This failure affected one resident and placed 43 addition residents that received pain management at risk of unresolved pain, discomfort and decreased quality of life. Findings included: Resident # 10 Record review of consolidated physician's orders [REDACTED].#10 was [AGE] years old, readmitted [DATE] with an original admitted [DATE]. Resident #10 had [DIAGNOSES REDACTED]. Record review of the most recent two MDSs' dated 2/19/2017 and 3/16/17 revealed Resident #10 had moderate cognitive impairment, usually made herself understood and sometimes understood others. She required extensive to total dependence with all of her ADLs. Her MDS documented she was on scheduled pain medication, did not receive as needed pain medication, but indicated she should receive a pain assessment interview. The MDS indicated she did not have pain during this assessment. All other pain areas were marked as blank (including facial expressions, vocal complaints of pain, and protective movements). Resident #10's skin assessment indicated she had a Stage 4 pressure sore upon admission. Record review of care plan updated 3/1/17 indicated Resident #10 was at risk for occasional pain related to pressure ulcers and generalized pain. The intervention included: Administer [MEDICATION NAME] 5/325 mg pain medication prior to treatments and therapy, if indicated; .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules, and resident satisfaction with results, impact on functional ability and impact on cognition; Hospice as indicated (initiated 12/23/16); identify and record previous pain history and management; Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care; Observe/document for side effects of pain medication .Report occurrences to the physician. Record review Resident #10 of the physician order [REDACTED]. Further review of the form revealed the following orders: [MEDICATION NAME] Tablet 7.5-325 Mg. dated 01/12/17 to give 1 tablet by mouth every 6 hours for pain. Order for hospice consult ordered 03/01/17 was discontinued on 03/30/17. New order for hospice consult dated 04/07/17. [MEDICATION NAME] (used to treat chronic pain and neruropathic pain) order dated 04/06/17 [MEDICATION NAME] Capsule 100 mg as needed for prn pain bid, and [MEDICATION NAME] Capsule 100 mg 1 capsule by mouth at bedtime for pain. Record review of MAR indicated [REDACTED]&3) in which pain levels were listed at 4 (on a scale of 1 to 10 with 10 being the worst pain). There was no subsequent documentation in medical record to note this and/or any additional follow up needs. There was one day April 14 (shift 1)-pain level was noted at 2. Then on April 14 (shift 3&4) pain level increased to 4. There were no progress notes in medical record to indicate what was done as a follow-up. Record review of Resident #10's telephone physician order [REDACTED].D. documented: give [MEDICATION NAME] 100 mg q HS, and then bid prn. Interview with ADON at 10:47 am, 4/19/17 she stated the medication review report dated 4/18/17 shows [MEDICATION NAME] Capsule 100 mg give 1 capsule by mouth as needed for prn pain bid dated 4/6/17. Record review of Resident # 10's MAR for April 2017 revealed [MEDICATION NAME] was administered at night (HS) on April 6 - April 9th, then April 12-17. Further review of the MAR indicated [REDACTED] 04/06/2017-04/18/2017 Further review of the same MAR indicated [REDACTED]. Observation of LVN G and CNA H perform a mechanical lift transfer on Resident # 10 on 4/17/17 at 10:45 am. Resident # 10 was yelling the entire time my butt, my butt, hurts. Resident # 10 proceeded to bite down on her blanket throughout the transfer. No additional pain meds were administered at that time. Interview on 4/17/17 immediately after the transfer observation, LVN G stated she was the MDS nurse and knew nothing about Resident #10. LVN G stated she was just asked to come help out from another hall. Interview on 4/17/17 at 11 am LVN E and MA-C were asked if they knew what levels of pain Resident #10 had been experiencing. Both LVN E and MA-C stated they were not sure as to what was being done in this area. LVN E stated she was new to the floor and had not worked with Resident #10 that much. She was unaware what her pain regimen was at the time. MA-C stated she basically followed the physician's orders [REDACTED]. Review of Resident #10's telephone orders revealed Hospice was not consulted until 4/17/17 by the DON. Record review revealed Resident 10's skin assessments revealed sacral wound has had minimal improvements over the past two months. Some length improvements; but possible increased depth noted. On 3/15 The wound care eval shows a length of 5.7, width of 4.6, Depth of 1.0 On 4/6 17 the wound was L 6.2, W 4.1, Depth .5 On 4/12/17 Wound M.D from advantage wound stated measurements were at 5.4 L, 4.6 Width, and 1.4 cm Depth. Bed 30%,slough, 40% granulation, and 30% epi mod amt of ss drainage noted. On 4/13, wound assessment, no documentation on sizing L,W, or depth. Observation and interviews during wound care for Resident # 10 on 4/18/17 at 1:45 pm revealed the ADON was performing the wound care, and asked Resident # 10, prior to the procedure, if she was having any pain. Resident # 10 stated she was having a little pain, but to go ahead with the wound care. At that time, the ADON stated Resident # 10 was on scheduled pain medication, and she had already taken her morning dose. Resident # 10 was complaining of pain when the ADON touched her wound, but again she said to go ahead, get it over with. Surveyor asked if Resident # 10 could have anything for breakthrough pain. The ADON called the physician to get a one-time order for [MEDICATION NAME] 7.5 mg for pain. The [MEDICATION NAME] 7.5 mg was given to Resident # 10 at 2:05 pm following surveyor intervention. Interview and observation on 4/19/17 at 10:30 am with Resident #10, she stated :my butt and back aches; it continuously aches; can you tell the nurse to give me a shot?. Her facial expression was grimacing with pain. Interview with MA-C on 4/19/17 at 10:49 am she said she had her [MEDICATION NAME] 7.5 this am at 6:00 am according to the physician's orders [REDACTED]. Interview and record review with the ADON on 4/19/17 at 11:30 am stated she was glad hospice was picking up the patient so now Resident #10's pain would be controlled better. Reviewed pain management observation sheets and documentation with ADON, who stated there should be documentation in the medical record progress notes every time pain medicine was given and its effectiveness or ineffective, however there was none. Upon survey exit 4/19/17 consent forms for hospice still had not been signed. Record review of the facility Pain Management Policy dated 2012 revealed in part: Practice Guidelines state: (5) Each resident identified for pain will have a Pain Management Care Plan. The Care Plan will have individualized interventions related to that resident's individual control of pain management. The Care Plan should include both pharmacological and non-pharmacological pain management interventions. RCS Assignment Sheet/Care Kardex updated if appropriate. (6) The Licensed Nurse will implement a Medication Administration Record [REDACTED] (10 The staff will implement the Care Plan, monitor the resident, and administer therapeutic interventions of pain, if ordered. Based on the Facility's CMS 672 dated 4/17/17 44 residents were receiving Pain Management

Based on observation, interview, and record review, the facility failed to ensure they had evidence that all alleged violations involving mistreatment, neglect or abuse, including injuries of unknown source were thoroughly investigated and the results of all investigations were reported to State Agency within 5 working days of the incident for 4 of 9 residents (CR#1, Resident #3, Resident #4, and Resident #5) reviewed for neglect as evidenced by: The facility failed to thoroughly investigate when CR#1 made an attempt to commit suicide. The facility failed to investigate and report to the state agency when Resident #3 had a fractured hand from an unknown source. The facility failed to investigate and report to the state agency when Resident #4 had a fractured rib from an unknown source. The facility failed to investigate and report to the state agency Resident #5 ' s, who resided in the locked unit, fractured finger. An Immediate Jeopardy (IJ) was identified on 11/15/2016. While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected 4 residents placed 91 residents at risk for abuse, neglect, harm or death. Findings included: CR#1 Record review of CR#1's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR#1 was discharged from the facility on 11/09/16 to a psychiatric hospital due to suicide attempt. Record review of CR#1 MDS dated [DATE] revealed he had a BIMS score of 2 which indicated severe cognitive impairment. Record review of CR #1's care plan dated 10/22/16 revealed he was at risk for elopement and wandering. Record review of CR #1's care plan dated 11/9/16 revealed he had a behavior problem related to dementia with behavioral disturbance and Alzheimer's. Record review of CR#1's Incident/Accident Report dated 11/09/16 revealed CR#1 had a made a Suicide Attempt at 4:30 PM, in his bedroom, with no apparent injury noted. In an interview on 11/13/16 at 11:06 AM CNA A stated she was doing rounds when she went into CR#1's room. She called out his name but he did not answer. When she went into the room Resident #1 had the bed alarm cord tied around his neck lying on bed with his neck upward. Resident stated he wanted to die. In an interview on 11/13/16 at 11:13 AM LVN B stated when she was called into the room by CNA A CR#1 had the bed alarm cord wrapped around his neck. CR#1's stated he wanted to die. He was not happy and wanted to go home, he also talked about his ex-wife. CR #1 was sent to the hospital the same day as the incident. In an interview on 11/14/16 at 1:50 PM the Administrator stated the facility did not see any reason to report the suicide attempt to the state agency because they investigated the matter and did not see any neglect and staff intervened as they were supposed to do. The resident did not have any injuries. Resident #3 Record review of Resident #3 ' s face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. Resident #3 required limited assistance with one person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #3 ' s Care Plans dated 10/02/2016 revealed care plans for: -ADLs: self-care deficit related to confusion/forgetfulness. Interventions included: The resident required extensive assist by 1 staff member for toileting and transfers. -Limited mobility related to weakness. Interventions included: The resident was able to ambulate with supervision/ cueing. Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 10:35 am revealed a CNA reported that resident #3 was mumbling look at my hand while sitting at the dining table. Upon assessment, her right hand was noted with [MEDICAL CONDITION] and Resident #3 was holding her right hand in a semi-closed position. Her right wrist had a quarter sized blue bruise and Resident #3 could not open her hand. Resident #3 was medicated with Tylenol 650mg for facial grimacing and guarding of right hand. Resident #3 was alert but disoriented. The Physician was notified and an x-ray was ordered. Record review of Resident #3 ' s x-ray report dated 10/30/2016 read: -Findings: [MEDICAL CONDITION] radius was seen with dorsal displacement and angulation. The soft tissues were swollen. Conclusion: Acute [MEDICAL CONDITION] radius (a [MEDICAL CONDITION] bone in the arm on the end next to the wrist.) Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 1:40 pm revealed the nurse received an order to send Resident #3 to hospital for evaluation of fracture. Record review of x-ray report from hospital dated 10/30/2016 revealed: -Impression: Comminuted fracture (bone was broken into more than two pieces) of the distal radius with dorsal displacement. Requested Incident/Accident report on 11/14/2016 at 1:00 pm along with Investigation Report from Unit Manager regarding Resident #3 ' s right hand fracture. Unit Manager said she would look for the Incident/Accident report but was not sure that an Investigation report was completed. On 11/14/2016 at 3:00 pm, Unit Manager was able to produce page 1 of an Incident/Accident Report. Unit Manager was unsure of where page 2 of the Incident/Accident report was. Unit Manager could not find an Investigation Report. Record review of Incident/Accident Report dated 10/30/2016 at 10:00 am revealed incident with Resident #3 occurred at 9:00 am on 10/30/2016 in the dining room. Type of injury was documented as: unexplained injury to right hand with [MEDICAL CONDITION] and bruising to right wrist. Resident #3 complained of pain to area and was unable to open hand upon command. Cold compress was applied. Page 2 of Incident/Accident Report was not provided. In an interview with LVN P on 11/16/2016 at 11:59 am she revealed that an agency CNA F was at the table in the dining area with Resident #3 and the CNA asked her if she had seen Resident #3 ' s hand. LVN P said she looked at Resident #3 ' s hand and saw a bruise and swelling on Resident #3 ' s inner wrist. LVN P said the bruise was bluish in color and about the size of a quarter. LVN P said Resident #3 was complaining of pain so she was medicated with 650 mg of Tylenol. LVN P said the physician, week-end charge nurse, unit manager and family were notified and orders received from physician for x-ray of hand. Interview on 11/14/16 at 3:53 pm Investigation Report regarding the fracture of Resident #3 ' s right hand was requested from the DON. The DON said she could not find an Investigation Report but did find a witness statements provided by CNAs. Record review of Agency CNA F ' s written statement dated 10/30/2016 revealed that Agency CNA F arrived on 10/30/2016 for her 6:00 am to 2:00 pm shift. Agency CNA F wrote, As I was (Sic) toileting residents I found Resident #3 trying to pull up her clothes with one hand. She was favoring her right hand but I didn ' t notice any injury until 9:30 am . Agency CNA F wrote Resident #3 asked her to look at her hand several times, not understanding her she kept reading Today ' s paper until she said loudly Rub my hand and put it in my face. At that moment Agency CNA F saw Resident #3 ' s hand was swollen and looked abnormal. Her wrist was painful with light touch. Agency CNA F called the nurse as soon as possible and reported what she saw. The Nurse took over from there. Record review of CNA G ' s written report dated 10/30/2016 read: When she came on shift this morning, Resident #3 ' s hand was already swollen. She had started complaining of pain and CNA G reported it to the nurse. Interview on 11/16/2016 at 11:05 am with the Unit Manager, she said that a meeting was held recently to discuss why all the bruising and fractures of unknown origin were occurring on the female locked unit. Unit Manager said all things were considered . The Unit Manager did not feel that any abuse was going on related to fractures and bruising but the facility was looking in to it. The Unit Manager further revealed that Former Administrator, Former DON and herself had a meeting when all the injuries of unknown origin occurred and it was decided by the Former DON and Former Administrator that the injuries did not need to be reported to the state. An attempt to reach Agency CNA F on 11/17/2016 at 11:22 am for an interview regarding Resident #3 ' s injury was unsuccessful. A message was left. Call was not returned. Resident #4 Record review of Resident #4 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #4 ' s MDS dated [DATE] revealed she had a BIMS score of 99 (Resident was unable to complete the interview). Record review of Resident #4 ' s Radiology Report dated 10/13/16 revealed a fracture involving lateral portion of the left 7th rib with minimal displacement. Record review of Resident #4 ' s clinical record revealed no incident report for the injury that was discovered on 10/13/16. Record review of the facility ' s Incident/Accident forms for October 2016 revealed no form was completed when Resident #4 was discovered to have broken ribs on 10/13/16. Record review of Resident #4 ' s Progress Notes dated 10/14/16 revealed pain in upper left rib cage area, resident showing pain through facial grimacing. X-ray results returned showing a fracture involving lateral portion of the left 7th rib with minimal displacement. The Administrative Staff were notified. Resident #4 could not recall a recent fall. Observation and interview on 11/14/16 at 8:52 AM revealed Resident #4 pointing at ribs with facial grimacing. Resident #4 could not explain how she got the injury. In an interview on 11/14/16 at 8:55 AM CNA C stated on 10/13/16 Resident #4 pointed at her chest and looked like she was in pain. Resident #4 could not say how she got hurt and did not have a recent fall. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with the Former Administrator and he did not feel this injury met the status of being reportable. Resident #4 had a coughing fit so they attributed the fracture to coughing. The Incident was not investigated. In an interview on 11/15/16 at 9:51 AM the Unit Manager stated the physician wrote a note yesterday, 11/14/16, regarding the fracture to the ribs which could have been caused by coughing. This information was not documented on 10/13/16 but the Unit Manager stated the Physician thought he had written it at that time. Resident #5 Record review of Resident #5 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #5 ' s MDS dated [DATE] revealed she had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #5 ' s Radiology Report dated 10/24/16 revealed an acute right hand fracture as described. There was a fracture involving the base of the fourth proximal phalanx with no displacement with soft tissue swelling. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 8:15 AM, resident was found on floor in bedroom, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 12:44 PM, resident was found in bathroom on floor, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Investigation Follow-up dated 10/24/16 revealed the summary of investigation/ (Reasonable Conclusion) was blank. Observation and interview on 11/14/16 at 8:32 AM revealed Resident #5 was ambulating with a walker. Resident #5 could not explain how she fractured her finger. In an interview on 11/14/16 at 8:55 AM CNA C stated she was not sure how Resident #5 fractured her finger but knew she had a multiple falls that week and a recent Urinary Tract Infection. In an interview on 11/14/16 at 1:02 PM LVN D stated she came to work on 10/24/16. She went to check on Resident #5 on 10/24/16 and noticed her hand was swollen. An X-ray was ordered by the physician. The x-ray confirmed a fracture. LVN D did not know how the fracture occurred but she knew the resident had a few falls this weekend. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with the Former Administratorand he did not feel Resident #5 ' s injury met the status of being reportable. Resident #5 had a few falls recently so they attributed the fracture to the fall. The Unit Manager said the facility did not do an investigation for this incident. In an interview on 11/15/16 at 10:35 AM the Corporate Nurse stated she was not informed of these injuries when they first occurred. The facility would usually contact her with injuries like this so they could discuss them and she could walk them through what they needed to do. The Corporate Nurse said yesterday (11/14/16) the facility reviewed the above incidents and could not determine the cause of the Residents ' injuries. Those three injuries happened during the tenure of the Former Administrator. In an interview on 11/15/16 at 11:01 AM with the Administrator, who was the Abuse Coordinator, stated based on the nature of the incidents being injuries of unknown origin and the regulation, the incidents should have been investigated and reported to the state agency. The Administrator stated we reported the incidents once they came to our attention. The Former Administrator and Former DON were supposed to investigate these incidents and report them, the facility could not find investigation reports. In an interview on 11/15/16 at 2:05 PM the DON stated she had to go back and document a lot of the incidents in the incident log. Some of the incidents that occurred were not on the incident log but the facility was trying to do the best they could with organizing paperwork from the last Administration. The Former DON was responsible for tracking these incidents. In an interview on 11/16/16 at 10:50 AM the Unit Manager stated the Former Administrator had the final say on doing investigation and calling in incidents to the state agency. When residents had a fall and an injury was discovered within 24 hours they would just attribute the incident to the fall. We went over the facility policy and determined that these things should be investigated and reported. The new Administration has in-serviced me and educated me. If things needed to be reported staff do not have to wait or get Administration ' s approval, they can report incidents if they suspect abuse. The facility was aware that all these fractures occurred on the same unit. Record review of the facility policy Incident/Accident Reporting for Residents or Visitors dated June 2007 read in part .Serious/High Risk Incidents Requiring Further Investigation . Fall resulting in fractures and/or closed head injuries unexplained injuries resulting in significant/serious harm .State reportable incidents 3. All serious incidents and other incidents that demonstrate a need for corrective action should be thoroughly investigated 9. The Administrator or Director of Nursing must notify the appropriate state agency as required by state regulations. The exact date, time, and name of contact at the state agency must be recorded on the appropriate investigation form Record review of the facility's Abuse & Neglect Prohibition policy date September 2016 read in part .Investigation 1. The facility will conduct an investigation of any alleged mistreatment, abuse, neglect, injuries of unknown origin .2. The facility will report all investigation findings to the .state agency .within 5 working days.3. The facility will investigate all patterns, trends, or incidents that suggest the possible prescence of .injuries of unknown origin .4. Evidence of investigation .are maintained by the Administrator. An IJ was identified on 11/15/16 and the Administrator and DON were notified at 3:40pm. A plan of removal (POR) for the IJ was submitted on 11/16/16 at 12:11pm and after several revisions it was accepted on 11/17/16 at 10:52am. The POR included in part: The facility investigated and called DADS and reported the incidents. Administrator , DON and the ADON completed and audit of the incident/accident reports for September, October and November 2016 to ensure no there were no other incidents required an investigation and needed to be reported to DADS. This was completed on November 15, 2016. The facility trained all staff on the Abuse; this was completed by 11/16/16. Facility staff were trained on policy and procedure for completing incident/accident reports, reporting any incidents to their immediate supervisor, initiating and investigation of an incident and reporting the incident to DADS. The Administrator will be responsible for timely reporting incidents to DADS, local law enforcement and Elder Justice. Monitoring by surveyors to ensure PoR was implemented was as follows: In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on procedures of how to complete an incident/accident form, including required documentation, initiation of an investigation and reporting to DADS. No identified issues were noted. On 11/18/16 nursing staff from two different shifts were interviewed regarding the new policy and procedures for residents with injuries of unknown source, initiating an investigation of an incident, reporting it to the immediate supervisor, the Administrator and DADS. No identified issues were noted. Staff interviewed consisted of LVNs, RNs and CNAs. An Immediate Jeopardy (IJ) was identified on 11/15/16 . While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility 672 dated 11/13/16 indicated the census was 94.

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for 4 of 9 residents (CR #1, Resident #3, Resident #4 and Resident #5) reviewed for neglect. This was evidenced by: The facility failed to thoroughly investigate when CR#1 made an attempt to commit suicide. The facility failed to investigate and report to the state agency when Resident #3 had a fractured hand from an unknown source. The facility failed to investigate and report to the state agency when Resident #4 had a fractured rib from an unknown source. The facility failed to investigate and report to the state agency Resident #5 ' s, who resided in the locked unit, fractured finger. An Immediate Jeopardy (IJ) was identified on 11/15/2016. While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected 4 residents placed 91 residents at risk for abuse, neglect, harm or death. Findings included: Record review of the facility's Abuse & Neglect Prohibition policy date September 2016 read in part .Investigation 1. The facility will conduct an investigation of any alleged mistreatment, abuse, neglect, injuries of unknown origin .2. The facility will report all investigation findings to the .state agency .within 5 working days.3. The facility will investigate all patterns, trends, or incidents that suggest the possible prescence of .injuries of unknown origin .4. Evidence of investigation .are maintained by the Administrator. CR#1 Record review of CR#1's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR#1 was discharged from facility on 11/09/16 to the hospital. Record review of CR#1 MDS dated [DATE] revealed he had a BIMS score of 2 which indicated severe cognitive impairment. Record review of CR#1's Incident/Accident Report dated 11/09/16 revealed CR#1 had a made a Suicide Attempt at 4:30 PM, in his bedroom, with no apparent injury noted. In an interview on 11/13/16 at 11:06 AM CNA A stated she was doing rounds when she went into CR#1's room. She called out his name but he did not answer. When she went into the room Resident #1 had the bed alarm cord tied around his neck lying on bed with his neck upward. Resident stated he wanted to die. In an interview on 11/13/16 at 11:13 AM LVN B stated when she was called into the room by CNA A CR#1 had the bed alarm cord wrapped around his neck. CR#1's stated he wanted to die. He was not happy and wanted to go home, he also talked about his ex-wife. CR #1 was sent to the hospital the same day as the incident. In an interview on 11/14/16 at 1:50 PM the Administrator stated the facility did not see any reason to report the suicide attempt to the state agency because they investigated the matter and did not see any neglect and staff intervened as they were supposed to do. The resident did not have any injuries. Resident #3 Record review of Resident #3 ' s face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. Resident #3 required limited assistance with one person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #3 ' s Care Plans dated 10/02/2016 revealed care plans for: -ADLs: self-care deficit related to confusion/forgetfulness. Interventions included: The resident required extensive assist by 1 staff member for toileting and transfers. -Limited mobility related to weakness. Interventions included: The resident was able to ambulate with supervision/ cueing. Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 10:35 am revealed a CNA reported that resident #3 was mumbling look at my hand while sitting at the dining table. Upon assessment, her right hand was noted with [MEDICAL CONDITION] and Resident #3 was holding her right hand in a semi-closed position. Her right wrist had a quarter sized blue bruise and Resident #3 could not open her hand. Resident #3 was medicated with Tylenol 650mg for facial grimacing and guarding of right hand. Resident #3 was alert but disoriented. The Physician was notified and an x-ray was ordered. Record review of Resident #3 ' s x-ray report dated 10/30/2016 read: -Findings: [MEDICAL CONDITION] radius was seen with dorsal displacement and angulation. The soft tissues were swollen. Conclusion: Acute [MEDICAL CONDITION] radius (a [MEDICAL CONDITION] bone in the arm on the end next to the wrist.) Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 1:40 pm revealed the nurse received an order to send Resident #3 to hospital for evaluation of fracture. Record review of x-ray report from hospital dated 10/30/2016 revealed: -Impression: Comminuted fracture (bone was broken into more than two pieces) of the distal radius with dorsal displacement. Requested Incident/Accident report on 11/14/2016 at 1:00 pm along with Investigation Report from Unit Manager regarding Resident #3 ' s right hand fracture. Unit Manager said she would look for the Incident/Accident report but was not sure that an Investigation report was completed. On 11/14/2016 at 3:00 pm, Unit Manager was able to produce page 1 of an Incident/Accident Report. Unit Manager was unsure of where page 2 of the Incident/Accident report was. Unit Manager could not find an Investigation Report. Record review of Incident/Accident Report dated 10/30/2016 at 10:00 am revealed incident with Resident #3 occurred at 9:00 am on 10/30/2016 in the dining room. Type of injury was documented as: unexplained injury to right hand with [MEDICAL CONDITION] and bruising to right wrist. Resident #3 complained of pain to area and was unable to open hand upon command. Cold compress was applied. Page 2 of Incident/Accident Report was not provided. In an interview with LVN P on 11/16/2016 at 11:59 am she revealed that an agency CNA F was at the table in the dining area with Resident #3 and the CNA asked her if she had seen Resident #3 ' s hand. LVN P said she looked at Resident #3 ' s hand and saw a bruise and swelling on Resident #3 ' s inner wrist. LVN P said the bruise was bluish in color and about the size of a quarter. LVN P said Resident #3 was complaining of pain so she was medicated with 650 mg of Tylenol. LVN P said the physician, week-end charge nurse, unit manager and family were notified and orders received from physician for x-ray of hand. Interview on 11/14/16 at 3:53pm Investigation Report regarding the fracture of Resident #3 ' s right hand was requested from the DON. The DON said she could not find an Investigation Report but did find a witness statements provided by CNAs. Record review of Agency CNA F ' s written statement dated 10/30/2016 revealed that Agency CNA F arrived on 10/30/2016 for her 6:00 am to 2:00 pm shift. Agency CNA F wrote, As I was (Sic) toileting residents I found Resident #3 trying to pull up her clothes with one hand. She was favoring her right hand but I didn ' t notice any injury until 9:30 am . Agency CNA F wrote Resident #3 asked her to look at her hand several times, not understanding her she kept reading Today ' s paper until she said loudly Rub my hand and put it in my face. At that moment Agency CNA F saw Resident #3 ' s hand was swollen and looked abnormal. Her wrist was painful with light touch. Agency CNA F called the nurse as soon as possible and reported what she saw. The Nurse took over from there. Record review of CNA G ' s written report dated 10/30/2016 read: When she came on shift this morning, Resident #3 ' s hand was already swollen. She had started complaining of pain and she reported it to the nurse. Interview on 11/16/2016 at 11:05 am with the Unit Manager, she said that a meeting was held recently to discuss why all the bruising and fractures of unknown origin were occurring on the female locked unit. Unit Manager said all things were considered . The Unit Manager did not feel that any abuse was going on related to fractures and bruising but the facility was looking in to it. The Unit Manager further revealed that former Administrator, Former DON and herself had a meeting when all the injuries of unknown origin occurred and it was decided by the Former DON and Former Administrator that the injuries did not need to be reported to the state. An attempt to reach Agency CNA F on 11/17/2016 at 11:22 am for an interview regarding Resident #3 ' s injury was unsuccessful. A message was left. Call was not returned. Resident #4 Record review of Resident #4 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #4 ' s MDS revealed she had a BIMS score of 99 (Resident was unable to complete the interview). Record review of Resident #4 ' s Radiology Report dated 10/13/16 revealed a fracture involving lateral portion of the left 7th rib with minimal displacement. Record review of Resident #4 ' s clinical record revealed no incident report for the injury that was discovered on 10/13/16. Record review of the facility ' s Incident/Accident forms for October 2016 revealed no form was completed when Resident #4 was discovered to have broken ribs on 10/13/16. Record review of Resident #4 ' s Progress Notes dated 10/14/16 revealed pain in upper left rib cage area, resident showing pain through facial grimacing. X-ray results returned showing a fracture involving lateral portion of the left 7th rib with minimal displacement. The Administrative Staff were notified. Resident #4 could not recall a recent fall. Observation and interview on 11/14/16 at 8:52 AM revealed Resident #4 pointing at ribs with facial grimacing. Resident #4 could not explain how she got the injury. In an interview on 11/14/16 at 8:55 AM CNA C stated on 10/13/16 Resident #4 pointed at her chest and looked like she was in pain. Resident #4 could not say how she got hurt and did not have a recent fall. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with Former Administrator and he did not feel this injury met the status of being reportable. Resident #4 had a coughing fit so they attributed the fracture to coughing. The Incident was not investigated. In an interview on 11/15/16 at 9:51 AM the Unit Manager stated the physician wrote a note yesterday, 11/14/16, regarding the fracture to the ribs which could have been caused by coughing. This information was not documented on 10/13/16 but the Unit Manager stated the Physician thought he had written it at that time. Resident #5 Record review of Resident #5 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #5 ' s MDS dated [DATE] revealed she had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #5 ' s Radiology Report dated 10/24/16 revealed an acute right hand fracture as described. There was a fracture involving the base of the fourth proximal phalanx with no displacement with soft tissue swelling. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 8:15 AM, resident was found on floor in bedroom, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 12:44 PM, resident was found in bathroom on floor, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Investigation Follow-up dated 10/24/16 revealed the summary of investigation/ (Reasonable Conclusion) was blank. Observation and interview on 11/14/16 at 8:32 AM revealed Resident #5 was ambulating with a walker. Resident #5 could not explain how she fractured her finger. In an interview on 11/14/16 at 8:55 AM CNA C stated she was not sure how Resident #5 fractured her finger but knew she had a multiple falls that week and a recent Urinary Tract Infection. In an interview on 11/14/16 at 1:02 PM LVN D stated she came to work on 10/24/16. She went to check on Resident #5 on 10/24/16 and noticed her hand was swollen. An X-ray was ordered by the physician. The x-ray confirmed a fracture. LVN D did not know how the fracture occurred but she knew the resident had a few falls this weekend. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with the Former Administrator and he did not feel Resident #5 ' s injury met the status of being reportable. Resident #5 had a few falls recently so they attributed the fracture to the fall. The Unit Manager said the facility did not do an investigation for this incident. In an interview on 11/15/16 at 10:35 AM the Corporate Nurse stated she was not informed of these injuries when they first occurred. The facility would usually contact her with injuries like this so they could discuss them and she could walk them through what they needed to do. The Corporate Nurse said yesterday (11/14/16) the facility reviewed the above incidents and could not determine the cause of the Residents ' injuries. Those three injuries happened during the old Administration. In an interview on 11/15/16 at 11:01 AM with the Administrator, who was the Abuse Coordinator, stated based on the nature of the incidents being injuries of unknown origin and the regulation, the incidents should have been investigated and reported to the state agency. We reported the incidents once they came to our attention. The Former Administrator and Former DON were supposed to investigate these incidents and report them, the facility could not find investigation reports. In an interview on 11/15/16 at 2:05 PM the DON stated she had to go back and document a lot of the incidents in the incident log. Some of the incidents that occurred were not on the incident log but the facility was trying to do the best they could with organizing paperwork from the last Administration. The Former DON was responsible for tracking these incidents. In an interview on 11/16/16 at 10:50 AM the Unit Manager stated the Former Administrator had the final say on doing investigation and calling in incidents to the state agency. When residents had a fall and an injury was discovered in within 24 hours they would just attribute the incident to the fall. We went over the facility policy and determined that these things should be investigated and reported. The new Administration has in-serviced me and educated me. If things needed to be reported staff do not have to wait or get Administration ' s approval, they can report incidents if they suspect abuse. The facility was aware that all these fractures occurred on the same unit. Record review of the facility policy Incident/Accident Reporting for Residents or Visitors dated June 2007 read in part .Serious/High Risk Incidents Requiring Further Investigation . Fall resulting in fractures and/or closed head injuries unexplained injuries resulting in significant/serious harm .State reportable incidents 3. All serious incidents and other incidents that demonstrate a need for corrective action should be thoroughly investigated 9. The Administrator or Director of Nursing must notify the appropriate state agency as required by state regulations. The exact date, time, and name of contact at the state agency must be recorded on the appropriate investigation form Record review of the facility's Abuse & Neglect Prohibition policy date September 2016 read in part .Investigation 1. The facility will conduct an investigation of any alleged mistreatment, abuse, neglect, injuries of unknown origin .2. The facility will report all investigation findings to the .state agency .within 5 working days.3. The facility will investigate all patterns, trends, or incidents that suggest the possible prescence of .injuries of unknown origin .4. Evidence of investigation .are maintained by the Administrator. An IJ was identified on 11/15/16 and the Administrator and DON were notified at 3:40 pm. A plan of removal (POR) for the IJ was submitted on 11/16/16 at 12:11pm and after several revisions it was accepted on 11/17/16 at 10:52am. The POR included in part: The facility investigated and called DADS and reported the incidents. Administrator , DON and the ADON completed and audit of the incident/accident reports for September, October and November 2016 to ensure no there were no other incidents required an investigation and needed to be reported to DADS. This was completed on November 15, 2016. The facility trained all staff on the Abuse; this was completed by 11/16/16. Facility staff were trained on policy and procedure for completing incident/accident reports, reporting any incidents to their immediate supervisor, initiating and investigation of an incident and reporting the incident to DADS. The Administrator will be responsible for timely reporting incidents to DADS, local law enforcement and Elder Justice. Monitoring by surveyors to ensure PoR was implemented was as follows: In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on procedures of how to complete an incident/accident form, including required documentation, initiation of an investigation and reporting to DADS. No identified issues were noted. On 11/18/16 nursing staff from two different shifts were interviewed regarding the new policy and procedures for residents with injuries of unknown source, initiating an investigation of an incident, reporting it to the immediate supervisor, the Administrator and DADS. No identified issues were noted. Staff interviewed consisted of LVNs, RNs and CNAs. An Immediate Jeopardy (IJ) was identified on 11/15/16 . While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility 672 dated 11/13/16 indicated the census was 94.

Based on observation, interview and record review the facility administration failed to administer the facility in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 4 of 9 residents (CR#1, Resident #3, Resident #4, Resident #5) reviewed for neglect. The Administrator failed: -To implement the facility ' s policy and procedure on abuse and neglect, the facility's policy on reporting injuries of unknown origin to DADS as required by state and federal refulations, and the facility's policy on investigating injuries of unknown origin as required by state and federal laws. An Immediate Jeopardy (IJ) was identified on 11/15/2016 at 3:40pm. While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures affected four residents and placed 91 additional residents at risk whose care was compromised due to staff neglecting to adequately investigate and report injuries of unknown origin per state and federal regulations. Findings Include: CR#1 Record review of CR#1's face sheet revealed he was a [AGE] year old male that was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CR#1 was discharged from facility on 11/09/16 to the hospital. Record review of CR#1 MDS dated [DATE] revealed he had a BIMS score of 2 which indicated severe cognitive impairment. Record review of CR#1's Incident/Accident Report dated 11/09/16 revealed CR#1 had a made a Suicide Attempt at 4:30 PM, in his bedroom, with no apparent injury noted. In an interview on 11/13/16 at 11:06 AM CNA A stated she was doing rounds when she went into CR#1's room. She called out his name but he did not answer. When she went into the room Resident #1 had the bed alarm cord tied around his neck lying on bed with his neck upward. Resident stated he wanted to die. In an interview on 11/13/16 at 11:13 AM LVN B stated when she was called into the room by CNA A CR#1 had the bed alarm cord wrapped around his neck. CR#1's stated he wanted to die. He was not happy and wanted to go home, he also talked about his ex-wife. CR #1 was sent to the hospital the same day as the incident. In an interview on 11/14/16 at 1:50 PM the Administrator stated the facility did not see any reason to report the suicide attempt to the state agency because they investigated the matter and did not see any neglect and staff intervened as they were supposed to do. The resident did not have any injuries. Resident #4 Record review of Resident #4 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #4 ' s MDS revealed she had a BIMS score of 99 (Resident was unable to complete the interview). Record review of Resident #4 ' s Radiology Report dated 10/13/16 revealed a fracture involving lateral portion of the left 7th rib with minimal displacement. Record review of Resident #4 ' s clinical record revealed no incident report for the injury that was discovered on 10/13/16. Record review of the facility ' s Incident/Accident forms for October 2016 revealed no form was completed when Resident #4 was discovered to have broken ribs on 10/13/16. Record review of Resident #4 ' s Progress Notes dated 10/14/16 revealed pain in upper left rib cage area, resident showing pain through facial grimacing. X-ray results returned showing a fracture involving lateral portion of the left 7th rib with minimal displacement. The Administrative Staff were notified. Resident #4 could not recall a recent fall. Observation and interview on 11/14/16 at 8:52 AM revealed Resident #4 pointing at ribs with facial grimacing. Resident #4 could not explain how she got the injury. In an interview on 11/14/16 at 8:55 AM CNA C stated on 10/13/16 Resident #4 pointed at her chest and looked like she was in pain. Resident #4 could not say how she got hurt and did not have a recent fall. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with the Former Administrator and he did not feel this injury met the status of being reportable. Resident #4 had a coughing fit so they attributed the fracture to coughing. The Incident was not investigated. In an interview on 11/15/16 at 9:51 AM the Unit Manager stated the physician wrote a note yesterday regarding the fracture to the ribs which could have been caused by coughing. This information was not documented on 10/13/16 but the Unit Manager stated the Physician thought he had written it at that time. Resident #3 Record review of Resident #3 ' s face sheet revealed an [AGE] year old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s MDS dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment. Resident #3 required limited assistance with one person physical assist for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. Record review of Resident #3 ' s Care Plans dated 10/02/2016 revealed care plans for: -ADLs: self-care deficit related to confusion/forgetfulness. Interventions included: The resident required extensive assist by 1 staff member for toileting and transfers. -Limited mobility related to weakness. Interventions included: The resident was able to ambulate with supervision/ cueing. Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 10:35 am revealed a CNA reported that resident #3 was mumbling look at my hand while sitting at the dining table. Upon assessment, her right hand was noted with [MEDICAL CONDITION] and Resident #3 was holding her right hand in a semi-closed position. Her right wrist had a quarter sized blue bruise and Resident #3 could not open her hand. Resident #3 was medicated with Tylenol 650mg for facial grimacing and guarding of right hand. Resident #3 was alert but disoriented. The Physician was notified and an x-ray was ordered. Record review of Resident #3 ' s x-ray report dated 10/30/2016 read: -Findings: [MEDICAL CONDITION] radius was seen with dorsal displacement and angulation. The soft tissues were swollen. Conclusion: Acute [MEDICAL CONDITION] radius (a [MEDICAL CONDITION] bone in the arm on the end next to the wrist.) Record review of Resident #3 ' s nurse progress note dated 10/30/2016 at 1:40 pm revealed the nurse received an order to send Resident #3 to hospital for evaluation of fracture. Record review of x-ray report from hospital dated 10/30/2016 revealed: -Impression: Comminuted fracture (bone was broken into more than two pieces) of the distal radius with dorsal displacement. Requested Incident/Accident report on 11/14/2016 at 1:00 pm along with Investigation Report from Unit Manager regarding Resident #3 ' s right hand fracture. Unit Manager said she would look for the Incident/Accident report but was not sure that an Investigation report was completed. On 11/14/2016 at 3:00 pm, Unit Manager was able to produce page 1 of an Incident/Accident Report. Unit Manager was unsure of where page 2 of the Incident/Accident report was. Unit Manager could not find an Investigation Report. Record review of Incident/Accident Report dated 10/30/2016 at 10:00 am revealed incident with Resident #3 occurred at 9:00 am on 10/30/2016 in the dining room. Type of injury was documented as: unexplained injury to right hand with [MEDICAL CONDITION] and bruising to right wrist. Resident #3 complained of pain to area and was unable to open hand upon command. Cold compress was applied. Page 2 of Incident/Accident Report was not provided. In an interview with LVN P on 11/16/2016 at 11:59 am she revealed that an agency CNA F was at the table in the dining area with Resident #3 and the CNA asked her if she had seen Resident #3 ' s hand. LVN P said she looked at Resident #3 ' s hand and saw a bruise and swelling on Resident #3 ' s inner wrist. LVN P said the bruise was bluish in color and about the size of a quarter. LVN P said Resident #3 was complaining of pain so she was medicated with 650 mg of Tylenol. LVN P said the physician, week-end charge nurse, unit manager and family were notified and orders received from physician for x-ray of hand. Interview on 11/14/16 at 3:53pm Investigation Report regarding the fracture of Resident #3 ' s right hand was requested from the DON. The DON said she could not find an Investigation Report but did find a witness statements provided by CNAs. Record review of Agency CNA F ' s written statement dated 10/30/2016 revealed that Agency CNA F arrived on 10/30/2016 for her 6:00 am to 2:00 pm shift. Agency CNA F wrote, As I was (Sic) toileting residents I found Resident #3 trying to pull up her clothes with one hand. She was favoring her right hand but I didn ' t notice any injury until 9:30 am . Agency CNA F wrote Resident #3 asked her to look at her hand several times, not understanding her she kept reading Today ' s paper until she said loudly Rub my hand and put it in my face. At that moment Agency CNA F saw Resident #3 ' s hand was swollen and looked abnormal. Her wrist was painful with light touch. Agency CNA F called the nurse as soon as possible and reported what she saw. The Nurse took over from there. Record review of CNA G ' s written report dated 10/30/2016 read: When she came on shift this morning, Resident #3 ' s hand was already swollen. She had started complaining of pain and she reported it to the nurse. Interview on 11/16/2016 at 11:05 am with the Unit Manager, she said that a meeting was held recently to discuss why all the bruising and fractures of unknown origin were occurring on the female locked unit. Unit Manager said all things were considered . The Unit Manager did not feel that any abuse was going on related to fractures and bruising but the facility was looking in to it. The Unit Manager further revealed that Administrator A, DON A and herself had a meeting when all the injuries of unknown origin occurred and it was decided by the DON A and Administrator A that the injuries did not need to be reported to the state. An attempt to reach Agency CNA F on 11/17/2016 at 11:22 am for an interview regarding Resident #3 ' s injury was unsuccessful. A message was left. Call was not returned. Resident #5 Record review of Resident #5 ' s face sheet revealed she was a [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of Resident #5 ' s MDS dated [DATE] revealed she had a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #5 ' s Radiology Report dated 10/24/16 revealed an acute right hand fracture as described. There was a fracture involving the base of the fourth proximal phalanx with no displacement with soft tissue swelling. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 8:15 AM, resident was found on floor in bedroom, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Report dated 10/23/16 revealed Resident #5 had an un-witnessed fall at 12:44 PM, resident was found in bathroom on floor, no apparent injury noted. Record review of Resident #5 ' s Incident/Accident Investigation Follow-up dated 10/24/16 revealed the summary of investigation/ (Reasonable Conclusion) was blank. Observation and interview on 11/14/16 at 8:32 AM revealed Resident #5 was ambulating with a walker. Resident #5 could not explain how she fractured her finger. In an interview on 11/14/16 at 8:55 AM CNA C stated she was not sure how Resident #5 fractured her finger but knew she had a multiple falls that week and a recent Urinary Tract Infection. In an interview on 11/14/16 at 1:02 PM LVN D stated she came to work on 10/24/16. She went to check on Resident #5 on 10/24/16 and noticed her hand was swollen. An X-ray was ordered by the physician. The x-ray confirmed a fracture. LVN D did not know how the fracture occurred but she knew the resident had a few falls this weekend. In an interview on 11/14/16 at 2:35 PM the Unit Manager stated we discussed this information in the morning meeting with the Former Administrator and he did not feel Resident #5 ' s injury met the status of being reportable. Resident #5 had a few falls recently so they attributed the fracture to the fall. The Unit Manager said the facility did not do an investigation for this incident. In an interview on 11/15/16 at 10:35 AM the Corporate Nurse stated she was not informed of these injuries when they first occurred. The facility would usually contact her with injuries like this so they could discuss them and she could walk them through what they needed to do. The Corporate Nurse said yesterday (11/14/16) the facility reviewed the above incidents and could not determine the cause of the Residents ' injuries. Those three injuries happened during the old Administration. In an interview on 11/15/16 at 11:01 AM Administrator stated based on the nature of the incidents being injuries of unknown origin and the regulation, the incidents should have been investigated and reported to the state agency. We reported the incidents once they came to our attention. The Former Administrator and Former DON were supposed to investigate these incidents and report them, the facility could not find investigation reports. In an interview on 11/15/16 at 2:05 PM the DON stated she had to go back and document a lot of the incidents in the incident log. Some of the incidents that occurred were not on the incident log but the facility was trying to do the best they could with organizing paperwork from the last Administration. The Former DON was responsible for tracking these incidents. In an interview on 11/16/16 at 10:50 AM the Unit Manager stated the Former Administrator had the final say on doing investigation and calling in incidents to the state agency. When residents had a fall and an injury was discovered in within 24 hours they would just attribute the incident to the fall. We went over the facility policy and determined that these things should be investigated and reported. The new Administration has in-serviced me and educated me. If things needed to be reported staff do not have to wait or get Administration ' s approval, they can report incidents if they suspect abuse. The facility was aware that all these fractures occurred on the same unit. Record review of the facility policy Incident/Accident Reporting for Residents or Visitors dated June 2007 read in part .Serious/High Risk Incidents Requiring Further Investigation . Fall resulting in fractures and/or closed head injuries unexplained injuries resulting in significant/serious harm .State reportable incidents 3. All serious incidents and other incidents that demonstrate a need for corrective action should be thoroughly investigated 9. The Administrator or Director of Nursing must notify the appropriate state agency as required by state regulations. The exact date, time, and name of contact at the state agency must be recorded on the appropriate investigation form Record review of the facility's Abuse & Neglect Prohibition policy date September 2016 read in part .Investigation 1. The facility will conduct an investigation of any alleged mistreatment, abuse, neglect, injuries of unknown origin .2. The facility will report all investigation findings to the .state agency .within 5 working days.3. The facility will investigate all patterns, trends, or incidents that suggest the possible prescence of .injuries of unknown origin .4. Evidence of investigation .are maintained by the Administrator. An IJ was identified on 11/15/16 and the Administrator and DON were notified at 3:40pm. A plan of removal (POR) for the IJ was submitted on 11/16/16 at 12:11pm and after several revisions it was accepted on 11/17/16 at 10:52am. The POR included in part: The facility investigated and called DADS and reported the incidents. Administrator , DON and the ADON completed an audit of the incident/accident reports for September, October and November 2016 to ensure no there were no other incidents required an investigation and needed to be reported to DADS. This was completed on November 15, 2016. The facility trained all staff on the Abuse; this was completed by 11/16/16. Facility staff were trained on policy and procedure for completing incident/accident reports, reporting any incidents to their immediate supervisor, initiating and investigation of an incident and reporting the incident to DADS. The Administrator will be responsible for timely reporting incidents to DADS, local law enforcement and Elder Justice. Monitoring by surveyors to ensure PoR was implemented was as follows: In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on procedures of how to complete an incident/accident form, including required documentation, initiation of an investigation and reporting to DADS. No identified issues were noted. On 11/18/16 nursing staff from two different shifts were interviewed regarding the new policy and procedures for residents with injuries of unknown source, initiating an investigation of an incident, reporting it to the immediate supervisor, the Administrator and DADS. No identified issues were noted. Staff interviewed consisted of LVNs, RNs and CNAs. An Immediate Jeopardy (IJ) was identified on 11/15/16 . While the IJ was lowered on 11/18/2016 the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility 802 dated 11/13/16 indicated the census was 94.

Based on observation, interview and record review the facility failed to implement their policy and procedures that prohibit neglect for 1 (CR#1) of 16 residents reviewed for neglect. The facility failed to assess, monitor and provide treatment for [REDACTED]. CR #1 was admitted to facility on 9/09/2016 without a pressure ulcer and discharged to hospital on [DATE] with a Stage IV Pressure Ulcer to the left ischium. An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures affected one resident and placed seven residents at risk of worsening pressure ulcers, a decline in health status and infection. Findings Include: CR #1 Record review of CR #1 ' s face sheet revealed a [AGE] year old male with an initial admission date of [DATE] and a readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1 ' s clinical record revealed he was transferred to the hospital for [MEDICAL CONDITION] activity and a fall on 09/01/2016. He was re-admitted to the facility on [DATE]. Record review of CR #1 ' s Nursing Admission Intake Form dated 09/09/2016 completed by LVN A at 1:00pm revealed the following: CR #1 had [MEDICAL CONDITION] to his right hand described as [MEDICAL CONDITION] X2 , he was lethargic, confused and passive in behavior and did not respond to his name. He was incontinent of bowel and bladder. He was assessed as not having any abnormalities to his extremities. The Nurse ' s note part of the form read in part .skin turgor was fair .incontinent of bowel and bladder .right hand had [MEDICAL CONDITION] .with large closed, raised blister on top of his hand, right arm had open blister . with dressing in place . There was no documentation of any other skin breakdown or any pressure ulcers. In an interview with Licensed Vocational Nurse (LVN) A on 10/18/2016 at 2:30 pm she verified that she was the admitting nurse who admitted CR #1 to the facility. When asked about CR #1 and his wounds LVN A stated He has always had wounds, I can ' t be specific but she thought he had wounds to his knee and hip. LVN A further said that she believed CR #1 had been receiving wound care treatment since he returned to the facility and the wound care nurse provides the treatment. When asked what wounds were present on admission LVN A checked CR #1 ' s admission forms and said the only wounds were to CR #1 ' s arm and hand. LVN A was asked if she thoroughly performed an assessment including skin when admitting CR #1 to facility and she responded yes. Record review of CR #1 ' s braden scale score dated 09/09/2016 revealed a total score of 8. A total score of 12 or less represents high risk with less than or equal to 9 being severe risk. The area for skin condition, Pressure ulcer was blank. Stage 1, Stage 2, Stage 3 and Stage 4 were all blank indicating that none of these areas were noted on admission. Record review of CR #1 ' s interim plan of care dated 09/09/2016 revealed no skin breakdown but the potential for pressure ulcers due to mobility and incontinence. Record review of CR #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the following: CR #1 had short- and long-term memory impairment and his cognitive skills for daily decision making were severely impaired. CR #1 required extensive assistance of one person physical assist for bed mobility, transfer, eating and personal hygiene. CR #1 was totally dependent on one person physical assistance for dressing, toilet use and bathing. He used a wheel chair for mobility and had functional limitation in both upper and lower extremities bilaterally (both sides). CR #1 was always incontinent of bowel and bladder. The assessment section on the MDS for determining pressure ulcer risk had none of the above checked to indicate that none of the resources (such as pressure risk scale or clinical assessment) were used to determine the resident ' s risk of developing a pressure ulcer. The area on the MDS titled Risk of Pressure Ulcer was marked no to indicate the Resident was not at risk for developing pressure ulcers. The section for skin and ulcer treatments was marked as none of the above to indicate there were no pressure relieving devices for his chair or bed, no turning and repositioning program, no nutrition or hydration interventions and no pressure ulcer care being provided. CR #1 was assessed on the MDS as not having any pressure ulcers prior to or on admission. The section for current pressure ulcers Stage 1 -Stage 4 was left blank to indicate CR #1 did not have any pressure ulcers at the time of the assessment. Record review of Care Plan dated 11/12/2015 with a revised date of 09/12/2016 revealed CR #1 was care planned for Pressure Ulcers located on his right inner arm. This was described as a blister wound related to sensory perception, moisture incontinence, decreased activity, impaired mobility, nutrition/hydration risks, friction and shear problem. Approaches included: Apply pressure reduction mattress to bed. Apply pressure reduction cushion to chair or wheelchair. Reposition in chair frequently for comfort and pressure reduction. Turn and reposition while in bed frequently for comfort and pressure reduction. Provide incontinence care after each incontinent episode, or per established toileting plan. Measure and stage wound weekly using the pressure ulcer healing assessment form. Complete a full body check weekly and document. Monitor lab values as ordered. Pressure treatment as ordered, which was clean with normal saline, pat dry, cover with non-stick dressing till healed. On 09/29/2016 the following approaches were added: Order air mattress, wound care, daily off load of both hips, Heel Boots both feet. Record review of the Certified Nursing Assistance (CNA) shower review form binder revealed only one form for CR #1 dated 09/30/2016 that read in part .visual assessment .dryness. The picture revealed dryness to his abdomen and back. It did not reflect any skin breakdown or pressure ulcers. In an interview on 10/14/2016 at 2:29 PM with Resident Care Specialist (RCS) E, she stated from what she remembers, CR #1 had a small wound when he first went to the hospital and when he came back to the facility on [DATE] they were open. RCS E was not for sure of the time frame or dates CR #1 went to the hospital. In an interview with Unit Manager on 10/14/2016 at 5:22 pm she said the CNA Shower Review Book was incomplete and missing pages. She said she asked staff about it and they said they had thinned the shower book. Unit Manager said she would look for Comprehensive CNA Shower sheets for CR #1. Additional documentation was not provided by facility prior to exit. In an interview with DON on 10/18/2016 at 11:45 am she said that if any Resident Care Specialist noticed any wounds on a resident they should inform the nurse. The DON said that the RCS was to check the skin during showers/baths. Record review of CR #1 ' s clinical record did not reveal any additional Comprehensive CNA Shower Review forms. Record review of CR #1 ' s care plan dated 10/04/16 revealed the following: Pressure Ulcer Braden Scale was 10 to indicate he was a high risk for skin breakdown. He had a Left Ischium Stage 4 pressure ulcer related to moisture incontinence and impaired mobility. The approaches included in part: apply pressure reduction mattress, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinent episode .measure and stage wound weekly, complete a full body check weekly and document, monitor lab as ordered .pressure ulcer treatment as ordered, inform physician and family of change in wound status . Pressure ulcer left hip and both heels related to moisture/incontinence, impaired mobility, fragile skin and boggy heels. The approaches read in part: apply pressure reduction mattress to bed .turn and reposition while in bed .provide incontinence care .complete a full body check weekly and document .inform family and physician for changes to wound . Skin impairment (non-pressure ulcer) documented as trauma sites, left forearm, left dorsal hand, left knee and right knee. Approaches read in part: observe skin weekly and document findings . observe for safety needs with transfer .wound care as ordered . Review of CR #1 ' s care plan did not reveal any pressure ulcers to the left ischium or left hip prior to 10/04/16. Record review of facility ' s weekly pressure ulcer log dated 10/04/2016 revealed CR #1 had a left ischium wound, Stage 4 that measured 6cm X 6.2cm [MEDICAL CONDITION]. It was also documented that he was admitted with the pressure ulcer. The date of physician notification was documented as 10/4; prevention equipment was listed as air mattress and positioning pillows. Record review of facility ' s 24 hour report for 10/03/16 and 10/04/16 revealed no documentation for CR #1 regarding pressure ulcers. Record review of Head to Toe Skin Checks for CR #1 performed by facility nurses weekly revealed the following: 9/12/2016-area on form left blank, no documentation. 9/19/2016-skin intact. [DEVICE] site was present and both heels were dry. 9/26/2016-skin intact. 10/03/2016-open areas on upper and lower extremities. Treatment in progress. Record review of CR #1 ' s skin check form dated 10/04/2016 revealed the following information: Left forearm wound that measured 1.9 X 1.7 [MEDICAL CONDITION] described as 70% slough and 30% [MEDICATION NAME]. Left Dorsal hand wound that measured 1.8 X 1.9 and described as 100% eschar. Left ischium wound measured as 6 X 6.2 X .2. There was no other description of the wound. Record review of CR #1 ' s Nursing Daily Skilled Summary sheets revealed the following: 9/9/2016 at 1:30 pm-9/10/2016 1:00am revealed Skin: other, blisters. There was no documentation as to where the blisters were located. 9/11/2016 revealed under the skin section, no problems was checked. 9/12/2016 at 12:45 pm-Skin: no documentation noted. 9/12/2016 at 4:30 am-Skin: No documentation noted. 9/13/2016 at 1:20 am- Skin: No problems. 9/13/2016 at 4:00 am -Skin: No problems. 9/14/2016 at 1:30 am-Skin: No documentation noted. 9/15/2016 at 1:20 am-Skin: No problems. 9/16/2016 at 1:20 am-Skin: No problems. 9/17/2016 at 1:20 am-Skin: No documentation noted. 9/18/2016 at 2:00 am- Skin: No problem. It was documented that CR #1 was incontinent of bowel and bladder and 1:1 assistance with ADLs. 9/19/2016 at 4:04 am-Skin: No problems. 9/19/2016 at 4:00 pm-Skin: No problems. 9/20/2016 at 5:00 am-Skin: No problems. 9/20/2016 at 8:00 am-Skin: No documentation noted. 9/20/2016 at 4:00 pm-Skin: No problems. 9/21/2016 at 1:30 am-Skin: No documentation noted. It was also documented that incontinent care was done per staff. 9/21/2016 at 5:00 pm-Skin: No problems. 9/22/2016 at 1:30 am-Skin: No documentation noted. 9/23/2016 at 1:00 am-Skin: No documentation noted. 9/30/2016 at 1:00 am-Skin: Rash, blisters, [MEDICAL CONDITION]. No documentation as to where the rash, blisters and [MEDICAL CONDITION] were located on CR #1. Record review of physician orders [REDACTED]. -Order air mattress, Hydrogel dressing daily to left hip after clean with normal saline and pat dry, bilateral heel boots, Off-load bilateral hips, Apply non-occlusive dressing to all open [MEDICAL CONDITION] and to obtain a Wound care consult. Record review of Nurses note completed by the Wound Care Nurse for CR #1 dated 09/29/2016 at 6:00am read: Left hip pressure area measures at 6x5.5x0.1. Peri wound normal, partial thickness skin loss-area without signs and symptoms of infection or pain upon palpitation of site, order treated with Hydrogel as per MD ' s orders. Site #2 left lateral knee measuring at 2x2.4x0.1 wound bed with 100% granulation tissue-peri-wound normal without signs and symptoms of maceration-partial thickness loss to area- No signs and symptoms of infection of pain to site; area covered with non-occlusive dressing as per MD ' s orders. Site #3 Left lateral leg measuring at 2.1x1.5x0.1 wound bed with 100% granulation tissue without maceration to wound edges-No pain, tenderness, to area. Site #4 Left dorsal hand, dried blister with intact edges-No signs and symptoms of infection or pain noted to area-Area covered with non-occlusive dressing as per MD orders. Site #5 Left heel boggy but not open-MD request heel boots. Site #6-Right heel boggy but not open-MD also request heel boot. Treatment provided as per MD orders-Will continue to monitor and report identified changes as indicated. Orders were received for Vitamin C and zinc and prostat-Wound MD consulted as per orders. In an interview on 10/18/2016 at 11:48 am with the facility Wound Care Nurse she said that she evaluates residents within 24-48 hours of receiving a wound care referral. The Wound care nurse said she was not aware of any wounds for CR #1 until she received referral for evaluation of wounds for on 9/28/2016. The Wound Care nurse said she evaluated CR #1 on 9/29/2016. Record review of Post- Acute Care Progress Note for CR #1 dated 9/29/2016 revealed [DIAGNOSES REDACTED]. Record review of nurse ' s note dated 10/02/2016 (6am-2pm shift) for CR #1 revealed a dressing was applied to left side of hip and left leg for skin tear. Record review of CR #1 ' s Nurse ' s note dated 10/03/2016 at 10:00pm read in part . new order for stat venous Doppler to left arm due to swelling and pain . Record review of CR #1 ' s Nurse ' s note dated 10/04/16 at 7:10am read in part: skin and wound rounds made with wound care doctor .presents with the following sites: Left forearm wound measured at [MEDICAL CONDITION] with 70% slough and 30% [MEDICATION NAME] tissue, etiology is from trauma, apply [MEDICATION NAME] after cleaning with normal saline and cover with a dressing daily until area is closed. Left dorsal hand wound measured 1.8 X 1.9 [MEDICAL CONDITION] with 100% eschar, from trauma, paint area with [MEDICATION NAME] daily until closed, may cover with protective dressing. Left ischium wound measured 6 X 6.2 X .4 with 30% slough, 60% eschar and 10% granulation tissue. Record review of CR #1 ' s Treatment Administration Record for October 2016 revealed the following: -October 1, 2016-No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. -October 2, 2016- No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. Record review of Nurse note for CR #1 dated 10/04/2016 at 12:17pm revealed CR #1 was sent via 911 to hospital for positive [MEDICAL CONDITION] on Doppler of left upper extremity. Record review of History and Physical from hospital dated 10/04/2016 read in part . Assessment and Plan: 1. Sepsis, meets criteria with [MEDICAL CONDITION] leukocytosis, and lactic acid. Start the patient on IV fluids, looks on the drier side, 125ml. We will start on [MEDICATION NAME] (antibiotic). ID (infectious disease doctor) was to be consulted. Wound cultures were to be obtained. [MEDICAL CONDITION] from the wound infections as no other source is seen. 2. [MEDICAL CONDITION] of the left upper extremity. Start the patient on [MEDICATION NAME]. We will add newer anticoagulants. Tried to contact the family members for further information, but not available for now. We will try again and address the code status . Record review of Photographic Wound Documentation forms for CR #1 dated 10/04/2016 provided by hospital revealed the following: Left Forearm: yellow slough Left Hand: Black/Tan (Eschar) Left hip: Yellow slough, Black/Tan (Eschar) Right hip: Black/Tan (Eschar), Pressure Ulcer Right Knee/Leg: yellow slough Left Thigh: Red/Moist/Smooth/Shallow Left Knee: Red/Moist/Smooth/Shallow Observation on 10/17/2016 at 3:30 pm revealed CR #1 was in the hospital. CR #1 was non-responsive to verbal stimuli. CR #1 was receiving [MEDICATION NAME] antibiotic via Intravenous (IV.) He was receiving oxygen at 3 liters per minute via nasal cannula. In an interview with hospital charge nurse on 10/17/2016 at 3:35 pm he revealed that CR #1 was non-responsive to verbal or tactile stimuli. The charge nurse said CR #1 was being treated with IV antibiotics due [MEDICAL CONDITION]. In an interview with the Unit Manger on 10/18/2016 at 8:08 am regarding weekend coverage for wound care, she said that LVN F from a sister facility sometimes would cover the weekends or the Wound Care Nurse would pop in if needed. She further revealed that the Wound Care Nurse checked for omissions on the Treatment Administration Record that may have occurred over the weekend and notified the DON. The Unit Manager said that the facility had been using agency nurses for weekend coverage because the facility did not have enough facility staff for coverage. The Unit Manager said that if the Wound Care Nurse was not available on the weekend then it was the residents nurse ' s responsibility to change any dressings. The Unit Manager said that all residents should be receiving weekly skin checks and if a resident left the facility and returned that a complete assessment, including skin should be completed before leaving facility and upon readmission. In an interview on 10/18/2016 at 10:55 AM with the DON, she stated on the weekends they usually had a wound care nurse come from another facility to provide treatments. She stated that if there is no wound care nurse, the staffed floor nurse can provide wound care treatment. The DON stated wound care should be done daily. In an interview on 10/20/2016 at 2:17 PM with LVN F, he stated he worked at a sister facility and he helped on the weekends as a treatment nurse and a floor nurse. LVN F stated he has not done wound care at the facility for about two months and has been working as a floor nurse. LVN F stated when he was working at the facility he was unsure who did wound care when he was not doing it. LVN F stated he was not sure if he had worked with Resident #1 and that he did not sound familiar. In an interview with the Director of Nurses (DON) on 10/18/2016 at 11:05 am she said that weekly skin assessments were to be completed on every resident weekly by the nurse and documented. The Physician was to be notified if any issues and new orders were to be followed. In an interview on 10/19/2016 at 1:00 PM with the WCN, she stated at times when she would come to work on Mondays; there would be no dressings on some wounds. She stated she is not sure if the dressings came off in the shower or while providing care. The WCN stated while she is not working on the weekends, there is a wound care nurse that works and if that nurse is not there then the floor nurse can provide wound care treatment. Interview on 10/18/2016 at 1:00pm when asked how the wounds looked following the weekends when she was not at the facility the Wound Care Nurse said on Mondays when she returned to work on Mondays there were no dressings on some of the Resident's wounds. She could not give specific Resident names or dates. In an interview with the Wound Care Nurse on 10/18/2016 at 1:58 pm regarding CR #1 ' s wound, she said the stage 4 wound did not occur overnight . Record review of the facililty's Wound Care Assessment Policy and Procedure dated 08/12/2016 read in part .A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change, and compare the results to previous asessments and treatment. Wound treatment must be precise, consistent and completely documented. Record review of the facility's policy and procedure of Clean Dressing Change dated April 2005 and revised December 2009 read in part .The licensed nurse .applies dressings using clean technique to promote wound healing and prevent cross-contamination among and between residents and caregivers . Documentation .Document treatment in the treatment administration record .document indicated observations on the Daily Monitoring Pressure Ulcer Record .document wound assessment weekly on the Weekly Pressure Ulcer Record. An IJ was identified on 10/18/16 and the Administrator and DON were notified at 4:30pm. A plan of removal (POR) for the IJ was submitted on 10/19/16 at 9:47am and after several revisions it was accepted on 10/20/16 at 1:39pm. The POR included in part: Immediate Action: In detail the plan consists of the nursing staff and Resident Care Specialists will be re-educated on the utilization of the Stop and Watch tool to report any change in condition to include new wounds identified to the LVN ' s, RN ' s, Nurse managers and Director of Nurses. The Stop and Watch re-education was started on 10-18-16 and was completed on 10-19-16. A team of nurses consisting of the Director of Clinical Services, the Assistant Director of Nurses, Treatment Nurse, and Unit Manger #2 conducted head to toe skin audits of all residents in the facility by 10-18-2016. A skin sweep was completed by 9:30 pm on 10-18-16. The results were documented on the skin audits with copies given to the Interim- Administrator. The skin assessments started on 10-18-2016 at 5pm for all residents. The Medical Director of the facility was notified on 10-18-2016 of the Immediate Jeopardy status, at 8pm. A wound risk review meeting was conducted on 10-19-2016, at 6pm. All residents with wounds were reviewed with the Medical Director and any new orders for treatment were documented and implemented. The nursing clinical team contacted the attending physicians of all residents who were identified with skin issues and for those residents who were determined to be at risk for pressure ulcer development in order to get active orders either to treat or to reduce the risk of development. All new orders were implemented and documented in the clinical record and on the resident treatment sheets. A risk review was completed for residents to determine those residents at risk for skin integrity issues. The attending physician was present for meeting and preventative measures were identified and implemented as appropriate and the care plans were updated to include new interventions as necessary 10-19-2016. The Medical Director was notified of the action taken as a result of the skin audit on 10-18-16 at 9pm. Additionally, the facility will continue to have a RN treatment nurse Monday thru Friday. Treatments will continue on the weekends and holidays by a weekend treatment nurse who will be the facility nurse or an agency nurse with the backup plan of the Director of Clinical Services or her assistant providing coverage. Furthermore the wound doctor will continue to make on sight weekly facility visits, writing orders and making recommendations. Prevention/ Education The nursing staff including the Charge Nurses, resident care specialist and Medication techs will be educated on turning, positioning and preventing pressure ulcers. In-servicing started on 10-18-2016 and will be completed on 10-20-2016. Training was conducted by the facility certified wound nurse, with resources from the book Mastery of skin, wound, Ostomy Care. In detail the clinical staff learned how to stage wounds, how to correctly measure wound circumference and depth. Clinical staff learned about support surfaces, treatments such as silverdene, hydrogel, calcium alginate, and [DEVICE]. The clinical staff received handouts to use as resources, as well as a dressing change checklist, which gives a step by step process of assessing, changing, and cleaning wounds. Additionally Facility Managers will utilize the ADL round sheet starting 10-19-2016 to ensure residents are being turned and repositioned. This tool is an added tool to ensure that residents ' ADL needs are in fact being met. All validation tools are turned into the interim administrator at the end of the day for his review. Any trends or concerns are addressed. Finally, clinical staff were also educated on the incontinent care rounding , check and change system. Training began 10.18.2016, and finished on 10.19.2016 .the clinical staff are at the minimum , to make rounds every 2 hours to check and change. When showers are given, if the RCS ' s observe any skin concerns , then they will fill out the Stop and Watch alert tool so their charge nurse can follow up with the concern with an assessment. Any Stop and Watch tool that is utilized will be next reviewed by nursing administration to ensure it was followed up on with an assessment by the charge nurse. Monitoring by surveyors to ensure PoR was implemented was as follows: In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning care for residents with wounds, needing incontinent care and assistance with ADLs. No identified issues were noted. On 10/21/2016 nursing staff from three different shifts were interviewed regarding the new policy and procedures care for residents with wounds, needing incontinent care and assistance with ADLs. No identified issues were noted. Nurses interviewed consisted of LVNs and RNs. On 10/21/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found a resident with wounds and care for residents needing incontinent care and assistance with ADLs. No identified issues were noted. An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's 672 listed seven residents with pressure ulcer.

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent the development of and promote the healing of pressure sores for 1 of 11 residents (Closed Record, (CR) #1) reviewed for pressure ulcers. The facility failed to assess, monitor and provide treatment for [REDACTED]. CR #1 was admitted to facility on 9/09/2016 without a pressure ulcer and discharged to hospital on [DATE] with a Stage IV Pressure Ulcer to the left ischium. An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures affected one resident and placed seven residents at risk of worsening pressure ulcers, a decline in health status and infection. Findings Include: CR #1 Record review of CR #1 ' s face sheet revealed a [AGE] year old male with an initial admission date of [DATE] and a readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1 ' s clinical record revealed he was transferred to the hospital for [MEDICAL CONDITION] activity and a fall on 09/01/2016. He was re-admitted to the facility on [DATE]. Record review of CR #1 ' s Nursing Admission Intake Form dated 09/09/2016 completed by LVN A at 1:00pm revealed the following: CR #1 had [MEDICAL CONDITION] to his right hand described as [MEDICAL CONDITION] X2 , he was lethargic, confused and passive in behavior and did not respond to his name. He was incontinent of bowel and bladder. He was assessed as not having any abnormalities to his extremities. The Nurse ' s note part of the form read in part .skin turgor was fair .incontinent of bowel and bladder .right hand had [MEDICAL CONDITION] .with large closed, raised blister on top of his hand, right arm had open blister . with dressing in place . There was no documentation of any other skin breakdown or any pressure ulcers. In an interview with Licensed Vocational Nurse (LVN) A on 10/18/2016 at 2:30 pm she verified that she was the admitting nurse who admitted CR #1 to the facility. When asked about CR #1 and his wounds LVN A stated He has always had wounds, I can ' t be specific but she thought he had wounds to his knee and hip. LVN A further said that she believed CR #1 had been receiving wound care treatment since he returned to the facility and the wound care nurse provides the treatment. When asked what wounds were present on admission LVN A checked CR #1 ' s admission forms and said the only wounds were to CR #1 ' s arm and hand. LVN A was asked if she thoroughly performed an assessment including skin when admitting CR #1 to facility and she responded yes. Record review of CR #1 ' s braden scale score dated 09/09/2016 revealed a total score of 8. A total score of 12 or less represents high risk with less than or equal to 9 being severe risk. The area for skin condition, Pressure ulcer was blank. Stage 1, Stage 2, Stage 3 and Stage 4 were all blank indicating that none of these areas were noted on admission. Record review of CR #1 ' s interim plan of care dated 09/09/2016 revealed no skin breakdown but the potential for pressure ulcers due to mobility and incontinence. Record review of CR #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the following: CR #1 had short- and long-term memory impairment and his cognitive skills for daily decision making were severely impaired. CR #1 required extensive assistance of one person physical assist for bed mobility, transfer, eating and personal hygiene. CR #1 was totally dependent on one person physical assistance for dressing, toilet use and bathing. He used a wheel chair for mobility and had functional limitation in both upper and lower extremities bilaterally (both sides). CR #1 was always incontinent of bowel and bladder. The assessment section on the MDS for determining pressure ulcer risk had none of the above checked to indicate that none of the resources (such as pressure risk scale or clinical assessment) were used to determine the resident ' s risk of developing a pressure ulcer. The area on the MDS titled Risk of Pressure Ulcer was marked no to indicate the Resident was not at risk for developing pressure ulcers. The section for skin and ulcer treatments was marked as none of the above to indicate there were no pressure relieving devices for his chair or bed, no turning and repositioning program, no nutrition or hydration interventions and no pressure ulcer care being provided. CR #1 was assessed on the MDS as not having any pressure ulcers prior to or on admission. The section for current pressure ulcers Stage 1 -Stage 4 was left blank to indicate CR #1 did not have any pressure ulcers at the time of the assessment. Record review of Care Plan dated 11/12/2015 with a revised date of 09/12/2016 revealed CR #1 was care planned for Pressure Ulcers located on his right inner arm. This was described as a blister wound related to sensory perception, moisture incontinence, decreased activity, impaired mobility, nutrition/hydration risks, friction and shear problem. Approaches included: Apply pressure reduction mattress to bed. Apply pressure reduction cushion to chair or wheelchair. Reposition in chair frequently for comfort and pressure reduction. Turn and reposition while in bed frequently for comfort and pressure reduction. Provide incontinence care after each incontinent episode, or per established toileting plan. Measure and stage wound weekly using the pressure ulcer healing assessment form. Complete a full body check weekly and document. Monitor lab values as ordered. Pressure treatment as ordered, which was clean with normal saline, pat dry, cover with non-stick dressing till healed. On 09/29/2016 the following approaches were added: Order air mattress, wound care, daily off load of both hips, Heel Boots both feet. Record review of the Certified Nursing Assistance (CNA) shower review form binder revealed only one form for CR #1 dated 09/30/2016 that read in part .visual assessment .dryness. The picture revealed dryness to his abdomen and back. It did not reflect any skin breakdown or pressure ulcers. In an interview on 10/14/2016 at 2:29 PM with Resident Care Specialist (RCS) E, she stated from what she remembers, CR #1 had a small wound when he first went to the hospital and when he came back to the facility on [DATE] they were open. RCS E was not for sure of the time frame or dates CR #1 went to the hospital. In an interview with Unit Manager on 10/14/2016 at 5:22 pm she said the CNA Shower Review Book was incomplete and missing pages. She said she asked staff about it and they said they had thinned the shower book. Unit Manager said she would look for Comprehensive CNA Shower sheets for CR #1. Additional documentation was not provided by facility prior to exit. In an interview with DON on 10/18/2016 at 11:45 am she said that if any Resident Care Specialist noticed any wounds on a resident they should inform the nurse. The DON said that the RCS was to check the skin during showers/baths. Record review of CR #1 ' s clinical record did not reveal any additional Comprehensive CNA Shower Review forms. Record review of CR #1 ' s care plan dated 10/04/16 revealed the following: Pressure Ulcer Braden Scale was 10 to indicate he was a high risk for skin breakdown. He had a Left Ischium Stage 4 pressure ulcer related to moisture incontinence and impaired mobility. The approaches included in part: apply pressure reduction mattress, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinent episode .measure and stage wound weekly, complete a full body check weekly and document, monitor lab as ordered .pressure ulcer treatment as ordered, inform physician and family of change in wound status . Pressure ulcer left hip and both heels related to moisture/incontinence, impaired mobility, fragile skin and boggy heels. The approaches read in part: apply pressure reduction mattress to bed .turn and reposition while in bed .provide incontinence care .complete a full body check weekly and document .inform family and physician for changes to wound . Skin impairment (non-pressure ulcer) documented as trauma sites, left forearm, left dorsal hand, left knee and right knee. Approaches read in part: observe skin weekly and document findings . observe for safety needs with transfer .wound care as ordered . Review of CR #1 ' s care plan did not reveal any pressure ulcers to the left ischium or left hip prior to 10/04/16. Record review of facility ' s weekly pressure ulcer log dated 10/04/2016 revealed CR #1 had a left ischium wound, Stage 4 that measured 6cm X 6.2cm [MEDICAL CONDITION]. It was also documented that he was admitted with the pressure ulcer. The date of physician notification was documented as 10/4; prevention equipment was listed as air mattress and positioning pillows. Record review of facility ' s 24 hour report for 10/03/16 and 10/04/16 revealed no documentation for CR #1 regarding pressure ulcers. Record review of Head to Toe Skin Checks for CR #1 performed by facility nurses weekly revealed the following: 9/12/2016-area on form left blank, no documentation. 9/19/2016-skin intact. [DEVICE] site was present and both heels were dry. 9/26/2016-skin intact. 10/03/2016-open areas on upper and lower extremities. Treatment in progress. Record review of CR #1 ' s skin check form dated 10/04/2016 revealed the following information: Left forearm wound that measured 1.9 X 1.7 [MEDICAL CONDITION] described as 70% slough and 30% [MEDICATION NAME]. Left Dorsal hand wound that measured 1.8 X 1.9 and described as 100% eschar. Left ischium wound measured as 6 X 6.2 X .2. There was no other description of the wound. Record review of CR #1 ' s Nursing Daily Skilled Summary sheets revealed the following: 9/9/2016 at 1:30 pm-9/10/2016 1:00am revealed Skin: other, blisters. There was no documentation as to where the blisters were located. 9/11/2016 revealed under the skin section, no problems was checked. 9/12/2016 at 12:45 pm-Skin: no documentation noted. 9/12/2016 at 4:30 am-Skin: No documentation noted. 9/13/2016 at 1:20 am- Skin: No problems. 9/13/2016 at 4:00 am -Skin: No problems. 9/14/2016 at 1:30 am-Skin: No documentation noted. 9/15/2016 at 1:20 am-Skin: No problems. 9/16/2016 at 1:20 am-Skin: No problems. 9/17/2016 at 1:20 am-Skin: No documentation noted. 9/18/2016 at 2:00 am- Skin: No problem. It was documented that CR #1 was incontinent of bowel and bladder and 1:1 assistance with ADLs. 9/19/2016 at 4:04 am-Skin: No problems. 9/19/2016 at 4:00 pm-Skin: No problems. 9/20/2016 at 5:00 am-Skin: No problems. 9/20/2016 at 8:00 am-Skin: No documentation noted. 9/20/2016 at 4:00 pm-Skin: No problems. 9/21/2016 at 1:30 am-Skin: No documentation noted. It was also documented that incontinent care was done per staff. 9/21/2016 at 5:00 pm-Skin: No problems. 9/22/2016 at 1:30 am-Skin: No documentation noted. 9/23/2016 at 1:00 am-Skin: No documentation noted. 9/30/2016 at 1:00 am-Skin: Rash, blisters, [MEDICAL CONDITION]. No documentation as to where the rash, blisters and [MEDICAL CONDITION] were located on CR #1. Record review of physician orders [REDACTED]. -Order air mattress, Hydrogel dressing daily to left hip after clean with normal saline and pat dry, bilateral heel boots, Off-load bilateral hips, Apply non-occlusive dressing to all open [MEDICAL CONDITION] and to obtain a Wound care consult. Record review of Nurses note completed by the Wound Care Nurse for CR #1 dated 09/29/2016 at 6:00am read: Left hip pressure area measures at 6x5.5x0.1. Peri wound normal, partial thickness skin loss-area without signs and symptoms of infection or pain upon palpitation of site, order treated with Hydrogel as per MD ' s orders. Site #2 left lateral knee measuring at 2x2.4x0.1 wound bed with 100% granulation tissue-peri-wound normal without signs and symptoms of maceration-partial thickness loss to area- No signs and symptoms of infection of pain to site; area covered with non-occlusive dressing as per MD ' s orders. Site #3 Left lateral leg measuring at 2.1x1.5x0.1 wound bed with 100% granulation tissue without maceration to wound edges-No pain, tenderness, to area. Site #4 Left dorsal hand, dried blister with intact edges-No signs and symptoms of infection or pain noted to area-Area covered with non-occlusive dressing as per MD orders. Site #5 Left heel boggy but not open-MD request heel boots. Site #6-Right heel boggy but not open-MD also request heel boot. Treatment provided as per MD orders-Will continue to monitor and report identified changes as indicated. Orders were received for Vitamin C and zinc and prostat-Wound MD consulted as per orders. In an interview on 10/18/2016 at 11:48 am with the facility Wound Care Nurse she said that she evaluates residents within 24-48 hours of receiving a wound care referral. The Wound care nurse said she was not aware of any wounds for CR #1 until she received referral for evaluation of wounds for on 9/28/2016. The Wound Care nurse said she evaluated CR #1 on 9/29/2016. Record review of Post- Acute Care Progress Note for CR #1 dated 9/29/2016 revealed [DIAGNOSES REDACTED]. Record review of nurse ' s note dated 10/02/2016 (6am-2pm shift) for CR #1 revealed a dressing was applied to left side of hip and left leg for skin tear. Record review of CR #1 ' s Nurse ' s note dated 10/03/2016 at 10:00pm read in part . new order for stat venous Doppler to left arm due to swelling and pain . Record review of CR #1 ' s Nurse ' s note dated 10/04/16 at 7:10am read in part: skin and wound rounds made with wound care doctor .presents with the following sites: Left forearm wound measured at [MEDICAL CONDITION] with 70% slough and 30% [MEDICATION NAME] tissue, etiology is from trauma, apply [MEDICATION NAME] after cleaning with normal saline and cover with a dressing daily until area is closed. Left dorsal hand wound measured 1.8 X 1.9 [MEDICAL CONDITION] with 100% eschar, from trauma, paint area with [MEDICATION NAME] daily until closed, may cover with protective dressing. Left ischium wound measured 6 X 6.2 X .4 with 30% slough, 60% eschar and 10% granulation tissue. Record review of CR #1 ' s Treatment Administration Record for October 2016 revealed the following: -October 1, 2016-No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. -October 2, 2016- No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. Record review of Nurse note for CR #1 dated 10/04/2016 at 12:17pm revealed CR #1 was sent via 911 to hospital for positive [MEDICAL CONDITION] on Doppler of left upper extremity. Record review of History and Physical from hospital dated 10/04/2016 read in part . Assessment and Plan: 1. Sepsis, meets criteria with [MEDICAL CONDITION] leukocytosis, and lactic acid. Start the patient on IV fluids, looks on the drier side, 125ml. We will start on [MEDICATION NAME] (antibiotic). ID (infectious disease doctor) was to be consulted. Wound cultures were to be obtained. [MEDICAL CONDITION] from the wound infections as no other source is seen. 2. [MEDICAL CONDITION] of the left upper extremity. Start the patient on [MEDICATION NAME]. We will add newer anticoagulants. Tried to contact the family members for further information, but not available for now. We will try again and address the code status . Record review of Photographic Wound Documentation forms for CR #1 dated 10/04/2016 provided by hospital revealed the following: Left Forearm: yellow slough Left Hand: Black/Tan (Eschar) Left hip: Yellow slough, Black/Tan (Eschar) Right hip: Black/Tan (Eschar), Pressure Ulcer Right Knee/Leg: yellow slough Left Thigh: Red/Moist/Smooth/Shallow Left Knee: Red/Moist/Smooth/Shallow Observation on 10/17/2016 at 3:30 pm revealed CR #1 was in the hospital. CR #1 was non-responsive to verbal stimuli. CR #1 was receiving [MEDICATION NAME] antibiotic via Intravenous (IV.) He was receiving oxygen at 3 liters per minute via nasal cannula. In an interview with hospital charge nurse on 10/17/2016 at 3:35 pm he revealed that CR #1 was non-responsive to verbal or tactile stimuli. The charge nurse said CR #1 was being treated with IV antibiotics due [MEDICAL CONDITION]. In an interview with the Unit Manger on 10/18/2016 at 8:08 am regarding weekend coverage for wound care, she said that LVN F from a sister facility sometimes would cover the weekends or the Wound Care Nurse would pop in if needed. She further revealed that the Wound Care Nurse checked for omissions on the Treatment Administration Record that may have occurred over the weekend and notified the DON. The Unit Manager said that the facility had been using agency nurses for weekend coverage because the facility did not have enough facility staff for coverage. The Unit Manager said that if the Wound Care Nurse was not available on the weekend then it was the residents nurse ' s responsibility to change any dressings. The Unit Manager said that all residents should be receiving weekly skin checks and if a resident left the facility and returned that a complete assessment, including skin should be completed before leaving facility and upon readmission. In an interview on 10/18/2016 at 10:55 AM with the DON, she stated on the weekends they usually had a wound care nurse come from another facility to provide treatments. She stated that if there is no wound care nurse, the staffed floor nurse can provide wound care treatment. The DON stated wound care should be done daily. In an interview on 10/20/2016 at 2:17 PM with LVN F, he stated he worked at a sister facility and he helped on the weekends as a treatment nurse and a floor nurse. LVN F stated he has not done wound care at the facility for about two months and has been working as a floor nurse. LVN F stated when he was working at the facility he was unsure who did wound care when he was not doing it. LVN F stated he was not sure if he had worked with Resident #1 and that he did not sound familiar. In an interview with the Director of Nurses (DON) on 10/18/2016 at 11:05 am she said that weekly skin assessments were to be completed on every resident weekly by the nurse and documented. The Physician was to be notified if any issues and new orders were to be followed. In an interview on 10/19/2016 at 1:00 PM with the WCN, she stated at times when she would come to work on Mondays; there would be no dressings on some wounds. She stated she is not sure if the dressings came off in the shower or while providing care. The WCN stated while she is not working on the weekends, there is a wound care nurse that works and if that nurse is not there then the floor nurse can provide wound care treatment. Interview on 10/18/2016 at 1:00pm when asked how the wounds looked following the weekends when she was not at the facility the Wound Care Nurse said on Mondays when she returned to work on Mondays there were no dressings on some of the Resident's wounds. She could not give specific Resident names or dates. In an interview with the Wound Care Nurse on 10/18/2016 at 1:58 pm regarding CR #1 ' s wound, she said the stage 4 wound did not occur overnight . Record review of the facililty's Wound Care Assessment Policy and Procedure dated 08/12/2016 read in part .A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing. You should complete a comprehensive wound assessment during every dressing change, and compare the results to previous asessments and treatment. Wound treatment must be precise, consistent and completely documented. Record review of the facility's policy and procedure of Clean Dressing Change dated April 2005 and revised December 2009 read in part .The licensed nurse .applies dressings using clean technique to promote wound healing and prevent cross-contamination among and between residents and caregivers . Documentation .Document treatment in the treatment administration record .document indicated observations on the Daily Monitoring Pressure Ulcer Record .document wound assessment weekly on the Weekly Pressure Ulcer Record. An IJ was identified on 10/18/16 and the Administrator and DON were notified at 4:30pm. A plan of removal (POR) for the IJ was submitted on 10/19/16 at 9:47am and after several revisions it was accepted on 10/20/16 at 1:39pm. The POR included in part: Immediate Action: In detail the plan consists of the nursing staff and Resident Care Specialists will be re-educated on the utilization of the Stop and Watch tool to report any change in condition to include new wounds identified to the LVN ' s, RN ' s, Nurse managers and Director of Nurses. The Stop and Watch re-education was started on 10-18-16 and was completed on 10-19-16. A team of nurses consisting of the Director of Clinical Services, the Assistant Director of Nurses, Treatment Nurse, and Unit Manger #2 conducted head to toe skin audits of all residents in the facility by 10-18-2016. A skin sweep was completed by 9:30 pm on 10-18-16. The results were documented on the skin audits with copies given to the Interim- Administrator. The skin assessments started on 10-18-2016 at 5pm for all residents. The Medical Director of the facility was notified on 10-18-2016 of the Immediate Jeopardy status, at 8pm. A wound risk review meeting was conducted on 10-19-2016, at 6pm. All residents with wounds were reviewed with the Medical Director and any new orders for treatment were documented and implemented. The nursing clinical team contacted the attending physicians of all residents who were identified with skin issues and for those residents who were determined to be at risk for pressure ulcer development in order to get active orders either to treat or to reduce the risk of development. All new orders were implemented and documented in the clinical record and on the resident treatment sheets. A risk review was completed for residents to determine those residents at risk for skin integrity issues. The attending physician was present for meeting and preventative measures were identified and implemented as appropriate and the care plans were updated to include new interventions as necessary 10-19-2016. The Medical Director was notified of the action taken as a result of the skin audit on 10-18-16 at 9pm. Additionally, the facility will continue to have a RN treatment nurse Monday thru Friday. Treatments will continue on the weekends and holidays by a weekend treatment nurse who will be the facility nurse or an agency nurse with the backup plan of the Director of Clinical Services or her assistant providing coverage. Furthermore the wound doctor will continue to make on sight weekly facility visits, writing orders and making recommendations. Prevention/ Education The nursing staff including the Charge Nurses, resident care specialist and Medication techs will be educated on turning, positioning and preventing pressure ulcers. In-servicing started on 10-18-2016 and will be completed on 10-20-2016. Training was conducted by the facility certified wound nurse, with resources from the book Mastery of skin, wound, Ostomy Care. In detail the clinical staff learned how to stage wounds, how to correctly measure wound circumference and depth. Clinical staff learned about support surfaces, treatments such as silverdene, hydrogel, calcium alginate, and [DEVICE]. The clinical staff received handouts to use as resources, as well as a dressing change checklist, which gives a step by step process of assessing, changing, and cleaning wounds. Additionally Facility Managers will utilize the ADL round sheet starting 10-19-2016 to ensure residents are being turned and repositioned. This tool is an added tool to ensure that residents ' ADL needs are in fact being met. All validation tools are turned into the interim administrator at the end of the day for his review. Any trends or concerns are addressed. Finally, clinical staff were also educated on the incontinent care rounding , check and change system. Training began 10.18.2016, and finished on 10.19.2016 .the clinical staff are at the minimum , to make rounds every 2 hours to check and change. When showers are given, if the RCS ' s observe any skin concerns , then they will fill out the Stop and Watch alert tool so their charge nurse can follow up with the concern with an assessment. Any Stop and Watch tool that is utilized will be next reviewed by nursing administration to ensure it was followed up on with an assessment by the charge nurse. Monitoring by surveyors to ensure PoR was implemented was as follows: In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning care for residents with wounds, needing incontinent care and assistance with ADLs. No identified issues were noted. On 10/21/2016 nursing staff from three different shifts were interviewed regarding the new policy and procedures care for residents with wounds, needing incontinent care and assistance with ADLs. No identified issues were noted. Nurses interviewed consisted of LVNs and RNs. On 10/21/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found a resident with wounds and care for residents needing incontinent care and assistance with ADLs. No identified issues were noted. An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's 672 listed seven residents with pressure ulcer.

Based on interview and record review the facility failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 8 of 15 residents (CR#1, Resident #7, Resident #2, Resident #12, Resident #13, Resident #10, Resident #9 and Resident #8 ) reviewed for effective administration. The Administrator failed: --to supervise the Director of Nursing to ensure she was monitoring and training the nursing staff to provide accurate skin assessments, and provide wound care as per physician orders. --supervise the DON to ensure that nursing staff was trained in recognizing and reporting changes in condition after falls for residents on anticoagulants medications. --Implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent neglect. The DON failed to: -train and supervise the nursing staff to ensure they were providing care to include accurate skin assessments, and provided wound care as per physician orders. - train and supervise the nursing staff to ensure they were providing ADLs, including incontinent care and oral care to residents as needed. -Implement the proper amount of weekend staff to provide wound care to residents An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of actual harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected eight residents and placed 75 residents who have skin break down and who were dependent on staff for care being provided timely and receiving medical treatment resulting in a decline in health and quality of life. Intakes: # 7 Findings Included: CR #1 Record review of CR #1 ' s face sheet revealed a [AGE] year old male with an initial admission date of [DATE] and a readmitted [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1 ' s clinical record revealed he was transferred to the hospital for [MEDICAL CONDITION] activity and a fall on 09/01/2016. He was re-admitted to the facility on [DATE]. Record review of CR #1 ' s Nursing Admission Intake Form dated 09/09/2016 at 1:00pm revealed the following: CR #1 had [MEDICAL CONDITION] to his right hand described as [MEDICAL CONDITION] X2 , he was lethargic, confused and passive in behavior and did not respond to his name. He was incontinent of bowel and bladder. He was assessed has not having any abnormalities to his extremities. The Nurse ' s note part of the form read in part .skin turgor was fair .incontinent of bowel and bladder .right hand had [MEDICAL CONDITION] .with large closed, raised blister on top of his hand, right arm had open blister . with dressing in place . There was no documentation of any other skin breakdown or any pressure ulcers. In an interview with Licensed Vocational Nurse (LVN) A on 10/18/2016 at 2:30 pm she verified that she was the admitting nurse who admitted CR #1 to the facility. When asked about CR #1 and his wounds LVN A stated He has always had wounds, I can ' t be specific but she thought he had wounds to his knee and hip. LVN A further said that she believed CR #1 had been receiving wound care treatment since he returned to the facility and the wound care nurse provides the treatment. When asked what wounds were present on admission LVN A checked CR #1 ' s admission forms and said the only wounds were to CR #1 ' s arm and hand. LVN A was asked if she thoroughly performed an assessment including skin when admitting CR #1 to facility and she responded yes. Record review of CR #1 ' s braden scale score dated 09/09/2016 revealed a total score of 8. A total score of 12 or less represents high risk with less than or equal to 9 being severe risk. The area for skin condition, Pressure ulcer was blank. Stage 1, Stage 2, Stage 3 and Stage 4 were all blank indicating that none of these areas were noted on admission. Record review of CR #1 ' s interim plan of care dated 09/09/2016 revealed no skin breakdown but the potential for pressure ulcers due to mobility and incontinence. Record review of CR #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the following: CR #1 had short- and long-term memory impairment and his cognitive skills for daily decision making were severely impaired. CR #1 required extensive assistance of one person physical assist for bed mobility, transfer, eating and personal hygiene. CR #1 was totally dependent on one person physical assistance for dressing, toilet use and bathing. He used a wheel chair for mobility and had functional limitation in both upper and lower extremities bilaterally (both sides). CR #1 was always incontinent of bowel and bladder. The assessment section for determining pressure ulcer risk had none of the above checked to indicate that none of the resources (such as pressure risk scale or clinical assessment) were used to determine the resident ' s risk of developing a pressure ulcer. The area titled Risk of Pressure Ulcer was marked no to indicate the Resident was not at risk for developing pressure ulcers. The section for skin and ulcer treatments was marked as none of the above to indicate there were no pressure relieving devices for his chair or bed, no turning and repositioning program, no nutrition or hydration interventions and no pressure ulcer care being provided. CR #1 was assessed as not having any pressure ulcers prior to or on admission. The section for current pressure ulcers Stage 1 -Stage 4 was left blank to indicate CR #1 did not have any pressure ulcers at the time of the assessment. Record review of Care Plan dated 11/12/2015 with a revised date of 09/12/2016 revealed CR #1 was care planned for Pressure Ulcers located on his right inner arm. This was described as a blister wound related to sensory perception, moisture incontinence, decreased activity, impaired mobility, nutrition/hydration risks, friction and shear problem. Approaches included: Apply pressure reduction mattress to bed. Apply pressure reduction cushion to chair or wheelchair. Reposition in chair frequently for comfort and pressure reduction. Turn and reposition while in bed frequently for comfort and pressure reduction. Provide incontinence care after each incontinent episode, or per established toileting plan. Measure and stage wound weekly using the pressure ulcer healing assessment form. Complete a full body check weekly and document. Monitor lab values as ordered. Pressure treatment as ordered, which was clean with normal saline, pat dry, cover with non-stick dressing till healed. On 09/29/2016 the following approaches were added: Order air mattress, wound care, daily off load of both hips, Heel Boots both feet. Record review of the Certified Nursing Assistance (CNA) shower review form binder revealed only one form for CR #1 dated 09/30/2016 that read in part .visual assessment .dryness. The picture revealed dryness to his abdomen and back. It did not reflect any skin breakdown or pressure ulcers. In an interview on 10/14/2016 at 2:29 PM with Resident Care Specialist (RCS) E, she stated from what she remembers, CR #1 had a small wound when he first went to the hospital and when he came back to the facility on [DATE] they were open. RCS E was not for sure of the time frame or dates CR #1 went to the hospital. In an interview with Unit Manager on 10/14/2016 at 5:22 pm she said the CNA Shower Review Book was incomplete and missing pages. She said she asked staff about it and they said they had thinned the shower book. Unit Manager said she would look for Comprehensive CNA Shower sheets for CR #1. Documentation never received from facility. Record review of CR #1 ' s clinical record did not reveal any additional Comprehensive CNA Shower Review forms. Record review of CR #1 ' s care plan dated 10/04/16 revealed the following: Pressure Ulcer Braden Scale was 10 to indicate he was a high risk for skin breakdown. He had a Left Ischium Stage 4 pressure ulcer related to moisture incontinence and impaired mobility. The approaches included in part: apply pressure reduction mattress, turn and reposition while in bed frequently for comfort and pressure reduction, provide incontinence care after each incontinent episode .measure and stage wound weekly, complete a full body check weekly and document, monitor lab as ordered .pressure ulcer treatment as ordered, inform physician and family of change in wound status . Pressure ulcer left hip and both heels related to moisture/incontinence, impaired mobility, fragile skin and boggy heels. The approaches read in part: apply pressure reduction mattress to bed .turn and reposition while in bed .provide incontinence care .complete a full body check weekly and document .inform family and physician for changes to wound . Skin impairment (non-pressure ulcer) documented as trauma sites, left forearm, left dorsal hand, left knee and right knee. Approaches read in part: observe skin weekly and document findings . observe for safety needs with transfer .wound care as ordered . Review of CR #1 ' s care plan did not reveal any pressure ulcers to the left ischium or left hip prior to 10/04/16. Record review of facility ' s weekly pressure ulcer log dated 10/04/2016 revealed CR #1 had a left ischium wound, Stage 4 that measured 6cm X 6.2cm [MEDICAL CONDITION]. It was also documented that he was admitted with the pressure ulcer. The date of physician notification was documented as 10/4; prevention equipment was listed as air mattress and positioning pillows. Record review of Head to Toe Skin Checks for CR #1 performed by facility nurses weekly revealed the following: 9/12/201-area on form left blank, no documentation. 9/19/2016-skin intact. [DEVICE] site was present and both heels were dry. 9/26/2016-skin intact. 10/03/2016-open areas on upper and lower extremities. Treatment in progress. Record review of CR #1 ' s skin check form dated 10/04/2016 revealed the following information:Left forearm wound that measured 1.9 X 1.7 [MEDICAL CONDITION] described as 70% slough and 30% [MEDICATION NAME].Left Dorsal hand wound that measured 1.8 X 1.9 and described as 100% eschar.Left ischium wound measured as 6 X 6.2 X .2. There was no other description of the wound. Record review of CR #1 ' s Nursing Daily Skilled Summary sheets revealed the following: 9/9/2016 at 1:30 pm-9/10/2016 1:00am revealed Skin: other, blisters. (There was no documentation as to where the blisters were located.) 9/11/2016 revealed under the skin section, no problems was checked. 9/12/2016 at 12:45 pm-Skin: no documentation noted. 9/12/2016 at 4:30 am-Skin: No documentation noted. 9/13/2016 at 1:20 am- Skin: No problems. 9/13/2016 at 4:00 am -Skin: No problems. 9/14/2016 at 1:30 am-Skin: No documentation noted. 9/15/2016 at 1:20 am-Skin: No problems. 9/16/2016 at 1:20 am-Skin: No problems. 9/17/2016 at 1:20 am-Skin: No documentation noted. 9/18/2016 at 2:00 am- Skin: No problem. It was documented that CR #1 was incontinent of bowel and bladder and 1:1 assistance with ADLs. 9/19/2016 at 4:04 am-Skin: No problems. 9/19/2016 at 4:00 pm-Skin: No problems. 9/20/2016 at 5:00 am-Skin: No problems. 9/20/2016 at 8:00 am-Skin: No documentation noted. 9/20/2016 at 4:00 pm-Skin: No problems. 9/21/2016 at 1:30 am-Skin: No documentation noted. It was also documented that incontinent care was done per staff. 9/21/2016 at 5:00 pm-Skin: No problems. 9/22/2016 at 1:30 am-Skin: No documentation noted. 9/23/2016 at 1:00 am-Skin: No documentation noted. 9/30/2016 at 1:00 am-Skin: Rash, blisters, [MEDICAL CONDITION]. No documentation as to where the rash, blisters and [MEDICAL CONDITION] were located on CR #1. Record review of physician orders [REDACTED]. -Order air mattress, Hydrogel dressing daily to left hip after clean with normal saline and pat dry, bilateral heel boots, Off-load bilateral hips, Apply non-occlusive dressing to all open [MEDICAL CONDITION] and to obtain a Wound care consult. Record review of Nurses note for CR #1 dated 09/29/2016 at 6:00am read: Left hip pressure area measures at 6x5.5x0.1. Peri wound normal, partial thickness skin loss-area without signs and symptoms of infection or pain upon palpitation of site, order treated with Hydrogel as per MD ' s orders. Site #2 left lateral knee measuring at 2x2.4x0.1 wound bed with 100% granulation tissue-peri-wound normal without signs and symptoms of maceration-partial thickness loss to area- No signs and symptoms of infection of pain to site; area covered with non-occlusive dressing as per MD ' s orders. Site #3 Left lateral leg measuring at 2.1x1.5x0.1 wound bed with 100% granulation tissue without maceration to wound edges-No pain, tenderness, to area. Site #4 Left dorsal hand, dried blister with intact edges-No signs and symptoms of infection or pain noted to area-Area covered with non-occlusive dressing as per MD orders. Site #5 Left heel boggy but not open-MD request heel boots. Site #6-Right heel boggy but not open-MD also request heel boot. Treatment provided as per MD orders-Will continue to monitor and report identified changes as indicated. Orders were received for Vitamin C and zinc and prostat-Wound MD consulted as per orders. Record review of Post- Acute Care Progress Note for CR #1 dated 9/29/2016 revealed [DIAGNOSES REDACTED]. Record review of nurse ' s note dated 10/02/2016 (6am-2pm shift) for CR #1 revealed a dressing was applied to left side of hip and left leg for skin tear. Record review of CR #1 ' s Nurse ' s note dated 10/03/2016 at 10:00pm read in part . new order for stat venous Doppler to left arm due to swelling and pain . Record review of CR #1 ' s Nurse ' s note dated 10/04/16 at 7:10am read in part: skin and wound rounds made with wound care doctor .presents with the following sites: Left forearm wound measured at [MEDICAL CONDITION] with 70% slough and 30% [MEDICATION NAME] tissue, etiology is from trauma, apply [MEDICATION NAME] after cleaning with normal saline and cover with a dressing daily until area is closed. Left dorsal hand wound measured 1.8 X 1.9 [MEDICAL CONDITION] with 100% eschar, from trauma, paint area with [MEDICATION NAME] daily until closed, may cover with protective dressing. Left ischium wound measured 6 X 6.2 X .4 with 30% slough, 60% eschar and 10% granulation tissue. Record review of CR #1 ' s Treatment Administration Record for October 2016 revealed the following: -October 1, 2016-No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. -October 2, 2016- No initials showing that wound care was performed to the Left hip area per physician orders. No initials or documentation that wound care was provided to left hand. No initials or documentation that wound care was provided to Left knee per physician orders. No initials or documentation that wound care was provided to Right knee per physician orders. Record review of Nurse note for CR #1 dated 10/04/2016 at 12:17pm revealed CR #1 was sent via 911 to hospital for positive [MEDICAL CONDITION] on Doppler of left upper extremity. Record review of History and Physical from hospital dated 10/04/2016 read in part . Assessment and Plan: 1. Sepsis, meets criteria with [MEDICAL CONDITION] leukocytosis, and lactic acid. Start the patient on IV fluids, looks on the drier side, 125ml. We will start on [MEDICATION NAME] (antibiotic). ID (infectious disease doctor) was to be consulted. Wound cultures were to be obtained. [MEDICAL CONDITION] from the wound infections as no other source is seen. 2. [MEDICAL CONDITION] of the left upper extremity. Start the patient on [MEDICATION NAME]. We will add newer anticoagulants. Tried to contact the family members for further information, but not available for now. We will try again and address the code status . Record review of Photographic Wound Documentation forms for CR #1 dated 10/04/2016 provided by hospital revealed the following: Left Forearm: yellow slough Left Hand: Black/Tan (Eschar) Left hip: Yellow slough, Black/Tan (Eschar) Right hip: Black/Tan (Eschar), Pressure Ulcer Right Knee/Leg: yellow slough Left Thigh: Red/Moist/Smooth/Shallow Left Knee: Red/Moist/Smooth/Shallow Observation on 10/17/2016 at 3:30 pm revealed CR #1 was in the hospital. CR #1 was non-responsive to verbal stimuli. CR #1 was receiving [MEDICATION NAME] antibiotic via Intravenous (IV.) He was receiving oxygen at 3 liters per minute via nasal cannula. In an interview with hospital charge nurse on 10/17/2016 at 3:35 pm he revealed that CR #1 was non-responsive to verbal or tactile stimuli. The charge nurse said CR #1 was being treated with IV antibiotics due [MEDICAL CONDITION]. In an interview on 10/18/2016 at 11:48 am with the facility Wound Care Nurse she said that she evaluates residents within 24-48 hours of receiving a wound care referral. The Wound care nurse said she was not aware of any wounds for CR #1 until she received referral for evaluation of wounds for on 9/28/2016. The Wound Care nurse said she evaluated CR #1 on 9/29/2016. In an interview with the Wound Care Nurse on 10/18/2016 at 1:58 pm regarding CR #1 ' s wound, she said the stage 4 wound did not occur overnight . An IJ was identified on 10/18/16 and the Administrator and DON were notified at 4:30pm. A plan of removal (POR) for the IJ was submitted on 10/19/16 at 9:47am and after several revisions it was accepted on 10/20/16 at 1:39pm. The POR included in part: Immediate Action: In detail the plan consists of the nursing staff and Resident Care Specialists will be re-educated on the utilization of the Stop and Watch tool to report any change in condition to include new wounds identified to the LVN ' s, RN ' s, Nurse managers and Director of Nurses. The Stop and Watch re-education was started on 10-18-16 and was completed on 10-19-16. A team of nurses consisting of the Director of Clinical Services, the Assistant Director of Nurses, Treatment Nurse, and Unit Manger #2 conducted head to toe skin audits of all residents in the facility by 10-18-2016. A skin sweep was completed by 9:30 pm on 10-18-16. The results were documented on the skin audits with copies given to the Interim- Administrator. The skin assessments started on 10-18-2016 at 5pm for all residents. The Medical Director of the facility was notified on 10-18-2016 of the Immediate Jeopardy status, at 8pm. A wound risk review meeting was conducted on 10-19-2016, at 6pm. All residents with wounds were reviewed with the Medical Director and any new orders for treatment were documented and implemented. The nursing clinical team contacted the attending physicians of all residents who were identified with skin issues and for those residents who were determined to be at risk for pressure ulcer development in order to get active orders either to treat or to reduce the risk of development. All new orders were implemented and documented in the clinical record and on the resident treatment sheets. A risk review was completed for residents to determine those residents at risk for skin integrity issues. The attending physician was present for meeting and preventative measures were identified and implemented as appropriate and the care plans were updated to include new interventions as necessary 10-19-2016. The Medical Director was notified of the action taken as a result of the skin audit on 10-18-16 at 9pm. Additionally, the facility will continue to have a RN treatment nurse Monday thru Friday. Treatments will continue on the weekends and holidays by a weekend treatment nurse who will be the facility nurse or an agency nurse with the backup plan of the Director of Clinical Services or her assistant providing coverage. Furthermore the wound doctor will continue to make on sight weekly facility visits, writing orders and making recommendations. Prevention/ Education The nursing staff including the Charge Nurses, resident care specialist and Medication techs will be educated on turning, positioning and preventing pressure ulcers. In-servicing started on 10-18-2016 and will be completed on 10-20-2016. Training was conducted by the facility certified wound nurse, with resources from the book Mastery of skin, wound, Ostomy Care. In detail the clinical staff learned how to stage wounds, how to correctly measure wound circumference and depth. Clinical staff learned about support surfaces, treatments such as silverdene, hydrogel, calcium alginate, and [DEVICE]. The clinical staff received handouts to use as resources, as well as a dressing change checklist, which gives a step by step process of assessing, changing, and cleaning wounds. Additionally Facility Managers will utilize the ADL round sheet starting 10-19-2016 to ensure residents are being turned and repositioned. This tool is an added tool to ensure that residents ' ADL needs are in fact being met. All validation tools are turned into the interim administrator at the end of the day for his review. Any trends or concerns are addressed. Finally, clinical staff were also educated on the incontinent care rounding , check and change system. Training began 10.18.2016, and finished on 10.19.2016 .the clinical staff are at the minimum , to make rounds every 2 hours to check and change. When showers are given, if the RCS ' s observe any skin concerns , then they will fill out the Stop and Watch alert tool so their charge nurse can follow up with the concern with an assessment. Any Stop and Watch tool that is utilized will be next reviewed by nursing administration to ensure it was followed up on with an assessment by the charge nurse. An Immediate Jeopardy (IJ) was identified on 10/19/2016. While the IJ was lowered on 10/21/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems Resident #7 Record review of face sheet for Resident #7 revealed she was a [AGE] year old female with an admission date of [DATE] and a readmitted [DATE]. Diagnoses: [REDACTED]. Record review of Minimum Data Set ((MDS) dated [DATE] for Resident #7 revealed a Brief Interview for Mental Status (BIMS) score of 2 which indicates severe cognitive impairment. MDS further revealed that Resident #7 was total dependence with two person assist for dressing, toilet use and personal hygiene. Record review of Care Plan for Resident #7 dated 10/14/2016 revealed a care plan for: Record review of care plan dated 08/31/2016 for Resident #7 revealed a care plan for Incontinence of Bowel and Bladder; Interventions: Monitor for incontinence every 2 hours/prn, change promptly and apply a protective skin barrier to skin. Monitor for signs and symptoms of skin break down-report to MD and RP. Assess for causes of incontinence. Place resident on a 2 hour toileting program if appropriate. Observation of incontinent care for Resident #7 on 10/18/2016 at 11:45am revealed Resident #7 ' s brief was saturated and chucks pad beneath resident was saturated with urine. Brown ring outline on chucks pad noted. Interview with Resident Care Specialist (RCS) C on 10/18/2016 at 11:55am revealed that she rounds on residents hourly and she could not explain why Resident #7 ' s brief was saturated. Resident # 10 Record review of face sheet for Resident #10 revealed a [AGE] year old female with an admission date of [DATE] and a readmitted [DATE]. Diagnoses: [REDACTED]. [MEDICAL CONDITION], Dementia, Essential Hypertension, Dysphagia, Diabetes Mellitus due to underlying condition with unspecified complications, pressure ulcer of sacral region, [MEDICAL CONDITION], muscle weakness and difficulty walking. Record review of Minimum Data Set ((MDS) dated [DATE] for Resident #10 revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment. MDS further revealed Resident #10 required extensive assistance with one person physical assist for bed mobility, dressing, and personal hygiene. Resident #10 was total dependence with one person assist for toilet use. Record review of care plan dated 9/27/2016 for Resident #10 revealed a pressure wound to the right buttock and sacrum. Approaches included providing wound care as ordered. Record review of physician orders [REDACTED].#10 revealed orders to: Cleanse sacrum with dakins solution, pat dry, pack area with silver aginate and cover with a protective dressing every day and as needed. Cleanse right buttocks with dakins solution, pat dry, apply silve aginate and cover with a dry dressing daily and as needed. Record review of Resident #10 ' s Treatment Administration Record for October 2016 revealed no initials or documentation of wound care provided on 10/1/16 and 10/02/16 (which were weekend days) of Resident #10 ' s sacrum or right buttock wound. Resident # 2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Minimum Data Set ((MDS) dated [DATE] for Resident #2 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. MDS further revealed that Resident #2 required extensive assistance with two person physical assist for bed mobility, dressing and toilet use. Record review of Care Plans dated 10/07/2016 for Resident #2 revealed the following care plans: At risk for skin breakdown related to Incontinence. Interventions: Monitor for incontinence every 2 hours and as needed, change promptly. Record review of care plans for Resident #2 dated 10/04/2016 revealed the following care plans: Actual Pressure Ulcer to right mid buttocks, right posterior thigh, left posterior thigh, and left gluteal fold. Approaches included: Pressure ulcer treatment as ordered. Inform family and M.D. of changes in wound status. Record review of Skin Monitoring: Comprehensive CNA Shower Review for Resident #2 revealed the following: 9/02/2016-Resident refused shower. 9/05/2016-Resident refused shower. 9/09/2016-Bed bath given. No documentation of wounds noted. 9/14/2016-No documentation of wounds noted. 10/03/2016-Shower. No documentation of wounds noted. 10/07/2016-Shower. No documentation of wounds noted. 10/10/2016-No documentation of wounds noted. 10/12/2016-resident refused shower. She will wait until Friday. 10/14/2016-Shower. No documentation of wounds noted. Record review of Resident #2's treatment Administration Record for October 2016 revealed there was no documentation noted that wound care was provided to any wounds for Resident #2 on the following days: October 1, 2016 October 2, 2016 October 7, 206 October 8, 2016 In an interview with Resident #2 on 10/19/2016 at 10:50 am she stated Dressing is changed every day but they didn ' t change them on the weekends before, but this weekend they did . Resident #12 Record review of resident #12 ' s clinical face sheet revealed a [AGE] year old male with an admission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. MDS further revealed that resident #12 was total dependence with two person physical assist for bed mobility, toilet use and transfers. Resident #12 was total dependence with one person physical assist for dressing, eating and personal hygiene. Review of care plans for Resident #12 dated 10/17/2016 revealed he was care planned for: Impaired Skin Integrity: Interventions; Perform treatments per order, report to M.D. any skin breakdown. Monitor areas for increase breakdown. Assess skin weekly and record findings in clinical record. Observation of Resident #12 on 10/18/2016 at 11:01 am revealed resident in bed with head of bed elevated. Resident #12 ' s gown had light brown wet area (softball sized). The tubing adaptor for the [DEVICE] revealed the adaptor was missing a cap and was leaking onto Resident #12. Interview with LVN D on 10/18/2016 at 11:05am revealed that she had just checked on Resident #12 within the hour and the tubing was not leaking. LVN D said Resident #12 pulls on the [DEVICE] occasionally and he might have removed the cap from the adapter. Resident #13 Record review of face sheet for Resident #13 revealed a [AGE] year old male with an admission date of [DATE]. His [DIAGNOSES REDACTED]. Record review of MDS for Resident #13 dated 09/13/2016 revealed Resident #13 was severely impaired for Cognitive Skills for Daily Decision Making. Resident #13 was total dependence with one person physical assist for bed mobility, dressing, eating, and personal hygiene. Resident #13 was total dependence with two person assist for transfer and toilet use. Record review of care plan dated 09/07/2016 for Resident #13 revealed he was care planned for: Contractures: Interventions; encourage/supervise/assist the resident with the use of supportive devices (hand rolls) as recommended. Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Record review of Care Plans for Resident #13 dated 10/19/2016 revealed he was care planned for:Impaired skin Integrity: Interventions; perform treatments per order, report any breakdown, monitor areas for increase breakdown, signs and symptoms of infection-report to MD . Assess skin weekly and record findings in clinical record. Observation on 10/18/2016 at 1:50pm of Resident #13 revealed he was lying in bed with head of bed elevated. Resident #13 had slid down in bed and was coughing. Resident #13 ' s lips were dry and peeling. The Unit Manager at bedside said he needs good mouth care and needs to be suctioned . The Unit Manager attempted suctioning and Resident #13 refused by clenching his mouth. The Unit Manager attempted to provide mouth care and was successful. The U

Based on interview and record review the facility failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one (Resident #1) of 18 reviewed for effective administration. The Administrator failed to: -Implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent abuse and neglect. -Adequately staff the locked unit to provide supervision and prevent accidents or injury for the residents. -Supervise the DON to ensure nursing staff conducted thorough accurate assessments following heat exposure and burns. -Supervise the DON to ensure nursing staff provided appropriate emergency care for a resident following heat exposure and burns. -Supervise the DON to ensure nursing staff accompanied residents outside and monitored residents per facility policy. The DON failed to: -Adequately staff the locked unit to provide supervision and prevent accidents or injury for the residents. -Train and monitor the nursing staff on assessments of Residents when they had a change in condition after heat exposure and burns. -Train and monitor nursing staff on providing care to residents in an emergency situation. -Train and monitor nursing staff on monitoring and accompanying residents while outside per facility policy. An Immediate Jeopardy (IJ) was identified on 08/09/2016. While the IJ was lowered on 08/14/2016 the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected one resident whose needs were not met and placed the 18 residents in the locked unit at risk who are dependent on staff for care of being provided timely medical treatment resulting in a decline in health and quality of life. Intakes: # 2, 7, 5, 2 Findings Included: Resident #1 Record review of Resident #1's admission sheet revealed she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed she had both short and long term memory problems and severe cognitive deficit in daily decision making. Record review of Resident #1 ' s MDS dated [DATE] revealed she required supervision with transfers, ambulation and eating. Record review of Resident #1's Care Plan dated 6/29/2016 revealed she had care plans to match her ADL needs. Record review of Resident #1's Care Plan dated 6/29/2016 revealed she was a fall risk. Record review of Resident #1 ' s Care Plan dated 8/2/2016 revealed she had an actual fall on 8/2/2016. Record review of Resident #1 ' s Incident/Accident Report findings read, Observe resident exit door to courtyard. Approximately 10 minutes, offered resident ice cream and water, and she accepted and consumed. Approximately 20 minutes later, observes redness to face, upper chest, decrease in response time, heavy sweating . In an interview on 8/9/2016 at 10:10 AM with LVN A she stated that around 3 PM on 8/7/2016 she was on the secure unit passing out snacks and waiting for a CNA to come help her on the unit. LVN A stated she went outside and gave Resident #1 a snack and she begin to eat it. LVN A stated, 20 minutes later she noticed the other residents that were outside had come in but Resident #1 had not come in. LVN A stated various times she went outside to see if Resident #1 would come inside and she refused. LVN A stated she went back outside and noticed Resident #1 sweating and mumbling words that she couldn ' t understand. LVN A stated she went inside to get help and saw CMA C and asked for help. She also stated CNA B came to help as well. She stated with the help of CNA B and CMA C they were able to get Resident #1 back into the facility and gave her fluids. LVN A stated she put Resident #1 back in bed and by this time LPN D came to assist and went to get the crash cart and called 911 EMS. LVN A stated when 911 got to the facility Resident #1 was lying in bed, labored breathing, slow responsiveness and very lethargic. LVN A stated her skin had redness to her face and upper chest. In an interview on 8/9/2016 at 2:10 PM with CNA B, she stated that on 8/7/2016 she arrived to the facility at 2:00 PM. She stated around 3:30 PM, almost 4 PM, LVN A asked for help outside and Resident #1 was sitting on the bench while Resident #2 was wiping Resident #1 ' s nose. CNA B stated that she and CMA C helped LVN A get Resident #1 into a wheelchair. CNA B stated Resident #1 was so weak that she couldn ' t stand up by herself or pick her legs up. During this time there was water outside with them that CMA C provided and LVN A poured the water on Resident #1 ' s head and her cheeks began to peel and they rushed her inside to the shower room. CNA B stated LVN A told her to put cold water on her but CNA B stated she told her no, it would shock her and they put warm water on her, starting with the legs and working their way up. CNA B stated at that point they were then instructed by LVN A to push Resident #1 into her room and for CMA C to get some ice. CNA B stated Resident #1 ' s breathing was shallow and LPN D was bringing the oxygen to put on her but 911 EMS had arrived and took over. CNA B stated CMA C took Resident #1 ' s temperature and it was 104.1. In an interview on 8/9/2016 at 3:48 PM with the DON, she stated the secure unit is normally staffed with two workers; either a nurse and an aide or a nurse and a medication aide. The DON stated LVN A usually calls her on the weekend about anything and everything. The DON stated she was not aware that LVN A was working alone until she called stating she was sending Resident #1 to the emergency room . In an interview on 8/10/2016 at 12:15 PM with Resident #2, she stated she was sitting by the middle window in the dining room and she saw Resident #1 sitting outside. When Resident #2 went outside, she asked Resident #1 if she was ready to come back inside because it was hot and she said, No Resident #2 stated Resident #1 was sweating when she went out there, but not a lot. Resident #2 stated Resident #1 was outside for about an hour. Record review of Resident #1 ' s Communication Form dated 8/7/2016 stated the change in condition was due to increase temperature . Temperature noted at 101.0 degrees. In an interview with emergency room (ER) Nurse on 08/11/2016 at 12:41 pm she said the facility nurse called ER to give report and said that Resident #1 was in and out of the facility all day and was being sent to ER for congestion and a temp of 100.0. ER nurse said when Resident #1 arrived she had 2nd [MEDICAL CONDITION] her right cheek, right breast, left great toe [MEDICAL CONDITION] her legs. ER nurse said Resident #1 had a rectal temperature of 106.0 upon arrival to ER and her [MEDICATION NAME] was 6. Resident #1 was unresponsive, had no gag reflex, intravenous fluids were started, ice packs were used to cool down resident and she was intubated. ER nurse said she called facility after Resident #1 arrived as Resident #1 ' s injuries were not consistent with the original report. ER nurse said she spoke to LVN A and informed her that the report was inconsistent with the injuries. ER nurse reported that LVN A said I didn ' t pour anything on her after ER nurse had informed her that Resident #1 had contact 2nd degree burns. ER nurse said she informed LVN A that she was not accusing her of pouring anything on resident but needed more information regarding injuries as being outside for 20 minutes would not cause 2nd degree contact burns. ER nurse said LVN A insisted resident had only been outside for 20 minutes and then LVN A hung up on ER nurse. In an interview with emergency room (ER) physician on 08/11/2016 at 12:47 pm she revealed that Resident #1 presented to emergency room unresponsive, dehydrated, without gag reflex and was intubated. ER physician said Resident #1 had 2nd [MEDICAL CONDITION] her right cheek, right side of neck, right breast and left foot. ER physician said that Resident #1 had a rectal temperature of 106.0 degrees upon arrival to ER but believes that her core temperature was much higher before arriving to facility as the Emergency Medical Personal (EMS) had informed her that Resident #1 had towels packed with ice all around her when they arrived and her gown and bed linens were soaking wet. ER physician said Resident #1 was going to be admitted to hospital and once admitting physician and ER physician discussed the extent of [MEDICAL CONDITION] was decided that she should be transported to a burn unit. In a 2nd interview with ER physician on 08/17/2016 at 9:48 am she said she believes Resident #1 was left outside unattended for more than 1 hour to sustain the injuries that she did. ER physician further said that Resident #1 would have had to have contact with the hot concrete on the patio for more than 30 minutes to sustain the 2nd [MEDICAL CONDITION] her right cheek, right side of neck and right breast. ER physician further revealed that she is positive that Resident #1 ' s core body temperature was higher than 106.0 before arriving to ER due to the ice packed towels that the facility had packed around resident when EMS arrived. Attempted interview with admitting physician via phone on 08/11/2016 at 12:55 pm. Message left to call surveyor. Received voicemail from admitting physician on 08/16/2016 to call her. Telephone call returned on 08/17/2016 at 9:54 am. Interview with Admitting Physician on 08/17/2016 at 9:54 am revealed that when she evaluated Resident #1 in the ER that Resident #1 had 2nd [MEDICAL CONDITION] her right cheek, right side of neck, and right breast. Admitting physician said [MEDICAL CONDITION] consistent with [MEDICAL CONDITION] it appeared that Resident #1 had fallen and had been lying on her right side in a fetal position on a hot surface as Resident #1 ' s right side of face, right side of neck, right breast and left medial foot had 2nd [MEDICAL CONDITION] them. When asked by surveyor how long did she suspect Resident #1 had contact with hot surface, admitting physician said 20-30 minutes contact with hot surface. Admitting physician said Resident #1 was outside longer than 30 minutes for the dehydration and other injuries related to heat exposure. Admitting physician said once Resident #1 was hydrated they were able to see the extant of [MEDICAL CONDITION] due to the degree of [MEDICAL CONDITION] surface area they chose to transfer Resident #1 to a burn facility. In an interview on 8/12/ at 12:41 pm with Administrator regarding IJ and how it came about. Administrator said that she believes that LVN A is typically a very good nurse and that she has had conversations in the past with LVN A about trying to be A Super Nurse . Administrator further said I believe LVN A reacted, got scared and the situation was not handled correctly. Administrator said she became aware of the incident with Resident #1 on 8/07/2016 at 5:00 pm when she received a call from LVN A. Administrator said that LVN A revealed that Resident #1 and another resident were outside on the enclosed patio without staff supervision and LVN A said that Resident #1 refused to come inside. Administrator said that LVN A said Resident #1 was outside for only 20 minutes and then she was able to bring her back into the facility and hydrate her. Administrator said that nursing documentation revealed that Resident #1 was outside from 2:45 pm to 3:15 pm on 08/07/2016. Administrator further revealed that CMA C and ADON informed her that Resident was out of it and they put her in the shower to cool her off. In an interview with DON on 08/12/2016 at 12:00 pm regarding IJ, she said she believes the IJ came about due to no communication with management and Resident #1 was left outside unattended. Record review of Addendum to Excessive Heat Policy and Procedure provided by facility on 08/14/2016 read: -Monitoring of the outside of the facility for residents by staff will be every 30 minutes x24 hours then Q1 hour thereafter. -Documentation of any resident on the outside of the facility (recovery of the resident will be immediate) will be recorded on the log. -Dementia video will be monitored for residents on the courtyard. Record review of the Abuse & Neglect policy dated July 2016 read, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. The facility 672 listed a census of 98 residents.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect of residents for 1 of 7 (#1) residents reviewed for neglect. The facility failed to ensure that Resident #1, who resided in the locked unit, was properly supervised. LVN A was the only staff member on the secure unit, when Resident #1 left outside for an extended period of time exposed to high temperatures and the sun. Resident #1 experienced heat exhaustion and second [MEDICAL CONDITION] on her face, right breast, right shin and left foot. She was sent to a local hospital who transferred to a burn unit at another hospital. Resident #1 was placed on hospice. An IJ was identified on 08/09/16. While the IJ was removed on 08/14/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 resident and placed 17 residents at risk of not receiving supervision, that could lead to injuries. 2, 7, 5, 2 Findings Include: Resident #1 Record review of Resident #1's admission sheet revealed she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS assessment dated [DATE] revealed she had both short and long term memory problems and severe cognitive deficit in daily decision making. Resident #1 required extensive assistance with one person physical assist for bed mobility, dressing and personal hygiene. Resident #1 required supervision with one person physical assist for locomotion on unit. Record review of care plan initiated on 12/30/2015 with a review date of 6/29/2016 revealed Resident #1 was care planned for falls due to history of previous falls, unsteady gait, blood pressure changes and sedatives.observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted and observe for potential medication related causes. Record review of care plan initiated on 12/30/2015 with a review date of 6/29/2016 revealed Resident #1 was care planned for behavior symptoms related to [MEDICAL CONDITION], Dementia with behaviors and anxiety. Target behaviors indicated include: wanders, trespasses in others room and history of exit seeking. Approaches: give simple, clear directions, repeat as needed, allow choices within individual's decision making abilities, and notify MD as needed. Record review of Care plan for Resident #1 dated 12/30/2015 with a reviewed date of 06/29/2016 revealed resident was cared planned for risk of elopement related to wandering, dementia, and history of elopement /wandering attempts and ambulation or mobility status. Approaches: orient resident to environment, document any attempts to elope, observe increases in elopement attempts to identify potential patterns or reasons for attempted exits, provide safe location for wandering behaviors. Record review of care plan dated 12/30/2015 with a review date of 06/29/2016 for Resident #1 revealed she was care planned for Wandering related to Dementia with behaviors. Approaches: reorient and redirect resident as needed, take for supervised walks, observe for increased safety risks, wandering into others rooms, constant wandering without rest, and exit seeking behaviors. Attempt to identify patterns or increased wandering activity to identify potential wants, needs, or past roles individual is seeking. Record review of Resident #1 ' s Care Plan dated 8/2/2016 revealed she had a fall on 8/2/2016 and suffered abrasion to left side of forehead. Approaches: continue interventions on the at-risk plan. Record review of Resident #1's Incident/Accident Report for 8/2/2016 fall read: · Time of Incident: 1:30 AM · Exact Location: Outside Patio · Injury Type: Hematoma to left forehead; abrasion · Findings: Nurse summoned from station one by assigned RCS (resident care specialist). Resident observed with a large hematoma to left side of forehead. RCS stated resident observed outside on patio on the ground. · Temp: 97.7, B.P:108/78, O2 Stats: 98% · Action taken: observe resident closely. Record review of Resident #1 ' s nursing notes for 8/7/2016 written by LVN A read in part: · 3:25 pm attempted to encourage resident to come in. when asked to come in resident stated no . offered ice cream and water, consumed 100% ice cream and 240 cc water · 3:48 pm observed resident sweating, redness to face, redness to upper chest area, skin warm, abrasions to forehead. Call (Sic) resident name, resident slow to respond. Immediately notified RCS (resident care specialist) for assistance and nurse and RCS transfer resident in building to nearest room for assessment · 3:50 pm vitals taken. 2nd nurse called 911, cool water and ice packs placed on resident to decrease 101 degree temperature taken by nurse. 123/168, 18, 90 pulse, 83% on RA (room air). 2nd nurse immediately obtained O2 and non-re breather mask, congestion heard on auscultation. · 3:56 pm while in the process of administering O2, EMS (Emergency Medical Service) personnel walked in, HOB (head of bed) elevated . · 3:57 pm Resident left facility, labored breathing, congestion noted, redness to face, redness to upper chest area . Record review of Resident #1 ' s physician's order [REDACTED]. Take one by mouth every day at 9 AM. ([MEDICATION NAME] is a medication that may make your skin more sensitive to the sun and may cause you to sunburn more easily. While taking this medicine, avoid long exposure to the sun. While in the sun, wear protective clothing and a sunscreen lotion that is SPF15 or higher . <http://www.summitmedicalgroup.com/library/medications/[MEDICATION NAME][MEDICATION NAME][MEDICATION NAME]/>) Record review of website for a history of the temperture where the facility was located revealed a temperature of 98 degrees. (<http://www.accuweather.com/en/us/jacinto-city-tx/ /august-weather/ 9>) Record review of Resident #1 ' s Communication Form dated 8/7/2016 stated the change in condition was due to increase temperature . Temperature noted at 101 degrees.(Body temperature) Record review of Resident #1 ' s Incident/Accident Report dated 08/07/2016 completed by LVN A findings read, Observe (Sic) resident exit door to courtyard. Approximately 10 minutes, offered resident ice cream and water, and she accepted and consumed. Approximately 20 minutes later, observes (Sic) redness to face, upper chest, decrease in response time, heavy sweating . Record review of the Police report dated 08/07/16 read in part, Upon arrival the officer was met by two employees located in station three of the business, identified as LVN A and Certified Nursing assistant (CNA) B. LVN A then stated Resident #1 .walked out of her room and proceeded to the foyer area (outside of the facility) located on the south side of the building. LVN A stated Resident #1 was eating a Popsicle and proceeded to sit down on the bench. LVN A stated she asked Resident #1 to come in approximately three times and Resident #1 refused to cooperate. LVN A stated after the third attempt she forced Resident #1 into the building .LVN A stated the incident took place at 3:00pm and Resident #1 was out in the foyer area for twenty five minutes . The Officer then contacted CNA B . who stated Resident #1 constantly refused to come inside . The Officer proceeded to the hospital . the on duty physician stated Resident #1 was brought into this location half dead with possible first/second [MEDICAL CONDITION] her body. The physician stated there was no way twenty-five minutes in the sun could result in the type [MEDICAL CONDITION] #1 sustained . The Officer then made contact with the ER nurse who stated Resident #1 was running 106 degrees temperature and had [MEDICAL CONDITION] her body . The Officer proceeded to the Fire Department and with an EMS worker who stated when he arrived Resident #1 was laying in room [ROOM NUMBER]A with several cold towels to her body. The EMS Worker stated he observed the patient foaming out her mouth and nonresponsive physically /verbally .The Officer then proceeded to the Facility and spoke with LVN A in attempt to obtain a written statement. LVN A was unsure about making a statement on form and stated her supervisor advised against her making any written statement . Record review of facility investigation report dated 8/8/2016 report details read, at 5:00 pm, the Administrator received a call from LVN A stating Resident #1 was sent to the ER for heat exhaustion. Upon investigation, LVN A informed the Administrator the resident had only been outside for 20 minutes. However, it had been reported from the ER physician that the resident had second [MEDICAL CONDITION] was on a ventilator. The two witnesses that were present are CNA B and MA C. Record review of hospital emergency room report dated 08/07/2016 at 4:35 pm for Resident #1 dictated by hospital admitting physician revealed: The ER received a telephone report from facility that Resident #1 was being sent to ER for congestion and temperature of 101.0 degrees and that Resident #1 had been in and out of the facility all day. Upon arrival to the ER it was noted that Resident #1 was drooling and unresponsive. Resident #1 ' s blood pressure was so low that it could not be taken but Resident #1 did have a pulse. The report further revealed that the clinical findings for Resident #1 did not match the report that was given by the nursing home. The report read: The patient ' s clinical findings did not coincide with the story given by the nurse (LVN A) at the facility. The patient was noted to have second-[MEDICAL CONDITION] the right cheek, right breast, right shin, and bilateral feet. This was told to LVN A at facility and explained that the patient had second degree burns. LVN A stated we didn ' t pour anything on her. The Admitting Physician advised the nurse that she did not accuse her of pouring anything on the patient, but rather it seemed that Resident #1 had contact with a hot surface such as being outside on the ground in the heat. The nurse (LVN A) denied this. The report further read: The Admitting Physician noted that she was quite concerned with this nursing home and she did not believe the information provided to me by the nurse (LVN A) at the nursing home, the patient's (Resident #1) clinical picture, and physical findings were not consistent in anyway with the story that was given . Assessment and Plan: 1. Acute [MEDICAL CONDITION] secondary to malignant hypertension with second [MEDICAL CONDITION] severe prolonged heat exposure. We will admit patient to ICU. The patient has been intubated. We will consult pulmonology for further recommendations. We will continue with current vent settings for now. 2. [MEDICAL CONDITION], likely secondary to acute rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood) 3. Diabetes type II 4. Acute [MEDICAL CONDITION] with acute rhabdomyolysis secondary to prolonged heat exposure. 5. Surveillance, epidemiology, and end results. The patient does meet surveillance, epidemiology and end results criteria with [MEDICAL CONDITION] lactic acidosis, but given the patient ' s [DIAGNOSES REDACTED] from prolonged heat exposure, she felt all of these criteria can be explained by that heat exposure. 16. Suspected neglect. As mentioned above in the history of present illness, I (Admitting Physician) did feel that the facility ' s story of what happened with this patient (Resident #1) is inaccurate and purposely so. I do feel that the patient was neglected. I feel that if it was not, if she had been watched thoroughly; a. She would not fallen last week and received abrasions. b. She would not have been out in the heat for a prolonged amount of time today and presented to the ER as she did. Record review of hospital emergency room report dated 08/07/2016 and signed at 8:43 pm by the ER Department physician read: It was important to note that the story given by the nursing home staff to EMS and the police department did not seem consistent with the injuries found on this patient. There was very real concern for neglect at the facility in the case of this patient and formal complaint will be filed with Department of Aging and Disability services. In an interview with emergency room (ER) Nurse on 08/11/2016 at 12:41 pm she said the facility nurse called ER to give report and said that Resident #1 was in and out of the facility all day and was being sent to ER for congestion and a temp of 100.0. ER nurse said when Resident #1 arrived she had 2nd [MEDICAL CONDITION] her right cheek, right breast, left great toe [MEDICAL CONDITION] her legs. ER nurse said Resident #1 had a rectal temperature of 106.0 upon arrival to ER and her [MEDICATION NAME] was 6. Resident #1 was unresponsive, had no gag reflex, intravenous fluids were started, ice packs were used to cool down resident and she was intubated. ER nurse said she called facility after Resident #1 arrived as Resident #1 ' s injuries were not consistent with the original report. ER nurse said she spoke to LVN A and informed her that the report was inconsistent with the injuries. ER nurse reported that LVN A said I didn ' t ' t pour anything on her after ER nurse had informed her that Resident #1 had contact 2nd degree burns. ER nurse said she informed LVN A that she was not accusing her of pouring anything on resident but needed more information regarding injuries as being outside for 20 minutes would not cause 2nd degree contact burns. ER nurse said LVN A insisted resident had only been outside for 20 minutes and then LVN A hung up on ER nurse. In an interview with emergency room (ER) physician on 08/11/2016 at 12:47 pm she revealed that Resident #1 presented to emergency room unresponsive, dehydrated, without gag reflex and was intubated. ER physician said Resident #1 had 2nd [MEDICAL CONDITION] her right cheek, right side of neck, right breast and left foot. ER physician said that Resident #1 had a rectal temperature of 106.0 degrees upon arrival to ER but believes that her core temperature was much higher before arriving to facility as the Emergency Medical Personal (EMS) had informed her that Resident #1 had towels packed with ice all around her when they arrived and her gown and bed linens were soaking wet. ER physician said Resident #1 was going to be admitted to hospital and once admitting physician and ER physician discussed the extent of [MEDICAL CONDITION] was decided that she should be transported to a burn unit. In an interview on 8/9/2016 at 9:00 AM with Resident #1 ' s Responsible Party (RP) revealed he stated Resident #1 had a fall last week on 8/2/2016 on the same outside patio and sustained an abrasion to her forehead. He stated he came to the facility to speak with the Administrator regarding the fall from 8/2/2016 to see if there was anything that could be done for the patio so that no one else falls or gets hurt while outside. He stated the Administrator said she would reach out to corporate environment director for answers. Further interview revealed he received a phone call from LVN A on 8/7/2016 stating Resident #1 would be transferred to the hospital. He stated LVN A informed him that she tried several times to get Resident #1 back into the facility, as she was sitting outside on the patio; she refused several times. LVN A stated Resident #1 was only outside for 20 minutes. He stated he would get to the hospital as soon as he could. Prior to getting to the hospital, Resident #1 ' s RP stated he received a call from the hospital doctor wanting to know when he could get to the hospital and wanted to know if he knew anything else about her care because what she was seeing did not match with what the nurse from the nursing facility stated. Resident #1 ' s RP stated he did not and was told she refused to come inside. When he got to the hospital, he stated he could see she [MEDICAL CONDITION] her entire body. The doctors at the hospital informed him that Resident #1 would be transferred to a burn unit in a different hospital. In an interview on 8/9/2016 at 9:50 AM with MA C, she stated around 3:45pm she was on another unit when LVN A came around the corner and asked her to page a nurse because she needed help. MA C went to page the nurse and she then asked LVN A if she needed her help and LVN A said, yes . MA C stated when she went to the secure unit with LVN A she seen Resident #1 sitting outside in a chair. LVN A was calling Resident #1 ' s name but she was unresponsive. MA C helped LVN A transfer Resident #1 in a wheelchair. LVN A then asked MA C to get ice and water and LVN A rolled Resident #1 into the shower room and began putting water on her body. MA C stated she asked LVN A what the scars were from that were on her face and LVN A stated it was from a previous fall that Resident #1 had. In an interview on 8/9/2016 at 10:10 AM with LVN A she stated that around 3:00 PM on 8/7/2016 she was on the secure unit passing out snacks and waiting for a CNA to come help her on the unit. LVN A stated she went outside and gave Resident #1 a snack and she began to eat it. LVN A stated 20 minutes later she noticed the other residents that were outside had come in but Resident #1 did not come in. LVN A stated various times she went outside to see if Resident #1 would come inside and she refused. LVN A stated she went back outside and noticed Resident #1 was sweating and mumbling small words that she could not understand. LVN A stated she went inside and asked MA C for her to help with Resident #1. She also stated CNA B came to help as well. She stated with the help of CNA B and MA C they got Resident #1 back into the facility and gave her fluids. LVN A stated she got Resident #1 back in the bed and by this time Licensed Practical Nurse (LPN) D came to assist. LPN D then went to get the crash cart and called 911. LVN A stated when 911 got to the facility Resident #1 was lying in bed, labored breathing, slow responsiveness and very lethargic. LVN A stated her skin had redness to her face and upper chest. In an interview on 8/9/2016 at 2:10 PM with CNA B, she stated that on 8/7/2016 she arrived at the facility at 2 PM. She stated around 3:30 PM, almost 4 PM, LVN A asked for help outside and Resident #1 was sitting on the bench while Resident #2 was wiping Resident #1 ' s nose. CNA B stated her and MA C helped LVN A get Resident #1 into a wheelchair. CNA B stated Resident #1 was so weak that she could not stand up by herself or pick her legs up. During this time there was water outside with them that MA C provided and LVN A poured the water on Resident #1 ' s head and her cheeks began to peel and they rushed her inside to the shower room. CNA B stated LVN A told her to put cold water on her but CNA B stated she told her no, it would shock her and they put warm water on her, starting with the legs and working their way up. CNA B stated at that point they were then instructed by LVN A to push Resident #1 into her room and for MA C to get some ice. CNA B stated Resident #1 ' s breathing was shallow and LPN D was bringing the oxygen to put on her but EMS had arrived and took over. CNA B stated MA C took Resident #1 ' s temperature and it was 104.1. In an interview on 8/9/2016 at 2:53 PM with LPN D, she stated around 4 PM she was on another hall working when CNA B called to her saying they needed help and Resident #1 was not responding. LPN D stated she went over and immediately called 911. She stated Resident #1 was in a wheelchair when she saw her. She stated Resident #1 ' s eyes were closed and she was nonresponsive but warm to touch. LPN D stated one side of Resident #1 ' s forehead was peeling, but she could not remember which side exactly. When LPN D asked LVN A what happened, she stated LVN A told her Resident #1 was outside and when she tried to get her in, she refused. LPN D stated she heard gurgling sounds from Resident #1 and went to get the crash cart but by the time she got back EMS had arrived. In an interview on 8/9/2016 at 3:48 PM with the DON, she stated the secure unit was normally staffed with two workers; either a nurse and an aide or a nurse and a medication aide. The DON stated LVN A usually called her on the weekend about anything and everything. The DON stated she was not aware that LVN A was working alone until she called stating she was sending Resident #1 to the emergency room . In an interview on 8/10/2016 at 12:15 PM with Resident #2, she stated she was sitting by the middle window in the dining room and she saw Resident #1 sitting outside in a chair. Resident #2 stated Resident #1 was outside for about an hour. In an interview on 8/12/2016 at 11:20 AM with LVN E she stated she was on call for 8/6/2016 and 8/7/2016. She stated LVN A called her after 2:00 PM in the afternoon and told her she needed a CNA because she was by herself on the secure unit. LVN E informed her that she would try to call someone in to help her. In an interview with the ER physician on 08/17/2016 at 9:48 am she said she believed Resident #1 was left outside unattended for more than 1 hour to sustain the injuries that she did. The ER physician further said that Resident #1 would have had to have contact with the hot concrete on the patio for more than 30 minutes to sustain the 2nd [MEDICAL CONDITION] her right cheek, right side of neck and right breast. ER physician further revealed that she was positive that Resident #1's core body temperature was higher than 106.0 before arriving to ER due to the ice packed towels that the facility had packed around resident when EMS arrived. Attempted interview with admitting physician via phone on 08/11/2016 at 12:55 pm, message to return call was left. Interview with Admitting Physician on 08/17/2016 at 9:54 am revealed that when she evaluated Resident #1 in the ER that Resident #1 had 2nd [MEDICAL CONDITION] her right cheek, right side of neck, and right breast. Admitting physician said [MEDICAL CONDITION] consistent with [MEDICAL CONDITION] it appeared that Resident #1 had fallen and had been lying on her right side in a fetal position on a hot surface as Resident #1 ' s right side of face, right side of neck, right breast and left medial foot had 2nd [MEDICAL CONDITION] them. When asked by surveyor how long did she suspect Resident #1 had contact with hot surface, admitting physician said 20-30 minutes contact with hot surface. Admitting physician said Resident #1 was outside longer than 30 minutes for the dehydration and other injuries related to heat exposure. Admitting physician said once Resident #1 was hydrated they were able to see the extent of [MEDICAL CONDITION] due to the degree of [MEDICAL CONDITION] surface area they chose to transfer Resident #1 to a burn facility. Record review of Excessive Heat policy dated June 2012 read, Facility will establish procedures to be taken to prepare the facility, in the even excessive heat occurs in or to provide adequate care and comfort to residents . Record review of the Abuse & Neglect policy dated July 2016 read, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin and misappropriation of property .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. An IJ was identified on 08/09/16 and the Administrator and DON were notified at 3:30PM. A plan of removal (POR) for the IJ was submitted on 08/09/16 at 9:06PM and after several revisions it was accepted on 08/12/16 at 1:07PM. The POR included in part: Immediate Action 1. The facility assessed residents at risk of hydration. 2. Hydration stations were set up at each entrance/exit. Dietary staff was educated on their responsibility to replenish the hydration stations from the dietary manager. The set times for hydration [MEDICATION NAME] are: 7am, 9am, 11am, 1:30pm, 3:30pm, 5:30pm and 7pm. All training for the dietary staff was completed on 8/10/16. The dietary aide will be responsible for [MEDICATION NAME]. The dietary manager will be responsible for monitoring compliance. On off hours the cook, Manager on Duty (for weekends) and weekend RN supervisor will also monitor for compliance. All of the hydration carts were set up on 8/7/16. Each resident will continued to be offered fluids upon two hour rounds, when outside with staff and at meals. Hydration through activities will also be offered. 3. Logs were put into place for the secured unit for monitoring for exit seeking. The logs are visual checks to ensure that no one is outside in any extreme weather. It documents if anyone is outside and what the staff did to redirect the patient from outside. This is done each hour. Management spot checks the logs throughout the day and on weekends with the manager on duty. The cameras will be checked daily from the maintenance director and on the weekend by the manager on duty. If a monitor is not functioning the maintenance director and administrator will be notified and if it is not able to be repaired the facility will purchase another one immediately. The nurse along with the DON, Admin, Unit Manager and Managers on duty will monitor the log. 4. Interventions the facility put into place to redirect the residents away from the exit during extreme weather, were door alarms, stop signs on each exit door leading out outside, black mat at each exit. All of these interventions were put into place on 8/8/16. The black mat is a technique used with Alzheimer/dementia patients. Management checks these interventions daily to ensure they are in place. The maintenance director will check the alarms daily and document his findings on a daily log. The manager on duty for the weekend will also document a check that the alarms are operable. Any issues will be immediately reported to the administrator and maintenance director. There are blinds on several of the windows. The facility will remove the blinds as of 8/12/16. 5. Umbrella purchased for outside courtyard seating area to provide shade when residents are outside on sunny day and was purchased on 8/8/16. Residents will not be outside without the supervision of staff or a family member. If a resident does go outside unattended, the staff will attempt to redirect the resident. If the resident refuses the staff will stay with the resident and offer hydration until the resident agrees to return inside. 6. Education started on 8/8/16 to nursing staff related to heat and their response on what to do when you see a resident outside in extreme temperatures. No staff will work until in-servicing has taken place. All in-servicing will be completed by 8/11/16. On Call Nurse have been in-serviced that the DON and LNFA must be notified of a call in or a no call no show by the DON (8/8/16) The on call nurse is required to call the LNFA and DON to inform us of any call in and her solution to address the issue. If on call nurse cannot find replacement within on call staff must report to facility for duty. Until the on call nurse can reach the facility the nurses have been in-serviced that staff must be adjusted to ensure that one staff member may not be left on the unit. (8/11/16). The facility will schedule two staff members on the unit. And depending on the census staffing will be adjusted. The logs were put in place for staff to do visual checks to check the patio every hour. Administration developed the logs and staff were in-serviced by the DON (8/8/16). The patio has been assessed for shaded areas. However, because the entire roof area is open all areas of the patio are subjected to sunlight until sundown. There are no blind spots at all to the block the visibility to the courtyard. Monitoring to ensure PoR was implemented was as follows: Policy on how to care of the residents during periods of extreme heat was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning staffing, care for residents outside in extreme temperatures, hydration and the monitoring of residents in the locked units. No identified issues were noted. On 08/14/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning staffing, care for residents outside in extreme temperatures, hydration and the monitoring of residents in the locked units. Nurses interviewed consisted of LVNs and RNs. On 08/14/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident outside in an extreme temperature, hydration of residents and care of residents in the locked unit. While the IJ was removed on 08/14/16 at 11:20 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility census listed 18 residents in the locked unit

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision for 1 (Resident #1) of 6 residents reviewed on the locked unit for hazards and supervision. The facility failed to ensure that Resident #1, who resided in the locked unit, was properly supervised. LVN A was the only staff member on the secure unit, when Resident #1 left outside for an extended period of time exposed to high temperatures and the sun. Resident #1 experienced heat exhaustion and second degree burns located on her face, right breast, right shin and left foot. She was sent to a local hospital who transferred to a burn unit at another hospital. Resident #1 was placed on hospice. An IJ was identified on 08/09/16. While the IJ was removed on 08/14/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. This failure affected 1 resident and placed 17 residents at risk of not receiving supervision, that could lead to injuries, Complaint/ Incident #s 2, 7, 5, 2 Findings Include: Resident #1 Record review of Resident #1's admission sheet revealed she was [AGE] years old and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS assessment dated [DATE] revealed she had both short and long term memory problems and severe cognitive deficit in daily decision making. Resident #1 required extensive assistance with one person physical assist for bed mobility, dressing and personal hygiene. Resident #1 required supervision with one person physical assist for locomotion on unit. Record review of care plan initiated on 12/30/2015 with a review date of 6/29/2016 revealed Resident #1 was care planned for falls due to history of previous falls, unsteady gait, blood pressure changes and sedatives.observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted and observe for potential medication related causes. Record review of care plan initiated on 12/30/2015 with a review date of 6/29/2016 revealed Resident #1 was care planned for behavior symptoms related to psychosis, Dementia with behaviors and anxiety. Target behaviors indicated include: wanders, trespasses in others room and history of exit seeking. Approaches: give simple, clear directions, repeat as needed, allow choices within individual's decision making abilities, and notify MD as needed. Record review of Care plan for Resident #1 dated 12/30/2015 with a reviewed date of 06/29/2016 revealed resident was cared planned for risk of elopement related to wandering, dementia, and history of elopement /wandering attempts and ambulation or mobility status. Approaches: orient resident to environment, document any attempts to elope, observe increases in elopement attempts to identify potential patterns or reasons for attempted exits, provide safe location for wandering behaviors. Record review of care plan dated 12/30/2015 with a review date of 06/29/2016 for Resident #1 revealed she was care planned for Wandering related to Dementia with behaviors. Approaches: reorient and redirect resident as needed, take for supervised walks, observe for increased safety risks, wandering into others rooms, constant wandering without rest, and exit seeking behaviors. Attempt to identify patterns or increased wandering activity to identify potential wants, needs, or past roles individual is seeking. Record review of Resident #1 ' s Care Plan dated 8/2/2016 revealed she had a fall on 8/2/2016 and suffered abrasion to left side of forehead. Approaches: continue interventions on the at-risk plan. Record review of Resident #1's Incident/Accident Report for 8/2/2016 fall read: · Time of Incident: 1:30 AM · Exact Location: Outside Patio · Injury Type: Hematoma to left forehead; abrasion · Findings: Nurse summoned from station one by assigned RCS (resident care specialist). Resident observed with a large hematoma to left side of forehead. RCS stated resident observed outside on patio on the ground. · Temp: 97.7, B.P:108/78, O2 Stats: 98% · Action taken: observe resident closely. Record review of Resident #1 ' s nursing notes for 8/7/2016 written by LVN A read in part: · 3:25 pm attempted to encourage resident to come in. when asked to come in resident stated no . offered ice cream and water, consumed 100% ice cream and 240 cc water · 3:48 pm observed resident sweating, redness to face, redness to upper chest area, skin warm, abrasions to forehead. Call (Sic) resident name, resident slow to respond. Immediately notified RCS (resident care specialist) for assistance and nurse and RCS transfer resident in building to nearest room for assessment · 3:50 pm vitals taken. 2nd nurse called 911, cool water and ice packs placed on resident to decrease 101 degree temperature taken by nurse. 123/168, 18, 90 pulse, 83% on RA (room air). 2nd nurse immediately obtained O2 and non-re breather mask, congestion heard on auscultation. · 3:56 pm while in the process of administering O2, EMS (Emergency Medical Service) personnel walked in, HOB (head of bed) elevated . · 3:57 pm Resident left facility, labored breathing, congestion noted, redness to face, redness to upper chest area . Record review of Resident #1 ' s physician's order [REDACTED]. Take one by mouth every day at 9 AM. (Norvasc is a medication that may make your skin more sensitive to the sun and may cause you to sunburn more easily. While taking this medicine, avoid long exposure to the sun. While in the sun, wear protective clothing and a sunscreen lotion that is SPF15 or higher . <http://www.summitmedicalgroup.com/library/medications/pma_amlodipine_valsartan_hydrochlorothiazide_oral/>) Record review of website for a history of the temperture where the facility was located revealed a temperature of 98 degrees. (<http://www.accuweather.com/en/us/jacinto-city-tx/ /august-weather/ 9>) Record review of Resident #1 ' s Communication Form dated 8/7/2016 stated the change in condition was due to increase temperature . Temperature noted at 101 degrees.(Body temperature) Record review of Resident #1 ' s Incident/Accident Report dated 08/07/2016 completed by LVN A findings read, Observe (Sic) resident exit door to courtyard. Approximately 10 minutes, offered resident ice cream and water, and she accepted and consumed. Approximately 20 minutes later, observes (Sic) redness to face, upper chest, decrease in response time, heavy sweating . Record review of the Police report dated 08/07/16 read in part, Upon arrival the officer was met by two employees located in station three of the business, identified as LVN A and Certified Nursing assistant (CNA) B. LVN A then stated Resident #1 .walked out of her room and proceeded to the foyer area (outside of the facility) located on the south side of the building. LVN A stated Resident #1 was eating a Popsicle and proceeded to sit down on the bench. LVN A stated she asked Resident #1 to come in approximately three times and Resident #1 refused to cooperate. LVN A stated after the third attempt she forced Resident #1 into the building .LVN A stated the incident took place at 3:00pm and Resident #1 was out in the foyer area for twenty five minutes . The Officer then contacted CNA B . who stated Resident #1 constantly refused to come inside . The Officer proceeded to the hospital . the on duty physician stated Resident #1 was brought into this location half dead with possible first/second degree burns to her body. The physician stated there was no way twenty-five minutes in the sun could result in the type of burns Resident #1 sustained . The Officer then made contact with the ER nurse who stated Resident #1 was running 106 degrees temperature and had serious burns to her body . The Officer proceeded to the Fire Department and with an EMS worker who stated when he arrived Resident #1 was laying in room 215A with several cold towels to her body. The EMS Worker stated he observed the patient foaming out her mouth and nonresponsive physically /verbally .The Officer then proceeded to the Facility and spoke with LVN A in attempt to obtain a written statement. LVN A was unsure about making a statement on form and stated her supervisor advised against her making any written statement . Record review of facility investigation report dated 8/8/2016 report details read, at 5:00 pm, the Administrator received a call from LVN A stating Resident #1 was sent to the ER for heat exhaustion. Upon investigation, LVN A informed the Administrator the resident had only been outside for 20 minutes. However, it had been reported from the ER physician that the resident had second degree burns and was on a ventilator. The two witnesses that were present are CNA B and MA C. Record review of hospital emergency room report dated 08/07/2016 at 4:35 pm for Resident #1 dictated by hospital admitting physician revealed: The ER received a telephone report from facility that Resident #1 was being sent to ER for congestion and temperature of 101.0 degrees and that Resident #1 had been in and out of the facility all day. Upon arrival to the ER it was noted that Resident #1 was drooling and unresponsive. Resident #1 ' s blood pressure was so low that it could not be taken but Resident #1 did have a pulse. The report further revealed that the clinical findings for Resident #1 did not match the report that was given by the nursing home. The report read: The patient ' s clinical findings did not coincide with the story given by the nurse (LVN A) at the facility. The patient was noted to have second-degree burns to the right cheek, right breast, right shin, and bilateral feet. This was told to LVN A at facility and explained that the patient had second degree burns. LVN A stated we didn ' t pour anything on her. The Admitting Physician advised the nurse that she did not accuse her of pouring anything on the patient, but rather it seemed that Resident #1 had contact with a hot surface such as being outside on the ground in the heat. The nurse (LVN A) denied this. The report further read: The Admitting Physician noted that she was quite concerned with this nursing home and she did not believe the information provided to me by the nurse (LVN A) at the nursing home, the patient's (Resident #1) clinical picture, and physical findings were not consistent in anyway with the story that was given . Assessment and Plan: 1. Acute respiratory failure secondary to malignant hypertension with second degree burns from severe prolonged heat exposure. We will admit patient to ICU. The patient has been intubated. We will consult pulmonology for further recommendations. We will continue with current vent settings for now. 2. Hyperkalemia, likely secondary to acute rhabdomyolysis (the breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood) 3. Diabetes type II 4. Acute renal failure with acute rhabdomyolysis secondary to prolonged heat exposure. 5. Surveillance, epidemiology, and end results. The patient does meet surveillance, epidemiology and end results criteria with tachycardia and lactic acidosis, but given the patient ' s [DIAGNOSES REDACTED] from prolonged heat exposure, she felt all of these criteria can be explained by that heat exposure. 16. Suspected neglect. As mentioned above in the history of present illness, I (Admitting Physician) did feel that the facility ' s story of what happened with this patient (Resident #1) is inaccurate and purposely so. I do feel that the patient was neglected. I feel that if it was not, if she had been watched thoroughly; a. She would not fallen last week and received abrasions. b. She would not have been out in the heat for a prolonged amount of time today and presented to the ER as she did. Record review of hospital emergency room report dated 08/07/2016 and signed at 8:43 pm by the ER Department physician read: It was important to note that the story given by the nursing home staff to EMS and the police department did not seem consistent with the injuries found on this patient. There was very real concern for neglect at the facility in the case of this patient and formal complaint will be filed with Department of Aging and Disability services. In an interview with emergency room (ER) Nurse on 08/11/2016 at 12:41 pm she said the facility nurse called ER to give report and said that Resident #1 was in and out of the facility all day and was being sent to ER for congestion and a temp of 100.0. ER nurse said when Resident #1 arrived she had 2nd degree burns to her right cheek, right breast, left great toe and burns to her legs. ER nurse said Resident #1 had a rectal temperature of 106.0 upon arrival to ER and her lactate was 6. Resident #1 was unresponsive, had no gag reflex, intravenous fluids were started, ice packs were used to cool down resident and she was intubated. ER nurse said she called facility after Resident #1 arrived as Resident #1 ' s injuries were not consistent with the original report. ER nurse said she spoke to LVN A and informed her that the report was inconsistent with the injuries. ER nurse reported that LVN A said I didn ' t ' t pour anything on her after ER nurse had informed her that Resident #1 had contact 2nd degree burns. ER nurse said she informed LVN A that she was not accusing her of pouring anything on resident but needed more information regarding injuries as being outside for 20 minutes would not cause 2nd degree contact burns. ER nurse said LVN A insisted resident had only been outside for 20 minutes and then LVN A hung up on ER nurse. In an interview with emergency room (ER) physician on 08/11/2016 at 12:47 pm she revealed that Resident #1 presented to emergency room unresponsive, dehydrated, without gag reflex and was intubated. ER physician said Resident #1 had 2nd degree burns to her right cheek, right side of neck, right breast and left foot. ER physician said that Resident #1 had a rectal temperature of 106.0 degrees upon arrival to ER but believes that her core temperature was much higher before arriving to facility as the Emergency Medical Personal (EMS) had informed her that Resident #1 had towels packed with ice all around her when they arrived and her gown and bed linens were soaking wet. ER physician said Resident #1 was going to be admitted to hospital and once admitting physician and ER physician discussed the extent of the burns it was decided that she should be transported to a burn unit. In an interview on 8/9/2016 at 9:00 AM with Resident #1 ' s Responsible Party (RP) revealed he stated Resident #1 had a fall last week on 8/2/2016 on the same outside patio and sustained an abrasion to her forehead. He stated he came to the facility to speak with the Administrator regarding the fall from 8/2/2016 to see if there was anything that could be done for the patio so that no one else falls or gets hurt while outside. He stated the Administrator said she would reach out to corporate environment director for answers. Further interview revealed he received a phone call from LVN A on 8/7/2016 stating Resident #1 would be transferred to the hospital. He stated LVN A informed him that she tried several times to get Resident #1 back into the facility, as she was sitting outside on the patio; she refused several times. LVN A stated Resident #1 was only outside for 20 minutes. He stated he would get to the hospital as soon as he could. Prior to getting to the hospital, Resident #1 ' s RP stated he received a call from the hospital doctor wanting to know when he could get to the hospital and wanted to know if he knew anything else about her care because what she was seeing did not match with what the nurse from the nursing facility stated. Resident #1 ' s RP stated he did not and was told she refused to come inside. When he got to the hospital, he stated he could see she had burns throughout her entire body. The doctors at the hospital informed him that Resident #1 would be transferred to a burn unit in a different hospital. In an interview on 8/9/2016 at 9:50 AM with MA C, she stated around 3:45pm she was on another unit when LVN A came around the corner and asked her to page a nurse because she needed help. MA C went to page the nurse and she then asked LVN A if she needed her help and LVN A said, yes . MA C stated when she went to the secure unit with LVN A she seen Resident #1 sitting outside in a chair. LVN A was calling Resident #1 ' s name but she was unresponsive. MA C helped LVN A transfer Resident #1 in a wheelchair. LVN A then asked MA C to get ice and water and LVN A rolled Resident #1 into the shower room and began putting water on her body. MA C stated she asked LVN A what the scars were from that were on her face and LVN A stated it was from a previous fall that Resident #1 had. In an interview on 8/9/2016 at 10:10 AM with LVN A she stated that around 3:00 PM on 8/7/2016 she was on the secure unit passing out snacks and waiting for a CNA to come help her on the unit. LVN A stated she went outside and gave Resident #1 a snack and she began to eat it. LVN A stated 20 minutes later she noticed the other residents that were outside had come in but Resident #1 did not come in. LVN A stated various times she went outside to see if Resident #1 would come inside and she refused. LVN A stated she went back outside and noticed Resident #1 was sweating and mumbling small words that she could not understand. LVN A stated she went inside and asked MA C for her to help with Resident #1. She also stated CNA B came to help as well. She stated with the help of CNA B and MA C they got Resident #1 back into the facility and gave her fluids. LVN A stated she got Resident #1 back in the bed and by this time Licensed Practical Nurse (LPN) D came to assist. LPN D then went to get the crash cart and called 911. LVN A stated when 911 got to the facility Resident #1 was lying in bed, labored breathing, slow responsiveness and very lethargic. LVN A stated her skin had redness to her face and upper chest. In an interview on 8/9/2016 at 2:10 PM with CNA B, she stated that on 8/7/2016 she arrived at the facility at 2 PM. She stated around 3:30 PM, almost 4 PM, LVN A asked for help outside and Resident #1 was sitting on the bench while Resident #2 was wiping Resident #1 ' s nose. CNA B stated her and MA C helped LVN A get Resident #1 into a wheelchair. CNA B stated Resident #1 was so weak that she could not stand up by herself or pick her legs up. During this time there was water outside with them that MA C provided and LVN A poured the water on Resident #1 ' s head and her cheeks began to peel and they rushed her inside to the shower room. CNA B stated LVN A told her to put cold water on her but CNA B stated she told her no, it would shock her and they put warm water on her, starting with the legs and working their way up. CNA B stated at that point they were then instructed by LVN A to push Resident #1 into her room and for MA C to get some ice. CNA B stated Resident #1 ' s breathing was shallow and LPN D was bringing the oxygen to put on her but EMS had arrived and took over. CNA B stated MA C took Resident #1 ' s temperature and it was 104.1. In an interview on 8/9/2016 at 2:53 PM with LPN D, she stated around 4 PM she was on another hall working when CNA B called to her saying they needed help and Resident #1 was not responding. LPN D stated she went over and immediately called 911. She stated Resident #1 was in a wheelchair when she saw her. She stated Resident #1 ' s eyes were closed and she was nonresponsive but warm to touch. LPN D stated one side of Resident #1 ' s forehead was peeling, but she could not remember which side exactly. When LPN D asked LVN A what happened, she stated LVN A told her Resident #1 was outside and when she tried to get her in, she refused. LPN D stated she heard gurgling sounds from Resident #1 and went to get the crash cart but by the time she got back EMS had arrived. In an interview on 8/9/2016 at 3:48 PM with the DON, she stated the secure unit was normally staffed with two workers; either a nurse and an aide or a nurse and a medication aide. The DON stated LVN A usually called her on the weekend about anything and everything. The DON stated she was not aware that LVN A was working alone until she called stating she was sending Resident #1 to the emergency room . In an interview on 8/10/2016 at 12:15 PM with Resident #2, she stated she was sitting by the middle window in the dining room and she saw Resident #1 sitting outside in a chair. Resident #2 stated Resident #1 was outside for about an hour. In an interview on 8/12/2016 at 11:20 AM with LVN E she stated she was on call for 8/6/2016 and 8/7/2016. She stated LVN A called her after 2:00 PM in the afternoon and told her she needed a CNA because she was by herself on the secure unit. LVN E informed her that she would try to call someone in to help her. In an interview with the ER physician on 08/17/2016 at 9:48 am she said she believed Resident #1 was left outside unattended for more than 1 hour to sustain the injuries that she did. The ER physician further said that Resident #1 would have had to have contact with the hot concrete on the patio for more than 30 minutes to sustain the 2nd degree burns to her right cheek, right side of neck and right breast. ER physician further revealed that she was positive that Resident #1's core body temperature was higher than 106.0 before arriving to ER due to the ice packed towels that the facility had packed around resident when EMS arrived. Attempted interview with admitting physician via phone on 08/11/2016 at 12:55 pm, message to return call was left. Interview with Admitting Physician on 08/17/2016 at 9:54 am revealed that when she evaluated Resident #1 in the ER that Resident #1 had 2nd degree burns on her right cheek, right side of neck, and right breast. Admitting physician said the burns were consistent with contact burns and it appeared that Resident #1 had fallen and had been lying on her right side in a fetal position on a hot surface as Resident #1 ' s right side of face, right side of neck, right breast and left medial foot had 2nd degree burns on them. When asked by surveyor how long did she suspect Resident #1 had contact with hot surface, admitting physician said 20-30 minutes contact with hot surface. Admitting physician said Resident #1 was outside longer than 30 minutes for the dehydration and other injuries related to heat exposure. Admitting physician said once Resident #1 was hydrated they were able to see the extent of the burns and due to the degree of the burns and surface area they chose to transfer Resident #1 to a burn facility. Record review of Excessive Heat policy dated June 2012 read, Facility will establish procedures to be taken to prepare the facility, in the even excessive heat occurs in or to provide adequate care and comfort to residents . An IJ was identified on 08/09/16 and the Administrator and DON were notified at 3:30PM. A plan of removal (POR) for the IJ was submitted on 08/09/16 at 9:06PM and after several revisions it was accepted on 08/12/16 at 1:07PM. The POR included in part: Immediate Action 1. The facility assessed residents at risk of hydration. 2. Hydration stations were set up at each entrance/exit. Dietary staff was educated on their responsibility to replenish the hydration stations from the dietary manager. The set times for hydration replenishment are: 7am, 9am, 11am, 1:30pm, 3:30pm, 5:30pm and 7pm. All training for the dietary staff was completed on 8/10/16. The dietary aide will be responsible for replenishment. The dietary manager will be responsible for monitoring compliance. On off hours the cook, Manager on Duty (for weekends) and weekend RN supervisor will also monitor for compliance. All of the hydration carts were set up on 8/7/16. Each resident will continued to be offered fluids upon two hour rounds, when outside with staff and at meals. Hydration through activities will also be offered. 3. Logs were put into place for the secured unit for monitoring for exit seeking. The logs are visual checks to ensure that no one is outside in any extreme weather. It documents if anyone is outside and what the staff did to redirect the patient from outside. This is done each hour. Management spot checks the logs throughout the day and on weekends with the manager on duty. The cameras will be checked daily from the maintenance director and on the weekend by the manager on duty. If a monitor is not functioning the maintenance director and administrator will be notified and if it is not able to be repaired the facility will purchase another one immediately. The nurse along with the DON, Admin, Unit Manager and Managers on duty will monitor the log. 4. Interventions the facility put into place to redirect the residents away from the exit during extreme weather, were door alarms, stop signs on each exit door leading out outside, black mat at each exit. All of these interventions were put into place on 8/8/16. The black mat is a technique used with Alzheimer/dementia patients. Management checks these interventions daily to ensure they are in place. The maintenance director will check the alarms daily and document his findings on a daily log. The manager on duty for the weekend will also document a check that the alarms are operable. Any issues will be immediately reported to the administrator and maintenance director. There are blinds on several of the windows. The facility will remove the blinds as of 8/12/16. 5. Umbrella purchased for outside courtyard seating area to provide shade when residents are outside on sunny day and was purchased on 8/8/16. Residents will not be outside without the supervision of staff or a family member. If a resident does go outside unattended, the staff will attempt to redirect the resident. If the resident refuses the staff will stay with the resident and offer hydration until the resident agrees to return inside. 6. Education started on 8/8/16 to nursing staff related to heat and their response on what to do when you see a resident outside in extreme temperatures. No staff will work until in-servicing has taken place. All in-servicing will be completed by 8/11/16. On Call Nurse have been in-serviced that the DON and LNFA must be notified of a call in or a no call no show by the DON (8/8/16) The on call nurse is required to call the LNFA and DON to inform us of any call in and her solution to address the issue. If on call nurse cannot find replacement within on call staff must report to facility for duty. Until the on call nurse can reach the facility the nurses have been in-serviced that staff must be adjusted to ensure that one staff member may not be left on the unit. (8/11/16). The facility will schedule two staff members on the unit. And depending on the census staffing will be adjusted. The logs were put in place for staff to do visual checks to check the patio every hour. Administration developed the logs and staff were in-serviced by the DON (8/8/16). The patio has been assessed for shaded areas. However, because the entire roof area is open all areas of the patio are subjected to sunlight until sundown. There are no blind spots at all to the block the visibility to the courtyard. Monitoring to ensure PoR was implemented was as follows: Policy on how to care of the residents during periods of extreme heat was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning staffing, care for residents outside in extreme temperatures, hydration and the monitoring of residents in the locked units. No identified issues were noted. On 08/14/16 nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning staffing, care for residents outside in extreme temperatures, hydration and the monitoring of residents in the locked units. Nurses interviewed consisted of LVNs and RNs. On 08/14/16 CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident outside in an extreme temperature, hydration of residents and care of residents in the locked unit. While the IJ was removed on 08/14/16 at 11:20 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility census listed 18 residents in the locked unit

Based on interview and record review, the facility failed to consult with the resident's physician when there was a change in condition in one of ten residents (Resident #3) reviewed for consulting with the physician. The Assistant Director of Nursing (ADON) failed to properly assess, identify a change of condition and immediately consult with the physician or seek emergency medical care for Resident #3 after a change in condition resulting in the resident being admitted to intensive care unit and in a semi-coma (mild coma state where the person reacts to stimuli). These failures affected one resident whose care was compromised due to staff neglecting to adequately assess, monitor and immediately consult with the physician and placed the other 51 residents residing on the 200 hall at risk for not having a change of condition immediately reported to the physician, which could lead to decline in health, hospitalization , or death. # 0 and # 2 Findings include: Resident # 3 Record review of Resident #3 ' s clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3 ' s care plan dated 5/14/16 revealed he was care planned for behaviors including screaming loudly, abusive language, and hanging out of bed. Resident #3 was also care planned for a [DIAGNOSES REDACTED]. Record review of Resident #3 ' s clinical record revealed the Medication Administration Record [REDACTED]. (It was increased to [MEDICATION NAME] 25 mg one by mouth twice a day and [MEDICATION NAME] 50mg one by mouth at bedtime from [MEDICATION NAME] 25mg one at bedtime.) Resident #3 had received the new dosage from 5/16/16-5/21/16 with no documentation of lethargy on MAR indicated [REDACTED]. Record review of physician orders [REDACTED]. Accuchecks BID AC (meaning two times a day with meals.) Interview on 5/26/16 at 2:12PM the Assistant Director of Nurses (ADON) said that Resident #3 had slept during his shift. When asked if he was notified that Resident #3 did not eat or take his AM medications he said yes. When asked if he went in to see Resident # 3, ADON said yes and he was able to arouse him. When asked if he consulted with the physician of Resident #3 ' s change of condition, the ADON said no, he thought he was just sleepy because of new medications. When asked if Resident #3 had slept all shift and was unable to be aroused for medications or meals before, he said no. When asked if he discussed Resident #3 ' s condition on the 24 hour report, the ADON said I don ' t recall . In the interview on 5/26/16 at 2:20pm, the ADON reported checking Resident #3 ' s blood sugar but would not give a specific result, however record review of MAR for 5/22/16 revealed no results for blood sugar for the morning shift. Interview on 5/26/16 at 2:30PM the Director of Nursing (DON) said that she did not know how Resident #3 ' s condition was during the morning shift. She said that the first time she heard anything about Resident #3 ' s condition was when Licensed Vocational Nurse (LVN) C notified her after 2PM and EMS was alerted. Interview on 5/26/16 at 3:35PM, LVN C said that Certified Nursing Assistant (CNA) A came to get her around 2PM to check on Resident #3 because he was unresponsive. When she went into Resident #3 ' s room she discovered the resident in bed, unresponsive. He was not arousable to verbal or physical stimuli. LVN C said that the resident also had labored breathing. LVN C said she immediately notified the physician and called 911. She said Resident #3 was flaccid (soft or limp) and did not open his eyes. Blood sugar checked revealed a result of 19. [MEDICATION NAME] was given and the blood sugar increased slightly to 24 and Resident #3 was transported to the Hospital. LVN C said that the ADON had already gone at this time. She said she did not get report from ADON regarding Resident #3 and he was not included on the 24 hour report used to give report to the oncoming shift. LVN C said that Resident #3 was usually active, trying to get out of bed. Interview on 5/28/16 at 10:42AM CNA) A said that Resident #3 was not responsive during her shift (6a-2p). She said that on 5/22/16 she was unable to awaken Resident #3 to eat breakfast or take his morning medications. She said she notified the ADON, but he did not go to check on the resident. She stated she did not see the ADON (He was also the 6a-2p charge nurse) until after 9AM. She said that mid-morning (unable to specify time) she went in to check Resident #3 and he was in the same state, unable to be aroused. She said Resident #3 was not able to wake up for lunch and did not eat lunch. She again notified the ADON and he said Resident #3 was just sleeping because of the new medication he was on and did not go in to the room to check on the resident. She stated that at around 2PM she went to get the evening shift nurse to look at Resident #3. Licensed Vocational Nurse (LVN) C went to check on the resident and the resident was unresponsive and unable to be aroused. LVN C immediately called the physician and alerted EMS. CNA A said that she never saw the ADON go in to Resident #3 ' s room to check on him. CNA A said she did not notify anyone else on the morning shift because she notified the ADON and she thought that would be enough. When asked, what the process was for reporting resident change of condition, she said she should have notified the Director of Nursing (DON) when the ADON did not check the resident. CNA A said that Resident #3 was never like this, he was very active and she stated he ate all of his meals. Interview on 5/28/16 at 10:22AM, Medication Aide (MA) K said that Resident #3 was not able to be aroused to take his 9AM medications on 5/22/16 and she notified the ADON . She said she was not sure if he went to check on the resident, but she never saw him go in Resident #3 ' s room. MA K said that Resident # 3 usually was awake and would take his medications. Record review of nurses notes from 5/22/16 revealed a note from LVN C at 2:30PM, the note read the following: Received resident lying in bed. Nonresponsive to verbal stimuli. Vital signs were, Blood Pressure-152/78, Pulse-86, Respirations-16, Temperature 99.1, Oxygen saturation 98% on room air. Blood sugar was 19. [MEDICATION NAME] administered blood sugar increased to 24, physician notified, new order to send resident to Hospital. Transported by EMS at 2:45PM, all parties notified. Record review of Resident #3 ' s chart initially did not include nurse ' s note from 6am-2pm shift on 5/22/16 or blood sugar results. When the surveyor requested the MARs for Resident #3 additional records were received. Review of the additional records revealed: a nurses note on a separate sheet of paper dated 5/22/16 at 12:50PM from the ADON that read in part: Resident resting without acute changes. No signs of distress noted, arousable to stimuli. Interview on 5/28/16 at 11:19AM the DON said that Resident #3 was in a coma at the Hospital. She said that if the CNAs notify a charge nurse of a change of condition on a resident, then the nurse should immediately go in to assess the resident and notify the physician of a change of condition. She said that if the nurse did not respond, then the CNA should notify someone else, following the chain of command. She said that ADON told her the reason he did not notify anyone of Resident #3 ' s change of condition was because he thought he was just sleeping due to change in medications. Interview on 6/2/16 at 1:38PM, Corporate Nurse said that ADON had been suspended by the corporate office pending an investigation. The facility census on Station 2 was 52.

Based on interview and record review, the facility failed to develop and implement policies and procedures that prohibit neglect for one of ten residents (Resident #3) reviewed for consulting with the physician. The Assistant Director of Nursing (ADON) failed to properly assess, identify a change of condition and immediately consult with the physician or seek emergency medical care for Resident #3 after a change in condition resulting in the resident being admitted to intensive care unit and in a semi-coma (mild coma state where the person reacts to stimuli). These failures affected one resident whose care was compromised due to staff neglecting to adequately assess, monitor and immediately consult with the physician and placed the other 51 residents residing on the 200 hall at risk for not having a change of condition immediately reported to the physician, which could lead to decline in health, hospitalization , or death. # 0 and # 2 Findings include: Resident # 3 Record review of Resident #3 ' s clinical record revealed he was a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3 ' s care plan dated 5/14/16 revealed he was care planned for behaviors including screaming loudly, abusive language, and hanging out of bed. Resident #3 was also care planned for a [DIAGNOSES REDACTED]. Record review of Resident #3 ' s clinical record revealed the Medication Administration Record [REDACTED]. (It was increased to [MEDICATION NAME] 25 mg one by mouth twice a day and [MEDICATION NAME] 50mg one by mouth at bedtime from [MEDICATION NAME] 25mg one at bedtime.) Resident #3 had received the new dosage from 5/16/16-5/21/16 with no documentation of lethargy on MAR indicated [REDACTED]. Record review of physician orders [REDACTED]. Accuchecks BID AC (meaning two times a day with meals.) Interview on 5/26/16 at 2:12PM the Assistant Director of Nurses (ADON) said that Resident #3 had slept during his shift. When asked if he was notified that Resident #3 did not eat or take his AM medications he said yes. When asked if he went in to see Resident # 3, ADON said yes and he was able to arouse him. When asked if he consulted with the physician of Resident #3 ' s change of condition, the ADON said no, he thought he was just sleepy because of new medications. When asked if Resident #3 had slept all shift and was unable to be aroused for medications or meals before, he said no. When asked if he discussed Resident #3 ' s condition on the 24 hour report, the ADON said I don ' t recall . In the interview on 5/26/16 at 2:20pm, the ADON reported checking Resident #3 ' s blood sugar but would not give a specific result, however record review of MAR for 5/22/16 revealed no results for blood sugar for the morning shift. Interview on 5/26/16 at 2:30PM the Director of Nursing (DON) said that she did not know how Resident #3 ' s condition was during the morning shift. She said that the first time she heard anything about Resident #3 ' s condition was when Licensed Vocational Nurse (LVN) C notified her after 2PM and EMS was alerted. Interview on 5/26/16 at 3:35PM, LVN C said that Certified Nursing Assistant (CNA) A came to get her around 2PM to check on Resident #3 because he was unresponsive. When she went into Resident #3 ' s room she discovered the resident in bed, unresponsive. He was not arousable to verbal or physical stimuli. LVN C said that the resident also had labored breathing. LVN C said she immediately notified the physician and called 911. She said Resident #3 was flaccid (soft or limp) and did not open his eyes. Blood sugar checked revealed a result of 19. [MEDICATION NAME] was given and the blood sugar increased slightly to 24 and Resident #3 was transported to the Hospital. LVN C said that the ADON had already gone at this time. She said she did not get report from ADON regarding Resident #3 and he was not included on the 24 hour report used to give report to the oncoming shift. LVN C said that Resident #3 was usually active, trying to get out of bed. Interview on 5/28/16 at 10:42AM CNA) A said that Resident #3 was not responsive during her shift (6a-2p). She said that on 5/22/16 she was unable to awaken Resident #3 to eat breakfast or take his morning medications. She said she notified the ADON, but he did not go to check on the resident. She stated she did not see the ADON (He was also the 6a-2p charge nurse) until after 9AM. She said that mid-morning (unable to specify time) she went in to check Resident #3 and he was in the same state, unable to be aroused. She said Resident #3 was not able to wake up for lunch and did not eat lunch. She again notified the ADON and he said Resident #3 was just sleeping because of the new medication he was on and did not go in to the room to check on the resident. She stated that at around 2PM she went to get the evening shift nurse to look at Resident #3. Licensed Vocational Nurse (LVN) C went to check on the resident and the resident was unresponsive and unable to be aroused. LVN C immediately called the physician and alerted EMS. CNA A said that she never saw the ADON go in to Resident #3 ' s room to check on him. CNA A said she did not notify anyone else on the morning shift because she notified the ADON and she thought that would be enough. When asked, what the process was for reporting resident change of condition, she said she should have notified the Director of Nursing (DON) when the ADON did not check the resident. CNA A said that Resident #3 was never like this, he was very active and she stated he ate all of his meals. Interview on 5/28/16 at 10:22AM, Medication Aide (MA) K said that Resident #3 was not able to be aroused to take his 9AM medications on 5/22/16 and she notified the ADON . She said she was not sure if he went to check on the resident, but she never saw him go in Resident #3 ' s room. MA K said that Resident # 3 usually was awake and would take his medications. Record review of nurses notes from 5/22/16 revealed a note from LVN C at 2:30PM, the note read the following: Received resident lying in bed. Nonresponsive to verbal stimuli. Vital signs were, Blood Pressure-152/78, Pulse-86, Respirations-16, Temperature 99.1, Oxygen saturation 98% on room air. Blood sugar was 19. [MEDICATION NAME] administered blood sugar increased to 24, physician notified, new order to send resident to Hospital. Transported by EMS at 2:45PM, all parties notified. Record review of Resident #3 ' s chart initially did not include nurse ' s note from 6am-2pm shift on 5/22/16 or blood sugar results. When the surveyor requested the MARs for Resident #3 additional records were received. Review of the additional records revealed: a nurses note on a separate sheet of paper dated 5/22/16 at 12:50PM from the ADON that read in part: Resident resting without acute changes. No signs of distress noted, arousable to stimuli. Interview on 5/28/16 at 11:19AM the DON said that Resident #3 was in a coma at the Hospital. She said that if the CNAs notify a charge nurse of a change of condition on a resident, then the nurse should immediately go in to assess the resident and notify the physician of a change of condition. She said that if the nurse did not respond, then the CNA should notify someone else, following the chain of command. She said that ADON told her the reason he did not notify anyone of Resident #3 ' s change of condition was because he thought he was just sleeping due to change in medications. Interview on 6/2/16 at 1:38PM, Corporate Nurse said that ADON had been suspended by the corporate office pending an investigation. The facility census on Station 2 was 52.

Based on observations, interview and record review, the facility failed to develop and implement policies and procedures that prohibit the mistreatment and neglect of residents for two of 11 residents (Resident #1 and Resident #2) reviewed for neglect as evidenced by: The facility failed to obtain the x-ray results for Resident #1, who fell on [DATE]. Resident #1 had a stat (immediately) x-ray ordered by the physician. The x-ray was obtained on 4/30/16 at 3:30pm but the results were not obtained by the facility staff for 45 hours on 5/2/16 at 12:30 p.m. The x-ray results revealed a fracture at the base of the tibial tuberosity (the upper part of the leg closest to the knee) and resident was then sent to hospital for treatment. Resident # 2 had a fall on 05/12/16 at 4:00 am. The resident was not provided any medical intervention until 6:20 pm when she was transferred to the hospital and was assessed to have pneumonia and a left anterior iliac spine (the attachment site for the thigh muscle that helps bend the hip and knee) avulsion fracture (where the tendon and/or ligament pulls away from the bone). An IJ was identified on 05/18/16. While the IJ was removed on 05/21/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents who received injuries from a fall that required them to be transferred to the hospital for treatment and placed 57 additional residents who were totally dependent on staff for care and activities of daily living (ADL) at risk for neglect and injury. Intakes: # 5 and # 9 Findings Include: Record review of Abuse and Neglect Policy provided by facility with a revision date of June 2013 read: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. -Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. -Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. 4. The facility will provide education for those additional individuals involved with the resident. Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female with an original admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Her primary language was Spanish. Record review of Resident # 1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed to have modified impaired cognitive skills for daily decision making. The MDS further revealed the resident required supervision with one person physical assist with transfers, dressing, and toilet use. The MDS also revealed Resident #1 required limited assistance of one person with locomotion on the unit and for personal hygiene. Record review of Resident #1 ' s care plan dated 10/29/15 with a review date of 4/21/16 for Resident #1 revealed the following: -Cognitive Deficit as evidenced by a short-term and long term memory loss related to severe impairment with possible signs and symptoms of [MEDICAL CONDITION]. Approaches documented included: orient to time, day, date and place as care is provided, staff will introduce self and or visitors whenever possible, staff will offer options in simple terms regarding care for resident to choose, explain any changes in care to resident as needed, and provide resident time to think/react to information given. -[DIAGNOSES REDACTED]. -Pain related to chronic disease ([MEDICAL CONDITIONS], and [MEDICAL CONDITION]). Approaches included: positioning and support, music, administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing), monitor every shift, notify physician if interventions are not consistently effective, medicate resident for pain prior to treatments, therapy referral as indicated. Record review of Resident #1 ' s care plan dated 2/22 (no year documented) revealed she was care planned for falls. Approaches included: provide device to fall prevention, evaluate progress every month and as needed, explain using terms and gestures resident can understand, allow ample time and do not rush and keep MD and Director of Nursing (DON) informed of resident progress. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 11:30 am revealed Resident #1 was found on the floor near the doorway of another resident ' s room. Resident #1 was found sitting on her bottom . Resident #1 was assisted to her wheelchair by nurse and CNA ' s (certified nursing assistant) and then put back in bed. Nurses note further read: Resident #1 ' s left knee was reddened and had a small non-bleeding abrasion and a large green hematoma. The on-call physician was called and ordered an x-ray and Tylenol 325mg. Resident #1 declined Tylenol and denied pain at the time. (As conveyed by CNA A who spoke both Spanish and English). X-rays were ordered and said to arrive in two hours. Nurse Supervisor also notified, assisted in the attempt to administer Tylenol and succeeded with Resident #1 now complaining of pain. The 325mg Tylenol was administered at noon and family was notified via voicemail. Record review of Resident #1 ' s Situation Background Assessment Recommendation (SBAR) Communication Form dated 04/30/16 at 11:30 am read in part . the physician was notified that Resident #1 was found on floor in the doorway of another resident ' s room, sitting on her bottom. In the section for Mental Status Evaluation the word agitated was written. Documented on the Skin Evaluation section abrasion was checked and hematoma (L) knee large was written. Documented under the Pain Evaluation the words facial grimacing was written and a pain score of 10 was documented on a scale of 1/10. New orders were received for an x-ray of the left knee and Tylenol 325mg. SBAR Communication Form was signed by Agency Nurse C. In an interview on 05/19/16 at 12:33 pm with Agency Nurse C she said she felt she did everything she was supposed to do regarding the care of Resident #1 following her fall on 4/30/16. Agency Nurse C said she assessed Resident #1 after her fall on 4/30/16 but did not perform range of motion to her extremities. She said Resident #1 seemed alright and even assisted staff with the transfer to the wheelchair and then to the bed. When asked why she did not perform neuro vital signs, Agency Nurse C said Resident #1 was not cooperative and kept ranting and raving and refusing care. Agency Nurse C said Resident #1 denied any pain. Agency Nurse C further revealed after Resident #1 was assisted to bed she noted a Large green hematoma to Resident #1 ' s left knee with a small abrasion and was not sure if the injury was new or old. Agency Nurse C said she notified Registered Nurse (RN) D who was the weekend supervisor about the fall and RN D assisted her (Agency Nurse C) through the whole ordeal . Agency Nurse C said she did not notify the DON of the fall because RN D said not to. Agency Nurse C said the physician and RP were called. She stated she had received the order for the x-ray to the left knee. When asked if x-rays were ordered STAT, Agency Nurse C could not recall. Agency Nurse C further revealed she did not follow up on the x-ray report but did inform the incoming nurse, Licensed Vocational Nurse (LVN) G of Resident #1 ' s fall and documented it on the 24 hour report. Record review of Resident #1 ' s Medication Administration Record [REDACTED]. The April 16 MAR further revealed Resident #1 received daily Aspirin 81 mg. Record review of Resident #1 ' s Pain Evaluation dated 4/30/16 (post fall) revealed Resident #1 had received PRN (as needed) pain medication. Pain was rated at a 5-6 on the FACES pain scale. The Pain Evaluation form further revealed Resident #1 denied pain in the last five days. Record review of Resident #1 ' s Head to Toe Skin Check dated 04/30/16 for the 6:00 am to 2:00 pm shift read: (L) knee green colored hematoma. STAT x-ray pending. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 12:00 pm read: neuro check refused by Resident #1. Will follow up for pain assessment. Resident #1 seemed to be alert and oriented according to baseline. Record review of Resident #1 ' s nurse notes dated 4/30/16 at 12:30 pm read: neuro check denied. Resident #1 will not allow vitals and denied pain. Fusses with care. Seems alert and oriented according to baseline. Will follow up with pain assessment and neuro in 30 minutes. Record review of nurse notes dated 4/30/16 at 1:00 pm -5:30pm revealed Resident #1 refused neuro checks and denied pain and pain management. Record review of nurse notes dated 04/30/16 at 2:13 pm read: Called Nurse Practitioner to get order for STAT [MEDICATION NAME] injection due to Resident #1 continuously fussing , denying care and seeming agitated. STAT ordered for 2mg injection to ensure Resident #1 complies with x-ray. Record review of nurse notes dated 04/30/16 at 2:30 pm read in part .Denies [MEDICATION NAME] injection. Will follow up in 1 hour. Record review of nurse notes dated 04/30/16 at 3:30 pm read: X-ray tech arrived; was able to obtain x-ray on (L) knee of Resident #1. Neuro checks attempted. Resident #1 denied and refused care. Resident #1 seemed alert and oriented according to baseline. No pain indicated. Record review of Neurological Record dated 4/30/16-5/4/16 revealed neurological vital signs were started on 04/30/16 at 6:00 pm. Record review of nurse notes dated 05/02/16 at 11:20 am revealed: Nurse Practitioner on site. Assessed resident. New order, send to hospital emergency room for [DIAGNOSES REDACTED]. Message left. Resident #1 told by translator of new order. Resident #1 sitting in wheelchair. Call light in reach. Record review of x-ray report of Resident #1 ' s left knee provided by facility DON revealed the report had been faxed to the facility on [DATE] at 12:35 pm. The X-ray dated 04/30/16 revealed: [MEDICAL CONDITION] tibia. Hand written by Assistant Director of Nursing (ADON) at bottom of faxed x-ray report revealed: RP notified, MD notified, verbal order to send to hospital emergency for fracture. Record review of nurse notes dated 05/02/16 at 2:30 pm revealed: Resident #1 continued to be out of bed sitting in wheelchair. Denies any pain or discomfort. Resident #1 transferred to hospital for evaluation. Record review of a different Complaint Investigation Worksheet dated 05/18/16 revealed on 04/30/16 during the 2pm-10pm shift a male resident (unknown) purposely ran over a female resident (unknown) with his electric wheelchair. The male resident was angry at the female resident for an unknown reason. The nurse (unknown) took over. The complainant was calling to report that the Administrator was notified about the incident, however the Administrator was negative, ugly and said not to bother her while she was at home, she would take care of that mess on Monday. The Administrator was the reason why nothing else was done. The complainant requested the facility to be investigated to ensure the Administrator was held responsible for her actions. Record review of Provider Investigation Report dated 05/02/16 read: Resident #1 was examined and an abrasion and hematoma was noted to the left knee. Resident #1 was also complaining of pain to the left knee. Physician was notified. A portable x-ray was ordered 05/01/16. On 05/01/16 when asked what happened to her knee by CNA B, Resident #1 stated A young man in a wheelchair pushed her off her the chair . When asked to explain what happened, Resident #1 stated A young man in a wheelchair pushed me. I was leaving my room and I saw him sitting in the middle of the hallway. He went back then forward then back again and forward and I fell on floor . The young man was identified as Resident #3. On 05/02/16 when conducting the follow up incident report and review of x-ray. X-ray revealed a fracture of proximal tibia. Investigation of the incident initiated. MD notified of x-ray results. Resident #3 was placed 1:1 monitoring. Resident #1 was transferred to hospital for evaluation and treatment. Investigation remained in progress. Interview with CNA A was conducted on 05/02/16; Resident #1 stated Resident #3 pushed her down. Resident #3 repeated he made her fall. Resident #1 appeared to be very upset pointing at Resident #3. An interview was conducted with Resident #3. Resident #3 denied knocking Resident #1 down. Resident #3 stated he was sitting in his doorway in his wheelchair and the resident came out of her room screaming and cursing in his doorway. Resident #3 was unable to determine what she was saying because she was screaming and talking so fast. Resident #3 stated Resident #1 was still screaming and cursing stood up and began grabbing on his leg. Resident #3 stated he then put his chair in reverse and backed up, Resident #1 fell to the floor. On 05/02/16 a follow up interview was conducted with Resident #1. Resident #1 then stated she went to the resident ' s room to get some money. Resident #1 was trying to get him to give her some money and Resident #3 kicked her with his legs and Resident #1 fell . Resident #3 denied trying to hurt Resident #1. Incident occurred on 04/30/16. Administrator and DON were notified 05/02/16. Facility confirmed that Resident #1 wandered out of her room into Resident #3 ' s room. Resident #3 denied knocking Resident #1 down on purpose Record review of Resident #1 ' s nurse notes dated 05/02/16 at 7:15 pm revealed: Resident #1 received awake and alert from hospital. Assessment done. Resident #1 noted with cast to left lower extremity. In an interview with the DON on 05/17/16 at 10:15 am she said she was pulling incident reports on Monday (05/02/16) and saw the incident report involving Resident #1 and Resident #3. The DON said staff reported Resident #3 backed into (Resident #1) but believed it was an accident. The DON revealed Resident #3 denied the incident and had said Resident #1 was trying to touch his leg and he backed up (moved away) and Resident #1 fell forward out of her wheelchair. The DON believed the incident to be an accident and revealed Resident #1 had dementia but insisted Resident #3 caused her to fall. In an interview with the DON on 05/17/16 at 1:30 pm she said the incident with Resident #1 and Resident #3 happened on 4/30/16 during the weekend and she became aware of the situation on Monday 5/02/16. The DON said the nurse on duty was an agency nurse (Agency Nurse C) and the facility no longer used agency nurses. The DON further revealed that one on one education was provided to Agency Nurse C for reporting incidents. The DON said she was reviewing the incident reports on Monday (05/02/16) and realized the incident occurred on 4/30/16 and an x-ray had been ordered but not received. The DON revealed the x-ray report was obtained on 05/02/16 and Resident #1 was sent to hospital for evaluation and treatment. When the DON was asked why the x-ray was not received before 05/02/16 she said she was not sure but would find out. She said the Nurse should have followed up on the x-ray and put it on the 24 hour report. The DON further revealed she can ' t believe staff wouldn't assess appropriately . In an interview on 05/18/16 at 12:46 pm the Administrator revealed she had been notified over the weekend by a CNA that Resident #3 ran over Resident #1 with his wheelchair and that the abuse incident was investigated by the DON on 05/02/16 and it was reported to state. The Administrator was not sure why there was an issue regarding Resident #1 and her care as the incident was investigated. She said it was an accident and staff have been educated after the incident when to notify the Administrator and DON of an incident. Observation and interview on 05/17/16 at 12:15pm of Resident #1 revealed she did not have a splint or cast on her left leg. Her left knee was slightly larger than her right knee. Resident #1 said she was at Resident #3 ' s doorway and went to look at something in Resident #3 ' s room and he moved his electric wheelchair. Resident #1 could not recall if Resident #3 moved his chair backwards or forwards and she fell out of her wheelchair to the floor and hit her knee. Resident #1 complained of pain to her left knee. Resident #1 rated the pain at a 4 out of a scale of 1 to 10. In an interview with Resident #1 at 1:00 pm on 05/17/16 revealed she had pain to left leg after the fall but could not recall if she was medicated for the pain. In an interview with Resident #1 ' s physician on 05/17/16 at 11:30 am he said he was not sure of the situation with Resident #1 and he had just heard about the situation earlier this day. He further revealed he would have to review the chart to see what the Nurse Practitioner did concerning Resident #1. In an interview on 05/17/16 at 1:10 pm Resident #1 ' s physician said it was not an ideal situation regarding Resident #1 and her fall on 4/30/16. The physician said people fall at home and do not go to the emergency room until a few days later and then they find out they have a broken bone. When the physician was asked about Resident #1 falling on 04/30/16 and not diagnosed with [REDACTED]. Record review of 24 Hour Report/Change of Condition for Station 3 dated 4/30/16 revealed: Resident #1 refused medications/fell at 11:30 am, hematoma left knee and denies pain and neuro checks. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/01/16 revealed: Resident #1 was status [REDACTED].#1. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/02/16 revealed: Resident #1 went to emergency room for evaluation and returned at 7:15pm. Cast to left lower extremity. [MEDICATION NAME] 600mg 1 po (by mouth) every 4 hours as needed. Tylenol #3 po every 4 hours as needed. Follow up with ortho appointment. Ice pack for the splint x20 minutes every 2 hours x24 hours then 3-4 times for the next 2 days. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/17/16 revealed: Resident #1 had not been seen for ortho follow up per emergency room physician recommendation. Report further revealed cast was removed and RP (responsible person) was notified. In an interview with LVN G on 05/19/16 at 1:51 pm she said she received report from Agency Nurse C on 4/30/16 and was informed that Resident #1 had a fall. LVN G said Resident #1 did not complain of pain during the whole night shift. LVN G said Resident #1 even transferred herself from bed to wheelchair at 2:00 am and was in the hall in her wheelchair. LVN G said Resident #1 ' s knee was red with bruising but not swollen. LVN G said she called for x-ray report on 4/30/16 during her shift but could not recall what time and said she was told the report was not ready. In an interview on 05/19/16 at 10:39 am with CNA Ashe said the day was busy on 04/30/16 and a construction worker notified her that a resident was on the floor. CNA A said when she arrived to the scene that Resident #1 was in a sitting position on the floor in hallway with her legs extended in front of Resident #3 ' s doorway. CNA A said she called for Agency Nurse C. CNA A said she asked Resident #1 if she was in pain and Resident #1 said she was. CNA A said she could not recall what Resident #1 rated her pain at but thought it was a 7 on a scale of 1 to 10. CNA A said Resident #1 was complaining of pain to her left knee and complete left leg and that she informed Agency Nurse C. CNA A said it took three staff to assist Resident #1 to her wheelchair and then to bed and was told by Agency Nurse C to leave her in bed the rest of the day. CNA A said Agency Nurse C tried bending Resident #1 ' s left leg once she was in bed and Resident #1 screamed in pain. CNA A further revealed it was very difficult to provide incontinent care after the fall due to Resident #1 ' s pain. CNA A said Resident #1 normally assisted with incontinent care by moving her own legs but could not after the fall due to pain. CNA A said Agency Nurse C was aware of Resident #1 ' s pain level and thought she medicated Resident #1 with a Tylenol but was not sure. Interview with the Social Worker (SW) on 05/20/16 at 12:00pm revealed Resident #1 had an order to follow-up with the orthopedic physician for her fracture. The SW said Nursing had started working on the referral. She said she usually does the referral but this was a tough case. Resident #1's physician at the facility was not her primary care physician (PCP) and according to the insurance Resident #1's PCP had to make the referral. Since Resident #1 had not seen her PCP a referral could not be obtained for the orthopedic physician. When asked the SW did not have an explanation why Resident #1 had not been seen by the PCP. In an interview with Certified Nurse Aide (CNA) F on 05/20/16 at 2:22 pm she said that CNA A called for assistance on 4/30/16 because Resident #1 was found in hallway on floor. CNA F said Resident #1 was in a sitting position with legs extended in hall outside of Resident #3 ' s room. CNA F said Resident #1 was complaining of pain to her left leg and Resident #1 shook her leg and was touching it . CNA F said the nurse took vital signs while Resident #1 was on the floor and then they assisted Resident #1 to the wheelchair and then to bed. CNA F said she provided care for Resident #1 on 05/01/16 and was very careful when providing incontinent care for Resident #1 due to complaints of pain. CNA F said the nurse was notified during the shift that Resident #1 complained of pain but did not know if Resident #1 was medicated. Interview with the ADON on 05/18/16 at 1:22 pm he said if a resident was found on the floor, a head to toe assessment should be completed, physician notified, responsible party notified, obtain orders from physician, and start Neuro vitals on all unwitnessed falls or on residents who ' s fell and could not verbalize their needs. The ADON said all orders should be followed up on and you should call for diagnostics within 4 hours if not received. Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the Minimal Data Set (MDS) for Resident #2 dated 03/21/16 reveled Resident #2 was severely cognitively impaired. The MDS further revealed Resident #2 was totally dependent and required two people physical assistance for bed mobility, toilet use and personal hygiene and required total dependence with one person assist for eating and dressing. Record review of the Care Plans dated 09/28/2015 with a review date of 03/24/16 revealed Resident #2 was care planned for Cognitive deficit, communication deficit and self-care deficit. -Cognitive Deficit evidenced by: short term memory loss, long term memory loss and altered cognitive skills with daily decision making as evidenced by; sever impairment. Approaches included: orient resident to time, day, date and place as care is provided, staff will introduce self, staff will offer options in simple terms regarding care for resident, explain in changes in care to resident as needed, and provide time to think/react to information given. - Communication deficit and never makes self-understood and never understands others. No approaches identified. -Self-care deficit related to: total assist with bed mobility, total assist with transfers, total assist with locomotion, total assist with toileting, total assist with dressing and grooming and total assist with bathing. Approach: encourage and monitor independence, place call light in reach .assist in turning every two hours, pressure relieving mattress, assist with toileting as needed and give incontinent care every two hours and as needed. Record review of nurse notes dated 05/12/16 at 5:00 am revealed the charge nurse was doing rounds and found Resident #2 siting on floor on her buttocks next to her bed with pillows on the floor around her. No injuries or bruising was noted. This was noted at 4:00 am. Resident was placed back in bed on air mattress by the charge nurse with the assistance of two CNA s. Further assessment was done and no injuries were noted . Vital signs: Blood Pressure -132/70, Pulse-74, Respirations-18, Temperature-98.1. [MEDICATION NAME] injection was given to left buttock at 4:05 am. The medication was unsuccessful for treating the behaviors. ADON notified physician and was told to call back with any changes in Resident #2 ' s status. Neuro checks were in progress. Resident continued to kick and hit trying to throw herself back on the floor. Resident #2 was redirected about kicking and moving, trying to throw self out of bed. Resident #2 continued this behavior. RP called and no voicemail was available. Record review of nurse notes date 05/12/16 at 6:30 am revealed Resident #2 in bed kicking legs in air. No facial grimacing noted. status [REDACTED]. Discoloration and puffiness noted to right eye with skin intact in area. Suctioned x1 with secretions thin and yellowish in color. Record review of physician order [REDACTED]. Record review of nurses note dated 05/12/16 at 6:20 pm revealed EMS (emergency medical service) here to transport Resident #2 to hospital. RP at bedside. Record review of hospital records for Resident #2 revealed she was admitted to hospital on [DATE] at 7:37 pm for a fall from her bed. Review of pelvis x-ray dated 5/12/16 for Resident #2 revealed: left anterior inferior iliac spine avulsion fracture. Record review of x-ray of chest for Resident #2 revealed: bibasilar pneumonia [MEDICAL CONDITION] and/ pneumonia. In an interview with the ADON on 05/17/16 at 12:40 pm he could not recall why Resident #2 was admitted to the hospital. The ADON said that Resident #2 did have a fall but did not hit her head. The ADON said neuro vitals were performed and the physician was notified. The ADON further revealed that a Nurse Practitioner from the physician ' s office evaluated Resident #2 and sent Resident #2 to emergency room for a fall and altered mental status. The ADON further revealed that [MEDICAL CONDITION] care was provided daily and as needed for Resident #2. Observation on 05/18/16 at 9:00 am revealed Resident #2 in hospital with responsible party at bedside. An attempt to interview Resident #2 was made but was unsuccessful due to her cognitive status. In an interview with responsible party on 05/18/16 at 9:02 am she revealed Resident #2 had pneumonia. When asked about fall and injuries related to the fall, responsible party said she was not aware of a fall. In an interview with the DON on 05/18/16 at 12:45 pm she revealed the facility had not followed up on Resident #2 since she was sent to hospital for evaluation on 05/12/16. The DON said she would follow up on Resident #2. In an interview on 05/20/16 at 2:00 pm the DON revealed she had not followed up or received any information regarding Resident #2 and her hospital stay. The DON revealed the Admission coordinator and liaison were responsible for obtaining information on residents who were sent out and usually no information was obtained until resident returned to the facility. When surveyor informed the DON of the fracture to Resident #2 ' s iliac spine and that Resident #2 had a fall at 4:00 am and not sent out until 6:20 pm the DON did not have a comment. Record review of Resident #2 ' s MAR for May 2016 revealed no pain medication was given to Resident #2 on 5/12/16. The MAR further revealed Resident #2 had prn orders for Tylenol #3; 1 tablet per tube every 4 hours as needed and an order for [REDACTED]. Record review of Fall Management policy and procedure provided by facility dated February 19, 2016 read: Post Fall; monitor patient ' s blood pressure, pulse and respirations. Notify the practitioner if you note a change in baseline. A neurological record is conducted upon actual injury, suspected head trauma or any change in level of consciousness. Record review of SBAR Communication policy and procedure dated July 10, 2015 read: SBAR communication breaks communication down into four steps. 1. Situation: a concise description of the patient ' s current situation. 2. Background: historical or current patient data relevant to the patient ' s problem. 3. Assessment: a summary of the nurse ' s analysis of the current situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about patients care. An IJ was identified on 05/18/16 and the Administrator and DON were notified at 12:59pm. A plan of removal (POR) for the IJ was submitted on 05/19/16 at 9:01am and after several revisions it was accepted on 05/20/16 at 6:46pm. The POR included in part: Plan of Removal for Immediate Jeopardy The nursing staff has reviewed x-ray orders received in the past 30 days to assure that x-rays were requested, x-rays were taken, results were received and notification was made to the physician and the responsible party. This audit started on 5/18/16 and was completed on 5/18/16. Care plans and orders were reviewed to assure that orders received in response to the results were implemented timely. This was also done as of 5/18/16. Beginning May 19, 2016 newly received x-ray orders will be logged in a notebook. With each order, the nurse will note the order, the date the order was received, the date and time the request for x-rays was made, the date the x-ray was taken, the date and time the results were received and the date and time the physician and responsible party were notified of the results of the x-rays. Orders will be implemented in response to the results when received. Upon a resident fall, the resident will have a head to toe assessment. A neurological assessment w

Based on observation, interview and record review, the facility failed to implement their written policies and procedures concerning the prohibition, investigating and reporting of neglect for two of 6 residents (Resident #1 and Resident #2) reviewed for falls and change in condition. The facility failed to obtain the x-ray results for Resident #1, who fell on [DATE]. Resident #1 had a stat (immediately) x-ray ordered by the physician. The x-ray was obtained on 4/30/16 at 3:30pm but the results were not obtained by the facility staff for 45 hours on 5/2/16 at 12:30 p.m. The x-ray results revealed a fracture at the base of the tibial tuberosity (the upper part of the leg closest to the knee) and resident was then sent to hospital for treatment. Resident # 2 had a fall on 05/12/16 at 4:00 am. The resident was not provided any medical intervention until 6:20 pm when she was transferred to the hospital and was assessed to have pneumonia and a left anterior iliac spine (the attachment site for the thigh muscle that helps bend the hip and knee) avulsion fracture (where the tendon and/or ligament pulls away from the bone). An IJ was identified on 05/18/16. While the IJ was removed on 05/21/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents who received injuries from a fall that required them to be transferred to the hospital for treatment and placed 57 additional residents who were totally dependent on staff for care and activities of daily living (ADL) at risk for neglect and injury. Intakes: # 5 and # 9 Findings Include: Record review of Abuse and Neglect Policy provided by facility with a revision date of June 2013 read: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. -Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. -Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. 4. The facility will provide education for those additional individuals involved with the resident. Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female with an original admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Her primary language was Spanish. Record review of Resident # 1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed to have modified impaired cognitive skills for daily decision making. The MDS further revealed the resident required supervision with one person physical assist with transfers, dressing, and toilet use. The MDS also revealed Resident #1 required limited assistance of one person with locomotion on the unit and for personal hygiene. Record review of Resident #1 ' s care plan dated 10/29/15 with a review date of 4/21/16 for Resident #1 revealed the following: -Cognitive Deficit as evidenced by a short-term and long term memory loss related to severe impairment with possible signs and symptoms of [MEDICAL CONDITION]. Approaches documented included: orient to time, day, date and place as care is provided, staff will introduce self and or visitors whenever possible, staff will offer options in simple terms regarding care for resident to choose, explain any changes in care to resident as needed, and provide resident time to think/react to information given. -[DIAGNOSES REDACTED]. -Pain related to chronic disease ([MEDICAL CONDITIONS], and [MEDICAL CONDITION]). Approaches included: positioning and support, music, administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing), monitor every shift, notify physician if interventions are not consistently effective, medicate resident for pain prior to treatments, therapy referral as indicated. Record review of Resident #1 ' s care plan dated 2/22 (no year documented) revealed she was care planned for falls. Approaches included: provide device to fall prevention, evaluate progress every month and as needed, explain using terms and gestures resident can understand, allow ample time and do not rush and keep MD and Director of Nursing (DON) informed of resident progress. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 11:30 am revealed Resident #1 was found on the floor near the doorway of another resident ' s room. Resident #1 was found sitting on her bottom . Resident #1 was assisted to her wheelchair by nurse and CNA ' s (certified nursing assistant) and then put back in bed. Nurses note further read: Resident #1 ' s left knee was reddened and had a small non-bleeding abrasion and a large green hematoma. The on-call physician was called and ordered an x-ray and Tylenol 325mg. Resident #1 declined Tylenol and denied pain at the time. (As conveyed by CNA A who spoke both Spanish and English). X-rays were ordered and said to arrive in two hours. Nurse Supervisor also notified, assisted in the attempt to administer Tylenol and succeeded with Resident #1 now complaining of pain. The 325mg Tylenol was administered at noon and family was notified via voicemail. Record review of Resident #1 ' s Situation Background Assessment Recommendation (SBAR) Communication Form dated 04/30/16 at 11:30 am read in part . the physician was notified that Resident #1 was found on floor in the doorway of another resident ' s room, sitting on her bottom. In the section for Mental Status Evaluation the word agitated was written. Documented on the Skin Evaluation section abrasion was checked and hematoma (L) knee large was written. Documented under the Pain Evaluation the words facial grimacing was written and a pain score of 10 was documented on a scale of 1/10. New orders were received for an x-ray of the left knee and Tylenol 325mg. SBAR Communication Form was signed by Agency Nurse C. In an interview on 05/19/16 at 12:33 pm with Agency Nurse C she said she felt she did everything she was supposed to do regarding the care of Resident #1 following her fall on 4/30/16. Agency Nurse C said she assessed Resident #1 after her fall on 4/30/16 but did not perform range of motion to her extremities. She said Resident #1 seemed alright and even assisted staff with the transfer to the wheelchair and then to the bed. When asked why she did not perform neuro vital signs, Agency Nurse C said Resident #1 was not cooperative and kept ranting and raving and refusing care. Agency Nurse C said Resident #1 denied any pain. Agency Nurse C further revealed after Resident #1 was assisted to bed she noted a Large green hematoma to Resident #1 ' s left knee with a small abrasion and was not sure if the injury was new or old. Agency Nurse C said she notified Registered Nurse (RN) D who was the weekend supervisor about the fall and RN D assisted her (Agency Nurse C) through the whole ordeal . Agency Nurse C said she did not notify the DON of the fall because RN D said not to. Agency Nurse C said the physician and RP were called. She stated she had received the order for the x-ray to the left knee. When asked if x-rays were ordered STAT, Agency Nurse C could not recall. Agency Nurse C further revealed she did not follow up on the x-ray report but did inform the incoming nurse, Licensed Vocational Nurse (LVN) G of Resident #1 ' s fall and documented it on the 24 hour report. Record review of Resident #1 ' s Medication Administration Record [REDACTED]. The April 16 MAR further revealed Resident #1 received daily Aspirin 81 mg. Record review of Resident #1 ' s Pain Evaluation dated 4/30/16 (post fall) revealed Resident #1 had received PRN (as needed) pain medication. Pain was rated at a 5-6 on the FACES pain scale. The Pain Evaluation form further revealed Resident #1 denied pain in the last five days. Record review of Resident #1 ' s Head to Toe Skin Check dated 04/30/16 for the 6:00 am to 2:00 pm shift read: (L) knee green colored hematoma. STAT x-ray pending. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 12:00 pm read: neuro check refused by Resident #1. Will follow up for pain assessment. Resident #1 seemed to be alert and oriented according to baseline. Record review of Resident #1 ' s nurse notes dated 4/30/16 at 12:30 pm read: neuro check denied. Resident #1 will not allow vitals and denied pain. Fusses with care. Seems alert and oriented according to baseline. Will follow up with pain assessment and neuro in 30 minutes. Record review of nurse notes dated 4/30/16 at 1:00 pm -5:30pm revealed Resident #1 refused neuro checks and denied pain and pain management. Record review of nurse notes dated 04/30/16 at 2:13 pm read: Called Nurse Practitioner to get order for STAT [MEDICATION NAME] injection due to Resident #1 continuously fussing , denying care and seeming agitated. STAT ordered for 2mg injection to ensure Resident #1 complies with x-ray. Record review of nurse notes dated 04/30/16 at 2:30 pm read in part .Denies [MEDICATION NAME] injection. Will follow up in 1 hour. Record review of nurse notes dated 04/30/16 at 3:30 pm read: X-ray tech arrived; was able to obtain x-ray on (L) knee of Resident #1. Neuro checks attempted. Resident #1 denied and refused care. Resident #1 seemed alert and oriented according to baseline. No pain indicated. Record review of Neurological Record dated 4/30/16-5/4/16 revealed neurological vital signs were started on 04/30/16 at 6:00 pm. Record review of nurse notes dated 05/02/16 at 11:20 am revealed: Nurse Practitioner on site. Assessed resident. New order, send to hospital emergency room for [DIAGNOSES REDACTED]. Message left. Resident #1 told by translator of new order. Resident #1 sitting in wheelchair. Call light in reach. Record review of x-ray report of Resident #1 ' s left knee provided by facility DON revealed the report had been faxed to the facility on [DATE] at 12:35 pm. The X-ray dated 04/30/16 revealed: [MEDICAL CONDITION] tibia. Hand written by Assistant Director of Nursing (ADON) at bottom of faxed x-ray report revealed: RP notified, MD notified, verbal order to send to hospital emergency for fracture. Record review of nurse notes dated 05/02/16 at 2:30 pm revealed: Resident #1 continued to be out of bed sitting in wheelchair. Denies any pain or discomfort. Resident #1 transferred to hospital for evaluation. Record review of a different Complaint Investigation Worksheet dated 05/18/16 revealed on 04/30/16 during the 2pm-10pm shift a male resident (unknown) purposely ran over a female resident (unknown) with his electric wheelchair. The male resident was angry at the female resident for an unknown reason. The nurse (unknown) took over. The complainant was calling to report that the Administrator was notified about the incident, however the Administrator was negative, ugly and said not to bother her while she was at home, she would take care of that mess on Monday. The Administrator was the reason why nothing else was done. The complainant requested the facility to be investigated to ensure the Administrator was held responsible for her actions. Record review of Provider Investigation Report dated 05/02/16 read: Resident #1 was examined and an abrasion and hematoma was noted to the left knee. Resident #1 was also complaining of pain to the left knee. Physician was notified. A portable x-ray was ordered 05/01/16. On 05/01/16 when asked what happened to her knee by CNA B, Resident #1 stated A young man in a wheelchair pushed her off her the chair . When asked to explain what happened, Resident #1 stated A young man in a wheelchair pushed me. I was leaving my room and I saw him sitting in the middle of the hallway. He went back then forward then back again and forward and I fell on floor . The young man was identified as Resident #3. On 05/02/16 when conducting the follow up incident report and review of x-ray. X-ray revealed a fracture of proximal tibia. Investigation of the incident initiated. MD notified of x-ray results. Resident #3 was placed 1:1 monitoring. Resident #1 was transferred to hospital for evaluation and treatment. Investigation remained in progress. Interview with CNA A was conducted on 05/02/16; Resident #1 stated Resident #3 pushed her down. Resident #3 repeated he made her fall. Resident #1 appeared to be very upset pointing at Resident #3. An interview was conducted with Resident #3. Resident #3 denied knocking Resident #1 down. Resident #3 stated he was sitting in his doorway in his wheelchair and the resident came out of her room screaming and cursing in his doorway. Resident #3 was unable to determine what she was saying because she was screaming and talking so fast. Resident #3 stated Resident #1 was still screaming and cursing stood up and began grabbing on his leg. Resident #3 stated he then put his chair in reverse and backed up, Resident #1 fell to the floor. On 05/02/16 a follow up interview was conducted with Resident #1. Resident #1 then stated she went to the resident ' s room to get some money. Resident #1 was trying to get him to give her some money and Resident #3 kicked her with his legs and Resident #1 fell . Resident #3 denied trying to hurt Resident #1. Incident occurred on 04/30/16. Administrator and DON were notified 05/02/16. Facility confirmed that Resident #1 wandered out of her room into Resident #3 ' s room. Resident #3 denied knocking Resident #1 down on purpose Record review of Resident #1 ' s nurse notes dated 05/02/16 at 7:15 pm revealed: Resident #1 received awake and alert from hospital. Assessment done. Resident #1 noted with cast to left lower extremity. In an interview with the DON on 05/17/16 at 10:15 am she said she was pulling incident reports on Monday (05/02/16) and saw the incident report involving Resident #1 and Resident #3. The DON said staff reported Resident #3 backed into (Resident #1) but believed it was an accident. The DON revealed Resident #3 denied the incident and had said Resident #1 was trying to touch his leg and he backed up (moved away) and Resident #1 fell forward out of her wheelchair. The DON believed the incident to be an accident and revealed Resident #1 had dementia but insisted Resident #3 caused her to fall. In an interview with the DON on 05/17/16 at 1:30 pm she said the incident with Resident #1 and Resident #3 happened on 4/30/16 during the weekend and she became aware of the situation on Monday 5/02/16. The DON said the nurse on duty was an agency nurse (Agency Nurse C) and the facility no longer used agency nurses. The DON further revealed that one on one education was provided to Agency Nurse C for reporting incidents. The DON said she was reviewing the incident reports on Monday (05/02/16) and realized the incident occurred on 4/30/16 and an x-ray had been ordered but not received. The DON revealed the x-ray report was obtained on 05/02/16 and Resident #1 was sent to hospital for evaluation and treatment. When the DON was asked why the x-ray was not received before 05/02/16 she said she was not sure but would find out. She said the Nurse should have followed up on the x-ray and put it on the 24 hour report. The DON further revealed she can ' t believe staff wouldn't assess appropriately . In an interview on 05/18/16 at 12:46 pm the Administrator revealed she had been notified over the weekend by a CNA that Resident #3 ran over Resident #1 with his wheelchair and that the abuse incident was investigated by the DON on 05/02/16 and it was reported to state. The Administrator was not sure why there was an issue regarding Resident #1 and her care as the incident was investigated. She said it was an accident and staff have been educated after the incident when to notify the Administrator and DON of an incident. Observation and interview on 05/17/16 at 12:15pm of Resident #1 revealed she did not have a splint or cast on her left leg. Her left knee was slightly larger than her right knee. Resident #1 said she was at Resident #3 ' s doorway and went to look at something in Resident #3 ' s room and he moved his electric wheelchair. Resident #1 could not recall if Resident #3 moved his chair backwards or forwards and she fell out of her wheelchair to the floor and hit her knee. Resident #1 complained of pain to her left knee. Resident #1 rated the pain at a 4 out of a scale of 1 to 10. In an interview with Resident #1 at 1:00 pm on 05/17/16 revealed she had pain to left leg after the fall but could not recall if she was medicated for the pain. In an interview with Resident #1 ' s physician on 05/17/16 at 11:30 am he said he was not sure of the situation with Resident #1 and he had just heard about the situation earlier this day. He further revealed he would have to review the chart to see what the Nurse Practitioner did concerning Resident #1. In an interview on 05/17/16 at 1:10 pm Resident #1 ' s physician said it was not an ideal situation regarding Resident #1 and her fall on 4/30/16. The physician said people fall at home and do not go to the emergency room until a few days later and then they find out they have a broken bone. When the physician was asked about Resident #1 falling on 04/30/16 and not diagnosed with [REDACTED]. Record review of 24 Hour Report/Change of Condition for Station 3 dated 4/30/16 revealed: Resident #1 refused medications/fell at 11:30 am, hematoma left knee and denies pain and neuro checks. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/01/16 revealed: Resident #1 was status [REDACTED].#1. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/02/16 revealed: Resident #1 went to emergency room for evaluation and returned at 7:15pm. Cast to left lower extremity. [MEDICATION NAME] 600mg 1 po (by mouth) every 4 hours as needed. Tylenol #3 po every 4 hours as needed. Follow up with ortho appointment. Ice pack for the splint x20 minutes every 2 hours x24 hours then 3-4 times for the next 2 days. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/17/16 revealed: Resident #1 had not been seen for ortho follow up per emergency room physician recommendation. Report further revealed cast was removed and RP (responsible person) was notified. In an interview with LVN G on 05/19/16 at 1:51 pm she said she received report from Agency Nurse C on 4/30/16 and was informed that Resident #1 had a fall. LVN G said Resident #1 did not complain of pain during the whole night shift. LVN G said Resident #1 even transferred herself from bed to wheelchair at 2:00 am and was in the hall in her wheelchair. LVN G said Resident #1 ' s knee was red with bruising but not swollen. LVN G said she called for x-ray report on 4/30/16 during her shift but could not recall what time and said she was told the report was not ready. In an interview on 05/19/16 at 10:39 am with CNA Ashe said the day was busy on 04/30/16 and a construction worker notified her that a resident was on the floor. CNA A said when she arrived to the scene that Resident #1 was in a sitting position on the floor in hallway with her legs extended in front of Resident #3 ' s doorway. CNA A said she called for Agency Nurse C. CNA A said she asked Resident #1 if she was in pain and Resident #1 said she was. CNA A said she could not recall what Resident #1 rated her pain at but thought it was a 7 on a scale of 1 to 10. CNA A said Resident #1 was complaining of pain to her left knee and complete left leg and that she informed Agency Nurse C. CNA A said it took three staff to assist Resident #1 to her wheelchair and then to bed and was told by Agency Nurse C to leave her in bed the rest of the day. CNA A said Agency Nurse C tried bending Resident #1 ' s left leg once she was in bed and Resident #1 screamed in pain. CNA A further revealed it was very difficult to provide incontinent care after the fall due to Resident #1 ' s pain. CNA A said Resident #1 normally assisted with incontinent care by moving her own legs but could not after the fall due to pain. CNA A said Agency Nurse C was aware of Resident #1 ' s pain level and thought she medicated Resident #1 with a Tylenol but was not sure. Interview with the Social Worker (SW) on 05/20/16 at 12:00pm revealed Resident #1 had an order to follow-up with the orthopedic physician for her fracture. The SW said Nursing had started working on the referral. She said she usually does the referral but this was a tough case. Resident #1's physician at the facility was not her primary care physician (PCP) and according to the insurance Resident #1's PCP had to make the referral. Since Resident #1 had not seen her PCP a referral could not be obtained for the orthopedic physician. When asked the SW did not have an explanation why Resident #1 had not been seen by the PCP. In an interview with Certified Nurse Aide (CNA) F on 05/20/16 at 2:22 pm she said that CNA A called for assistance on 4/30/16 because Resident #1 was found in hallway on floor. CNA F said Resident #1 was in a sitting position with legs extended in hall outside of Resident #3 ' s room. CNA F said Resident #1 was complaining of pain to her left leg and Resident #1 shook her leg and was touching it . CNA F said the nurse took vital signs while Resident #1 was on the floor and then they assisted Resident #1 to the wheelchair and then to bed. CNA F said she provided care for Resident #1 on 05/01/16 and was very careful when providing incontinent care for Resident #1 due to complaints of pain. CNA F said the nurse was notified during the shift that Resident #1 complained of pain but did not know if Resident #1 was medicated. Interview with the ADON on 05/18/16 at 1:22 pm he said if a resident was found on the floor, a head to toe assessment should be completed, physician notified, responsible party notified, obtain orders from physician, and start Neuro vitals on all unwitnessed falls or on residents who ' s fell and could not verbalize their needs. The ADON said all orders should be followed up on and you should call for diagnostics within 4 hours if not received. Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the Minimal Data Set (MDS) for Resident #2 dated 03/21/16 reveled Resident #2 was severely cognitively impaired. The MDS further revealed Resident #2 was totally dependent and required two people physical assistance for bed mobility, toilet use and personal hygiene and required total dependence with one person assist for eating and dressing. Record review of the Care Plans dated 09/28/2015 with a review date of 03/24/16 revealed Resident #2 was care planned for Cognitive deficit, communication deficit and self-care deficit. -Cognitive Deficit evidenced by: short term memory loss, long term memory loss and altered cognitive skills with daily decision making as evidenced by; sever impairment. Approaches included: orient resident to time, day, date and place as care is provided, staff will introduce self, staff will offer options in simple terms regarding care for resident, explain in changes in care to resident as needed, and provide time to think/react to information given. - Communication deficit and never makes self-understood and never understands others. No approaches identified. -Self-care deficit related to: total assist with bed mobility, total assist with transfers, total assist with locomotion, total assist with toileting, total assist with dressing and grooming and total assist with bathing. Approach: encourage and monitor independence, place call light in reach .assist in turning every two hours, pressure relieving mattress, assist with toileting as needed and give incontinent care every two hours and as needed. Record review of nurse notes dated 05/12/16 at 5:00 am revealed the charge nurse was doing rounds and found Resident #2 siting on floor on her buttocks next to her bed with pillows on the floor around her. No injuries or bruising was noted. This was noted at 4:00 am. Resident was placed back in bed on air mattress by the charge nurse with the assistance of two CNA s. Further assessment was done and no injuries were noted . Vital signs: Blood Pressure -132/70, Pulse-74, Respirations-18, Temperature-98.1. [MEDICATION NAME] injection was given to left buttock at 4:05 am. The medication was unsuccessful for treating the behaviors. ADON notified physician and was told to call back with any changes in Resident #2 ' s status. Neuro checks were in progress. Resident continued to kick and hit trying to throw herself back on the floor. Resident #2 was redirected about kicking and moving, trying to throw self out of bed. Resident #2 continued this behavior. RP called and no voicemail was available. Record review of nurse notes date 05/12/16 at 6:30 am revealed Resident #2 in bed kicking legs in air. No facial grimacing noted. status [REDACTED]. Discoloration and puffiness noted to right eye with skin intact in area. Suctioned x1 with secretions thin and yellowish in color. Record review of physician order [REDACTED]. Record review of nurses note dated 05/12/16 at 6:20 pm revealed EMS (emergency medical service) here to transport Resident #2 to hospital. RP at bedside. Record review of hospital records for Resident #2 revealed she was admitted to hospital on [DATE] at 7:37 pm for a fall from her bed. Review of pelvis x-ray dated 5/12/16 for Resident #2 revealed: left anterior inferior iliac spine avulsion fracture. Record review of x-ray of chest for Resident #2 revealed: bibasilar pneumonia [MEDICAL CONDITION] and/ pneumonia. In an interview with the ADON on 05/17/16 at 12:40 pm he could not recall why Resident #2 was admitted to the hospital. The ADON said that Resident #2 did have a fall but did not hit her head. The ADON said neuro vitals were performed and the physician was notified. The ADON further revealed that a Nurse Practitioner from the physician ' s office evaluated Resident #2 and sent Resident #2 to emergency room for a fall and altered mental status. The ADON further revealed that [MEDICAL CONDITION] care was provided daily and as needed for Resident #2. Observation on 05/18/16 at 9:00 am revealed Resident #2 in hospital with responsible party at bedside. An attempt to interview Resident #2 was made but was unsuccessful due to her cognitive status. In an interview with responsible party on 05/18/16 at 9:02 am she revealed Resident #2 had pneumonia. When asked about fall and injuries related to the fall, responsible party said she was not aware of a fall. In an interview with the DON on 05/18/16 at 12:45 pm she revealed the facility had not followed up on Resident #2 since she was sent to hospital for evaluation on 05/12/16. The DON said she would follow up on Resident #2. In an interview on 05/20/16 at 2:00 pm the DON revealed she had not followed up or received any information regarding Resident #2 and her hospital stay. The DON revealed the Admission coordinator and liaison were responsible for obtaining information on residents who were sent out and usually no information was obtained until resident returned to the facility. When surveyor informed the DON of the fracture to Resident #2 ' s iliac spine and that Resident #2 had a fall at 4:00 am and not sent out until 6:20 pm the DON did not have a comment. Record review of Resident #2 ' s MAR for May 2016 revealed no pain medication was given to Resident #2 on 5/12/16. The MAR further revealed Resident #2 had prn orders for Tylenol #3; 1 tablet per tube every 4 hours as needed and an order for [REDACTED]. Record review of Fall Management policy and procedure provided by facility dated February 19, 2016 read: Post Fall; monitor patient ' s blood pressure, pulse and respirations. Notify the practitioner if you note a change in baseline. A neurological record is conducted upon actual injury, suspected head trauma or any change in level of consciousness. Record review of SBAR Communication policy and procedure dated July 10, 2015 read: SBAR communication breaks communication down into four steps. 1. Situation: a concise description of the patient ' s current situation. 2. Background: historical or current patient data relevant to the patient ' s problem. 3. Assessment: a summary of the nurse ' s analysis of the current situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about patients care. An IJ was identified on 05/18/16 and the Administrator and DON were notified at 12:59pm. A plan of removal (POR) for the IJ was submitted on 05/19/16 at 9:01am and after several revisions it was accepted on 05/20/16 at 6:46pm. The POR included in part: Plan of Removal for Immediate Jeopardy The nursing staff has reviewed x-ray orders received in the past 30 days to assure that x-rays were requested, x-rays were taken, results were received and notification was made to the physician and the responsible party. This audit started on 5/18/16 and was completed on 5/18/16. Care plans and orders were reviewed to assure that orders received in response to the results were implemented timely. This was also done as of 5/18/16. Beginning May 19, 2016 newly received x-ray orders will be logged in a notebook. With each order, the nurse will note the order, the date the order was received, the date and time the request for x-rays was made, the date the x-ray was taken, the date and time the results were received and the date and time the physician and responsible party were notified of the results of the x-rays. Orders will be implemented in response to the results when received. Upon a resident fall, the resident will have a head to toe assessment. A neurolog

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for two of 10 residents reviewed (Resident #1 and Resident #2) for falls. The facility failed to obtain the x-ray results for Resident #1, who fell on [DATE]. Resident #1 had a stat (immediately) x-ray ordered by the physician. The x-ray was obtained on 4/30/16 at 3:30pm but the results were not obtained by the facility staff for 45 hours on 5/2/16 at 12:30 p.m. The x-ray results revealed a fracture at the base of the tibial tuberosity (the upper part of the leg closest to the knee) and resident was then sent to hospital for treatment. Resident # 2 had a fall on 05/12/16 at 4:00 am. The resident was not provided any medical intervention until 6:20 pm when she was transferred to the hospital and was assessed to have pneumonia and a left anterior iliac spine (the attachment site for the thigh muscle that helps bend the hip and knee) avulsion fracture (where the tendon and/or ligament pulls away from the bone). An IJ was identified on 05/18/16. While the IJ was removed on 05/21/16, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents who received injuries from a fall that required them to be transferred to the hospital for treatment and placed 57 additional residents who were totally dependent on staff for care and activities of daily living (ADL) at risk for neglect and injury. Intakes: # 5 and # 9 Findings Include: Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female with an original admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Her primary language was Spanish. Record review of Resident # 1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed to have modified impaired cognitive skills for daily decision making. The MDS further revealed the resident required supervision with one person physical assist with transfers, dressing, and toilet use. The MDS also revealed Resident #1 required limited assistance of one person with locomotion on the unit and for personal hygiene. Record review of Resident #1 ' s care plan dated 10/29/15 with a review date of 4/21/16 for Resident #1 revealed the following: -Cognitive Deficit as evidenced by a short-term and long term memory loss related to severe impairment with possible signs and symptoms of [MEDICAL CONDITION]. Approaches documented included: orient to time, day, date and place as care is provided, staff will introduce self and or visitors whenever possible, staff will offer options in simple terms regarding care for resident to choose, explain any changes in care to resident as needed, and provide resident time to think/react to information given. -[DIAGNOSES REDACTED]. -Pain related to chronic disease ([MEDICAL CONDITIONS], and [MEDICAL CONDITION]). Approaches included: positioning and support, music, administer [MEDICATION NAME] as ordered, see physician orders, implement pain management flow sheet, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing), monitor every shift, notify physician if interventions are not consistently effective, medicate resident for pain prior to treatments, therapy referral as indicated. Record review of Resident #1 ' s care plan dated 2/22 (no year documented) revealed she was care planned for falls. Approaches included: provide device to fall prevention, evaluate progress every month and as needed, explain using terms and gestures resident can understand, allow ample time and do not rush and keep MD and Director of Nursing (DON) informed of resident progress. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 11:30 am revealed Resident #1 was found on the floor near the doorway of another resident ' s room. Resident #1 was found sitting on her bottom . Resident #1 was assisted to her wheelchair by nurse and CNA ' s (certified nursing assistant) and then put back in bed. Nurses note further read: Resident #1 ' s left knee was reddened and had a small non-bleeding abrasion and a large green hematoma. The on-call physician was called and ordered an x-ray and Tylenol 325mg. Resident #1 declined Tylenol and denied pain at the time. (As conveyed by CNA A who spoke both Spanish and English). X-rays were ordered and said to arrive in two hours. Nurse Supervisor also notified, assisted in the attempt to administer Tylenol and succeeded with Resident #1 now complaining of pain. The 325mg Tylenol was administered at noon and family was notified via voicemail. Record review of Resident #1 ' s Situation Background Assessment Recommendation (SBAR) Communication Form dated 04/30/16 at 11:30 am read in part . the physician was notified that Resident #1 was found on floor in the doorway of another resident ' s room, sitting on her bottom. In the section for Mental Status Evaluation the word agitated was written. Documented on the Skin Evaluation section abrasion was checked and hematoma (L) knee large was written. Documented under the Pain Evaluation the words facial grimacing was written and a pain score of 10 was documented on a scale of 1/10. New orders were received for an x-ray of the left knee and Tylenol 325mg. SBAR Communication Form was signed by Agency Nurse C. In an interview on 05/19/16 at 12:33 pm with Agency Nurse C she said she felt she did everything she was supposed to do regarding the care of Resident #1 following her fall on 4/30/16. Agency Nurse C said she assessed Resident #1 after her fall on 4/30/16 but did not perform range of motion to her extremities. She said Resident #1 seemed alright and even assisted staff with the transfer to the wheelchair and then to the bed. When asked why she did not perform neuro vital signs, Agency Nurse C said Resident #1 was not cooperative and kept ranting and raving and refusing care. Agency Nurse C said Resident #1 denied any pain. Agency Nurse C further revealed after Resident #1 was assisted to bed she noted a Large green hematoma to Resident #1 ' s left knee with a small abrasion and was not sure if the injury was new or old. Agency Nurse C said she notified Registered Nurse (RN) D who was the weekend supervisor about the fall and RN D assisted her (Agency Nurse C) through the whole ordeal . Agency Nurse C said she did not notify the DON of the fall because RN D said not to. Agency Nurse C said the physician and RP were called. She stated she had received the order for the x-ray to the left knee. When asked if x-rays were ordered STAT, Agency Nurse C could not recall. Agency Nurse C further revealed she did not follow up on the x-ray report but did inform the incoming nurse, Licensed Vocational Nurse (LVN) G of Resident #1 ' s fall and documented it on the 24 hour report. Record review of Resident #1 ' s Medication Administration Record [REDACTED]. The April 16 MAR further revealed Resident #1 received daily Aspirin 81 mg. Record review of Resident #1 ' s Pain Evaluation dated 4/30/16 (post fall) revealed Resident #1 had received PRN (as needed) pain medication. Pain was rated at a 5-6 on the FACES pain scale. The Pain Evaluation form further revealed Resident #1 denied pain in the last five days. Record review of Resident #1 ' s Head to Toe Skin Check dated 04/30/16 for the 6:00 am to 2:00 pm shift read: (L) knee green colored hematoma. STAT x-ray pending. Record review of Resident #1 ' s nurse notes dated 04/30/16 at 12:00 pm read: neuro check refused by Resident #1. Will follow up for pain assessment. Resident #1 seemed to be alert and oriented according to baseline. Record review of Resident #1 ' s nurse notes dated 4/30/16 at 12:30 pm read: neuro check denied. Resident #1 will not allow vitals and denied pain. Fusses with care. Seems alert and oriented according to baseline. Will follow up with pain assessment and neuro in 30 minutes. Record review of nurse notes dated 4/30/16 at 1:00 pm -5:30pm revealed Resident #1 refused neuro checks and denied pain and pain management. Record review of nurse notes dated 04/30/16 at 2:13 pm read: Called Nurse Practitioner to get order for STAT [MEDICATION NAME] injection due to Resident #1 continuously fussing , denying care and seeming agitated. STAT ordered for 2mg injection to ensure Resident #1 complies with x-ray. Record review of nurse notes dated 04/30/16 at 2:30 pm read in part .Denies [MEDICATION NAME] injection. Will follow up in 1 hour. Record review of nurse notes dated 04/30/16 at 3:30 pm read: X-ray tech arrived; was able to obtain x-ray on (L) knee of Resident #1. Neuro checks attempted. Resident #1 denied and refused care. Resident #1 seemed alert and oriented according to baseline. No pain indicated. Record review of Neurological Record dated 4/30/16-5/4/16 revealed neurological vital signs were started on 04/30/16 at 6:00 pm. Record review of nurse notes dated 05/02/16 at 11:20 am revealed: Nurse Practitioner on site. Assessed resident. New order, send to hospital emergency room for [DIAGNOSES REDACTED]. Message left. Resident #1 told by translator of new order. Resident #1 sitting in wheelchair. Call light in reach. Record review of x-ray report of Resident #1 ' s left knee provided by facility DON revealed the report had been faxed to the facility on [DATE] at 12:35 pm. The X-ray dated 04/30/16 revealed: [MEDICAL CONDITION] tibia. Hand written by Assistant Director of Nursing (ADON) at bottom of faxed x-ray report revealed: RP notified, MD notified, verbal order to send to hospital emergency for fracture. Record review of nurse notes dated 05/02/16 at 2:30 pm revealed: Resident #1 continued to be out of bed sitting in wheelchair. Denies any pain or discomfort. Resident #1 transferred to hospital for evaluation. Record review of Provider Investigation Report dated 05/02/16 read: Resident #1 was examined and an abrasion and hematoma was noted to the left knee. Resident #1 was also complaining of pain to the left knee. Physician was notified. A portable x-ray was ordered 05/01/16. On 05/01/16 when asked what happened to her knee by CNA B, Resident #1 stated A young man in a wheelchair pushed her off her the chair . When asked to explain what happened, Resident #1 stated A young man in a wheelchair pushed me. I was leaving my room and I saw him sitting in the middle of the hallway. He went back then forward then back again and forward and I fell on floor . The young man was identified as Resident #3. On 05/02/16 when conducting the follow up incident report and review of x-ray. X-ray revealed a fracture of proximal tibia. Investigation of the incident initiated. MD notified of x-ray results. Resident #3 was placed 1:1 monitoring. Resident #1 was transferred to hospital for evaluation and treatment. Investigation remained in progress. Interview with CNA A was conducted on 05/02/16; Resident #1 stated Resident #3 pushed her down. Resident #3 repeated he made her fall. Resident #1 appeared to be very upset pointing at Resident #3. An interview was conducted with Resident #3. Resident #3 denied knocking Resident #1 down. Resident #3 stated he was sitting in his doorway in his wheelchair and the resident came out of her room screaming and cursing in his doorway. Resident #3 was unable to determine what she was saying because she was screaming and talking so fast. Resident #3 stated Resident #1 was still screaming and cursing stood up and began grabbing on his leg. Resident #3 stated he then put his chair in reverse and backed up, Resident #1 fell to the floor. On 05/02/16 a follow up interview was conducted with Resident #1. Resident #1 then stated she went to the resident ' s room to get some money. Resident #1 was trying to get him to give her some money and Resident #3 kicked her with his legs and Resident #1 fell . Resident #3 denied trying to hurt Resident #1. Incident occurred on 04/30/16. Administrator and DON were notified 05/02/16. Facility confirmed that Resident #1 wandered out of her room into Resident #3 ' s room. Resident #3 denied knocking Resident #1 down on purpose Record review of Resident #1 ' s nurse notes dated 05/02/16 at 7:15 pm revealed: Resident #1 received awake and alert from hospital. Assessment done. Resident #1 noted with cast to left lower extremity. In an interview with the DON on 05/17/16 at 10:15 am she said she was pulling incident reports on Monday (05/02/16) and saw the incident report involving Resident #1 and Resident #3. The DON said staff reported Resident #3 backed into (Resident #1) but believed it was an accident. The DON revealed Resident #3 denied the incident and had said Resident #1 was trying to touch his leg and he backed up (moved away) and Resident #1 fell forward out of her wheelchair. The DON believed the incident to be an accident and revealed Resident #1 had dementia but insisted Resident #3 caused her to fall. In an interview with the DON on 05/17/16 at 1:30 pm she said the incident with Resident #1 and Resident #3 happened on 4/30/16 during the weekend and she became aware of the situation on Monday 5/02/16. The DON said the nurse on duty was an agency nurse (Agency Nurse C) and the facility no longer used agency nurses. The DON further revealed that one on one education was provided to Agency Nurse C for reporting incidents. The DON said she was reviewing the incident reports on Monday (05/02/16) and realized the incident occurred on 4/30/16 and an x-ray had been ordered but not received. The DON revealed the x-ray report was obtained on 05/02/16 and Resident #1 was sent to hospital for evaluation and treatment. When the DON was asked why the x-ray was not received before 05/02/16 she said she was not sure but would find out. She said the Nurse should have followed up on the x-ray and put it on the 24 hour report. The DON further revealed she can ' t believe staff wouldn't assess appropriately . In an interview on 05/18/16 at 12:46 pm the Administrator revealed she had been notified over the weekend by a CNA that Resident #3 ran over Resident #1 with his wheelchair and that the abuse incident was investigated by the DON on 05/02/16 and it was reported to state. The Administrator was not sure why there was an issue regarding Resident #1 and her care as the incident was investigated. She said it was an accident and staff have been educated after the incident when to notify the Administrator and DON of an incident. Observation and interview on 05/17/16 at 12:15pm of Resident #1 revealed she did not have a splint or cast on her left leg. Her left knee was slightly larger than her right knee. Resident #1 said she was at Resident #3 ' s doorway and went to look at something in Resident #3 ' s room and he moved his electric wheelchair. Resident #1 could not recall if Resident #3 moved his chair backwards or forwards and she fell out of her wheelchair to the floor and hit her knee. Resident #1 complained of pain to her left knee. Resident #1 rated the pain at a 4 out of a scale of 1 to 10. In an interview with Resident #1 at 1:00 pm on 05/17/16 revealed she had pain to left leg after the fall but could not recall if she was medicated for the pain. In an interview with Resident #1 ' s physician on 05/17/16 at 11:30 am he said he was not sure of the situation with Resident #1 and he had just heard about the situation earlier this day. He further revealed he would have to review the chart to see what the Nurse Practitioner did concerning Resident #1. In an interview on 05/17/16 at 1:10 pm Resident #1 ' s physician said it was not an ideal situation regarding Resident #1 and her fall on 4/30/16. The physician said people fall at home and do not go to the emergency room until a few days later and then they find out they have a broken bone. When the physician was asked about Resident #1 falling on 04/30/16 and not diagnosed with [REDACTED]. Record review of 24 Hour Report/Change of Condition for Station 3 dated 4/30/16 revealed: Resident #1 refused medications/fell at 11:30 am, hematoma left knee and denies pain and neuro checks. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/01/16 revealed: Resident #1 was status [REDACTED].#1. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/02/16 revealed: Resident #1 went to emergency room for evaluation and returned at 7:15pm. Cast to left lower extremity. [MEDICATION NAME] 600mg 1 po (by mouth) every 4 hours as needed. Tylenol #3 po every 4 hours as needed. Follow up with ortho appointment. Ice pack for the splint x20 minutes every 2 hours x24 hours then 3-4 times for the next 2 days. Record review of 24 Hour Report/Change of Condition for Station 3 dated 05/17/16 revealed: Resident #1 had not been seen for ortho follow up per emergency room physician recommendation. Report further revealed cast was removed and RP (responsible person) was notified. In an interview with LVN G on 05/19/16 at 1:51 pm she said she received report from Agency Nurse C on 4/30/16 and was informed that Resident #1 had a fall. LVN G said Resident #1 did not complain of pain during the whole night shift. LVN G said Resident #1 even transferred herself from bed to wheelchair at 2:00 am and was in the hall in her wheelchair. LVN G said Resident #1 ' s knee was red with bruising but not swollen. LVN G said she called for x-ray report on 4/30/16 during her shift but could not recall what time and said she was told the report was not ready. In an interview on 05/19/16 at 10:39 am with CNA Ashe said the day was busy on 04/30/16 and a construction worker notified her that a resident was on the floor. CNA A said when she arrived to the scene that Resident #1 was in a sitting position on the floor in hallway with her legs extended in front of Resident #3 ' s doorway. CNA A said she called for Agency Nurse C. CNA A said she asked Resident #1 if she was in pain and Resident #1 said she was. CNA A said she could not recall what Resident #1 rated her pain at but thought it was a 7 on a scale of 1 to 10. CNA A said Resident #1 was complaining of pain to her left knee and complete left leg and that she informed Agency Nurse C. CNA A said it took three staff to assist Resident #1 to her wheelchair and then to bed and was told by Agency Nurse C to leave her in bed the rest of the day. CNA A said Agency Nurse C tried bending Resident #1 ' s left leg once she was in bed and Resident #1 screamed in pain. CNA A further revealed it was very difficult to provide incontinent care after the fall due to Resident #1 ' s pain. CNA A said Resident #1 normally assisted with incontinent care by moving her own legs but could not after the fall due to pain. CNA A said Agency Nurse C was aware of Resident #1 ' s pain level and thought she medicated Resident #1 with a Tylenol but was not sure. Interview with the Social Worker (SW) on 05/20/16 at 12:00pm revealed Resident #1 had an order to follow-up with the orthopedic physician for her fracture. The SW said Nursing had started working on the referral. She said she usually does the referral but this was a tough case. Resident #1's physician at the facility was not her primary care physician (PCP) and according to the insurance Resident #1's PCP had to make the referral. Since Resident #1 had not seen her PCP a referral could not be obtained for the orthopedic physician. When asked the SW did not have an explanation why Resident #1 had not been seen by the PCP. In an interview with Certified Nurse Aide (CNA) F on 05/20/16 at 2:22 pm she said that CNA A called for assistance on 4/30/16 because Resident #1 was found in hallway on floor. CNA F said Resident #1 was in a sitting position with legs extended in hall outside of Resident #3 ' s room. CNA F said Resident #1 was complaining of pain to her left leg and Resident #1 shook her leg and was touching it . CNA F said the nurse took vital signs while Resident #1 was on the floor and then they assisted Resident #1 to the wheelchair and then to bed. CNA F said she provided care for Resident #1 on 05/01/16 and was very careful when providing incontinent care for Resident #1 due to complaints of pain. CNA F said the nurse was notified during the shift that Resident #1 complained of pain but did not know if Resident #1 was medicated. Interview with the ADON on 05/18/16 at 1:22 pm he said if a resident was found on the floor, a head to toe assessment should be completed, physician notified, responsible party notified, obtain orders from physician, and start Neuro vitals on all unwitnessed falls or on residents who ' s fell and could not verbalize their needs. The ADON said all orders should be followed up on and you should call for diagnostics within 4 hours if not received. Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the Minimal Data Set (MDS) for Resident #2 dated 03/21/16 reveled Resident #2 was severely cognitively impaired. The MDS further revealed Resident #2 was totally dependent and required two people physical assistance for bed mobility, toilet use and personal hygiene and required total dependence with one person assist for eating and dressing. Record review of the Care Plans dated 09/28/2015 with a review date of 03/24/16 revealed Resident #2 was care planned for Cognitive deficit, communication deficit and self-care deficit. -Cognitive Deficit evidenced by: short term memory loss, long term memory loss and altered cognitive skills with daily decision making as evidenced by; sever impairment. Approaches included: orient resident to time, day, date and place as care is provided, staff will introduce self, staff will offer options in simple terms regarding care for resident, explain in changes in care to resident as needed, and provide time to think/react to information given. - Communication deficit and never makes self-understood and never understands others. No approaches identified. -Self-care deficit related to: total assist with bed mobility, total assist with transfers, total assist with locomotion, total assist with toileting, total assist with dressing and grooming and total assist with bathing. Approach: encourage and monitor independence, place call light in reach .assist in turning every two hours, pressure relieving mattress, assist with toileting as needed and give incontinent care every two hours and as needed. Record review of nurse notes dated 05/12/16 at 5:00 am revealed the charge nurse was doing rounds and found Resident #2 siting on floor on her buttocks next to her bed with pillows on the floor around her. No injuries or bruising was noted. This was noted at 4:00 am. Resident was placed back in bed on air mattress by the charge nurse with the assistance of two CNA s. Further assessment was done and no injuries were noted . Vital signs: Blood Pressure -132/70, Pulse-74, Respirations-18, Temperature-98.1. [MEDICATION NAME] injection was given to left buttock at 4:05 am. The medication was unsuccessful for treating the behaviors. ADON notified physician and was told to call back with any changes in Resident #2 ' s status. Neuro checks were in progress. Resident continued to kick and hit trying to throw herself back on the floor. Resident #2 was redirected about kicking and moving, trying to throw self out of bed. Resident #2 continued this behavior. RP called and no voicemail was available. Record review of nurse notes date 05/12/16 at 6:30 am revealed Resident #2 in bed kicking legs in air. No facial grimacing noted. status [REDACTED]. Discoloration and puffiness noted to right eye with skin intact in area. Suctioned x1 with secretions thin and yellowish in color. Record review of physician order [REDACTED]. Record review of nurses note dated 05/12/16 at 6:20 pm revealed EMS (emergency medical service) here to transport Resident #2 to hospital. RP at bedside. Record review of hospital records for Resident #2 revealed she was admitted to hospital on [DATE] at 7:37 pm for a fall from her bed. Review of pelvis x-ray dated 5/12/16 for Resident #2 revealed: left anterior inferior iliac spine avulsion fracture. Record review of x-ray of chest for Resident #2 revealed: bibasilar pneumonia [MEDICAL CONDITION] and/ pneumonia. In an interview with the ADON on 05/17/16 at 12:40 pm he could not recall why Resident #2 was admitted to the hospital. The ADON said that Resident #2 did have a fall but did not hit her head. The ADON said neuro vitals were performed and the physician was notified. The ADON further revealed that a Nurse Practitioner from the physician ' s office evaluated Resident #2 and sent Resident #2 to emergency room for a fall and altered mental status. The ADON further revealed that [MEDICAL CONDITION] care was provided daily and as needed for Resident #2. Observation on 05/18/16 at 9:00 am revealed Resident #2 in hospital with responsible party at bedside. An attempt to interview Resident #2 was made but was unsuccessful due to her cognitive status. In an interview with responsible party on 05/18/16 at 9:02 am she revealed Resident #2 had pneumonia. When asked about fall and injuries related to the fall, responsible party said she was not aware of a fall. In an interview with the DON on 05/18/16 at 12:45 pm she revealed the facility had not followed up on Resident #2 since she was sent to hospital for evaluation on 05/12/16. The DON said she would follow up on Resident #2. In an interview on 05/20/16 at 2:00 pm the DON revealed she had not followed up or received any information regarding Resident #2 and her hospital stay. The DON revealed the Admission coordinator and liaison were responsible for obtaining information on residents who were sent out and usually no information was obtained until resident returned to the facility. When surveyor informed the DON of the fracture to Resident #2 ' s iliac spine and that Resident #2 had a fall at 4:00 am and not sent out until 6:20 pm the DON did not have a comment. Record review of Resident #2 ' s MAR for May 2016 revealed no pain medication was given to Resident #2 on 5/12/16. The MAR further revealed Resident #2 had prn orders for Tylenol #3; 1 tablet per tube every 4 hours as needed and an order for [REDACTED]. Record review of Abuse and Neglect Policy provided by facility with a revision date of June 2013 read: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. -Neglect: means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. -Training: 1. The facility will train each employee regarding these policies. 2. The facility will ensure that such training is provided during orientation, annually and more often as determined by the facility. 3. The facility will provide training regarding related policies and procedures. 4. The facility will provide education for those additional individuals involved with the resident. Record review of Fall Management policy and procedure provided by facility dated February 19, 2016 read: Post Fall; monitor patient ' s blood pressure, pulse and respirations. Notify the practitioner if you note a change in baseline. A neurological record is conducted upon actual injury, suspected head trauma or any change in level of consciousness. Record review of SBAR Communication policy and procedure dated July 10, 2015 read: SBAR communication breaks communication down into four steps. 1. Situation: a concise description of the patient ' s current situation. 2. Background: historical or current patient data relevant to the patient ' s problem. 3. Assessment: a summary of the nurse ' s analysis of the current situation, along with the time frame in which a response is expected; this step commonly involves interaction between the sender and receiver and may include questions about patients care. An IJ was identified on 05/18/16 and the Administrator and DON were notified at 12:59pm. A plan of removal (POR) for the IJ was submitted on 05/19/16 at 9:01am and after several revisions it was accepted on 05/20/16 at 6:46pm. The POR included in part: Plan of Removal for Immediate Jeopardy The nursing staff has reviewed x-ray orders received in the past 30 days to assure that x-rays were requested, x-rays were taken, results were received and notification was made to the physician and the responsible party. This audit started on 5/18/16 and was completed on 5/18/16. Care plans and orders were reviewed to assure that orders received in response to the results were implemented timely. This was also done as of 5/18/16. Beginning May 19, 2016 newly received x-ray orders will be logged in a notebook. With each order, the nurse will note the order, the date the order was received, the date and time the request for x-rays was made, the date the x-ray was taken, the date and time the results were received and the date and time the physician and responsible party were notified of the results of the x-rays. Orders will be implemented in response to the results when received. Upon a resident fall, the resident will have a head to toe assessment. A neurological assessment will be completed with any unwitnessed fall or falls involving the head. The neuros will be completed each shift for 72 hours. Any abnormal results or a resident refusing will be called into the MD and RP for notification. Any change in the neuro/vital signs will be immediately reported to the MD. The resident will be assessed for pain and any new onset of pain will be immediately addressed. The MD will be notified of the onset of pain for further evaluation and treatment. The charge nurse will continue to monitor the resident each shift for 72 hours. The charge nurse documentation will focus on the occurrence. Prior to the end of each shift the nursing staff will be

Based on interview and record review the facility failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for two of 10 residents (Resident #1 and Resident #2) reviewed for effective administration. The Administrator failed to: -implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent abuse and neglect. -Supervise the DON to ensure nursing staff conducted accurate assessments of residents when they had a change in condition or injury after a fall. -Supervise the DON to ensure nursing staff conducted neurological vital signs following unwitnessed resident falls. -Supervise the DON to ensure nursing staff obtained diagnostic reports (x-ray) following a fall per physician orders. The DON failed to -Train and monitor the nursing staff on assessments of Residents when they had a change in condition after a fall. -Train and monitor nursing staff on neurological vital signs following falls. -Train and monitor nursing staff on following up on diagnostics ordered after a fall. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of pattern and a severity of harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure affected two residents whose needs were not met and placed the 59 residents at risk who are dependent on staff for care of being provided timely medical treatment resulting in a decline in health and quality of life. Intakes: # 5 and # 9 Findings Included: Attempted interview with Administrator on [DATE] at 12:59 pm regarding IJ and how it came about. Administrator said she needed to go get a pen and paper and did not return to conference room. DON remained in conference room. In an interview on [DATE] at 1:25 pm with Administrator, she requested that surveyor explain how the incident was an IJ. Administrator said she did not feel that there was immediacy and she would call Regional Director. In an interview with DON on [DATE] at 1:05 pm she revealed that she believes the IJ came about due to No follow through with report of x-ray . The DON said she became aware of the incident involving Resident #1 and Resident #3 on [DATE] when she was reviewing incident reports that occurred over the weekend. DON said she monitors the staff by having unit managers and an ADON. DON said that inservices have been provided regarding assessments of residents after a fall and sometimes she provides 1 to 1 training with staff if needed. DON revealed that the facility has a check off list of skills for staff to complete such as CPR, medication administration and vitals. DON said the ADON and unit manger assist her with training and inservices. Resident #1 Record review of the face sheet for Resident #1 revealed a [AGE] year old female with an original admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of Resident # 1 ' s Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed to have modified impaired cognitive skills for daily decision making. The MDS further revealed the resident required supervision with one person physical assist with transfers, dressing, and toilet use. The MDS also revealed Resident #1 required limited assistance of one person with locomotion on the unit and for personal hygiene. Record review of Resident #1 ' s nurse notes dated [DATE] at 11:30 am revealed Resident #1 was found on the floor near the doorway of another resident ' s room. Resident #1 was found sitting on her bottom . Resident #1 was assisted to her wheelchair by nurse and CNA ' s (certified nursing assistant) and then put back in bed. Nurses note further read: Resident #1 ' s left knee was reddened and had a small non-bleeding abrasion and a large green hematoma. The on-call physician was called and ordered an x-ray and Tylenol 325mg. Resident #1 declined Tylenol and denied pain at the time. (As conveyed by the Spanish/English speaking CNA.) X-rays were ordered and said to arrive in two hours. Nurse Supervisor also notified, assisted in the attempt to administer Tylenol and succeeded with Resident #1 now complaining of pain. The 325mg Tylenol was administered at noon and family was notified via voicemail. Record review of Resident #1 ' s Situation Background Assessment Recommendation (SBAR) Communication Form dated [DATE] at 11:30 am read in part . the physician was notified that Resident #1 was found on floor in the doorway of another resident ' s room, sitting on her bottom. In the section for Mental Status Evaluation the word agitated was written. Documented on the Skin Evaluation section abrasion was checked and hematoma (L) knee large was written. Documented under the Pain Evaluation the words facial grimacing was written and a pain score of 10 was documented on a scale of ,[DATE]. New orders were received for an x-ray of the left knee and Tylenol 325mg. SBAR Communication Form was signed by Agency Nurse C. Record review of Resident #1 ' s Head to Toe Skin Check dated [DATE] for the 6:00 am to 2:00 pm shift read: (L) knee green colored hematoma. STAT x-ray pending. Record review of Neurological Record dated [DATE]-[DATE] revealed neurological vital signs were started on [DATE] at 6:00 pm. Record review of x-ray report of Resident #1 ' s left knee provided by facility DON revealed the report had been faxed to the facility on [DATE] at 12:35 pm. The X-ray dated [DATE] revealed: [MEDICAL CONDITION] tibia. Hand written by Assistant Director of Nursing (ADON) at bottom of faxed x-ray report revealed: RP notified, MD notified, verbal order to send to hospital emergency for fracture. Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old female with an admission date of [DATE] and a readmission date of [DATE]. The resident had [DIAGNOSES REDACTED]. Record review of the Minimal Data Set (MDS) for Resident #2 dated [DATE] reveled Resident #2 was severely cognitively impaired. The MDS further revealed Resident #2 was totally dependent and required two people physical assistance for bed mobility, toilet use and personal hygiene and required total dependence with one person assist for eating and dressing. Record review of nurse notes dated [DATE] at 5:00 am revealed the charge nurse was doing rounds and found Resident #2 siting on floor on her buttocks next to her bed with pillows on the floor around her. No injuries or bruising was noted. This was noted at 4:00 am. Resident was placed back in bed on air mattress by the charge nurse with the assistance of two CNA ' s . [MEDICAL CONDITION] care completed. [MEDICAL CONDITION] care completed. Vital signs: ,[DATE], 74, 18, 98.1. [MEDICATION NAME] injection was given to left buttock at 4:05 am but was unsuccessful for behaviors. ADON notified physician and was told to call back with any changes in Resident #2 ' s status. Neuro checks were in progress. Resident continued to kick and hit trying to throw herself back on the floor. Resident #2 was redirected about kicking and moving, trying to throw self out of bed. Resident #2 continued this behavior. RP called and no voicemail was available. Record review of nurse notes date [DATE] at 6:30 am revealed Resident #2 in bed kicking legs in air. No facial grimacing noted. status [REDACTED]. Discoloration and puffiness noted to right eye with skin intact in area. Suctioned x1 with secretions thin and yellowish in color. Record review of nurses note dated [DATE] at 6:20 pm revealed EMS (emergency medical service) here to transport Resident #2 to hospital. RP at bedside. Record review of physician order [REDACTED]. Record review of hospital records for Resident #2 revealed Resident #2 was admitted to hospital on [DATE] at 7:37 pm for a fall from her bed. Review of pelvis x-ray dated [DATE] for Resident #2 revealed: left anterior inferior iliac spine avulsion fracture. Record review of x-ray of chest for Resident #2 revealed: bibasilar pneumonia [MEDICAL CONDITION] and/ pneumonia. Observation on [DATE] at 12:00 pm revealed Resident #2 was not in facility. In an interview with the ADON on [DATE] at 12:40 pm he could not recall why Resident #2 was admitted to the hospital. The ADON said that Resident #2 did have a fall but did not hit her head. The ADON said neuro vitals were performed and the physician was notified. The ADON further revealed that a Nurse Practitioner from the physician ' s office evaluated Resident #2 and sent Resident #2 to emergency room for a fall and altered mental status. The ADON further revealed that [MEDICAL CONDITION] care was provided daily and as needed for Resident #2. Record review of a different Complaint Investigation Worksheet dated [DATE] revealed on [DATE] during the 2pm-10pm shift a male resident (unknown) purposely ran over a female resident (unknown) with his electric wheelchair. The male resident was angry at the female resident for an unknown reason. The nurse (unknown) took over. The complainant was calling to report that the Administrator was notified about the incident, however the Administrator was negative, ugly and said not to bother her while she was at home, she would take care of that mess on Monday. The Administrator was the reason why nothing else was done. The complainant requested the facility to be investigated to ensure the Administrator was held responsible for her actions. An IJ was identified on [DATE] and the Administrator and DON were notified at 12:59pm. A plan of removal (POR) for the IJ was submitted on [DATE] at 9:01am and after several revisions it was accepted on [DATE] at 6:46pm. The POR included in part: Plan of Removal for Immediate Jeopardy The x-ray results for the identified resident have been reviewed on [DATE]. The physician ordered additional interventions, which have been implemented at this time. The intervention was the facility sent resident toER on [DATE]. The hospital sent EA back with a soft splint on her left leg. However, the resident removed the splint as of [DATE] and the physician dc ' d the order on this date. The nursing staff has reviewed x-ray orders received in the past 30 days to assure that x-rays were requested, x-rays were taken, results were received and notification was made to the physician and the responsible party. This audit started on [DATE] and was completed on [DATE]. Care plans and orders were reviewed to assure that orders received in response to the results were implemented timely. This was also done as of [DATE]. Beginning [DATE] newly received x-ray orders will be logged in an notebook. With each order, the nurse will note the order, the date the order was received, the date and time the request for x-rays was made, the date the x-ray was taken, the date and time the results were received and the date and time the physician and responsible party were notified of the results of the x-rays. Orders will be implemented in response to the results when received. Upon a resident fall, the resident will have a head to toe assessment. A neurological assessment will be completed with any unwitnessed fall or falls involving the head. The neuros will be completed each shift for 72 hours. Any abnormal results or a resident refusing will be called into the MD and RP for notification. Any change in the neuro/vital signs will be immediately reported to the MD. The resident will be assessed for pain and any new onset of pain will be immediately addressed. The MD will be notified of the on set of pain for further evaluation and treatment. The charge nurse will continue to monitor the resident each shift for 72 hours. The charge nurse documentation will focus on the occurrence. Prior to the end of each shift the nursing staff will be required to review the log to assure action has been taken for x-rays orders received during that shift. If the actions are not yet complete by the end of the shift, the nursing staff will highlight that section of the notebook so that the oncoming shift can follow up on outstanding steps in the process. The notebook will be reviewed by the Interdisciplinary Team every morning (M-F) during the morning meeting. The manager on duty on the weekend will review the notebook each day (S-S) to assure the process is followed. This started on [DATE]. Training On [DATE], the Director of Nursing, ADON and Unit Manager educated licensed nursing staff regarding the following: 1. The facility ' s policy regarding reporting incidents to the Director of Nursing and Administrator. 2. Their responsibility to use the X-ray notebook as described above. 3. All licensed staff were trained regarding assessments, incident/accident procedure which includes contacting the MD. No licensed staff will be allowed to work until education is provided by the Director of Nursing/designee. As of [DATE] Jacinto City has 21 nurses on their payroll and 19 have been inserviced as of 3:35pm. The remaining two nurses will be inserviced by 6pm on [DATE]. Monitoring The Director of Nursing conducts daily clinical meetings. All processes described will be reviewed. Any incident after hours or weekends will be called to the DON and she will walk each charge nurse through each step of the process to ensure the plan is adhered to and compliance occurs. This process started on [DATE] and went until [DATE]. Monitoring to ensure PoR was implemented was as follows: Policy on consulting physician ' s concerning changes of condition was reviewed. No identified issues noted. In-service sign in sheets were reviewed which revealed over 90 % of the nursing staff had received training on new procedures concerning consulting the physician, fall prevention and management protocol, pain assessments, assessing residents after a fall and neurological assessments. No identified issues were noted. On [DATE] nursing staff from three different shifts were interviewed regarding the new policy and procedures concerning resident ' s experiencing changes of conditions and consulting the physician, fall prevention and management protocol, pain assessments, assessing residents after a fall and neurological assessments. Nurses interviewed consisted of LVNs and RNs. On [DATE] CNAs were interviewed from two different shifts to assess knowledge level on what to do if they found the resident on the floor or witnessed a resident fall or if the resident had a change in condition. All CNAs interviewed identified conditions of residents that required nursing intervention. While the IJ was removed on [DATE] at 12:08pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. The facility's 672 listed a census of 99 residents.

Based on observation, interview and record review, the facility failed to ensure the resident was free from physical abuse. (Resident #1 ) Resident #1 had her legs held down by Certified Nursing Aide (CNA) A and her arm held by CNA B with bruises to her wrist while they were providing incontinent care. This failure affected one resident and placed 84 other residents who were occassionally or frequently incontinent at risk of being abused or harmed. Findings include: Resident #1 Record review of Resident #1's clinical chart revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's BIMS score dated 1/28/2016 revealed a score of 99, for non-interviewable. Resident #1's staff assessment revealed her as a 2, which indicated cognitive impairment. Record review of Resident #1's Care Plan dated 10/29/2015 and 1/22/2016 revealed that she refused care and becomes easily annoyed. Record Review of Resident #1's facesheet revealed that her language used was Spanish. Observation made on 2/2/2016 at 1:15 PM of Resident #1 sitting in her room in her chair. Interview on 2/2/2016 at 9:30AM with Resident #1 revealed that she was held down by two CNA ' s one evening. Resident #1 said they were rough with her and not nice. Interview on 2/3/2016 at 5:00 AM with CNA B revealed that she was training with CNA A and when they went into Resident #1 ' s room between 4 AM and 6 AM to do their rounds, Resident #1 was completely soiled. CNA B stated that Resident #1 was technically CNA A ' s resident since she was training; she was only following what she was told to do by CNA A. CNA B revealed that Resident #1 had not been changed since she was put to bed. CNA B stated that they had to change Resident #1 ' s entire bed linens. CNA B stated that Resident #1 was refusing care and being combative towards her and CNA A. CNA B stated, I guess I was damned either way. I would have been in trouble if I didn ' t change her and I am trouble for making her be changed. Further interview on 2/3/2016 at 5:00 AM CNA B stated that she held Resident #1 ' s arm while providing care and CNA A held both of Resident #1 ' s legs down. When CNA B was asked how she was trained to handle residents with behaviors and those refusing care, CNA B stated she was supposed to leave the resident and try again later and after that attempt failed she was to notify the resident's nurse. CNA B stated she believed it would be best to change Resident #1 because it was almost end of shift and she had not been changed all night. An attempt to contact CNA A was made, She was terminated from the facility. Her phone # was disconnected. Record Review of Resident #1 ' s skin assessment dated [DATE] revealed bruises to Resident #1 ' s left arm. Record Review revealed CNA A and CNA B were both in-serviced on 1/27/2016 on abuse and dealing with combative residents. Record Review of facilities investigation summary date 1/29/2016 read in part, Resident #1 became combative, kicking and throwing her arms around. While they were attempting care she began kicking and hitting CNA ' s. CNA ' s held her arm and legs. Record review during facility investigation revealed Resident #1 stated, last night an employee came to her room and was grabbing her by her wrist. Record Review revealed CNA A and CNA B were both in-serviced on 1/27/2016 on abuse and dealing with combative residents. Record Review of statements from CNA B read in part, I went to change the resident by the window during last rounds. She was combative and speaking her native tongue. I changed her and held her by her forearms to get the task accomplished. I tried to fold her arms into her gown but to no avail CNA A held her feet as not to get kicked. Record Review of statements from CNA C read in part, she was held down on night shift by two nurses .She was telling me in Spanish and was very upset telling me. Record review of the facility's investigation dated 1/29/2016 revealed the investigation findings were confirmed that Resident #1 was held down by CNA A and CNA B during an attempt to provide incontinent care. In exit on 2/3/16 at 4:00pm the Administrator said that if a resident was being combative or became aggitated during the care she would expect the staff to walk away and try later. The facility's CMS 802 listed 85 residents as incontinent.

Based on observation, interview and record review the facility failed to implement their written policy and procedures that prohibit neglect for 1 of fourteen resident s (Resident #2) reviewed for neglect. Resident #2 ' s helmet was not removed for assessment after an un-witnessed fall and Resident #2 had a head injury which required an emergency room visit and staples to the laceration on her scalp. This failure affected 1 resident whose care was compromised due to staff neglecting to perform a thorough assessment after an un-witnessed fall and placed 29 additional fall risk residents at risk for neglect and injury. Intake #: 1 Findings Include: Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old Hispanic female with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #2 ' s MDS not dated revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Care Plan dated 10/15/15 revealed Resident #2 was care planned for: Alteration in Communication related to: Language Barrier (Spanish)-Goals: Anticipated per staff. 1. Approaches: Use short phrases and questions that require yes or no answers. Use gestures as needed. 2. Use reassurance and patience when resident attempts to communicate. 3. Monitor resident for any changes. 4. Involve in activities which do not depend on resident ' s ability to communicate like, music, parties, movies. 5. For foreign language, encourage family to translate, use cue/cards/words that will assist in care of resident. 6. Encourage family involvement like bringing music etc. Care Plan dated 10/15/2015 for revealed Resident #2 was care planned for Communication related to: [MEDICAL CONDITION]. Approaches: 1. Ask resident yes/no questions. 2. Converse with resident while providing care. 3. Allow resident time to respond. 4. Be patient with resident. 5. Allow resident to vent frustrations. Care Plan further revealed that Resident #2 was care planned for [MEDICAL CONDITION] with an increased risk for fracture: Approach: 1. Administer medication as ordered. 2. Fall risk assessment. 3. Fall prevention protocol 4. Call bell within reach. 5. Notify MD as indicated. Record review of Nurse ' s notes dated 1/16/2016 at 11:20am said: Resident #2 ambulating in dining room, helmet and hip pads in place. Observed another resident push Resident #2 down. Resident #2 fell to the floor on left side. Did not hit her head. Assessment was done and Resident #2 was assisted up and was ambulatory with same range of motion. No injuries were noted and all parties were notified. Record review of Nurse ' s notes dated 1/16/2016 at 1:00pm: Family member was in facility to feed Resident #2 lunch. The family member removed the helmet to brush Resident #2' s hair and noted a 0.5cm laceration on back of head. Small amount of active bleeding was noted. Pressure applied and bleeding stopped. A call was placed to physician to update on Resident #2 ' s condition. Orders were received to transport resident to emergency room for evaluation. Record review of Nurse ' s note dated 1/16/2016 at 4:30pm revealed Resident #2 returned from hospital with 2 staples to laceration on back of her head. Record review of Neurological record revealed neurological checks were started on 1/16/2016 at 1:00pm and continued to 1/19/2016 at 10:30am. Record review of Provider Investigation Report dated 1/17/2016 read; Description of the Allegation: Resident was bumped by Resident #3 in the common area causing her to fall; head to toe assessment was completed by LVN X at 11:20am when resident fell . She failed to remove the resident ' s helmet when she completed her assessment. When Resident # 2's family member arrived for lunch he fed her and after lunch he removed her helmet to brush her hair and noted a laceration that required resident to be sent out for staples. Description of injury: Delay in resident treatment, incident at 11:20am and resident did not get sent out until 3:30pm. Description of Assessment: Head to toe assessment completed without removing resident ' s helmet. Record review of the facility's 'Incident Investigation Worksheet dated 1/17/2016 revealed Resident #2 had an un-witnessed fall on 1/16/2016 at 11:20am. Resident #2 was assessed by LVN X who failed to remove Resident #2 ' s helmet during assessment and reported no noted injuries. Incident Investigation Worksheet further revealed that Resident #2 ' s family member arrived to facility around 1:30pm and removed Resident #2 ' s helmet and noted a laceration. Resident #2 was transferred to the hospital where she received 2 staples to seal the laceration. In an Interview with DON on 2/02/2016 at 9:00am she said LVN X was suspended for a few days following the incident with Resident #2. DON said LVN X should have removed the helmet to do a thorough assessment following a fall. Observation on 2/3/2016 at 11:05am revealed Resident #2 ambulating about the dining area. Attempted interview with Resident #2 at same time. Resident not able to voice needs at that time In an interview on 2/3/2016 at 2:30pm with LVN X, she said she did not see Resident #2 ' s fall occur. She was told by other residents that Resident #3 pushed her down. LVN X revealed that she found Resident #2 lying on her side on the floor in the dining area. LVN X admitted that she did not remove Resident #2 ' s helmet during assessment and was aware she should have. The facility's CMS 802 listed a census of 106 and 30 with falls.

Based on observations, interviews and record review, the facility failed to ensure that 3 of 6 residents (Resident #2, #15, and Resident #13) reviewed for quality of care, received the care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. -Resident #2 ' s helmet was not removed for assessment after an un-witnessed fall and treatment was delayed for the laceration on the back of her head that required 2 staples. -Resident #15 was not medicated for pain because staff did not speak Spanish. -Resident # 13 was verbally abused by facility staff. This failure affected three residents and placed 60 other residents with falls and pain at risk for injury, increase in their pain and decline in health status. Intake: # 5 and # 1 Findings Include: Resident #2 Record review of Resident #2 ' s face sheet revealed a [AGE] year old Hispanic female with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #2's MDS , not dated revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Care Plan dated 10/15/15 revealed Resident #2 was care planned for: Alteration in Communication related to: Language Barrier (Spanish)-Goals: Anticipated per staff. The approaches included: 1. Use short phrases and questions that require yes or no answers. Use gestures as needed. 2. Use reassurance and patience when resident attempts to communicate. 3. Monitor resident for any changes. 4. Involve in activities which do not depend on resident ' s ability to communicate like, music, parties, movies. 5. For foreign language, encourage family to translate, use cue/cards/words that will assist in care of Resident. 6. Encourage family involvement like bringing music etc. Care Plan dated 10/15/2015 for revealed Resident #2 was care planned for Communication related to: [MEDICAL CONDITION]. Approaches: 1. Ask resident yes/no questions. 2. Converse with resident while providing care. 3. Allow resident time to respond. 4. Be patient with resident. 5. Allow resident to vent frustrations. Record review of Nurse ' s notes dated 1/16/2016 at 11:20am said: Resident #2 ambulating in dining room, helmet and hip pads in place. Observed another resident push Resident #2 down. Resident #2 fell to the floor on left side. Did not hit her head. Assessment was done and Resident #2 was assisted up and was ambulatory with same range of motion. No injuries were noted and all parties were notified. Record review of Nurse ' s notes dated 1/16/2016 at 1:00pm: Family member was in facility to feed Resident #2 lunch. The family member removed the helmet to brush Resident #2' s hair and noted a 0.5cm laceration on back of head. Small amount of active bleeding was noted. Pressure applied and bleeding stopped. A call was placed to physician to update on Resident #2 ' s condition. Orders were received to transport resident to emergency room for evaluation. Record review of Nurse ' s note dated 1/16/2016 at 4:30pm revealed Resident #2 returned from hospital with 2 staples to laceration on back of her head. Record review of Provider Investigation Report dated 1/17/2016 read; Description of the Allegation: Resident was bumped by Resident #3 in the common area causing her to fall; head to toe assessment was completed by LVN X at 11:20am when resident fell . She failed to remove the resident ' s helmet when she completed her assessment. When Resident # 2's family member arrived for lunch he fed her and after lunch he removed her helmet to brush her hair and noted a laceration that required resident to be sent out for staples. Description of injury: Delay in resident treatment, incident at 11:20am and resident did not get sent out until 3:30pm. Description of Assessment: Head to toe assessment completed without removing resident ' s helmet. Observation and interview on 2/03/2015 at 2:30pm revealed Resident #2 ambulating around the dining area in the locked unit. LVN X tried to redirect Resident #2 to activity with other residents. LVN X was speaking English to Resident #2. No staff present that spoke Spanish at that time. No communication board with resident or LVN X. In an interview on 2/03/2015 with LVN X at 2:40pm, she said that staffs use a communication board for some residents. She further said that if a resident speaks Spanish they have staff who will translate or they could call the residents family. LVN X was unaware of interpreter phone line. Observation on 2/03/2015 at 2:35pm revealed no communication board in Resident #2's room or with Resident #2. Resident #15 Record review of Resident #15 ' s face sheet revealed a [AGE] year old Hispanic male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #15 ' s Minimum Data Set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 8 which indicated moderate cognitive impairment. He was also required supervision for bed mobility, transfer, ambulation, dressing, eating and toilet use. Record review of Resident #15 ' s Care Plan dated 10/14/2015 revealed he was care planned for: Pain/Discomfort, Potential related to chronic disease or process .with an update to the care plan dated 11/17/15 that documents the problem as moderate stomach pain, [MEDICATION NAME] 5/325 every four hours as needed for pain. The goals were as follows: Resident #15 will have reduced pain as measured by verbal expression and/or decrease in behaviors .Resident #15 will verbally express increased satisfaction with pain control. The approaches included .positioning/support .music .administer [MEDICATION NAME] as ordered .observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions (facial grimacing, bracing, restlessness, rubbing) .notify physician if interventions were not consistently effective . Alteration in Communication related to: Language Barrier (Spanish) -Goals: Interpreter, Gestures. Approaches were as followed: 1. Use short phrases and questions that require yes or no answers. Use gestures as needed. 2. Use reassurance and patience when resident attempts to communicate. 3. Monitor resident for any changes. 4. Involve in activities which do not depend on resident ' s ability to communicate like, music, parties, movies. 5. For foreign language, encourage family to translate, use cue/cards/words that will assist in care of resident. 6. Encourage family involvement like bringing music etc. Record review of Resident #15's physician orders [REDACTED]. Start date was documented as 12/07/14. Record review of Resident #15's Medication Administration Record [REDACTED]. There was no documentation of pain medication administration on records on his Febuary's MAR Observation and Interview on 2/03/2016 at 4:45am revealed Resident #15 sitting in his wheelchair in the hall moaning loudly and grabbing his stomach and chest area. Resident #15 said he had been in pain since 1:00am. Resident #15 rated his pain at a 10 on a scale of 1-10, with 10 being the worse. He said he was given [MEDICATION NAME] for his pain around 1:00am or 2:00am. Resident #15 said the [MEDICATION NAME] did not help and he was not able to fall asleep and stayed up in the wheelchair all night. In an interview with LVN Z on 2/03/2016 at 5:05am she said that Resident #15 has gastro-[MEDICAL CONDITION] reflux and that he is non-compliant with his diet. She further revealed that she did not speak Spanish and could not communicate with Resident #15. When asked how she communicated with him, she said if there was staff available who could speak Spanish, she would have them translate. LVN Z said she could not communicate with him all night because there was no staff available who spoke Spanish. When asked why she did not call Resident #15 ' s family members regarding his pain and not being able to communicate, she said I ' m not waking them up at 2:00am for that . Observation on 2/03/2016 at 5:09am revealed Resident #15 was sitting in his wheelchair crying and complaining of chest pain and abdominal pain. Resident #15 said his pain was a 10 on a scale of 1-10. Resident #15 further said he just wanted help for his pain. In an interview on 2/03/2016 at 5:10am with the DON she said there was usually staff who could translate. The DON was not sure which staff could translate. She revealed that she could use her phone app for translations if needed. When asked about interpreter phone line, she said she believed the facility had one but would have to find out. In an interview with RN Y on 2/03/2016 at 5:15am he said he spoke a little Spanish and he would try and figure out what Resident #15 needed. RN Y said he could use his phone app to translate if he needed to. Observation on 2/03/16 at 10:00am revealed Resident #15 coming up the hall from his room in his wheelchair moaning and speaking in Spanish. He was moaning and rubbing his abdomen and chest. He said he was in pain and pointed to the area he had been rubbing. Medication Aide (MA) D went to get LVN R to assist the resident. Neither the MA D nor LVN R could understand what Resident #15 was saying. LVN R asked the Surveyor if she could translate for her because there was no one that could speak Spanish. Interview on 2/3/16 at 10:49am with the Division Director of Operations revealed the facility had a translation service they could use or there was always a staff member that could speak Spanish even though they might work in the kitchen. When asked if there was no staff available that could speak Spanish say at 1:00am in the morning he said they should call the family and get them to translate for them. Resident #13 Record review of Resident #13 ' s face sheet revealed an [AGE] year old Hispanic male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #13 ' s Care Plan dated 11/24/2014 revealed he was care planned for Cognitive Deficit; Moderate Impairment related to: short-term and long-term memory loss. Approaches included: 1. Orient resident to time, day, date and place as care is provided. 2. Staff will introduce self and/ or visitors whenever possible. 3. Staff will offer options in simple terms regarding care for resident to choose. 4. Explain any changes in care to resident as needed. 5. Provide time to think/react to information given. Record review of the facility's Incident Investigation Worksheet dated 1/28/2015 revealed Resident #13 was a Spanish speaker and was not ambulatory. Resident #13 was dependent on staff for incontinent care. Incident Investigation Worksheet further read: Resident informed another Spanish speaking nurse aide that his nurse aide on the 10-6 that night had come in to give him care and told him I ' m American and I ' m not going to change you . In an interview on 2/02/2016 at 9:05am Resident #13 revealed that a CNA on the night shift had told him she would not help him because she was American . Resident #13 said she did not speak Spanish and he felt she did not want to help him. Resident #13 further revealed that a lot of the staff did not speak Spanish but said they do try to help him. In an interview on 2/03/2016 at 1:00pm with LVN W she said that if she had a resident who spoke Spanish she would get a staff member to translate. When asked what she would do if no staff was available, she said she would call the resident ' s family. LVN W was not aware of the interpreter phone line. The facility census dated 2/02/2016 listed a census of 106 and 63 residents with pain and falls.

Based on observation, interview and record review the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical physical, mental and psychosocial well-being for 7 of 8 residents reviewed for abuse and neglect and quality of care. (Residents #6, #4, #8, #5, #3, #7and #1). The Administrator failed to: -- implement the facility Abuse, Neglect, and Exploitation (ANE) Policy to prevent abuse and neglect. --supervise the DON to ensure nursing staff conducted accurate assessmnets of residents when they had a change in condition and a fall. The DON failed to: -Train and monitor the staff on management of Residents with Dementia. -Train and monitor the nursing staff on assessing Residents when they had a change in condition and after a fall. These failures affected 7 residents and placed 103 residents at risk for inadequate care and diminishing health conditions. Intake #: 8, 0, 8, 2, An IJ was identified on 01/08/2016. While the IJ was removed on 01/13/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. Findings Include: In an interview on 01/08/16 at 2:13pm the Administrator said she monitored the DON by in-service of staff and monitoring her. She also said she was not aware of the situation regarding the abuse, neglect and quality of care. In an interview at 01/08/16 at 2:30pm the DON said she ensured the nurses were competent in their skills by having a policy and procedure, in-services and skill check-off sheets. In an interview on 1/09/2016 at 8:30am, Administrator said staff were going to be in-serviced on how to handle residents with Dementia. She said she knows that the staff was in-serviced on Dementia care by the state but was not sure how long ago as she is new to the facility and she would have to find out about the in-services. She also said that staff will be sent to Alzheimer ' s/Dementia training to be certified. In an interview with the DON 1/09/2016 at 2:30pm she said that the facility has policies on abuse and neglect. Staff is in-serviced monthly. DON said she had not held an in-service prior to the IJ as today was her third day at the facility. DON said staff will all be educated on Stop and Watch . DON also said that all employees will be in-serviced on falls, dementia, and abuse and neglect before the start of their shift. In an interview on 1/09/2016 at 9:10am with LVN D she said that she had only been with the facility for 3 weeks. LVN D was able to name the Administrator as the Abuse Coordinator but said she had not been in-serviced on Abuse and neglect, falls or dementia. LVN D said she did watch a new hire video but was not sure if the new hire video mentioned dementia or how to care for residents with dementia. In an interview on 01/09/2016 at 9:15am with Housekeeping P, she said she was new to the facility and had only been there a few days. When Housekeeping P was asked about abuse and neglect training, she said I ' m not sure . In an interview on 01/09/2016 at 8:53am with RCS Q, she was able to name the Administrator as abuse coordinator. RCS Q said she was in-serviced this morning on abuse and neglect as well as falls. RCS Q was not sure of when she had dementia training but knows that the facility provided it some time ago. In an interview on 1/09/2016 at 8:50am with Housekeeping F, he said that he was new to the facility and had only been employed for 2 weeks. Housekeeping F said he has not had abuse or neglect training, falls or dementia training and was not sure who the abuse coordinator was. In an interview with LVN S on 1/09/2016 at 8:55am she said that this was her second day working at the facility. She said she was in-serviced on falls, abuse and neglect this morning before her shift. LVN S was able to name the Administrator as the abuse coordinator. LVN S said she had not been in-serviced on residents with dementia or how to care for them. In an interview on 1/12/2016 with LVN C, she said she had recently been in-serviced on abuse and neglect. She named facility Administrator as the abuse coordinator. LVN C said she had training on dementia and residents with dementia was not sure when. In an interview on 1/12/2016 with ADON, she said that she was in-serviced on falls and abuse and neglect. She knows she had training on dementia and redirecting residents but was not sure how long ago. Resident #6 Record review of Resident # 6 ' s Care Plan dated 7/02/2014 with a review date of 10/15/2015 revealed: Resident #6 had moderate cognitive impairment due to short-term and long-term memory loss. Approach: Staff will offer options in simple terms regarding care for resident to choose, Provide time to think/react. Resident #6 was care planned for falls. Approach: Falling Star Program, Encourage resident to ask for assist, orient resident to environment, bed alarm, chair alarm, place call light in reach, observe for `potential patterns of falls to identify possible causes, Offer/assist to toilet frequently and as accepted, place frequently used items within reach, and observe for potential medication related causes. Observation on 1/06/2016 at 3:15pm revealed Resident #6 sitting in wheelchair attempting to enter her room but was not able to as medication cart was blocking the entrance to her room. Surveyor intervened and informed MA B that Resident #6 was trying to enter her room but could not due to the medication cart blocking entrance to room. MA B said he was aware she wanted in the room and that is why he had the cart there to block the entrance to prevent her from going in the room. He further revealed she was a fall risk and did not want her in the room. Observation on 1/06/2016 at 3:19pm revealed Resident #6 in her wheelchair wedged between medication cart and door to her room. Surveyor intervened and informed MA B and RCS K that Resident #6 was wedged between medication cart and door to her room. MA B and RCS K went over to Resident #6 and moved the cart and told Resident #6 she could not go to her room at this time. Resident #6 grabbed the handrail and tried to wheel herself into her room. Resident #6 said she wanted to look at the box in her closet. MA B and RCS K told her she was not able to go into her room at this time. Resident #6 would not release handrail as she continued to try and wheel herself into her room. MA B grabbed Resident #6 ' s wrist/arm and tried to pull her hand off the railing. RCS K then began prying Resident #6 ' s fingers from the handrail. The DON walked by and quickly removed MA B and RCS K from Resident #6. MA B and RCS K told the DON that they did not want Resident #6 in her room because she would make a mess and take things out of her closet and she was a fall risk. DON informed MA B and RCS K that Resident #6 had the right to enter her room. Interview on 1/06/2016 at 3:30pm with the DON revealed that she performed an assessment on Resident #6 and found no injuries. She further revealed that MA B and RCS K acted inappropriately and should have allowed her to enter her room or they could have tried redirecting her. The DON said they should not have grabbed Resident #6's hand or arm. The DON said staff would be in-serviced in Abuse/Neglect. The DON revealed that she was sure staff had training on Dementia but was not sure of the date. In an interview with RCS K on 1/06/2016 at 3:35pm she said that she was trying to re-direct Resident #6 because she did not want her in the room because Resident #6 was a fall risk. In an interview with Resident #6 at 3:45pm she said that MA B and RCS K hurt her wrist. Resident #6 said no one had ever grabbed her arm like that before. She said she just wanted to look in the box in her closet. Observation on 1/06/2016 at 3:45 pm revealed redness to Resident #6 ' s right wrist. Record review of MA B ' s written statement dated 1/06/2016 revealed at about 3pm, he was by the Med Aid Cart, and was about to move it. He was told by the RCS K not to move it because Resident #6 was a fall risk. Resident #6 tried to wheel herself in her room. As she tried to go inside, the RCS K grabbed her hand, telling her not to go in her room for her safety. He only touched the resident and nothing more. In an observation and interview with Resident #6 on 1/07/2016 at 9:40am she revealed she had three small bruises on her right wrist purple in color and in the shape of finger prints. Resident #6 said she had pain to her right wrist. In an interview with the DON on 1/07/2016 at 9:45am she revealed she was aware not aware of bruising. The DON said she would assess Resident #6 and administer Tylenol per orders for her pain to her right wrist. In an interview with DON on 1/07/2016 at 10:00am she verified that there were 3 small bruises to Resident #6 ' s right wrist. The DON said she had not noticed them before because they were under the wander guard. Resident #4 Record review of Resident #4 ' s Care Plan dated 12/14/2015 with a reviewed date of 12/23/15 revealed: Resident #4 had Cognitive Deficit; Resident had moderate independence with decision making. Resident had difficulty with making decisions in new situations. Approach: Provide clear choices and adequate information for resident to make decisions, Point out consequences of bad decisions, involve family members in decisions regarding important matters. Resident #4 was at risk for falls due to: history of previous falls, non-ambulation, blood pressure changes, and [MEDICAL CONDITION]. Approach: Falling star program, encourage resident to ask for assistance, physical therapy, occupational therapy, provide assistive devices such as wheelchair, place call light in reach, observe for potential patterns of falls to identify possible causes, and place frequently used items within reach. Resident #4 was care planned for, [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. In an interview with Resident #4 on 1/06/2016 at 9:40am he said he was at the facility for therapy and was feeling alright today. Observation at the same time revealed resident was well groomed, lying in bed with head of bed elevated. His call light was within reach. There were no falling star above the bed or doorway entrance to signify that Resident #4 was a fall risk. In an interview on 1/06/2016 at 2:20pm with LVN A she said she was called to dining room and found Resident #4 lying on his side on the floor. LVN A said she assessed Resident #4 and found 2 lacerations to the back of his head and he had a skin tear to right arm. Resident #4 was assisted to wheelchair and then assisted to his bed. LVN A said she started neuro vitals and notified physician of fall. She further said that orders were received for Tylenol 650mg for discomfort, wound care orders for skin tear of right arm and both wounds to head. LVN A said no orders were received for CT (cat scan). Record review of Interdisciplinary Post Fall Report dated 1/6/2016 revealed Resident #4 suffered a fall at 11:00am on 1/6/2016. Resident #4 was assessed by LVN A and assisted to wheelchair and then to bed. Record further revealed Resident #4 sustained an open area to the back of the head and right wrist. Record review of Resident #4 ' s Interdisciplinary Post Fall Review completed by LVN A and dated 1/06/16 read: Predisposing Diseases: Dementia. In an interview on 1/08/16 at 3:14pm with Resident #4 ' s RP revealed that Resident #4 did not have a [DIAGNOSES REDACTED].#4 ' s fall until he arrived at facility on 1/06/2016 after lunch time. He said LVN H told him they did not have his phone number in Resident #4 ' s chart. The RP said that Resident #4 is not acting like his self and had been acting different since the fall. The RP said that he arrived at facility at 11:00am today and Resident #4 would not wake up and his breakfast had not been eaten. He said he informed the nurse of Resident #4 ' s condition and she assessed him and said she would call the physician. The RP said LVN H told him that Resident #4 would be transferred to hospital for evaluation but that was over 3 hours ago and Resident #4 still had not woken up. Observation on 1/08/ at 3:14pm of Resident #4 revealed he was lying in bed with head of bed elevated. Resident ' s lips were dry and cracked and lunch was at bedside and had not been eaten. Resident #4 did not respond to verbal stimuli. The RP shook Resident #4 by the shoulder and Resident #4 did not respond. In an interview with LVN H on 1/08/2016 at 3:30pm she said that she had notified physician of change in mental status and Resident #4 was to be transferred to hospital. She further revealed that she contacted several ambulance companies and chose the one with the least estimated time of arrival. When asked if she called 911 for Resident #4 due to non-responsiveness, she said no. In an interview with the DON on 1/08/2016 at 3:35pm she revealed she was unaware that LVN H had not called 911. She was aware of change in condition on 1/07/2016 and had requested an order from physician for x-ray of skull on 1/07/2016. She further revealed that Resident #4 did not become unresponsive until 1:00pm on 1/08/2016. DON said she would have ADON call 911 immediately for transfer. Record review of nurse ' s notes dated 1/8/2016 at 12:00pm said hospital nurse was visiting with Resident #4 and family. Hospital nurse requested that nurse on duty to assess Resident #4. Resident #4 said he was not feeling well. Hospital nurse remained at bedside. Call was placed to physician regarding assessment and Resident #4 not feeling well and also made aware of recent fall from wheelchair. Record review of nurse ' s notes dated 1/8/2016 at 12:15pm read: placed call to hospital, spoke to emergency room nurse. Report given. Went to Resident #4 ' s room, made resident aware he would be transferred to hospital. Record review of nurse ' s note dated 1/08/2016 at 12:25pm read: placed call to ambulance service. The above report given to dispatcher. Stated will send ambulance right away. Made charge nurse aware. Record review of nurse ' s note dated 1/08/2016 at 12:30pm read: Resident in room. Son at bedside. Blood sugar (BS)=69. Call placed to MD. New order to give glucacon 1mg IM (intra-muscular)if resident not awake. Record review of nurse ' s note dated 1/08/2016 at 1:00pm read: BS=100. Resident responds to painful stimuli. Awaiting on transportation. Record review of nurse ' s note dated 1/08/2016 at 2:00pm read: Responds to painful stimuli and moves all extremities. No sign or symptoms of pain or discomfort. Record review of nurse ' s note dated 1/08/2016 at 2:30pm read: Awaiting on transportation. Resident denies pain. Respirations even and unlabored. Vital signs: blood pressure-140/78, 80, 20, 97%. Record review of nurse ' s note dated 1/08/2016 at 3:00pm read: Resident responding to painful stimuli. No signs of distress. Respirations 20 per minute. Son at bedside and aware of change of condition. Record review of nurse ' s note dated 1/08/2016 at 4:50pm read: EMS personnel arrived. Blood sugar at this time is 71. Blood pressure 140/79, pulse 79, respirations 20, and temperature 97.8. In an interview with DON on 1/08/2016 at 5:10pm she said that ADON and LVN H both will be counseled on assessment, the depth of assessment, and starting interventions. She stated They both failed to assess with urgency . Record review of emergency room visit dated 1/08/2016 revealed Patient is non-responsive. Per EMS, family says patient was not his normal self after fall. In an interview with Resident #4 ' s RP on 1/09/2016 at 2:00pm he revealed that Resident #4 was still not alert. In an interview on 1/11/2016 at 3:00pm with Resident #4 at hospital, resident responded to verbal stimuli. Resident #4 said he was not feeling well and hasn ' t felt well since the fall. He said he is hoping to get better so he can return to his home. Resident #8 Record review of Resident #8 ' s Care Plan dated 6/30/2015 with a review dated of 10/29/2015 revealed resident was at risk for falls. Approach: Falling Star program, encourage resident to ask for assistance, place call light in reach, place frequently used items within reach. In an interview on 1/10/2015 at 1:40pm with Administrator revealed Resident #8 was identified as having concerns with caregivers. Administrator said resident was not able to understand the RCS ' s in his room because they were speaking Spanish. Administrator said that Resident #8 ' s roommate spoke Spanish and told the RCS in Spanish not to hurt Resident #8 or he would report them. In an interview with Resident #8 at 3:00pm he said that one of the RCS ' s was rough with him while trying to change his brief. Resident #8 said RCS grabbed him by one leg and spun him around in bed so she could change his brief. Resident #8 further revealed that same RCS had pushed him into the bed before. Resident #8 was not sure of RCS ' s name. He said he had not seen her in about 4 days. In an interview with the DON on 1/10/2016 at 3:30pm she said we was not sure who the RCS was that Resident #8 was talking about, but she would find out. In an interview with the DON on 1/11/2016 at 11:40am she revealed that RCS G, RSC I and RCS H were all in Resident #8 ' s room when incident occurred and RSC H had provided a written statement. In a telephone interview on 1/13/2016 at 12:15pm with RCS H she said she was passing by Resident #8 ' s room and heard noise. RCS H said she opened the door and the curtain was drawn. She said RCS I was turning Resident #8 and moved his leg. She said she told RCS I to move Resident #8 slowly. RCS H said RCS I responded with That ' s not how I do it . When RCS H was asked if she did anything regarding the treatment of [REDACTED]. In a telephone interview on 1/13/2016 at 1:00pm with RCS G she said RCS I was changing Resident #8 and she was in the room to assist. RCS G said Resident #8 hollers every time he was changed. RCS G said that when RCS I turned Resident # 8 he screamed . RCS G further revealed that the Resident #8 ' s roommate heard Resident #8 screaming and roommate told them he was going to report them for being mean to Resident #8. In a telephone interview on 1/13/2016 at 1:20pm with RCS I she said she was in the room with RCS G who was giving Resident #8 a bed bath. RCS I said RCS H was also in the room to translate for Resident #8 ' s Spanish speaking roommate. RCS I said the roommate said in Spanish that he was going to report them for being mean to Resident #8 if they didn ' t stop. Resident #3 Record review of care plan dated 7/15/15 with a review date of 10/15/15 revealed resident was care planned for Depression/Anxiety. Approach: Provide calm, reassuring environment, encourage resident and staff to be alert to events or situations that precipitate episodes of restlessness or anxiety, calm and reassure as needed, modify environment to promote calm and comfort. In an interview with Resident #3 on 1/08/2016 at 1:40pm she said that RCS M was rude and mean to her. She further revealed that she doesn ' t put up with it and takes care of it herself by telling him off. Resident #3 further revealed she did not like it when RCS M was assigned to her hall and she was scared of him. Resident #3 had witnessed RCS M speak rudely to her roommate (Resident #5) and take her call light away so she would not be able to use it and stated her roommate was also scared of RCS M. Resident #3 said she had mentioned it to previous administrator and RCS M was moved to a different hall but now he was working on her hall again andshe was worried he might come into her room. In an interview with the DON on 1/08/2016 at 1:50pm she said she was aware of the incident involving Resident #3 and RCS M. She said RCS M had been removed from the floor and suspended pending investigation. Resident #5 Record review of Resident #5 ' s care plan dated 12/2/15 with a reviewed date of 12/17/15 revealed Resident #5 was care planned for falls. Approach: Place call light in reach, full body lift-hoyer, use calm, patient approach when using mechanical lift. Record review of Resident #5 ' s care plan dated 12/4/15 with a reviewed date of 12/17/15 revealed Resident #5 was care planned for falls. Approach: Falling Star Program, place call light in reach, place frequently used items in reach, offer/assist to toilet frequently and as accepted. Record review of Resident #5 ' s care plan dated 12/8/15 with a reviewed date of 12/17/15 revealed resident was care planned for anxiety. Approach: Administer medication as ordered, Monitor for side effects to medication, notify MD as indicated, monitor for effectiveness, refer to social services as indicated, refer to psych services as indicated. In an interview on 1/06/2016 at 1:45pm Resident #5 said she didn ' t like it when that mean man would come into her room. She said that whenever she used her call light he would come in the room and take it away. She said that RCS M told her This call light won ' t get you water and then took the call light away and placed it out of her reach. Resident #5 said she told the previous administrator and RCS M was moved to another hall but she sometimes will see him on her hall and is very worried he might hurt her. Observation at same time revealed no Falling Star over bed or outside of door to identify resident as a fall risk. In an interview on 1/06/2015 at 1:50pm Resident #5 ' s roommate (Resident #3) said that everything Resident #5 said was true. Resident #3 said she had witnessed him speaking rudely to Resident #5 and had witnessed him take her call light away. In an interview with DON on 1/08/2016 at 1:50pm she said she was aware of the incident involving Resident #5 and RCS M. She said RCS M has been removed from the floor and suspended pending investigation. DON said all employees will be in-serviced on abuse and neglect when they come in for their shifts. She said they would not be able to care for residents until they had been in-serviced. Resident #7 Record review of care plan dated 12/21/15 with a reviewed date of 1/7/16 revealed resident was care planned for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, place frequently used items within reach, offer/assist to toilet frequently and as accepted. In an interview with Resident #7 on 1/11/ at 11:25am he revealed that RCS G was rude and speaks aggressively towards him. He also said that when RCS G enters the room she refuses to give her name. Resident #7 also said that when he used the call light for pain medication RCS G just enters the room, turns off the call light and leaves the room. Resident #7 said she never returns to let him know if she told the nurse he needed something for pain. In an interview with DON on 1/11/2016 at 11:35am she said she was aware of the incident involving RCS G and incident was being investigated. The DON further said that she double checked the Medication Administration Record [REDACTED]. The DON also said staff would be receiving sensitivity training now and quarterly. In a telephone interview with RCS G on 1/13/2016 at 1:00pm she said that she took care of Resident #7 on Friday. She asked the nurse to tell Resident #7 that she was the only RCS on his hall. RCS G said that Resident #7 reported that she does not let him know when she tells the nurse he needs medicine for pain. She said she was not aware that she had to report back to him. She stated My tone is high sometimes, maybe I come off rude . Resident#1 Record review of Resident #1 ' s Care Plan dated 12/15/2015 revealed that he was at risk for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted, place frequently used items within reach, observe for potential medication related causes. In an interview on 1/06/2016 at 11:00am with Resident #1 he revealed that he had a fall while he was out on pass. He said he hit his head when he fell down 4-5 steps. Resident #1 said he fell on [DATE] and when he returned to the facility that same day, he did not tell any staff and the staff didn ' t ask about the bump and scratches to his forehead. Resident #1 said no one noticed the bump on his head and scratches until the hospital nurse came to visit him at the facility on 12/23/2015 . Resident #1 said the hospital nurse noticed immediately and she told the facility of the fall and his injuries. Resident further revealed that CT (cat scan) revealed a fracture to his neck and he needed to wear a neck brace. Observation at same time revealed resident was wearing neck brace per physician order. In a telephone interview on 1/06/2016 at 10:00am with hospital nurse she said that she was very concerned about Resident #1 ' s care and the assessment skills of the nurses at the facility. The hospital nurse said she noticed immediately that Resident #1 had a large bump to his forehead along with scratches. She said she asked Resident #1 about the bump and scratches and he said he fell down some stairs while he was out on pass. The Hospital nurse said the facility was not aware of Resident #1's fall until she notified them on 12/23/2015. Record review of nursing notes dated 12/23/2015 at 1:00pm revealed Resident #1 said he fell at home on 12/22/2015. Head to toe assessment performed. Resident #1 was alert and oriented. Small laceration on the forehead observed, scratch to the tip of nose. No bruising noted. Call placed to physician. No new orders received. Continue with Neuro vital signs, monitor for pain, bruising, redness or neurological change. Record review of Neurological record dated 12/23/2015 revealed that Neurological checks were started at 12:45am on 12/23/2015 and continued to 5:30pm on 12/23/2015. Record review of nurses note dated 12/23/2015 at 4:30pm revealed facility called hospital nurse regarding Resident #1 and his fall. Hospital nurse voiced concern regarding documentation of facility nurse and requested that hospital protocol be followed for falls with suspected head injuries. Record review of SBAR Communication Form dated 12/23/2015 at 6:05pm revealed that Resident #1's physician was notified of fall while Resident #1 was out on pass 12/22/2015. Orders received from physician to send Resident #1 to emergency room for evaluation and treatment for [REDACTED]. Record review of CT report dated 12/24/2015 read: Diagnostic Impression; C3 cervical [MEDICATION NAME] process fracture: acute Record review of physician order [REDACTED]. In an interview with the Director of Nursing (DON) on 1/8/2015 at 5:00pm she was unsure of policy regarding assessments of residents who go out on pass and how residents were monitored when they returned. The DON said she would find out. In an interview with DON on 1/11/2015 at 3:30pm she said that residents should be assessed before going out on pass and when they return. She further said that when residents go out on pass that the residents must inform the nurse and sign out on the Out of Facility Release of Responsibility form and they sign in when they return so that they know the resident has returned. She further revealed that the nurse on duty signs the form as well. Record review of Out of Facility Release of Responsibility form in Resident #1 ' s chart revealed Resident #1 signed himself out on pass on 12/18/15, 12/24/15, 12/28/15, 1/03/16, 1/04/16, and 1/07/16. There were no signatures by nurse or resident indicating that Resident #1 returned to facility on those days. Record review of Suspected resident abuse assessment, long-term care dated October 02, 2015 provided by facility read: -Residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. -The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. -The facility must not employ individuals who have been found guilty by court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nursing assistant registry concerning abuse, neglect, or mistreatment of [REDACTED]. -The facility must report to the state ' s nursing assistant registry or licensing authorities any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nursing assistant or other facility staff member. -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of a resident ' s property, are reported immediately, through established procedures, to the facility administrator and to other officials in accordance with state law. -The facility must have evidence that all alleged violations have been thoroughly investigated and must take precautions to prevent further potential abuse while the investigation is in process. An immediate jeopardy (IJ) was identified on 01/08/16 at 2:13 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/09/16 at 12:40pm and after several revisions were made it was accepted on 01/12/16 at 4:13pm. The POR included in part: Immediate Action: 1.The Interdiscplinary Team interviewed 69 interviewable residents, provided a copy of Resident ' s Rights to voice concerns and to be free of retaliation. copy of the DADS Hotline phone number and Compliance Hotline phone numbers to report any concerns. They were re-educated regarding where the phone numbers were posted in the facility for DADS Hotline and Compliance Hotlines. 2. The DON and Charge Nurses conducted Head to Toe skin checks on 37 non-interviewable residents and found no concerns following the completion of the assessment. 3. The facility mailed copies of the Resident Rights, DADS Hotline phone number and the company ' s Compliance Hotline phone numbers to the resident ' s responsible party / family member. 4. To protect non-interviewable residents from abuse included the following actions: · Certified Nursing Assistants will utilize the Stop & Watch tool following all ADL care to alert the charge nurse of any changes they observe. · Charge nurses will conduct weekly head to toes skin checks · Charge nurses will monitor residents for changes in behavior and complete the SBAR if they have a concern and notify the family and physician. 5. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and

F223 Based on interview and record review, the facility failed to ensure the right to be free from physical and verbal abuse was provided for 5 of 8 residents reviewed for abuse (Residents #6, #8, #5, #3 and #7) as evidenced by: Resident #6 was grabbed by her wrist/ arm and hand by Medication Aide (MA) B and Resident Care Specialist (RCS) K to prevent her from entering her room. RSC I handled Resident #8 roughly when she changed his brief by pulling him by one leg to reposition him in bed. RCS M verbally abused Resident #5. He took her call light away and told her that it would not help her get water. Resident #5 was scared of RCS M. RCS G was rude and mean to Resident #3. RCS G was rude and refused to tell Resident #7 her name. An IJ was identified on 01/08/2016. While the IJ was removed on 01/13/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected five residents and placed 105 residents at risk for mistreatment, abuse and neglect. Intake #: 8, 0, 8, 2 Findings Include: Resident #6 Record review of Resident #6 ' s face sheet revealed resident is a [AGE] year old female with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident # 6 ' s Care Plan dated 7/02/2014 with a review date of 10/15/2015 revealed: Resident #6 had moderate cognitive impairment due to short-term and long-term memory loss. Approach: Staff will offer options in simple terms regarding care for resident to choose, Provide time to think/react. Resident #6 was care planned for falls. Approach: Falling Star Program, Encourage resident to ask for assist, orient resident to environment, bed alarm, chair alarm, place call light in reach, observe for `potential patterns of falls to identify possible causes, Offer/assist to toilet frequently and as accepted, place frequently used items within reach, and observe for potential medication related causes. Resident #6 had [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. Observation on 1/06/2016 at 2:59pm revealed that there was no Falling Star above the Resident ' s door or above her bed to identify her as a fall risk. Observation on 1/06/2016 at 3:15pm revealed Resident #6 sitting in wheelchair attempting to enter her room but was not able to as medication cart was blocking the entrance to her room. Surveyor intervened and informed MA B that Resident #6 was trying to enter her room but could not due to the medication cart blocking entrance to room. MA B said he was aware she wanted in the room and that is why he had the cart there to block the entrance to prevent her from going in the room. He further revealed she was a fall risk and did not want her in the room. Observation on 1/06/2016 at 3:19pm revealed Resident #6 in her wheelchair wedged between medication cart and door to her room. Surveyor intervened and informed MA B and RCS K that Resident #6 was wedged between medication cart and door to her room. MA B and RCS K went over to Resident #6 and moved the cart and told Resident #6 she could not go to her room at this time. Resident #6 grabbed the handrail and tried to wheel herself into her room. Resident #6 said she wanted to look at the box in her closet. MA B and RCS K told her she was not able to go into her room at this time. Resident #6 would not release handrail as she continued to try and wheel herself into her room. MA B grabbed Resident #6 ' s wrist/arm and tried to pull her hand off the railing. RCS K then began prying Resident #6 ' s fingers from the handrail. The DON walked by and quickly removed MA B and RCS K from Resident #6. MA B and RCS K told the DON that they did not want Resident #6 in her room because she would make a mess and take things out of her closet and she was a fall risk. DON informed MA B and RCS K that Resident #6 had the right to enter her room. Interview on 1/06/2016 at 3:30pm with the DON revealed that she performed an assessment on Resident #6 and found no injuries. She further revealed that MA B and RCS K acted inappropriately and should have allowed her to enter her room or they could have tried redirecting her. The DON said they should not have grabbed Resident #6's hand or arm. The DON said staff would be in-serviced in Abuse/Neglect. The DON revealed that she was sure staff had training on Dementia but was not sure of the date. In an interview with RCS K on 1/06/2016 at 3:35pm she said that she was trying to re-direct Resident #6 because she did not want her in the room because Resident #6 was a fall risk. In an interview with Resident #6 at 3:45pm she said that MA B and RCS K hurt her wrist. Resident #6 said no one had ever grabbed her arm like that before. She said she just wanted to look in the box in her closet. Observation on 1/06/2016 at 3:45 pm revealed redness to Resident #6 ' s right wrist. Record review of MA B ' s written statement dated 1/06/2016 revealed at about 3pm, he was by the Med Aid Cart, and was about to move it. He was told by the RCS K not to move it because Resident #6 was a fall risk. Resident #6 tried to wheel herself in her room. As she tried to go inside, the RCS K grabbed her hand, telling her not to go in her room for her safety. He only touched the resident and nothing more. Record review of RCS K ' s written statement dated 1/06/2016 revealed that Resident #6 was trying to enter her room and RCS K intervened by trying to stop her because she was a fall risk. RCS K's written statement further revealed that she spoke to Resident #6, and touched her hand trying to redirect her away from the door because she was a fall risk. In an observation and interview with Resident #6 on 1/07/2016 at 9:40am she revealed she had three small bruises on her right wrist purple in color and in the shape of finger prints. Resident #6 said she had pain to her right wrist. In an interview with the Director of Nursing (DON) on 1/07/2016 at 9:45am she revealed she was aware not aware of bruising. The DON said she would assess Resident #6 and administer Tylenol per orders for her pain to her right wrist. In an interview with DON on 1/07/2016 at 10:00am she verified that there were 3 small bruises to Resident #6 ' s right wrist. The DON said she had not noticed them before because they were under the wander guard. Record review of Provider Investigation Report dated 1/07/2016 completed by DON read: Description of Allegation- The DON was walking down the hall towards room. Resident #6 was grabbing onto the door frame trying to pull herself into the room, RCS K was asking the resident where she was going, and reached towards residents hand, The DON could not see what RCS K did with the resident's hand because the resident's body and wheelchair were blocking my view. However, MA B then reached over and put his hand around the resident ' s wrist to prevent her from grabbing onto the other door frame, causing resident to become agitated. The DON intervened with the staff explaining to them resident ' s rights and allowed resident into her room to access items in her closet and then redirected her back to into the activity room. The DON removed both staff members from the floor, began education, and notified the administrator of the incident. Resident #8 Record review of Resident #8 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #8 ' s MDS dated [DATE] revealed resident was moderately impaired for cognitive skills for daily decision making. He was assessed as not having problems with moods or behaviors, needed extensive assistance of one to two staff members for all activities of daily living (ADL) except eating for which he required supervision only. Under the section for functional limitation in range of motion he was assessed as impairment on both sides for upper and lower extremities. Record review of Resident #8 ' s Care Plan dated 6/30/2015 with a review date of 10/29/2015 revealed resident was at risk for falls. Approach: Falling Star program, encourage resident to ask for assistance, place call light in reach, place frequently used items within reach. In an interview on 1/10/2015 at 1:40pm with Administrator revealed Resident #8 was identified as having concerns with caregivers. Administrator said resident was not able to understand the RCS ' s in his room because they were speaking Spanish. Administrator said that Resident #8 ' s roommate spoke Spanish and told the RCS in Spanish not to hurt Resident #8 or he would report them. In an interview with Resident #8 at 3:00pm he said that one of the RCS ' s was rough with him while trying to change his brief. Resident #8 said RCS grabbed him by one leg and spun him around in bed so she could change his brief. Resident #8 further revealed that same RCS had pushed him into the bed before. Resident #8 was not sure of RCS ' s name. He said he had not seen her in about 4 days. In an interview with the DON on 1/10/2016 at 3:30pm she said we was not sure who the RCS was that Resident #8 was talking about, but she would find out. In an interview with the DON on 1/11/2016 at 11:40am she revealed that RCS G, RSC I and RCS H were all in Resident #8 ' s room when incident occurred and RSC H had provided a written statement. In a telephone interview on 1/13/2016 at 12:15pm with RCS H she said she was passing by Resident #8 ' s room and heard noise. RCS H said she opened the door and the curtain was drawn. She said RCS I was turning Resident #8 and moved his leg. She said she told RCS I to move Resident #8 slowly. RCS H said RCS I responded with That ' s not how I do it . When RCS H was asked if she did anything regarding the treatment of [REDACTED]. In a telephone interview on 1/13/2016 at 1:00pm with RCS G she said RCS I was changing Resident #8 and she was in the room to assist. RCS G said Resident #8 hollers every time he was changed. RCS G said that when RCS I turned Resident # 8 he screamed that something was wrong with his leg RCS G further revealed that the Resident #8 ' s roommate heard Resident #8 screaming and roommate told them he was going to report them for being mean to Resident #8. In a telephone interview on 1/13/2016 at 1:20pm with RCS I she said she was in the room with RCS G who was giving Resident #8 a bed bath. RCS I said RCS H was also in the room to translate for Resident #8 ' s Spanish speaking roommate. RCS I said the roommate said in Spanish that he was going to report them for being mean to Resident #8 if they didn ' t stop. Resident #3 Record review of Resident #3 ' s face sheet revealed a [AGE] year old female with an admitted [DATE]. Diagnoses: [REDACTED]. Face sheet further revealed Resident #3 was her own legal guardian. Record review of care plan dated 7/15/15 with a review date of 10/15/15 revealed resident was care planned for Depression/Anxiety. Approach: Provide calm, reassuring environment, encourage resident and staff to be alert to events or situations that precipitate episodes of restlessness or anxiety, calm and reassure as needed, modify environment to promote calm and comfort. In an interview with Resident #3 on 1/08/2016 at 1:40pm she said that RCS M was rude and mean to her. She further revealed that she doesn ' t put up with it and takes care of it herself by telling him off. Resident #3 further revealed she did not like it when RCS M was assigned to her hall and she was scared of him. Resident #3 had witnessed RCS M speak rudely to her roommate (Resident #5) and take her call light away so she would not be able to use it and stated her roommate was also scared of RCS M. Resident #3 said she had mentioned it to previous administrator and RCS M was moved to a different hall but now he was working on her hall again andshe was worried he might come into her room. In an interview with the DON on 1/08/2016 at 1:50pm she said she was aware of the incident involving Resident #3 and RCS M. She said RCS M had been removed from the floor and suspended pending investigation. Resident #5 Record review of face sheet for Resident #5 revealed an [AGE] year old female who was admitted to facility on 12/02/2015. Diagnoses: [REDACTED]. Record review of MDS dated [DATE] revealed a BIMS score of 8. MDS further revealed that Resident #5 required extensive assistance with bed mobility and dressing. MDS revealed Resident #5 was total dependence for toileting. Record review of Resident #5 ' s care plan dated 12/2/15 with a reviewed date of 12/17/15 revealed Resident #5 was care planned for falls. Approach: Place call light in reach, full body lift-hoyer, use calm, patient approach when using mechanical lift. Record review of Resident #5 ' s care plan dated 12/4/15 with a reviewed date of 12/17/15 revealed Resident #5 was care planned for falls. Approach: Falling Star Program, place call light in reach, place frequently used items in reach, offer/assist to toilet frequently and as accepted. Record review of Resident #5 ' s care plan dated 12/8/15 with a reviewed date of 12/17/15 revealed resident was care planned for anxiety. Approach: Administer medication as ordered, Monitor for side effects to medication, notify MD as indicated, monitor for effectiveness, refer to social services as indicated, and refer to psych services as indicated. Interview on 01/06/16 at 1:30pm, Resident #5 said RCS M came into her room (date and time not provided) and told her, Here is your damn soup. He then told her he was not going to get her out of this damn bed. In an interview on 1/06/2016 at 1:45pm Resident #5 said she didn ' t like it when that mean man would come into her room. She said that whenever she used her call light he would come in the room and take it away. She said that RCS M told her This call light won ' t get you water and then took the call light away and placed it out of her reach. Resident #5 said she told the previous administrator and RCS M was moved to another hall but she sometimes will see him on her hall and is very worried he might hurt her. In an interview on 1/06/2015 at 1:50pm Resident #5 ' s roommate (Resident #3) said that everything Resident #5 said was true. Resident #3 said she had witnessed him speaking rudely to Resident #5 and had witnessed him take her call light away. In an interview with the DON on 1/08/2016 at 1:50pm she said she was aware of the incident involving Resident #5 and RCS M. She said RCS M had been removed from the floor and suspended pending investigation. Resident #7 Record review of Resident #7 ' s clinical record revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #7 ' s MDS dated [DATE] revealed a BIMS score of 13 which indicated no cognitive impairment. The MDS assessment further revealed that Resident #7 required extensive assistance for bed mobility and personal hygiene. Resident #7 was total dependence for transfer and toilet use. Record review of care plan dated 12/21/15 with a reviewed date of 1/7/16 revealed resident was care planned for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, place frequently used items within reach, offer/assist to toilet frequently and as accepted. In an interview with Resident #7 on 1/11/ at 11:25am he revealed that RCS G was rude and spoke aggressively towards him. He also said that when RCS G enters the room she refused to give her name. Resident #7 also said that when he used the call light for pain medication RCS G just entered the room, turns off the call light and leaves the room. Resident #7 said she never returns to let him know if she told the nurse he needed something for pain. In an interview with DON on 1/11/2016 at 11:35am she said she was aware of the incident involving RCS G and incident was being investigated. The DON further said that she double checked the Medication Administration Record [REDACTED]. The DON also said staff would be receiving sensitivity training now and quarterly. In a telephone interview with RCS G on 1/13/2016 at 1:00pm she said that she took care of Resident #7 on Friday. She asked the nurse to tell Resident #7 that she was the only RCS on his hall. RCS G said that Resident #7 reported that she did not let him know when she tells the nurse he needs medicine for pain. She said she was not aware that she had to report back to him. She stated My tone is high sometimes, maybe I come off rude Record review of in-service dated 12/22/2015 revealed staff was in-service on reporting abuse and able to assess the need to report. Record review of in-service dated 12/31/2015 revealed staff was in-service on understanding abuse. Record review of in-service dated 1/06/2016 revealed staff was in-serviced on Dementia care and communicating with dementia residents. Record review of Dementia, resident communication, long term care policy with revised date of October 02, 2015 provided by facility read: -Visual strategies; Approach the resident from the front, in his vision field, smile, present objects or written cues to focus attention on the communication topic, provide contextual and environmental cues; use colors, highlighting, enlargement, pictures, drawings, and symbols. -Auditory strategies; use calm, positive, unhurried speech, state the person ' s name and yours to increase a sense of familiarity, use praise and compliments befitting an adult. -Tactile Strategies; use touch to reassure, use touch to guide, lead, redirect, and prompt desired behavior, use familiar objects as reminders. In an interview on 01/06/16 at 11:30 am with RCS N revealed that she was not sure if she had been trained on working with residents with dementia. In an interview with Housekeeper F on 01/09/16 at 8:50am revealed that he had been working at the facility for two weeks and had not been trained on abuse or neglect. He was not sure who the abuse prohibition coordinator was and had not been trained on residents with dementia. Interview on 01/09/16 at 9:10am with Licensed Vocational Nurse (LVN) D revealed she had worked at the facility for three weeks and had not been trained or in-serviced on abuse and neglect or working with residents with dementia. Record review of Suspected resident abuse assessment, long-term care dated October 02, 2015 provided by facility read: -Residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. -The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. -The facility must not employ individuals who have been found guilty by court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nursing assistant registry concerning abuse, neglect, or mistreatment of [REDACTED]. -The facility must report to the state ' s nursing assistant registry or licensing authorities any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nursing assistant or other facility staff member. -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of a resident ' s property, are reported immediately, through established procedures, to the facility administrator and to other officials in accordance with state law. -The facility must have evidence that all alleged violations have been thoroughly investigated and must take precautions to prevent further potential abuse while the investigation is in process. An immediate jeopardy (IJ) was identified on 01/08/16 at 2:13 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/09/16 at 12:40pm and after several revisions were made it was accepted on 01/12/16 at 4:13pm. The POR included in part: Immediate Action: 1.The Interdiscplinary Team interviewed 69 interviewable residents, provided a copy of Resident ' s Rights to voice concerns and to be free of retaliation. copy of the DADS Hotline phone number and Compliance Hotline phone numbers to report any concerns. They were re-educated regarding where the phone numbers were posted in the facility for DADS Hotline and Compliance Hotlines. 2. The DON and Charge Nurses conducted Head to Toe skin checks on 37 non-interviewable residents and found no concerns following the completion of the assessment. 3. The facility mailed copies of the Resident Rights, DADS Hotline phone number and the company ' s Compliance Hotline phone numbers to the resident ' s responsible party / family member. 4. To protect non-interviewable residents from abuse included the following actions: Certified Nursing Assistants will utilize the Stop & Watch tool following all ADL care to alert the charge nurse of any changes they observe. Charge nurses will conduct weekly head to toes skin checks. Charge nurses will monitor residents for changes in behavior and complete the SBAR if they have a concern and notify the family and physician. 5. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. The staff will do the following: a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 6. If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified Training: The DON and the District Director of Clinical Services conducted re-education training for all Nursing, Dietary, Housekeeping, Laundry and Department Manager personnel January 8, 9 and 10, 2016. Training topics included were : Abuse and Neglect Prohibition Assessment of discomfort in Dementia Protocol Change in Condition Emergency Transports via 911 versus Non-emergency transfers. Abuse and Neglect Prohibition training included a review of the facility ' s policy on abuse and neglect prohibition. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how abuse and neglect are defined, prevention techniques, identification, investigation, protection and reporting responsibilities. Abuse and Neglect Prohibition training began January 8, 2016 and ended for all staff that were scheduled to work thru January 10, 2016 including RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Staff Development, Nurse Managers, Rehab Staff, Dietary, Housekeeping and Laundry Staff and Department Managers. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Abuse and Neglect Prohibition policy. The Assessment of discomfort in Dementia Protocol training included a review of how physical pain and affective discomfort experienced by people with dementia can be managed. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how the Assessment of Discomfort protocol should be applied when staff encounter situations with affected residents. Staff were trained on the steps they should follow which include: Conducting a physical evaluation Review residents history for potentially painful conditions Evaluating the discomfort and initiating non-pharmacologic comfort interventions Evaluate for pharmacologic interventions that are not [MEDICAL CONDITION] The Assessment of discomfort in Dementia Protocol training began January 8, 2016 and ended January 10, 2016 for RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy and Speech Therapy staff. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on The Assessment of Discomfort in Dementia Protocol program. The facility ' s policy for identification of change of condition requires the implementation of the Stop & Watch tool as well as Interact 4.0. These decision support tools provide reporting guidance to licensed nurses on whether specific symptoms, signs, and lab results are immediate versus non-immediate, or next day, for reporting purposes to the primary care clinician. Using the Interact 4.0 tool the licensed nurse can determine immediacy of reporting for vital signs, laboratory results and diagnostic procedures. The Director of Nursing Services was re-educated on Stop & Watch and Interact 4.0 on January 9, 2016 by the District Director of Clinical Services. The Director of Clinical Services and the Director of Nursing Services re-educated RN ' s, LVN ' s, Unit Managers, ADON ' s, Staff Development, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy, Speech Therapy and MDS nurses January 9 and 10, 2016 on the Stop & Watch and Interact 4.0 programs. Staff that were not able to attend any of the training offered between January 8 and 9, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Stop & Watch and Interact 4.0 programs. The licensed nurse will evaluate each situation based on individual resident condition at the time of the event. Once a medical emergency is identified, qualified staff evaluate the resident; initiate the appropriate emergency procedure(s), and calls 911. The licensed staff continues to provide care and monitor the resident until the emergency personnel arrive. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/08/16 until 01/10/16. The topics included in part: Abuse and Neglect, Dementia Resident. Observations were made from 01/08/06 until 01/10/16 to that staff -resident interaction was appropriate, for any residents that have a change in condition/falls and care of residents with dementia. Interviews conducted from 01/08/16-01/10/16 between 4:30am to 4:00 pm daily with RCSs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services regarding abuse and neglect and care of a resident with dementia. The Administrator and DON were informed on 01/13/16 at 1:35pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 1/06/2016 revealed a census of 110.

Based on observations, interviews and record review the facility failed to implement their policy and procedures that prohibit mistreatment, neglect and abuse for two (Resident #1,and #4) of eight residents reviewed for neglect and abuse. Resident #4 suffered a fall with lacerations to the head on 1/6/2016 and was not assessed appropriately after change in condition. He became non-responsive on 01/08/16 around 11:00am, the facility did not assess the resident appropriately and called for a non-emergency ambulance versus calling 911. The resident remained in the facility uintil 4:11pm. Resident #1 had an un-witnessed fall while out on pass. He was not assessed upon return to the facility. After the Hospital Nurse assessed the resident and told the facility he had the fall and injuries he was sent to the hospital. He was found to have a fracture to his cervical spine. An IJ was identified on 01/08/2016. While the IJ was removed on 01/13/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed 108 residents at risk for mistreatment, abuse and neglect. Intake #: 8, 0, 8, 2, Findings Include: Resident #4 Record review of Resident #4 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #4 ' s MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment, required one person assist with bed mobility, dressing, and toilet use. Record review of Resident #4 ' s Care Plan dated 12/14/2015 with a reviewed date of 12/23/15 revealed: Resident #4 had Cognitive Deficit; Resident had moderate independence with decision making. Resident had difficulty with making decisions in new situations. Approach: Provide clear choices and adequate information for resident to make decisions, Point out consequences of bad decisions, involve family members in decisions regarding important matters. Resident #4 was at risk for falls due to: history of previous falls, non-ambulation, blood pressure changes, and [MEDICAL CONDITION]. Approach: Falling star program, encourage resident to ask for assistance, physical therapy, occupational therapy, provide assistive devices such as wheelchair, place call light in reach, observe for potential patterns of falls to identify possible causes, and place frequently used items within reach. Resident #4 was care planned for, [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. In an interview with Resident #4 on 1/6/16 at 9:40am he said he was at the facility for therapy and was feeling alright today. Observation at the same time revealed resident was well groomed, very talkative and alert, lying in bed with head of bed elevated. His call light was within reach. There were no falling star above the bed or doorway entrance to signify that Resident #4 was a fall risk. Record review of Interdisciplinary Post Fall Report dated 1/6/2016 revealed Resident #4 suffered a fall at 11:00am on 1/6/2016. Record further revealed that Resident #4 ' s fall occurred in the dining room and LVN A was called to the dining room where she found resident lying on floor on his right side. Resident #4 was assessed by LVN A and assisted to wheelchair and then to bed. Record further revealed Resident #4 sustained an open area to the back of the head and right wrist. Record review of Incident/Accident Investigation Follow-up dated 1/6/16 revealed Resident #4 fell in dining room and LVN A was called to dining room by staff where LVN A found Resident #4 on the floor on his right side. Summary of investigation read: Resident stated he leaned forward to get up and fell to the floor. Past Interventions read: New resident to facility, no history of falls. Recommendations: encourage resident to ask for assistance avoid attempting to get up on his own. Record review of Resident #4 ' s Interdisciplinary Post Fall Review completed by LVN A and dated 1/6/16 read: Predisposing Diseases: Dementia. In an interview on 1/6/16 at 2:20pm with LVN A she said she was called to dining room and found Resident #4 lying on his side on the floor. LVN A said she assessed Resident #4 and found 2 lacerations to the back of his head and he had a skin tear to his right arm. Resident #4 was assisted to the wheelchair and then assisted to his bed. LVN A said she started neuro vitals and notified the physician of the fall. She further said that orders were received for Tylenol 650mg for discomfort, wound care orders for skin tear of right arm and both wounds to head. LVN A said no orders were received for CT (cat scan). Record review of Resident #4's physician's orders [REDACTED].monitor neuro checks every 15 minutes for one hour, every hour for four hours and then every four hours for 24 hours and every eight hours for 72 hours. Record review of Resident #4's Neurological Record read in part: frequency every 30 minutes for four hours, every one hour for four hours, every four hours for 24 hours, every eight hours for remaining 72 hours or as ordered by physician .neuro vital signs were done starting on 01/6/16 at 11:15am and ended on 01/07/16 at 10:30am. Record review of Resident #4's Neurological record dated 01/6/16-01/7/16 revealed neither the physican's order nor the instructions on the Neurological Record in regards to frequency was followed. In an interview on 01/7/16 at 9:30am with Resident #4, he said he was not feeling well and that he was hurting all over. In an interview with Resident #1 (Resident #4 ' s roommate) on 01/7/16 at 9:30am he said that immediately after hitting his head Resident #4 was not the same. He said Resident #4 did not act the same and he stayed in bed and did not eat. Interview on 01/7/16 at 9:40am LVN A when it was reported to her that Resident #4 was hurting all over she said she would assess him. Interview on 01/7/16 at 10:00am LVN A said Resident #4 was fine he was just tired. Interview on 01/7/16 at 10:15am with Resident #1 he said Resident #4 was not fine. He said Resident #4 had been tossing and turning all night and was in pain and did not sleep. Observation on 01/7/16 12:00pm revealed Resident was resting with his eyes closed. Observation and interview on 01/7/16 at 4:00pm revealed Resident #4 was in bed and not feeling well. He said he did not feel like getting out of bed. Observation on 01/8/16 at 8:00am revealed Resident #4 was in bed with his eyes closed. His breakfast tray was beside his bed untouched. Record review of nurse ' s notes dated 1/8/2016 at 12:15pm read: placed call to hospital, spoke to emergency room nurse. Report given. Went to Resident #4 ' s room, made resident aware he would be transferred to hospital. Observation and interview on 01/08/16 at 1:00pm revealed Resident #4 was in bed with eyes closed and did respond to verbal stimuli. His RP was at his bedside and said he would not wake up and shook his shoulder, Resident #4 did not respond. His lunch tray was at his bedside untouched. The RP said the Hospital Nurse told him that she would inform the Nurse at the facility that Resident #4 needed to be sent back to the hospital for evaluation. In an interview on 1/8/16 at 3:14pm with Resident #4 ' s Responsible Party (RP) revealed that Resident #4 did not have a [DIAGNOSES REDACTED]. Resdident #4's RP further revealed that he was not notified of Resident #4 ' s fall until he arrived at facility on 1/06/2016 after lunch time. He said LVN H told him they did not have his phone number in Resident #4 ' s chart. The RP said that Resident #4 was not acting like his self and had been acting different since the fall. The RP said that he arrived at facility at 11:00am today and Resident #4 would not wake up and his breakfast had not been eaten. He said he informed the nurse of Resident #4 ' s condition and she assessed him and said she would call the physician. The RP said LVN H told him that Resident #4 would be transferred to hospital for evaluation but that was over 3 hours ago and Resident #4 still had not woken up. Observation on 1/8/ at 3:14pm of Resident #4 revealed he was lying in bed with head of bed elevated. Resident ' s lips were dry and cracked and lunch was at bedside and had not been eaten. Resident #4 did not respond to verbal stimuli. The RP shook Resident #4 by the shoulder and Resident #4 did not respond. In an interview with LVN H on 1/8/16 at 3:30pm she said that she had notified physician of change in mental status and Resident #4 was to be transferred to hospital. She further revealed that she contacted several ambulance companies and chose the one with the least estimated time of arrival. When asked if she called 911 for Resident #4 due to non-responsiveness, she said no. She said this was not an emergency situation. In an interview with the DON on 1/8/16 at 3:35pm she revealed she was unaware that LVN H had not called 911. She was aware of change in condition on 1/7/16 and had requested an order from physician for x-ray of skull on 1/7/16. She further revealed that Resident #4 did not become unresponsive until 1:00pm on 1/8/16. DON said she would have ADON call 911 immediately for transfer. Record review of nurse ' s notes dated 1/8/16 at 12:00pm said hospital nurse was visiting with Resident #4 and family. Hospital nurse requested that nurse on duty to assess Resident #4. Resident #4 said he was not feeling well. VA Nurse remained at bedside. Call was placed to physician regarding assessment and Resident #4 not feeling well and also made aware of recent fall from wheelchair. Record review of nurse ' s note dated 1/8/16 at 12:25pm read: placed call to ambulance service. The above report given to dispatcher. Stated will send ambulance right away. Made charge nurse aware. Record review of nurse ' s note dated 1/8/16 at 12:30pm read: Resident in room. Son at bedside. Blood sugar (BS)=69. Call placed to MD. New order to give glucacon 1mg IM (intra-muscular)if resident not awake. Record review of nurse ' s note dated 1/8/16 at 1:00pm read: BS=100. Resident responds to painful stimuli. Awaiting on transportation. Son at bedside. Vital signs: Blood pressure-138/76, respirations-20, pulse- 78. Record review of nurse ' s note dated 1/8/16 at 2:00pm read: Responds to painful stimuli and moves all extremities. No sign or symptoms of pain or discomfort. Record review of nurse ' s note dated 1/8/16 at 2:30pm read: Awaiting on transportation. Resident denies pain. Respirations even and unlabored. Vital signs: blood pressure-140/78, 80, 20, 97%. Record review of nurse ' s note dated 1/8/16 at 3:00pm read: Resident responding to painful stimuli. No signs of distress. Respirations 20 per minute. Son at bedside and aware of change of condition. Record review of nurse ' s note dated 1/8/16 at 4:50pm read: EMS personnel arrived. Blood sugar at this time is 71. Blood pressure 140/79, pulse 79, respirations 20, and temperature 97.8. In an interview with DON on 1/8/16 at 5:10pm she said that ADON and LVN H both will be counseled on assessment, the depth of assessment, and starting interventions. She stated They both failed to assess with urgency . Record review of emergency room visit dated 1/08/2016 revealed resident was [AGE] years old and presented to emergency department post fall 3 days ago. Patient is non-responsive. Per EMS, family says patient was not his normal self after fall. Primary Impression: Urinary Tract Infection. Secondary Impressions: Altered mental status, [DIAGNOSES REDACTED]. In an interview with Resident #4 ' s RP on 1/9/16 at 2:00pm he revealed that Resident #4 was diagnosed with [REDACTED]. RP said Resident #4 was still not alert. In an interview on 1/11/16 at 3:00pm with Resident #4 at hospital, resident responded to verbal stimuli. Resident #4 said he was not feeling well and hasn ' t felt well since the fall. He said he is hoping to get better so he can return to his home. Resident#1 Record review of Resident #1 ' s clinical record revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Record review of Resident #1 ' s Care Plan dated 12/15/2015 revealed that he was at risk for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted, place frequently used items within reach, observe for potential medication related causes. In an interview on 1/06/2016 at 11:00am with Resident #1 he revealed that he had a fall while he was out on pass. He said he hit his head when he fell down 4-5 steps. Resident #1 said he fell on [DATE] and when he returned to the facility that same day, he did not tell any staff and the staff didn ' t ask about the bump and scratches to his forehead. Resident #1 said no one noticed the bump on his head and scratches until the hospital nurse came to visit him at the facility on 12/23/2015 . Resident #1 said the hospital nurse noticed immediately and she told the facility of the fall and his injuries. Resident further revealed that CT (cat scan) revealed a fracture to his neck and he needed to wear a neck brace. Observation at same time revealed resident was wearing neck brace per physician order. In a telephone interview on 1/06/2016 at 10:00am with the VA Nurse she said that she was very concerned about Resident #1 ' s care and the assessment skills of the nurses at the facility. The VA Nurse said she noticed immediately that Resident #1 had a large bump to his forehead along with scratches. She said she asked Resident #1 about the bump and scratches and he said he fell down some stairs while he was out on pass. The Hospital nurse said the facility was not aware of Resident #1's fall until she notified them on 12/23/2015. Record review of nursing notes dated 12/23/2015 at 1:00pm revealed Resident #1 said he fell at home on 12/22/2015. Head to toe assessment performed. Resident #1 was alert and oriented. Small laceration on the forehead observed, scratch to the tip of nose. No bruising noted. Call placed to physician. No new orders received. Continue with Neuro vital signs, monitor for pain, bruising, redness or neurological change. Record review of Neurological record dated 12/23/2015 revealed that Neurological checks were started at 12:45am on 12/23/2015 and continued to 5:30pm on 12/23/2015. Record review of nurses note dated 12/23/2015 at 4:30pm revealed facility called VA Nurse regarding Resident #1 and his fall. Hospital nurse voiced concern regarding documentation of facility nurse and requested that hospital protocol be followed for falls with suspected head injuries. Record review of the Situation, Background, Assessment and Recommendation (SBAR) Communication Form dated 12/23/2015 at 6:05pm revealed that Resident #1's physician was notified of fall while Resident #1 was out on pass 12/22/2015. Orders received from physician to send Resident #1 to emergency room for evaluation and treatment for [REDACTED]. Record review of CT report dated 12/24/2015 read: Diagnostic Impression; C3 cervical [MEDICATION NAME] process fracture: acute Record review of physician order [REDACTED]. In an interview with the Director of Nursing (DON) on 1/8/2016 at 5:00pm she was unsure of policy regarding assessments of residents who go out on pass and how residents were monitored when they returned. The DON said she would find out. In an interview with DON on 1/11/2016 at 3:30pm she said that residents should be assessed before going out on pass and when they return. She further said that when residents go out on pass that the residents must inform the nurse and sign out on the Out of Facility Release of Responsibility form and they sign in when they return so that they know the resident has returned. She further revealed that the nurse on duty signs the form as well. Record review of Out of Facility Release of Responsibility form in Resident #1 ' s chart revealed Resident #1 signed himself out on pass on 12/18/15, 12/24/15, 12/28/15, 1/03/16, 1/04/16, and 1/07/16. There were no signatures by nurse or resident indicating that Resident #1 returned to facility on those days. Record review of in-service dated 12/22/2015 revealed staff was in-service on reporting abuse and able to assess the need to report. Record review of in-service dated 12/31/2015 revealed staff was in-service on understanding abuse. Record review of in-service dated 1/06/2016 revealed staff was in-serviced on Dementia care and communicating with dementia residents. Record review of Dementia, resident communication, long term care policy with revised date of October 02, 2015 provided by facility read: -Visual strategies; Approach the resident from the front, in his vision field, smile, present objects or written cues to focus attention on the communication topic, provide contextual and environmental cues; use colors, highlighting, enlargement, pictures, drawings, and symbols. -Auditory strategies; use calm, positive, unhurried speech, state the person ' s name and yours to increase a sense of familiarity, use praise and compliments befitting an adult. -Tactile Strategies; use touch to reassure, use touch to guide, lead, redirect, and prompt desired behavior, use familiar objects as reminders. In an interview on 01/06/16 at 11:30 am with RCS N revealed that she was not sure if she had been trained on working with residents with dementia. In an interview with Housekeeper F on 01/09/16 at 8:50am revealed that he had been working at the facility for two weeks and had not been trained on abuse or neglect. He was not sure who the abuse prohibition coordinator was and had not been trained on residents with dementia. Interview on 01/09/16 at 9:10am with Licensed Vocational Nurse (LVN) D revealed she had worked at the facility for three weeks and had not been trained or in-serviced on abuse and neglect or working with residents with dementia. Record review of Suspected resident abuse assessment, long-term care dated October 02, 2015 provided by facility read: -Residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. -The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. -The facility must not employ individuals who have been found guilty by court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nursing assistant registry concerning abuse, neglect, or mistreatment of [REDACTED]. -The facility must report to the state ' s nursing assistant registry or licensing authorities any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nursing assistant or other facility staff member. -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of a resident ' s property, are reported immediately, through established procedures, to the facility administrator and to other officials in accordance with state law. -The facility must have evidence that all alleged violations have been thoroughly investigated and must take precautions to prevent further potential abuse while the investigation is in process. An immediate jeopardy (IJ) was identified on 01/08/16 at 2:13 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/09/16 at 12:40pm and after several revisions were made it was accepted on 01/12/16 at 4:13pm. The POR included in part: Immediate Action: 1.The Interdiscplinary Team interviewed 69 interviewable residents, provided a copy of Resident ' s Rights to voice concerns and to be free of retaliation. copy of the DADS Hotline phone number and Compliance Hotline phone numbers to report any concerns. They were re-educated regarding where the phone numbers were posted in the facility for DADS Hotline and Compliance Hotlines. 2. The DON and Charge Nurses conducted Head to Toe skin checks on 37 non-interviewable residents and found no concerns following the completion of the assessment. 3. The facility mailed copies of the Resident Rights, DADS Hotline phone number and the company ' s Compliance Hotline phone numbers to the resident ' s responsible party / family member. 4. To protect non-interviewable residents from abuse included the following actions: Certified Nursing Assistants will utilize the Stop & Watch tool following all ADL care to alert the charge nurse of any changes they observe. Charge nurses will conduct weekly head to toes skin checks. Charge nurses will monitor residents for changes in behavior and complete the SBAR if they have a concern and notify the family and physician. 5. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. The staff will do the following: a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 6. If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified Training: The DON and the District Director of Clinical Services conducted re-education training for all Nursing, Dietary, Housekeeping, Laundry and Department Manager personnel January 8, 9 and 10, 2016. Training topics included were : Abuse and Neglect Prohibition Assessment of discomfort in Dementia Protocol Change in Condition Emergency Transports via 911 versus Non-emergency transfers. Abuse and Neglect Prohibition training included a review of the facility ' s policy on abuse and neglect prohibition. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how abuse and neglect are defined, prevention techniques, identification, investigation, protection and reporting responsibilities. Abuse and Neglect Prohibition training began January 8, 2016 and ended for all staff that were scheduled to work thru January 10, 2016 including RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Staff Development, Nurse Managers, Rehab Staff, Dietary, Housekeeping and Laundry Staff and Department Managers. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Abuse and Neglect Prohibition policy. The Assessment of discomfort in Dementia Protocol training included a review of how physical pain and affective discomfort experienced by people with dementia can be managed. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how the Assessment of Discomfort protocol should be applied when staff encounter situations with affected residents. Staff were trained on the steps they should follow which include: Conducting a physical evaluation Review residents history for potentially painful conditions Evaluating the discomfort and initiating non-pharmacologic comfort interventions Evaluate for pharmacologic interventions that are not [MEDICAL CONDITION] The Assessment of discomfort in Dementia Protocol training began January 8, 2016 and ended January 10, 2016 for RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy and Speech Therapy staff. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on The Assessment of Discomfort in Dementia Protocol program. The facility ' s policy for identification of change of condition requires the implementation of the Stop & Watch tool as well as Interact 4.0. These decision support tools provide reporting guidance to licensed nurses on whether specific symptoms, signs, and lab results are immediate versus non-immediate, or next day, for reporting purposes to the primary care clinician. Using the Interact 4.0 tool the licensed nurse can determine immediacy of reporting for vital signs, laboratory results and diagnostic procedures. The Director of Nursing Services was re-educated on Stop & Watch and Interact 4.0 on January 9, 2016 by the District Director of Clinical Services. The Director of Clinical Services and the Director of Nursing Services re-educated RN ' s, LVN ' s, Unit Managers, ADON ' s, Staff Development, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy, Speech Therapy and MDS nurses January 9 and 10, 2016 on the Stop & Watch and Interact 4.0 programs. Staff that were not able to attend any of the training offered between January 8 and 9, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Stop & Watch and Interact 4.0 programs. The licensed nurse will evaluate each situation based on individual resident condition at the time of the event. Once a medical emergency is identified, qualified staff evaluate the resident; initiate the appropriate emergency procedure(s), and calls 911. The licensed staff continues to provide care and monitor the resident until the emergency personnel arrive. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/08/16 until 01/10/16. The topics included in part: Abuse and Neglect, Dementia Resident. Observations were made from 01/08/06 until 01/10/16 to that staff -resident interaction was appropriate, for any residents that have a change in condition/falls and care of residents with dementia. Interviews conducted from 01/08/16-01/10/16 between 4:30am to 4:00 pm daily with RCSs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services regarding abuse and neglect and care of a resident with dementia. The Administrator and DON were informed on 01/13/16 at 1:35pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. Facility 672 dated 1/06/2016 revealed a census of 110.

Based on observations, interviews and record review the facility failed to implement their policy and procedures that prohibit mistreatment, neglect and abuse for seven (Resident #1, #4, #6, #8, #5, #3 and #7) of eight residents reviewed for neglect and abuse. Resident #6 was grabbed by her wrist/ arm and hand by Medication Aide (MA) B and Resident Care Specialist (RCS) K to prevent her from entering her room. Resident #4 suffered a fall with lacerations to the head on 1/6/2016 and was not assessed appropriately after change in condition. He became non-responsive on 01/08/16 around 11:00am, the facility did not assess the resident appropriately and called for a non-emergency ambulance versus calling 911. The resident remained in the facility uintil 4:11pm. RSC I handled Resident #8 roughly when she changed his brief by pulling him by one leg to reposition him in bed. RCS M verbally abused Resident #5. He took her call light away and told her that it would not help her get water. Resident #5 was scared of RCS M. Resident #3 said RCS G was rude and mean to her. Resident #7 said RCS G was rude and refused to tell him her name. Resident #1 had an un-witnessed fall while out on pass. He was not assessed upon return to the facility. After the VA Nurse assessed the resident and told the facility he had the fall and injuries he was sent to the hospital. He was found to have a fracture to his cervical spine. An IJ was identified on 01/08/2016. While the IJ was removed on 01/13/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected seven residents and placed 103 residents at risk for mistreatment, abuse and neglect. Intake #: 8, 0, 8, 2, Findings Include: Record review of Suspected resident abuse assessment, long-term care dated October 02, 2015 provided by facility read: -Residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. -The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. -The facility must not employ individuals who have been found guilty by court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nursing assistant registry concerning abuse, neglect, or mistreatment of [REDACTED]. -The facility must report to the state ' s nursing assistant registry or licensing authorities any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nursing assistant or other facility staff member. -The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of an unknown source and misappropriation of a resident ' s property, are reported immediately, through established procedures, to the facility administrator and to other officials in accordance with state law. -The facility must have evidence that all alleged violations have been thoroughly investigated and must take precautions to prevent further potential abuse while the investigation is in process. Resident #6 Record review of Resident #6 ' s face sheet revealed resident is a [AGE] year old female with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident # 6 ' s Care Plan dated 7/02/2014 with a review date of 10/15/2015 revealed: Resident #6 had moderate cognitive impairment due to short-term and long-term memory loss. Approach: Staff will offer options in simple terms regarding care for resident to choose, Provide time to think/react. Resident #6 was care planned for falls. Approach: Falling Star Program, Encourage resident to ask for assist, orient resident to environment, bed alarm, chair alarm, place call light in reach, observe for potential patterns of falls to identify possible causes, Offer/assist to toilet frequently and as accepted, place frequently used items within reach, and observe for potential medication related causes. Resident #6 had a [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. Observation on 1/06/2016 at 2:59pm revealed that there was no Falling Star above residents door or above her bed to identify her as a fall risk. Observation on 1/06/2016 at 3:15pm revealed Resident #6 sitting in wheelchair attempting to enter her room but was not able to as medication cart was blocking the entrance to her room. Surveyor intervened and informed MA B that Resident #6 was trying to enter her room but could not due to the medication cart blocking entrance to room. MA B said he was aware she wanted in the room and that is why he had the cart there to block the entrance to prevent her from going in the room. He further revealed she was a fall risk and did not want her in the room. Observation on 1/06/2016 at 3:19pm revealed resident #6 in her wheelchair wedged between medication cart and door to her room. Surveyor intervened and informed MA B and RCS K that Resident #6 was wedged between medication cart and door to her room. MA B and RCS K went over to Resident #6 and moved the cart and told Resident #6 she could not go to her room at this time. Resident #6 grabbed handrail and tried to wheel herself into her room. Resident #6 said she wanted to look at the box in her closet. MA B and RCS K told her she was not able to go into her room at this time. Resident #6 would not release handrail as she continued to try and wheel herself into her room. MA B grabbed Resident #6 ' s wrist/arm and tried to pull her hand off railing. RCS K then began prying Resident #6 ' s fingers from the handrail. The DON walked by and quickly removed MA B and RCS K from Resident #6. MA B and RCS K told the DON that they did not want Resident #6 in her room because she would make a mess and takes things out of her closet and she was a fall risk. DON informed MA B and RCS K that Resident #6 had the right to enter her room. Interview on 1/06/2016 at 3:30pm with the DON revealed that she performed an assessment on Resident #6 and found no injuries. She further revealed that MA B and RCS K acted inappropriately and should have allowed her to enter her room or they could have tried redirecting. The DON said they should not have grabbed Resident #6's hand or arm. The DON said staff would be in-serviced in Abuse/Neglect. The DON revealed that she was sure staff had training on Dementia but was not sure of the date. In an interview with RCS K on 1/06/2016 at 3:35pm she said that she was trying to re-direct Resident #6 because she did not want her in the room because Resident #6 was a fall risk. In an interview with Resident #6 at 3:45pm she said that MA B and RCS K hurt her wrist. Resident #6 said no one had ever grabbed her arm like that before. She said she just wanted to look in the box in her closet. Observation on 1/06/2016 at 3:45 pm revealed redness to Resident #6 ' s right wrist. Record review of MA B ' s written statement dated 1/06/2016 revealed at about 3pm, he was by the Med Aid Cart, and was about to move it. He was told by the CNA not to move it because the resident was a fall risk. Resident #6 tried to wheel herself in her room. As she tried to go inside, the CNA grabbed her hand, telling her not to go in her room for her safety. He only touched the resident and nothing more. Record review of RCS K ' s written statement dated 1/06/2016 revealed that Resident #6 was trying to enter her room and RCS K intervened by trying to stop her because she was a fall risk. RCS K's written statement further revealed that shespoke to Resident #6, and touched her hand trying to redirect her away from the door because she was a fall risk. In an interview with Resident #6 on 1/07/2016 at 9:40am she revealed that she had pain to her right wrist. Observation at same time revealed 3 small round bruises with purple hue to right wrist. In an interview with the DON on 1/07/2016 at 9:45am she revealed she was aware not aware of bruising. The DON said she would assess resident and administer Tylenol per orders for pain to resident ' s right wrist. In an interview with DON on 1/07/2016 at 10:00am she verified that there were 3 small bruises to Resident #6 ' s right wrist. The DON said she had not noticed them before because they were under the wander guard. Record review of Provider Investigation Report dated 1/07/2016 completed by DON read: Description of Allegation- The DON was walking down the hall towards room. Resident #6 was grabbing onto the door frame trying to pull herself into the room, RCS K was asking the resident where she was going, and reached towards residents hand, The DON could not see what RCS K did with the resident's hand because the resident's body and wheelchair were blocking my view. However, MA B then reached over and put his hand around the resident ' s wrist to prevent her from grabbing onto the other door frame, causing resident to become agitated. The DON intervened with the staff explaining to them residents rights and allowed resident into her room to access items in her closet and then redirected her back to into the activity room. The DON removed both staff members from the floor, began education, and notified the administrator of the incident. After following up that employee ' s need to be suspended pending investigation,she followed back up with administrator. Record review of in-service dated 12/22/2015 revealed staff was in-service on reporting abuse and able to assess the need to report. Record review of in-service dated 12/31/2015 revealed staff was in-service on understanding abuse. Record review of in-service dated 1/06/2016 revealed staff was in-serviced on Dementia care and communicating with dementia residents. Record review of Dementia, resident communication, long term care policy with revised date of October 02, 2015 provided by facility read: -Visual strategies; Approach the resident from the front, in his vision field, smile, present objects or written cues to focus attention on the communication topic, provide contextual and environmental cues; use colors, highlighting, enlargement, pictures, drawings, and symbols. -Auditory strategies; use calm, positive, unhurried speech, state the person ' s name and yours to increase a sense of familiarity, use praise and compliments befitting an adult. -Tactile Strategies; use touch to reassure, use touch to guide, lead, redirect, and prompt desired behavior, use familiar objects as reminders. Resident #4 Record review of Resident #4 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #4 ' s MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment, required one person assist with bed mobility, dressing, and toilet use. Record review of Resident #4 ' s Care Plan dated 12/14/2015 with a reviewed date of 12/23/15 revealed: Resident #4 had Cognitive Deficit; Resident had moderate independence with decision making. Resident had difficulty with making decisions in new situations. Approach: Provide clear choices and adequate information for resident to make decisions, Point out consequences of bad decisions, involve family members in decisions regarding important matters. Resident #4 was at risk for falls due to: history of previous falls, non-ambulation, blood pressure changes, and [MEDICAL CONDITION]. Approach: Falling star program, encourage resident to ask for assistance, physical therapy, occupational therapy, provide assistive devices such as wheelchair, place call light in reach, observe for potential patterns of falls to identify possible causes, and place frequently used items within reach. Resident #4 was care planned for, [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. In an interview with Resident #4 on 1/6/16 at 9:40am he said he was at the facility for therapy and was feeling alright today. Observation at the same time revealed resident was well groomed, very talkative and alert, lying in bed with head of bed elevated. His call light was within reach. There were no falling star above the bed or doorway entrance to signify that Resident #4 was a fall risk. Record review of Interdisciplinary Post Fall Report dated 1/6/2016 revealed Resident #4 suffered a fall at 11:00am on 1/6/2016. Record further revealed that Resident #4 ' s fall occurred in the dining room and LVN A was called to the dining room where she found resident lying on floor on his right side. Resident #4 was assessed by LVN A and assisted to wheelchair and then to bed. Record further revealed Resident #4 sustained an open area to the back of the head and right wrist. Record review of Incident/Accident Investigation Follow-up dated 1/6/16 revealed Resident #4 fell in dining room and LVN A was called to dining room by staff where LVN A found Resident #4 on the floor on his right side. Summary of investigation read: Resident stated he leaned forward to get up and fell to the floor. Past Interventions read: New resident to facility, no history of falls. Recommendations: encourage resident to ask for assistance avoid attempting to get up on his own. Record review of Resident #4 ' s Interdisciplinary Post Fall Review completed by LVN A and dated 1/6/16 read: Predisposing Diseases: Dementia. In an interview on 1/6/16 at 2:20pm with LVN A she said she was called to dining room and found Resident #4 lying on his side on the floor. LVN A said she assessed Resident #4 and found 2 lacerations to the back of his head and he had a skin tear to his right arm. Resident #4 was assisted to the wheelchair and then assisted to his bed. LVN A said she started neuro vitals and notified the physician of the fall. She further said that orders were received for Tylenol 650mg for discomfort, wound care orders for skin tear of right arm and both wounds to head. LVN A said no orders were received for CT (cat scan). Record review of Resident #4's physician's orders [REDACTED].monitor neuro checks every 15 minutes for one hour, every hour for four hours and then every four hours for 24 hours and every eight hours for 72 hours. Record review of Resident #4's Neurological Record read in part: frequency every 30 minutes for four hours, every one hour for four hours, every four hours for 24 hours, every eight hours for remaining 72 hours or as ordered by physician .neuro vital signs were done starting on 01/6/16 at 11:15am and ended on 01/07/16 at 10:30am. Record review of Resident #4's Neurological record dated 01/6/16-01/7/16 revealed neither the physican's order nor the instructions on the Neurological Record in regards to frequency was followed. In an interview on 01/7/16 at 9:30am with Resident #4, he said he was not feeling well and that he was hurting all over. In an interview with Resident #1 (Resident #4 ' s roommate) on 01/7/16 at 9:30am he said that immediately after hitting his head Resident #4 was not the same. He said Resident #4 did not act the same and he stayed in bed and did not eat. Interview on 01/7/16 at 9:40am LVN A when it was reported to her that Resident #4 was hurting all over she said she would assess him. Interview on 01/7/16 at 10:00am LVN A said Resident #4 was fine he was just tired. Interview on 01/7/16 at 10:15am with Resident #1 he said Resident #4 was not fine. He said Resident #4 had been tossing and turning all night and was in pain and did not sleep. Observation on 01/7/16 12:00pm revealed Resident was resting with his eyes closed. Observation and interview on 01/7/16 at 4:00pm revealed Resident #4 was in bed and not feeling well. He said he did not feel like getting out of bed. Observation on 01/8/16 at 8:00am revealed Resident #4 was in bed with his eyes closed. His breakfast tray was beside his bed untouched. Record review of nurse ' s notes dated 1/8/2016 at 12:15pm read: placed call to hospital, spoke to emergency room nurse. Report given. Went to Resident #4 ' s room, made resident aware he would be transferred to hospital. Observation and interview on 01/08/16 at 1:00pm revealed Resident #4 was in bed with eyes closed and did respond to verbal stimuli. His RP was at his bedside and said he would not wake up and shook his shoulder, Resident #4 did not respond. His lunch tray was at his bedside untouched. The RP said the Hospital Nurse told him that she would inform the Nurse at the facility that Resident #4 needed to be sent back to the hospital for evaluation. In an interview on 1/8/16 at 3:14pm with Resident #4 ' s Responsible Party (RP) revealed that Resident #4 did not have a [DIAGNOSES REDACTED]. Resdident #4's RP further revealed that he was not notified of Resident #4 ' s fall until he arrived at facility on 1/06/2016 after lunch time. He said LVN H told him they did not have his phone number in Resident #4 ' s chart. The RP said that Resident #4 was not acting like his self and had been acting different since the fall. The RP said that he arrived at facility at 11:00am today and Resident #4 would not wake up and his breakfast had not been eaten. He said he informed the nurse of Resident #4 ' s condition and she assessed him and said she would call the physician. The RP said LVN H told him that Resident #4 would be transferred to hospital for evaluation but that was over 3 hours ago and Resident #4 still had not woken up. Observation on 1/8/ at 3:14pm of Resident #4 revealed he was lying in bed with head of bed elevated. Resident ' s lips were dry and cracked and lunch was at bedside and had not been eaten. Resident #4 did not respond to verbal stimuli. The RP shook Resident #4 by the shoulder and Resident #4 did not respond. In an interview with LVN H on 1/8/16 at 3:30pm she said that she had notified physician of change in mental status and Resident #4 was to be transferred to hospital. She further revealed that she contacted several ambulance companies and chose the one with the least estimated time of arrival. When asked if she called 911 for Resident #4 due to non-responsiveness, she said no. She said this was not an emergency situation. In an interview with the DON on 1/8/16 at 3:35pm she revealed she was unaware that LVN H had not called 911. She was aware of change in condition on 1/7/16 and had requested an order from physician for x-ray of skull on 1/7/16. She further revealed that Resident #4 did not become unresponsive until 1:00pm on 1/8/16. DON said she would have ADON call 911 immediately for transfer. Record review of nurse ' s notes dated 1/8/16 at 12:00pm said hospital nurse was visiting with Resident #4 and family. Hospital nurse requested that nurse on duty to assess Resident #4. Resident #4 said he was not feeling well. VA Nurse remained at bedside. Call was placed to physician regarding assessment and Resident #4 not feeling well and also made aware of recent fall from wheelchair. Record review of nurse ' s note dated 1/8/16 at 12:25pm read: placed call to ambulance service. The above report given to dispatcher. Stated will send ambulance right away. Made charge nurse aware. Record review of nurse ' s note dated 1/8/16 at 12:30pm read: Resident in room. Son at bedside. Blood sugar (BS)=69. Call placed to MD. New order to give glucacon 1mg IM (intra-muscular)if resident not awake. Record review of nurse ' s note dated 1/8/16 at 1:00pm read: BS=100. Resident responds to painful stimuli. Awaiting on transportation. Son at bedside. Vital signs: Blood pressure-138/76, respirations-20, pulse- 78. Record review of nurse ' s note dated 1/8/16 at 2:00pm read: Responds to painful stimuli and moves all extremities. No sign or symptoms of pain or discomfort. Record review of nurse ' s note dated 1/8/16 at 2:30pm read: Awaiting on transportation. Resident denies pain. Respirations even and unlabored. Vital signs: blood pressure-140/78, 80, 20, 97%. Record review of nurse ' s note dated 1/8/16 at 3:00pm read: Resident responding to painful stimuli. No signs of distress. Respirations 20 per minute. Son at bedside and aware of change of condition. Record review of nurse ' s note dated 1/8/16 at 4:50pm read: EMS personnel arrived. Blood sugar at this time is 71. Blood pressure 140/79, pulse 79, respirations 20, and temperature 97.8. In an interview with DON on 1/8/16 at 5:10pm she said that ADON and LVN H both will be counseled on assessment, the depth of assessment, and starting interventions. She stated They both failed to assess with urgency . Record review of emergency room visit dated 1/08/2016 revealed resident was [AGE] years old and presented to emergency department post fall 3 days ago. Patient is non-responsive. Per EMS, family says patient was not his normal self after fall. Primary Impression: Urinary Tract Infection. Secondary Impressions: Altered mental status, [DIAGNOSES REDACTED]. In an interview with Resident #4 ' s RP on 1/9/16 at 2:00pm he revealed that Resident #4 was diagnosed with [REDACTED]. RP said Resident #4 was still not alert. In an interview on 1/11/16 at 3:00pm with Resident #4 at hospital, resident responded to verbal stimuli. Resident #4 said he was not feeling well and hasn ' t felt well since the fall. He said he is hoping to get better so he can return to his home. Resident #3 Record review of Resident #3 ' s face sheet revealed a [AGE] year old female with an admitted [DATE]. Diagnoses: [REDACTED]. Face sheet further revealed Resident #3 was her own legal guardian. Record review of care plan dated 7/15/15 with a review date of 10/15/15 revealed resident was care planned for Depression/Anxiety. Approach: Provide calm, reassuring environment, encourage resident and staff to be alert to events or situations that precipitate episodes of restlessness or anxiety, calm and reassure as needed, modify environment to promote calm and comfort. In an interview with Resident #3 on 1/08/2016 at 1:40pm she said that RCS M was rude and mean to her. She further revealed that she doesn ' t put up with it and takes care of it herself by telling him off. Resident #3 further revealed she did not like it when RCS M was assigned to her hall and she was scared of him. Resident #3 had witnessed RCS M speak rudely to her roommate (Resident #5) and take her call light away so she would not be able to use it and stated her roommate was also scared of RCS M. Resident #3 said she had mentioned it to previous administrator and RCS M was moved to a different hall but now he was working on her hall again andshe was worried he might come into her room. In an interview with the DON on 1/08/2016 at 1:50pm she said she was aware of the incident involving Resident #3 and RCS M. She said RCS M had been removed from the floor and suspended pending investigation. Resident #7 Record review of Resident #7 ' s clinical record revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #7 ' s MDS dated [DATE] revealed a BIMS score of 13 which indicated no cognitive impairment. The MDS assessment further revealed that Resident #7 required extensive assistance for bed mobility and personal hygiene. Resident #7 was total dependence for transfer and toilet use. Record review of care plan dated 12/21/15 with a reviewed date of 1/7/16 revealed resident was care planned for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, place frequently used items within reach, offer/assist to toilet frequently and as accepted. In an interview with Resident #7 on 1/11/2016 at 11:25am he revealed that RCS G was rude and speaks aggressively towards him. He also said that when RCS G enters the room she refuses to give her name. Resident #7 also said that when he used the call light for pain medication RCS G just enters the room, turns off the call light and leaves the room. Resident #7 said she never returns to let him know if she told the nurse he needed something for pain. In an interview with DON on 1/11/2016 at 11:35am she said she was aware of the incident involving RCS G and incident was being investigated. The DON further said that she double checked the Medication Administration Record [REDACTED]. The DON also said staff would be receiving sensitivity training now and quarterly. In a telephone interview with RCS G on 1/13/2016 at 1:00pm she said that she took care of Resident #7 on Friday. She asked the nurse to tell Resident #7 that she was the only RCS on his hall. RCS G said that Resident #7 reported that she does not let him know when she tells the nurse he needs medicine for pain. She said she was not aware that she had to report back to him. She stated My tone is high sometimes, maybe I come off rude . Resident#1 Record review of Resident #1 ' s clinical record revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Record review of Resident #1 ' s Care Plan dated 12/15/2015 revealed that he was at risk for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted, place frequently used items within reach, observe for potential medication related causes. In an interview on 1/06/2016 at 11:00am with Resident #1 he revealed that he had a fall while he was out on pass. He said he hit his head when he fell down 4-5 steps. Resident #1 said he fell on [DATE] and when he returned to the facility that same day, he did not tell any staff and the staff didn ' t ask about the bump and scratches to his forehead. Resident #1 said no one noticed the bump on his head and scratches until the hospital nurse came to visit him at the facility on 12/23/2015 . Resident #1 said the hospital nurse noticed immediately and she told the facility of the fall and his injuries. Resident further revealed that CT (cat scan) revealed a fracture to his neck and he needed to wear a neck brace. Observation at same time revealed resident was wearing neck brace per physician order. In a telephone interview on 1/06/2016 at 10:00am with the VA Nurse she said that she was very concerned about Resident #1 ' s care and the assessment skills of the nurses at the facility. The VA Nurse said she noticed immediately that Resident #1 had a large bump to his forehead along with scratches. She said she asked Resident #1 about the bump and scratches and he said he fell down some stairs while he was out on pass. The Hospital nurse said the facility was not aware of Resident #1's fall until she notified them on 12/23/2015. Record review of nursing notes dated 12/23/2015 at 1:00pm revealed Resident #1 said he fell at home on 12/22/2015. Head to toe assessment performed. Resident #1 was alert and oriented. Small laceration on the forehead observed, scratch to the tip of nose. No bruising noted. Call placed to physician. No new orders received. Continue with Neuro vital signs, monitor for pain, bruising, redness or neurological change. Record review of Neurological record dated 12/23/2015 revealed that Neurological checks were started at 12:45am on 12/23/2015 and continued to 5:30pm on 12/23/2015. Record review of nurses note dated 12/23/2015 at 4:30pm revealed facility called VA Nurse regarding Resident #1 and his fall. Hospital nurse voiced concern regarding documentation of facility nurse and requested that hospital protocol be followed for falls with suspected head injuries. Record review of the Situation, Background, Assessment and Recommendation (SBAR) Communication Form dated 12/23/2015 at 6:05pm revealed that Resident #1's physician was notified of fall while Resident #1 was out on pass 12/22/2015. Orders received from physician to send Resident #1 to emergency room for evaluation and treatment for [REDACTED]. Record review of CT report dated 12/24/2015 read: Diagnostic Impression; C3 cervical [MEDICATION NAME] process fracture: acute Record review of physician order [REDACTED]. In an interview with the Director of Nursing (DON) on 1/8/2016 at 5:00pm she was unsure of policy regarding assessments of residents who go out on pass and how residents were monitored when they returned. The DON said she would find out. In an interview with DON on 1/11/2016 at 3:30pm she said that residents should be assessed before going out on pass and when they return. She further said that when residents go out on pass that the residents must inform the nurse and sign out on the Out of Facility Release of Responsibility form and they sign in when they return so that they know the resident has returned. She further revealed that the nurse on duty signs the form as well. Record review of Out of Facility Release of Responsibility form in Resident #1 ' s chart revealed Resident #1 signed himself out on pass on 12/18/15, 12/24/15, 12/28/15, 1/03/16, 1/04/16, and 1/07/16. There were no signatures by nurse or resident indicating that Resident #1 returned to facility on those days. Record review of in-service dated 12/22/2015 revealed staff was in-service on reporting abuse and able to assess the need to report. Record review of in-service dated 12/31/2015 revealed staff was in-service on understanding abuse. Record review of in-service dated 1/06/2016 revealed staff was in-serviced on Dementia care and communicating with dementia residents. Record review of Dementia, resident communication, long term care policy with revised date of October 02, 2015 provided by facility read: -Visual strategies; Approach the resident from the front, in his vision field, smile, present objects or written cues to focus attention on the communication topic, provide contextual and environmental cues; use colors, highlighting, enlargement, pictures, drawings, and symbols. -Auditory strategies; use calm, positive, unhurried speech, state the person ' s name and yours to increase a sense of fami

Based on observation, interview and record review the facility failed to provide the necessary care and services to ensure 2 of 4 residents (Resident #4 and Resident #1) reviewed attained the highest practicable, physical, mental and psychosocial well-being when the facility failed to properly assess residents after a fall. -Resident #4 suffered a fall with lacerations to the head on 1/6/2016 and was not assessed appropriately after change in condition. He became non-responsive on 01/08/16 around 11:00am, the facility did not assess the resident appropriately and called for a non-emergency ambulance versus calling 911. The resident remained in the facility from 11:00am until 4:11pm when he was transferred to the hospital via ambulance. Resident #1 had an un-witnessed fall while out on pass on 12/22/2015 . He was not assessed upon return to the facility the same day. After the Veterans Admistration (VA) Nurse assessed the resident on 12/23/15 and told the facility he had fallen and had injuries he was sent to the hospital. He was found to have a fracture to his cervical spine. An IJ was identified on 01/08/2016. While the IJ was removed on 01/13/2016, the facility remained out of compliance at a scope of pattern and a severity level of actual harm due to the facility needing more time to monitor the plan of removal for effectiveness. These failures affected two residents and placed 102 residents as needing assistance or dependent on staff for mobility at risk for not having their needs met, injury and a decline in health status. Intake #: 8, 0, 8, 2, Findings Include: Resident #4 Record review of Resident #4 ' s face sheet revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #4 ' s MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment, required one person assist with bed mobility, dressing, and toilet use. Record review of Resident #4 ' s Care Plan dated 12/14/2015 with a reviewed date of 12/23/15 revealed: Resident #4 had Cognitive Deficit; Resident had moderate independence with decision making. Resident had difficulty with making decisions in new situations. Approach: Provide clear choices and adequate information for resident to make decisions, Point out consequences of bad decisions, involve family members in decisions regarding important matters. Resident #4 was at risk for falls due to: history of previous falls, non-ambulation, blood pressure changes, and [MEDICAL CONDITION]. Approach: Falling star program, encourage resident to ask for assistance, physical therapy, occupational therapy, provide assistive devices such as wheelchair, place call light in reach, observe for potential patterns of falls to identify possible causes, and place frequently used items within reach. Resident #4 was care planned for, [DIAGNOSES REDACTED]. Approach: Administer medication as ordered, fall risk assessment, fall prevention protocol as indicated, call bell within reach, notify MD as indicated. In an interview with Resident #4 on 1/6/16 at 9:40am he said he was at the facility for therapy and was feeling alright today. Observation at the same time revealed resident was well groomed, very talkative and alert, lying in bed with head of bed elevated. His call light was within reach. There were no falling star above the bed or doorway entrance to signify that Resident #4 was a fall risk. Record review of Interdisciplinary Post Fall Report dated 1/6/2016 revealed Resident #4 suffered a fall at 11:00am on 1/6/2016. Record further revealed that Resident #4 ' s fall occurred in the dining room and LVN A was called to the dining room where she found resident lying on floor on his right side. Resident #4 was assessed by LVN A and assisted to wheelchair and then to bed. Record further revealed Resident #4 sustained an open area to the back of the head and right wrist. Record review of Incident/Accident Investigation Follow-up dated 1/6/16 revealed Resident #4 fell in dining room and LVN A was called to dining room by staff where LVN A found Resident #4 on the floor on his right side. Summary of investigation read: Resident stated he leaned forward to get up and fell to the floor. Past Interventions read: New resident to facility, no history of falls. Recommendations: encourage resident to ask for assistance avoid attempting to get up on his own. Record review of Resident #4 ' s Interdisciplinary Post Fall Review completed by LVN A and dated 1/6/16 read: Predisposing Diseases: Dementia. In an interview on 1/6/16 at 2:20pm with LVN A she said she was called to dining room and found Resident #4 lying on his side on the floor. LVN A said she assessed Resident #4 and found 2 lacerations to the back of his head and he had a skin tear to his right arm. Resident #4 was assisted to the wheelchair and then assisted to his bed. LVN A said she started neuro vitals and notified the physician of the fall. She further said that orders were received for Tylenol 650mg for discomfort, wound care orders for skin tear of right arm and both wounds to head. LVN A said no orders were received for CT (cat scan). Record review of Resident #4's physician's orders [REDACTED].monitor neuro checks every 15 minutes for one hour, every hour for four hours and then every four hours for 24 hours and every eight hours for 72 hours. Record review of Resident #4's Neurological Record read in part: frequency every 30 minutes for four hours, every one hour for four hours, every four hours for 24 hours, every eight hours for remaining 72 hours or as ordered by physician .neuro vital signs were done starting on 01/6/16 at 11:15am and ended on 01/07/16 at 10:30am. Record review of Resident #4's Neurological record dated 01/6/16-01/7/16 revealed neither the physican's order nor the instructions on the Neurological Record in regards to frequency was followed. In an interview on 01/7/16 at 9:30am with Resident #4, he said he was not feeling well and that he was hurting all over. In an interview with Resident #1 (Resident #4 ' s roommate) on 01/7/16 at 9:30am he said that immediately after hitting his head Resident #4 was not the same. He said Resident #4 did not act the same and he stayed in bed and did not eat. Interview on 01/7/16 at 9:40am LVN A when it was reported to her that Resident #4 was hurting all over she said she would assess him. Interview on 01/7/16 at 10:00am LVN A said Resident #4 was fine he was just tired. Interview on 01/7/16 at 10:15am with Resident #1 he said Resident #4 was not fine. He said Resident #4 had been tossing and turning all night and was in pain and did not sleep. Observation on 01/7/16 12:00pm revealed Resident was resting with his eyes closed. Observation and interview on 01/7/16 at 4:00pm revealed Resident #4 was in bed and not feeling well. He said he did not feel like getting out of bed. Observation on 01/8/16 at 8:00am revealed Resident #4 was in bed with his eyes closed. His breakfast tray was beside his bed untouched. Record review of nurse ' s notes dated 1/8/2016 at 12:15pm read: placed call to hospital, spoke to emergency room nurse. Report given. Went to Resident #4 ' s room, made resident aware he would be transferred to hospital. Observation and interview on 01/08/16 at 1:00pm revealed Resident #4 was in bed with eyes closed and did respond to verbal stimuli. His RP was at his bedside and said he would not wake up and shook his shoulder, Resident #4 did not respond. His lunch tray was at his bedside untouched. The RP said the Hospital Nurse told him that she would inform the Nurse at the facility that Resident #4 needed to be sent back to the hospital for evaluation. In an interview on 1/8/16 at 3:14pm with Resident #4 ' s Responsible Party (RP) revealed that Resident #4 did not have a [DIAGNOSES REDACTED]. Resdident #4's RP further revealed that he was not notified of Resident #4 ' s fall until he arrived at facility on 1/06/2016 after lunch time. He said LVN H told him they did not have his phone number in Resident #4 ' s chart. The RP said that Resident #4 was not acting like his self and had been acting different since the fall. The RP said that he arrived at facility at 11:00am today and Resident #4 would not wake up and his breakfast had not been eaten. He said he informed the nurse of Resident #4 ' s condition and she assessed him and said she would call the physician. The RP said LVN H told him that Resident #4 would be transferred to hospital for evaluation but that was over 3 hours ago and Resident #4 still had not woken up. Observation on 1/8/ at 3:14pm of Resident #4 revealed he was lying in bed with head of bed elevated. Resident ' s lips were dry and cracked and lunch was at bedside and had not been eaten. Resident #4 did not respond to verbal stimuli. The RP shook Resident #4 by the shoulder and Resident #4 did not respond. In an interview with LVN H on 1/8/16 at 3:30pm she said that she had notified physician of change in mental status and Resident #4 was to be transferred to hospital. She further revealed that she contacted several ambulance companies and chose the one with the least estimated time of arrival. When asked if she called 911 for Resident #4 due to non-responsiveness, she said no. She said this was not an emergency situation. In an interview with the DON on 1/8/16 at 3:35pm she revealed she was unaware that LVN H had not called 911. She was aware of change in condition on 1/7/16 and had requested an order from physician for x-ray of skull on 1/7/16. She further revealed that Resident #4 did not become unresponsive until 1:00pm on 1/8/16. DON said she would have ADON call 911 immediately for transfer. Record review of nurse ' s notes dated 1/8/16 at 12:00pm said hospital nurse was visiting with Resident #4 and family. Hospital nurse requested that nurse on duty to assess Resident #4. Resident #4 said he was not feeling well. VA Nurse remained at bedside. Call was placed to physician regarding assessment and Resident #4 not feeling well and also made aware of recent fall from wheelchair. Record review of nurse ' s note dated 1/8/16 at 12:25pm read: placed call to ambulance service. The above report given to dispatcher. Stated will send ambulance right away. Made charge nurse aware. Record review of nurse ' s note dated 1/8/16 at 12:30pm read: Resident in room. Son at bedside. Blood sugar (BS)=69. Call placed to MD. New order to give glucacon 1mg IM (intra-muscular)if resident not awake. Record review of nurse ' s note dated 1/8/16 at 1:00pm read: BS=100. Resident responds to painful stimuli. Awaiting on transportation. Son at bedside. Vital signs: Blood pressure-138/76, respirations-20, pulse- 78. Record review of nurse ' s note dated 1/8/16 at 2:00pm read: Responds to painful stimuli and moves all extremities. No sign or symptoms of pain or discomfort. Record review of nurse ' s note dated 1/8/16 at 2:30pm read: Awaiting on transportation. Resident denies pain. Respirations even and unlabored. Vital signs: blood pressure-140/78, 80, 20, 97%. Record review of nurse ' s note dated 1/8/16 at 3:00pm read: Resident responding to painful stimuli. No signs of distress. Respirations 20 per minute. Son at bedside and aware of change of condition. Record review of nurse ' s note dated 1/8/16 at 4:50pm read: EMS personnel arrived. Blood sugar at this time is 71. Blood pressure 140/79, pulse 79, respirations 20, and temperature 97.8. In an interview with DON on 1/8/16 at 5:10pm she said that ADON and LVN H both will be counseled on assessment, the depth of assessment, and starting interventions. She stated They both failed to assess with urgency . Record review of emergency room visit dated 1/08/2016 revealed resident was [AGE] years old and presented to emergency department post fall 3 days ago. Patient is non-responsive. Per EMS, family says patient was not his normal self after fall. Primary Impression: Urinary Tract Infection. Secondary Impressions: Altered mental status, [DIAGNOSES REDACTED]. In an interview with Resident #4 ' s RP on 1/9/16 at 2:00pm he revealed that Resident #4 was diagnosed with [REDACTED]. RP said Resident #4 was still not alert. In an interview on 1/11/16 at 3:00pm with Resident #4 at hospital, resident responded to verbal stimuli. Resident #4 said he was not feeling well and hasn ' t felt well since the fall. He said he is hoping to get better so he can return to his home. Resident#1 Record review of Resident #1 ' s clinical record revealed a [AGE] year old male with an admission date of [DATE]. Diagnoses: [REDACTED]. Record review of Resident #1 ' s Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Record review of Resident #1 ' s Care Plan dated 12/15/2015 revealed that he was at risk for falls. Approach: Falling Star Program, encourage resident to ask for assistance, place call light in reach, observe for potential patterns of falls to identify possible causes, offer/assist to toilet frequently and as accepted, place frequently used items within reach, observe for potential medication related causes. In an interview on 1/06/2016 at 11:00am with Resident #1 he revealed that he had a fall while he was out on pass. He said he hit his head when he fell down 4-5 steps. Resident #1 said he fell on [DATE] and when he returned to the facility that same day, he did not tell any staff and the staff didn ' t ask about the bump and scratches to his forehead. Resident #1 said no one noticed the bump on his head and scratches until the hospital nurse came to visit him at the facility on 12/23/2015 . Resident #1 said the hospital nurse noticed immediately and she told the facility of the fall and his injuries. Resident further revealed that CT (cat scan) revealed a fracture to his neck and he needed to wear a neck brace. Observation at same time revealed resident was wearing neck brace per physician order. In a telephone interview on 1/06/2016 at 10:00am with the VA Nurse she said that she was very concerned about Resident #1 ' s care and the assessment skills of the nurses at the facility. The VA Nurse said she noticed immediately that Resident #1 had a large bump to his forehead along with scratches. She said she asked Resident #1 about the bump and scratches and he said he fell down some stairs while he was out on pass. The Hospital nurse said the facility was not aware of Resident #1's fall until she notified them on 12/23/2015. Record review of nursing notes dated 12/23/2015 at 1:00pm revealed Resident #1 said he fell at home on 12/22/2015. Head to toe assessment performed. Resident #1 was alert and oriented. Small laceration on the forehead observed, scratch to the tip of nose. No bruising noted. Call placed to physician. No new orders received. Continue with Neuro vital signs, monitor for pain, bruising, redness or neurological change. Record review of Neurological record dated 12/23/2015 revealed that Neurological checks were started at 12:45am on 12/23/2015 and continued to 5:30pm on 12/23/2015. Record review of nurses note dated 12/23/2015 at 4:30pm revealed facility called VA Nurse regarding Resident #1 and his fall. Hospital nurse voiced concern regarding documentation of facility nurse and requested that hospital protocol be followed for falls with suspected head injuries. Record review of the Situation, Background, Assessment and Recommendation (SBAR) Communication Form dated 12/23/2015 at 6:05pm revealed that Resident #1's physician was notified of fall while Resident #1 was out on pass 12/22/2015. Orders received from physician to send Resident #1 to emergency room for evaluation and treatment for [REDACTED]. Record review of CT report dated 12/24/2015 read: Diagnostic Impression; C3 cervical [MEDICATION NAME] process fracture: acute Record review of physician order [REDACTED]. In an interview with the Director of Nursing (DON) on 1/8/2016 at 5:00pm she was unsure of policy regarding assessments of residents who go out on pass and how residents were monitored when they returned. The DON said she would find out. In an interview with DON on 1/11/2016 at 3:30pm she said that residents should be assessed before going out on pass and when they return. She further said that when residents go out on pass that the residents must inform the nurse and sign out on the Out of Facility Release of Responsibility form and they sign in when they return so that they know the resident has returned. She further revealed that the nurse on duty signs the form as well. Record review of Out of Facility Release of Responsibility form in Resident #1 ' s chart revealed Resident #1 signed himself out on pass on 12/18/15, 12/24/15, 12/28/15, 1/03/16, 1/04/16, and 1/07/16. There were no signatures by nurse or resident indicating that Resident #1 returned to facility on those days. An immediate jeopardy (IJ) was identified on 01/08/16 at 2:13 pm and the Administrator was informed at that time. A Plan of Removal (POR) for the IJ was submitted on 01/09/16 at 12:40pm and after several revisions were made it was accepted on 01/12/16 at 4:13pm. The POR included in part: Immediate Action: 1.The Interdiscplinary Team interviewed 69 interviewable residents, provided a copy of Resident ' s Rights to voice concerns and to be free of retaliation. copy of the DADS Hotline phone number and Compliance Hotline phone numbers to report any concerns. They were re-educated regarding where the phone numbers were posted in the facility for DADS Hotline and Compliance Hotlines. 2. The DON and Charge Nurses conducted Head to Toe skin checks on 37 non-interviewable residents and found no concerns following the completion of the assessment. 3. The facility mailed copies of the Resident Rights, DADS Hotline phone number and the company ' s Compliance Hotline phone numbers to the resident ' s responsible party / family member. 4. To protect non-interviewable residents from abuse included the following actions: · Certified Nursing Assistants will utilize the Stop & Watch tool following all ADL care to alert the charge nurse of any changes they observe. · Charge nurses will conduct weekly head to toes skin checks · Charge nurses will monitor residents for changes in behavior and complete the SBAR if they have a concern and notify the family and physician. 5. Using the care path \interact process on Fall Do Not Move Resident From The Floor Until Complete Assessment Is Done and visual assessment is done. The assessments include AROM and PROM and visual observation of any limb shortening or internal or external rotation of any obvious sign of fracture. The staff will do the following: a. Take vital signs - temperatures, BP, pulse, b. If vital signs- critical is not met per (care path) then proceed with initial nursing evaluation for injuries and \ or mental status change. Do not move off the floor until complete exam has been performed. c. Determine if suspected fracture or new bone deformity, head trauma, altered manta, ( decrease LOC, unresponsiveness, suspicious of [MEDICAL CONDITION] new or worsen cognitive impairment), laceration required sutures\staples if yes notify MD\NP\PA and transfer via EMS. 6. If resident falls and has any complaints of [MEDICAL CONDITION] or spinal injury, head trauma, perform Neurological assessment at the scene of fall If any abnormalities call EMS and send resident out. Do not move resident. A complete report and notify MD via telephone. If no answer within one hour,, the Medical Director will be contacted. The RP\facility will be notified Training: The DON and the District Director of Clinical Services conducted re-education training for all Nursing, Dietary, Housekeeping, Laundry and Department Manager personnel January 8, 9 and 10, 2016. Training topics included were : · Abuse and Neglect Prohibition · Assessment of discomfort in Dementia Protocol · Change in Condition · Emergency Transports via 911 versus Non-emergency transfers. Abuse and Neglect Prohibition training included a review of the facility ' s policy on abuse and neglect prohibition. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how abuse and neglect are defined, prevention techniques, identification, investigation, protection and reporting responsibilities. Abuse and Neglect Prohibition training began January 8, 2016 and ended for all staff that were scheduled to work thru January 10, 2016 including RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Staff Development, Nurse Managers, Rehab Staff, Dietary, Housekeeping and Laundry Staff and Department Managers. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Abuse and Neglect Prohibition policy. The Assessment of discomfort in Dementia Protocol training included a review of how physical pain and affective discomfort experienced by people with dementia can be managed. The training was provided by the Director of Nursing Services and the District Director of Clinical Services. The training was presented in an oral fashion with examples provided of how the Assessment of Discomfort protocol should be applied when staff encounter situations with affected residents. Staff were trained on the steps they should follow which include: · Conducting a physical evaluation · Review residents history for potentially painful conditions · Evaluating the discomfort and initiating non-pharmacologic comfort interventions · Evaluate for pharmacologic interventions that are not [MEDICAL CONDITION] The Assessment of discomfort in Dementia Protocol training began January 8, 2016 and ended January 10, 2016 for RN ' s, LVN ' s, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy and Speech Therapy staff. Staff that were not able to attend any of the training offered between January 8 thru January 10, 2016 will not be allowed to work with residents until they have been re-educated on The Assessment of Discomfort in Dementia Protocol program. The facility ' s policy for identification of change of condition requires the implementation of the Stop & Watch tool as well as Interact 4.0. These decision support tools provide reporting guidance to licensed nurses on whether specific symptoms, signs, and lab results are immediate versus non-immediate, or next day, for reporting purposes to the primary care clinician. Using the Interact 4.0 tool the licensed nurse can determine immediacy of reporting for vital signs, laboratory results and diagnostic procedures. The Director of Nursing Services was re-educated on Stop & Watch and Interact 4.0 on January 9, 2016 by the District Director of Clinical Services. The Director of Clinical Services and the Director of Nursing Services re-educated RN ' s, LVN ' s, Unit Managers, ADON ' s, Staff Development, Certified Nursing Assistants, Certified Medication Aides, Physical Therapy, Occupational Therapy, Speech Therapy and MDS nurses January 9 and 10, 2016 on the Stop & Watch and Interact 4.0 programs. Staff that were not able to attend any of the training offered between January 8 and 9, 2016 will not be allowed to work with residents until they have been re-educated on the facility ' s Stop & Watch and Interact 4.0 programs. The licensed nurse will evaluate each situation based on individual resident condition at the time of the event. Once a medical emergency is identified, qualified staff evaluate the resident; initiate the appropriate emergency procedure(s), and calls 911. The licensed staff continues to provide care and monitor the resident until the emergency personnel arrive. The surveyors confirmed the POR had been implemented sufficiently to remove the IJ by: Record Review of the In-Service sign-in sheet revealed that staff from the nursing department representing all three shifts had been in-serviced from 01/08/16 until 01/10/16. The topics included in part: Abuse and Neglect, Dementia Resident Change in Condition and assessments and Emergency transport versus non-emergency transport Observations were made from 01/08/06 until 01/10/16 , for any residents that have a change in condition/falls and care of residents with dementia. Interviews conducted from 01/08/16-01/10/16 between 4:30am to 4:00 pm daily with CNAs and Nurses on various shifts revealed staff were able to verbalize the information from the recent in-services. The Administrator and DON were informed on 01/13/16 at 1:35pm that the IJ was lowered; however the facility remained out of compliance at a pattern level and a severity of actual harm that is not immediate jeopardy due to facility needing more time to monitor the plan of removal for effectiveness. The Form CMS 672 listed 104 residents as needing assistance or dependent on staff for mobility.

Based on observation, interview and record review the facility failed to ensure a resident who entered the facility without a pressure sore did not develop a pressure sore or have a worsening of a pressure sore for 1 of 5 residents (CR #1) reviewed with pressure sores. -CR #1 who was admitted [DATE] with no pressure sores developed unstageable pressure sores to his bilateral heels and left buttock area. CR #1 had a physician's orders [REDACTED]. -CR #1 discharged from the facility on 2/14/13 to a hospital for inpatient care of complex pressure ulcers. This deficient practice affected 1 discharged resident and placed 100 residents receiving preventative skin care at risk for the development of pressure ulcers, delay in treatment resulting in worsening of the resident's skin and a decline in health. Findings Include: Complaint # 2 Interview with CR #1's family member on 2/26/13 at 4:45 PM revealed CR #1 went to the hospital for wound care treatment. The family member stated CR #1's care needs were not being met at the facility and requested CR #1 be sent to a hospital. Observation on 2/27/13 at 8:50 AM, CR #1 was observed at a local hospital in bed on an air mattress. His right heel had eschar (black dead tissue) and his left heel had pink/red tissue with some eschar to a small area. His buttock area had a deep open area with undermining and yellow tissue notes inside. Per the hospital treatment nurse at this time she stated the left heel and buttock areas had been surgically debrided the week before. CR #1 was observed crying and yelling when the nurse was performing care to his buttock. Record review of CR #1's face sheet revealed he admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Record review of CR #1's Nursing Daily Skilled Summary dated 12/6/13 revealed the following: Skin - No problems was checked, [MEDICAL CONDITION] - Incontinence was checked, Digestive - Incontinent of bowel was checked, Musculoskeletal - bed mobility and transfer extensive assistance was checked. Record review of CR #1's care plan titled Pressure Ulcers, dated 12/6/2012 revealed under RAP/Problem/Need/Strengths, Potential was checked related to moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problems and co-morbid conditions. Under Goal it read "will have intact skin without signs of skin breakdown through next review: by next 90 days". Further review revealed under Approach the following: "Apply pressure reduction mattress to bed". Record review of CR #1's admission MDS dated ,[DATE] /12 revealed he was at risk for pressure ulcers, and interventions were pressure relieving mattress for bed and chair and turning and repositioning. He was coded as frequently incontinent of both bowel and bladder, and needed extensive assistance of 2 persons for bed mobility, transfer and toileting. Record review of CR #1's out of facility release of responsibilty dated 12/16/2012 revealed CR #1 went out with family member at 10:30 (no AM or PM). There was no sign in. Record review of CR #1's out of facility release of responsibilty dated 12/23/12 at 11:35 (no AM or PM) revealed CR #1 went out with a family member at 11:35 and returned at 5:30 (no AM or PM). Record review of CR #1's laboratory records dated 1/2/13 revealed his [MEDICATION NAME] level was 3.1 (low - normal was 3.5-5.7). (A low [MEDICATION NAME] level is indicative of prolonged protein depravation/[MEDICAL CONDITION]. Low [MEDICATION NAME] levels are indicative that the body has begun to breakdown muscle to compensate for an inadequate intake of protein. In individuals with bed sores, protein is essential to help the body heal the wounds. Source: http://www.bedsorefaq.com). Record review of CR #1's out of facility release of responsibilty dated 1/5/13 revealed CR #1 went out with a family member at 1:26 PM and returned at 8:30 PM. Record review of CR #1's head to toe skin checks revealed the following on 1/16/13 under skin intact,"yes" was checked. Record review of CR #1's nurses notes dated 1/18/13 at 1:00 PM that CR #1 went to the VA with family member and the skin was intact. Further review revealed CR #1 returned to the facility the same day at 6:15 PM. Record review of CR #1's head to toe skin checks revealed on 1/23/13 under skin intact, "yes" was checked, but crossed off and "no" was checked. There is a hand written notation "see treatment book" for the locations of skin conditions/wounds. Record review of CR #1's out of facility release of responsibilty dated 1/24/13 revealed CR #1 went out with a family member at 2:05 (no AM or PM) and returned at 6:15 PM. Record review of CR #1's out of facility release of responsibilty dated 1/25/13 revealed CR #1 went out with a family member at 12:15 (no AM or PM). There was no documentation of when CR #1 returned. Record review of CR #1's non-pressure skin condition record dated 1/25/13 revealed "shear" on left buttuck, size 4.6 cm length x 4.2 cm width, depth of 0.5 cm and the progress notes was written new treatment in progress, resident returned from out of facility with new shear. Interventions documented were wheel chair cushion, pillows and "off load heel protectors". Record review of CR #1's weekly pressure ulcer record for right heel, date of onset of 1/27/13, revealed the following: date 1/27/13, no stage was documented, size was 6.5 cm x 6 cm, no depth, wound bed was red and purple, with dark red purple surrounding skin color, progress notes was written new treatment in progress deep tissue injury, and interventions were listed as wheel chair cushion and positioning devices type pillows and heel protectors Record review of CR #1's weekly pressure ulcer record for left heel, date of onset of 1/27/13 revealed the following: on 1/27/13 size was 6 cm (length) x 6 cm (width), no depth, wound bed was red and purple, progress notes was written new treatment in progress. Deep tissue injury, and under interventions was: bed type air, wheel chair cushion, positioning devices pillows, off load heel protectors and slide sheet. Record review of CR #1's care plan titled Pressure Ulcers, dated 1/27/13 revealed under RAP/Problem/Need/Strengths, Actual Pressure Ulcers was checked with hand written notation of Right heel DTI (deep tissue injury) related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problems, co-morbid conditions, drugs that affect wound healing, impaired diffuse or localized blood flow and refusal of care/treatment. Under Goal it read that the pressure ulcer will show signs of healing process as evident by decreased in depth, width and length by at least 1 cm and free of further break-down through next review: within 90 days and will have intact skin without signs of skin breakdown through next review: within 90 days. Further review revealed under Approach the following: Apply pressure reduction mattress to bed. Hand written under approaches was the following: air mattress, off load heel protectors, multivit (multivitamin), labs and [MEDICATION NAME] as ordered. Record review of CR #1's care plan titled Pressure Ulcers, dated 1/27/13 revealed under RAP/Problem/Need/Strengths, Actual Pressure Ulcers was checked with hand written notation of Left heel related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problems, co-morbid conditions, drugs that affect wound healing, impaired diffuse or localized blood flow and refusal of care/treatment. Under Goal it read that the pressure ulcer will show signs of healing process as evident by decreased in depth, width and length by at least 1 cm and free of further break-down through next review: within 90 days and will have intact skin without signs of skin breakdown through next review: within 90 days. Further review revealed under Approach the following: Apply pressure reduction mattress to bed. Hand written under Approaches was the following: air mattress, off load heel protectors, multivit (multivitamin), labs and [MEDICATION NAME] as ordered. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's nursing daily skilled summary dated 1/29/13 at 9:00 AM revealed the resident went out to the VA. There was no return time documented. Record review of CR #1's change of condition form dated 1/29/13 at 4:30 PM revealed a new area on left hip and testicle, started while out of facilty. Continued review of this note read, in part, "spoke with responsible party with DON present concerning resident taking muliple trips out of facility and prolonged exposure to moisture and injyr to bilateral heels. Responsible party stated "we had business at the bank today...was reminded that resident has an doctors appointment pending for wound care." Further review of this document read, "received call from nurse practioner and he will speak to responsible party about frequent out of facility trips". Record review of CR #1's weekly pressure ulcer record for left buttocks, date of onset of 1/29/13 revealed on 1/29/13, stage 2, size: 6 cm (length) x 6 cm (width), depth 0.5 cm, wound bed: red, interventions: wheelchair cushion, positions devices type hand written was "pillow", "off load heel protectors" and "slide sheet". Record review of CR #1's care plan titled Pressure Ulcers, dated 1/29/13 revealed under RAP/Problem/Need/Strengths, Actual Pressure Ulcers was checked with hand written notation of left buttock shearing related to sensory perception, moisture/incontinence, decreased activity, impaired mobility, nutritional/hydration risks, friction and shear problems, co-morbid conditions, drugs that affect wound healing, impaired diffuse or localized blood flow and refusal of care/treatment. Under Goal it read that the pressure ulcer will show signs of healing process as evident by decreased in depth, width and length by at least 1 cm and free of further break-down through next review: within 90 days and will have intact skin without signs of skin breakdown through next review: within 90 days. Further review revealed under Approach the following: "Apply pressure reduction mattress to bed". Hand written under approaches was the following: "air mattress, off load heel protectors, multivit (multivitamin), labs and [MEDICATION NAME] as ordered". Record review of CR #1's head to toe skin checks on 1/30/13 revealed under skin intact, "yes" was checked but crossed off and "no" was checked. Documented on the locations of skin conditions/wounds, the bilateral heels are circled with a hand written notation of P.U. (pressure ulcer), the peri-area is circled with a notation of stage 1 and on the bottom area it is circled with a notation of stage 2. Record review of CR #1's weekly pressure ulcer record for left heel, date of onset of 1/27/13 revealed on 2/3/13 stage 2, size was 6 cm x 6 cm, wound bed was purple and under interventions was wheel chair cushion, positioning devices type hand written was "pillow" and "off load heel protectors". Record review of CR #1's weekly pressure ulcer record for right heel, date of onset of 1/27/13, revealed on 2/3/13 stage 2 was checked, size was 6.5 cm x 6 cm, no depth, wound bed was purple and interventions were wheel chair cushion, positioning devices type pillows, off load heel protectors. Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of CR #1's weekly pressure ulcer record for left buttocks, date of onset of 1/29/13 revealed on 2/5/13, unstageable, size: 8.6 cm (length) x 6.6 (width), depth: unknown, wound bed: red, yellow, progress note: site has 60 % yellow slough notes and under interventions: wheelchair cushion, positioning devices type, hand written was "pillow". Hand written was also "off load heel protectors". Record review of CR #1's physician's orders [REDACTED]. Record review of CR #1's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"yelling discomfort". Record review of CR #1's laboratory records dated 2/8/13 revealed his [MEDICATION NAME] level was 2.3 (low). Record review of CR #1's weekly pressure ulcer record for left heel, date of onset of 1/27/13 revealed on 2/10/13 it was a stage 2, size was 6 cm x 6 cm with no depth, wound bed was purple and under interventions was wheel chair cushion, positioning devices type pillows and off load heel protectors. Record review of CR #1's weekly pressure ulcer record for right heel, date of onset of 1/27/13, revealed on 2/10/13 stage 2 was checked, size was 6.5 cm x 6 cm, no depth, wound bed was purple and under interventions was coded wheel chair cushion, positioning devices type pillows and off load heel protectors. Record review of CR #1's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"yelling stating he has pain". Record review of CR #1's nurse's note dated 2/11/2013, written by the administrator, read in part, "Administrator adivised by DON that he needed assistance with CR #1 (transfer to hospital)... needs a matt (mattress)... Nurse indicated to DON that treatment nurse called for a matt (decline in wound) and was told patient would need a wound care consultant...family is resistant to sending patient back to VA due to long wait time and the fact that he presented with new areas after last timeout..." Record review of CR #1's weekly pressure ulcer record for left buttocks, date of onset of 1/29/13 revealed on 2/12/13, unstageable, size 8.6 cm (length) x 6.6 cm (width), depth was unknown, wound bed was black, interventions were air bed, wheelchair cushion, positioning devices type hand written was "pillows". Hand written was also "off load heel protectors" Record review of CR #1's physician order's revealed an order dated 2/12/13 for an air mattress. Record review of a faxed confirmation from a medical supply company dated 2/12/13 revealed an order was called in to the company for a low air loss therapy mattress for CR #1. Record review of CR #1's nurses notes dated 2/12/13 read in part, "... Air mattress installed today...". Record review of CR #1's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The result of this medication was "ineffective". Record review of CR #1's nursing daily skilled summary dated 2/14 12 at 10:20 PM, revealed the resident was transferred to a hospital at 3:30 PM. Record review of the hospital admission wound assessment dated [DATE] revealed the left buttock pressure ulcer, stage 3, 9 cm (length) x 8.5 cm (width), unable to determine depth with white/grey non-viable tissue and/or non-adherent yellow tissue. Record review of the hospital admission wound assessment dated [DATE] revealed the left heel pressure ulcer, unstageable, length 7 cm, width 3.3 cm and unable to determine depth, obscured by necrosis/unstageable, deep tissue injury-purple or burgundy with adherent soft black eschar. Record review of the hospital admission wound assessment dated [DATE] revealed the right heel pressure ulcer, deep tissue injury, length 9.3 cm, width 9.2 cm and unable to determine deep tissue injury, with necrosis/unstageable, deep tissue injury-purple or burgundy adherent soft black eschar. Record review of the hosptial history and physical for date of admission of 2/14/13, dated 2/15/13 revealed reason for admission was impatient care of complex pressure ulcers. Continued review of this document read, in part, "...Assessment/Plan: 1. Complex pressure sores. Antibiotic therapies for suspected left infected buttock wound. Per Infectious Disease, I will consult specialis to see him here. 2. Bilateral foot pressure sores with eschar. We will have Podiatry evaluate the patient..." Record review of CR #1's hospital laboratory records dated 2/15/13 revealed his [MEDICATION NAME] level was 1.8 (low - normal is 3.5-5.0). In an interview with LVN B on 2/26/13 at 2:00 PM she stated the wounds were caused from the family taking the resident out to appointments. She stated the resident came back with deep tissue injuries. In an interview with the administrator on 2/27/13 at 11:25 AM, she stated CR #1's insurance was the VA. She stated she had called the VA for a mattress but they did not provide one for him. She stated she had to order a mattress for him. In an interview with LVN A on 2/27/13 at 1:30 PM, she stated she noticed CR #1's wounds to his heels on 1/27/13. She stated the right heel had a fluid filled blister and the left heel was a red area. In an interview with LVN B on 2/27/13 at 2:35 PM, she stated the buttock wound was initially coded as shearing on 1/25/13, but was changed to a pressure ulcer on 1/29/13. She stated treatment was started, and the resident was placed on a "watch" list for the staff to be "diligent" to make sure they were aware he had wounds. She stated the wound went from a stage 2 to unstageable the next week. She stated the treatment to the heel wounds were changed on 1/29/13, but the buttock wound treatment was not changed at that time. She stated the VA was contacted on 2/4/13 requesting an air mattress and the VA told the facility he would need to be seen before sending an air mattress. LVN B stated the dietician recommended nutritional interventions on 2/7/13. In an interview on 2/27/13 at 3:00 PM, the DON stated he thought the shearing to the buttock happened to CR #1 on 1/25/13 during a transfer out in the family van. In an interview on 2/27/13 at 4:00 PM, the Administrator stated the resident was on a "gentle" mattress. According to the paperwork given to the surveyor at this time, a "gentle" mattress is a pressure redistribution mattress used for prevention of wounds and stage 1 pressure ulcers. Record review of the facility's mattress system provided by the Administrator revealed the "Gentle" mattress is used for prevention of skin breakdown and for use with stage 1 pressure areas. Record review of the facility's policy and procedure Skin Management, revised August 2012, read, in part, "...17. The nurse will assure treatments, interventions, Care Plan, and the appropriated skin documentation records are initiated in a timely manner according to Practice Guidelines..." According to CMS 672 there were 100 residents receiving preventative skin care.

Based on interview and record review, the facility failed to provide 1 of 7 residents reviewed for injuries (Resident #1) with the necessary care and services when she had numerous falls in the facility. The facility failed to provide adequate assessments and interventions to prevent complications and further injury. -Resident #1 fell on [DATE], [DATE], [DATE] and [DATE] and was documented as having had no injuries. Resident #1 was sent to the hospital emergency room after having witnessed [MEDICAL CONDITION] activity and change in mental status on [DATE]. -The management group overseeing fall management and interventions did not see the resident after the falls or interview the staff involved. These failures related to fall risk assessments and monitoring caused harm to Resident #1 and has the potenial to cause harm to the other 124 residents residing in this facility. Findings include: Review of the Face Sheet for Resident #1 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. and Status/Post Lumbar Spine Fracture. She was readmitted after her last hospitalization on [DATE]. Review of the Care Plan dated [DATE] revealed Resident #1 was at risk for falls related to Mental Status, History. of Falls, balance problems, [MEDICAL CONDITION], Sedatives/Hypnotics, and [MEDICAL CONDITION] medications. The Approaches were: Place on the Star Program, Encourage Resident to ask for assistance, provide assistive devices, Alarms for chair and bed, call light within reach, identify possible causes, and offer assistance to bathroom frequently, and observe for potential medication related causes. Review of the last MDS quarterly report dated [DATE] revealed the resident had a low cognitive score related to dementia; she was uncooperative with care most of the time; she had frequent falls some with injuries; she was mobile with a wheelchair; required assistance for all transfers. Review of Resident #1 Nurses Notes, Fall assessments, Change of Condition and Interdisciplinary Post Fall Reviews revealed she had 4 known falls in the month of [DATE]: -[DATE]--documented Resident #1 was found in the floor in her bathroom at 6:30 PM after attempting to transferring herself. There was no injury noted. The doctor was not notified until 10:30 PM that night. The intervention was care plan revision. -[DATE]--documented Resident #1 was found in her room on the floor next to her bed at 2:00 PM. There was no injury noted. Summary of post fall review stated the resident refused Occupational Therapy for upper body strengthening. The fall intervention was to refer to Occupational Therapy. The Change in Condition noted that Resident #1 had Dementia and it also stated that she refused to follow instructions. -[DATE]--Documented Resident #1 fell to the floor in her bathroom at 12:30 PM witnessed by a housekeeper. There was no injury noted. -[DATE]--Documented Resident #1 was found on the floor by her bed at 2:00 PM. There was no injury noted. Review of the Change of Condition for [DATE] at 2:00 AM revealed Resident #1 was having possible [MEDICAL CONDITION] activity and was unable to communicate. The Doctor was notified of the resident's condition, a 911 call was placed by LVN B and the local city fire dept. emergency medical service responded. Review of the local city police dept. report revealed the local city fire dept. emergency medical service called the police and filed an assault complaint related to the condition of Resident #1 when emergency medical services arrived at the facility. The resident was documented as having bruises and open wounds to her left elbow and a large purple bruise to the left side of her head. Review of the Nurses notes from the month of [DATE] revealed no documentation of injury to Resident # 1 head or elbow. Review of the Discharge Details/[DIAGNOSES REDACTED]. The Hospital staff spoke to Resident's #1 family and it was decided the resident would be placed on palliative treatment only. Review of the Nurses Notes for [DATE] at 2:35 A.M. revealed Resident #1 was having labored breathing and was non responsive to verbal and physical stimuli. She expired shortly thereafter. She had a DNR (Do Not Rescusitate order). Interview with DON on [DATE] at 10:30 A.M. revealed the management team had a "stand-up" meeting each morning and went over the falls and decided the interventions for each fall. This surveyor asked DON if any of the team actually saw the residents after the falls. DON stated, "No, but that's probably a good idea". Interview with CNA A on [DATE] at 11:30 AM revealed she was working the night of [DATE] on the 10:00 PM to 6:00 AM shift. She stated she over heard another staff member talking about Resident #1 falling earlier that day ([DATE]). She stated she came to work between 9:30 PM and 10:00 PM that night. She stated, "When I went in to check her (Resident #1), she was wet so I changed her. I checked her again about midnight and she wasn't acting like herself. She usually fusses when I check her because she doesn't like to be bothered. But this time she didn't say anything and didn't resist care. She usually helps me when I turn her, but she didn't help at all. I talked to her but she didn't say anything...it's like she was trying to talk but couldn't. She didn't act like she was in pain, but I asked her and she didn't say anything." This surveyor asked CNA A if she reported this change to anyone and she stated she told the nurse (LVN B). She wasn't sure if the nurse assessed the resident at that time. She stated, "Something just told me to go back and check on her again. I went into her (Resident #1) room about 2:00 AM and it looked like she was having a [MEDICAL CONDITION]. She was shaking and kind of foaming at the mouth. I called the nurse and he came. Then he called 911. I stayed with her stroking her hair and talking to her. It was about 2:30 AM when the ambulance got there." This surveyor asked CNA A if she had noticed anything wrong with Resident #1 arm when she first went into her room. CNA A stated the Resident's arm had been bleeding and she went to the nurses station and told LVN B and RN A. Interview with DON on [DATE] at 11:50 AM revealed LVN B usually worked weekends only, but had come in on a Monday [DATE] to work. He worked 2 shifts that day 2:00 PM to 10:00 PM on one hall and 10:00 PM to 6:00 AM on Resident #1's hall. Interview with DON on [DATE] at 1:10 PM revealed he went through Resident #1's chart trying to locate documentation that LVN B assessed Resident #1 when he was notified of her change in mental status. He could not find any documentation. DON stated, "He (LVN B) should have intervened." Interview with RN A on [DATE] at 4:10 PM revealed she was in report for shift change (2:00 PM to 10:00 PM) when an aide said Resident #1 had fallen in her room. RN A stated that she and LVN A went to check on Resident #1. RN A stated that Resident #1 was on the floor by the bed. She stated that Resident #1 was sitting up and stated she was not injured. RN A stated,"She was talking and alert. We (LVN A and RN A) did a head to toe assessment and the only injuries were the pre-existing ones. She (Resident #1) stayed up in the W/C until about 9:30 PM and was the last one to go to bed that night. I do remember that at shift change (10:00 PM to 6:00 AM) a CNA told LVN A that Resident #1 arm was bleeding. She had dressings on her arms from old injuries." RN A stated that Resident #1 was not strong enough to fall and get up without assistance. Interview with LVN A, on [DATE] at 4:30 PM revealed that Resident #1 fell at shift change during report. He stated that he and RN A went down to the resident's room. The Resident was sitting in the floor by her bed. The Resident told us she was OK and said she had slipped down when trying to get into the bed. LVN A stated Resident #1 was alert and acting normal. He stated the Resident had no injuries and had good vital signs and neurological signs. LVN A stated the Resident had no head injury. Interview with LVN B on [DATE] at 9:30 A.M. revealed he was working on the 10:00 PM to 6:00 AM shift on [DATE]. He stated he was aware that Resident #1 had fallen earlier that day. He stated at shift change during report with RN A, CNA A came to the nurses station and said Resident #1 arm was bleeding. He stated he went to check on the Resident's arm and it was an old injury that had reopened on her left elbow. He stated, "I saw the injury on her (resident#1) left temple and recognized it as an injury from the fall on the 27th (October). When I first saw her that night I could tell she wasn't acting quite right, but it was not enough to alarm me. CNA A never told me about Resident #1's change in mental status. She came to me at about 2:00 AM and said she thought the resident was having a [MEDICAL CONDITION] (Resident #1). I went down immediately and assessed her. I called the doctor and then called 911. The EMS came a little while later and picked her up. They didn't say anything to me about how she looked (bruises and wounds)." Interview with LVN C on [DATE] at 11:10 AM revealed she was working on [DATE] when Resident #1 fell . LVN C stated there were no injuries. This surveyor asked the LVN C if she saw a head injury from resident#1's fall that day. She stated, "No." The LVN then stated, "I don't remember seeing one (head injury)." LVN C stated that she was also working on [DATE]th, 2012 when resident#1 fell . LVN C stated she did not remember any injuries then either. Review of the Facility Policy on Abuse and Neglect dated [DATE] revealed the following: -Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect. According to the Facility Resident Roster for [DATE] the census was 124.