Every finding on record at Jackson Memorial Long Term Care Center

Based on observations, records reviewed and interviews, the facility failed to provide adequate supervision to prevent falls for one resident (Resident #1) out of three sampled residents reviewed for accidents and falls during a complaint investigation survey. Resident #1 a newly admitted , vulnerable and cognitively impaired had an assigned one to one (1:1) sitter was left unsupervised exited the facility through an emergency exit door descending a flight of stairs. Staff found Resident #1 at the bottom of the stairs (8 steps total) with abrasions to the bridge of the nose, right hand, and forehead. There were 172 residents residing in the facility during the survey. The findings include:Observational tour on 02/26/2026 starting at 8:18 AM of the location of the incident involving Resident #1 revealed the resident exited the facility through the South Two Emergency Exit located approximately 30 feet from the resident's room.Record Review Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of unspecified part of left clavicle with routine healing, Traumatic Brain Injury (TBI), Impulse Disorder, Generalized Anxiety Disorder, Unspecified, and Polyneuropathy. Review of Fall assessment dated [DATE] timestamped 4:01AM revealed a Fall Risk Assessment score of 10 which indicated the resident was at risk for fall.Review of Nursing Progress Note dated 02/06/2026 timestamped 11:43 AM indicated:Resident noted with multiple trips to bathroom with watery stools. Resident with unsteady gait, and confusion. Resident on hourly rounds. Supervisor made aware and awaiting order for 1:1 supervision. Writer and ARNP (Advanced Registered Nurse Practitioner) at nurses' station working on new orders that were received from Psychiatrist regarding resident. At about 10:30 exit door alarm started to alarm, and staff was alerted to assist with resident that exited door. Writer entered area and observed resident sitting at the bottom of the steps. As writer assisted to help resident to and standing position with another staff resident noted with bleeding from right side of forehead and bridge of nose. Resident was able to walk back upstairs with two persons assist back to room. ARNP on unit at time of incident head-to-toe assessment done. Resident with 2 abrasions to right side of forehead, 1 abrasion to bridge of nose, 1 open area to right hand palm area, 1 open area to right hand 4th digit. MD (Medical Doctor) notified and gave order to transfer resident to [local hospital emergency room] 911 called.fire rescue attendants arrived in unit. Resident left unit via stretcher. Review of Physician Orders for Resident #1 revealed an order dated 02/05/2026 for 1:1 supervision to ensure safety and support cognitive recovery, and an order dated 2/05/2026 to maintain fall precautions every shift. Order dated 02/06/2026 to transfer resident to [local hospital] emergency room status post fall with abrasion to right side of forehead, nose and right hand.Record review of a Hospital Summary dated 02/07/2026 timestamped 5:39 AM revealed Computed Axial Tomography Scan (CT) results indicated no other acute traumatic injuries noted. Record review of Fall Care Plan initiated on 02/06/2026 and revised on 02/06/2026 revealed Resident #1 had potential for falls related to use of psychotropic medications, unsteady gait, restlessness, anxiety, agitation, status post TBI, poor safety awareness and required supervision. Revision included: Resident was found sitting at the bottom of the step with injuries noted and new order was received to transfer resident to hospital for further evaluation. Goal was that resident will be free from injurious falls through next review date. Interventions included 1:1 as indicated and maintain fall and safety precautions at all times. Interview with Staff A, Certified Nursing Assistant (CNA) on 02/26/2026 at 3;27 PM revealed when asked about Resident #1's incident and the facility's policy on 1:1 supervision, she stated: The resident asked me for some water, went to lay down in the bed, and I covered him with a sheet. I then walked 2 doors down to another room to ask who was going to cover my break. I know the facility policy for 1:1 supervision is for the sitter to maintain at the resident's bedside at all times without exceptions. Interview with Staff A, Certified Nursing Assistant (CNA) on 02/27/2026 at 11:13 AM revealed, when asked regarding facility policy on 1:1 sitter communicating with staff about break time, Staff A stated: If the sitter needs to communicate with other staff to request a break, then it should be done using the call light always. Interview with the Senior Director of Risk Manager on 02/27/2026 at 10:19 AM revealed when asked if the setting was appropriate for Resident #1 and sitter leaving him unsupervised, she responded: I do not think the resident was a candidate for long-term care. He needed more aggressive care due to his Traumatic Brain Injury and psychiatric history. I believe, due to the resident's restlessness and impulsiveness, the incident would have occurred anywhere else. I also think the resident's sitter should not have stepped away from the bedside this is why she was held accountable. Interview on 02/27/2026 at 10:46 AM, Staff B, Registered Nurse (RN) Leader on 02/27/2026 at 10:46 AM revealed a sitter's role when assigned to a 1:1 supervision is to be within one arm length from the resident and if a bathroom break is needed, it should be communicated via the call light. Interview with the Administrator on 02/27/2026 at 12:52 PM; when asked if the incident with Resident #1 could have been avoided, he stated: I do not think this incident could have been avoided because the resident was agitated since he arrived at this facility and it could have happened anywhere else. I also do not think what the sitter did was correct; she should have never left the resident alone. Interview with the Director of Nursing on 02/27/2026 at 2:08 PM revealed when asked if the setting was appropriate for Resident #1 and the facility's policy on 1:1 supervision, she stated: The facility's policy regarding 1:1 supervision is for the sitter to remain with the assigned resident at all times. If the sitter needs a break, she needs to use the call light to communicate it; there is no reason for the sitter to leave the room. I also do not think the resident was a proper candidate to be in this facility because he was agitated and had been treated with Haldol in the previous facility. Record review of the facility's Policy titled: Resident Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 04/04/2023 and revised on 04/15/2025 indicated: Policy: [NAME] Memorial Long-Term Care shall make every effort to ensure that residents are free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.2. Neglect is defined as 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. Type/Example of Neglect: b. Inadequate supervision (victim left alone caregiver present but unable to provide or not providing supervision).

Based on observation, record review, and interview, the facility failed to provide a safe environment free of potential accidents and hazards for all residents residing in the facility by failing to implement the facility's policy related to accident and hazards for five (Resident #57,Resident #68, Resident #47, Resident #112 and Resident #150) out of 45 residents sampled in the facility; as evidence by: 1) Resident #57's side rail padding was observed on the outer side of the bed rail 2) a bladed box cutter was a observed on Resident # 68's bedside table, 3) No safety floor mat on the left side of Resident # 47's bed, 4) Resident # 112 had no safety floor mat to the right side of the bed and 5) a pack of cigarettes observed in Resident #150's pant pocket. These deficient practices increase the risk of accidents, hazards and fires that could cause serious harm, serious injuries or even fatalities. There were 169 residents residing in the facility at the time of the survey. The findings include. Resident #57 During observation on 08/11/25 at 08:27 AM both of Resident #57's side rails and side pads were in place, but the right-side rail padding was observed on the outer side of the side rail, not in the proper position (photo evidence). On 08/11/25 11:43 AM Resident #57's right side rail padding still observed on the outer side of side rail (photo evidence). Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to Parkinson disease…Tracheostomy Status, Gastronomy Status, Dependence on respirator(ventilator)status. Review of Resident #57's Physician's Orders Sheet for August 2025 revealed an order dated 08/06/2025 to monitor resident for seizure activity. Special instructions: padded side rails, every shift. Record review of Resident #57 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is unknown. Record review of Resident #57's Care Plans revealed the Resident is at risk for injuries related to seizure disorder. Interventions include- Pad side rails. Keep bed in lowest position. Monitor resident for seizures activities and obtain new orders as needed and document accordingly. Interview on 08/13/2025 at 03:13 PM the Director of Nursing (DON) stated Side rail padding is in place for a resident with a seizure diagnosis to ensure safety. Nurse managers oversee the unit, while restorative staff occasionally conduct assessments. The current side rail paddings are loose because the straps are not secured close enough to the rails, and the pads are incorrectly positioned on the outside of the railing. The team is exploring better product options. There have been no incidents where the paddings failed to protect the patient during a seizure. An order is not required for side rail padding, as its use is based on nursing judgment. Interview on 08/14/2025 at 02:43 PM with Staff K, Registered Nurse (RN) stated Yes, my patient has side rail padding. The straps should be secured properly to keep the padding in place. The purpose of the pads is to protect the patient from injury. With the padding on, three side rails should be up and one down. I make sure the padding is secure by checking that all straps are tight and correctly positioned. Record Review of the facility policy and procedure titled Bed Safety & Bedrails 07/08/2024 indicate: f. Siderails may be padded for safety and/or appropriate diagnosis e.g. seizure. Resident #68 Observation on 08/11/2025 at 10:51 AM, in Resident #68’s room revealed the resident was not in the room. A box cutter with the blade inside was observed on the Resident’s bedside table. (Photo Evidence) On 08/11/2025 at 10:53 AM, the Charge Nurse was notified and stated: Oh wow, I can't believe he has that. He has been told many times that he is not supposed to have those types of items with him, but he does not listen. The Charge Nurse then removed the box cutter Record Review of Resident #68’s demographic face sheet revealed the resident was admitted on [DATE] with diagnosis that included, but not limited to Quadriplegia, C5-C7 incomplete. Record Review of Quarterly Minimum Data Set (MDS) reference dated 07/03/25 revealed Resident #68 is cognitively intact and has impairment to both sides of upper/lower extremities and used a wheelchair. Record Review of a Care Plan with start date 10/15/2024, last revised on 08/11/2025 revealed Resident #68 had episodes of anger, inappropriate/behavioral symptoms, and becomes angry or upset with staff when providing care. Resident #68 also keeps items such as scissors and cutter inside his room for his personal use. Goal: Resident #68's episode of anger/refusal of care/treatment will decrease through next review date and possible consequences/outcomes of non-compliance. Approach: Educate Resident #68 on safety concerns on facility policies. Interview on 08/12/2025 at 12:46 PM, Resident #68 was asked about the box cutter found in room; Resident # 68 stated: I know I am not supposed to have a box cutter or any type of sharp objects in my room, but I use it to cut my plants in the patio. I bought the box cutter about a month ago when I was out on day pass and I've been using it ever since. Last time I used it was four days ago in the patio, and no one said anything to me, I guess no one saw me. Interview on 08/12/2025 at 01:06 PM, Staff A, Registered Nurse (RN) was asked about the box cutter found on Resident #68's bedside table; Staff A, RN stated: Residents are not allowed to keep any items that may cause harm to them or others, like ropes or knives. I always make rounds in the morning and during shift (every 3-4 hrs.), but I did not see the box cutter in [Resident #68's] room”. Staff A, RN also revealed she does not check Resident #68 when he returns from being out on day pass; she is only supposed to check his skin. Interview on 08/12/2025 at 01:19 PM, Staff B, Certified Nursing Assistant (CNA) stated: The policy in this facility is that residents cannot have lighters, knives or anything else that can be harmful to them. When I perform any care, or make rounds int he morning, I check their beds and bedside table for any harmful items. Staff B, CNA also reported she was not assigned to Resident #68 on the day the box cutter was found in his room. Interview on 08/12/2025 01:29 PM, Staff C, Charge Nurse stated: The protocol for hazardous items is monitoring and checking residents' rooms for dangerous items that would cause harm to them or others. I know you found the box cutter in [Resident #68's] room yesterday but there was nothing on his bedside table when we made rounds that morning. When residents return from day pass, staff always checks their belongings, skin, and pockets. Interview on 08/13/2025 at 03:02 PM, the Director of Nursing (DON) stated: Some items that residents are not allowed to have are guns and knives. We ensure residents are not keeping these items by monitoring all residents daily. Also, when residents go out to the patio, there is always a staff member there to monitor them. If residents go out on pass, the nursing staff checks them and perform a head-to-to-toe assessment upon return. In regard to [Resident #68], we did not know he had a box cutter. Interview on 08/13/2025 at 03:30 PM, when asked about Resident #68's care plan, Staff E, MDS Coordinator stated: [Resident #68's] care plan was last updated on 08/11/2025. We updated it because staff had found a box cutter in his room and was educated (along with staff) in order to be in compliance with the facility's protocols. Record Review of the facility policy and procedure titled Safety/Risk Reduction dated 04/15/25 indicated the following: It is the policy of the facility to provide a safe environment to all residents. A multi-disciplinary team approach accomplishes this goal through systems that identify opportunities to improve and/or represent a risk thus ascertaining that there are systems in place to promote a safe living and working environment. No weapons are allowed on the premises including but not limited to firearms, and hunting knives, etc. Procedure: A. Every identifiable opportunity to enhance and provide a safe and healthy environment will be addressed through the following mechanisms: 2. Monitoring Programs include: Ransom safety checks including room searches, G. All newly admitted resident's belongings are inventoried upon admission and items identified as weapons will be confiscated. A Weapon is defined as any instrument or device designed or used for inflicting bodily harm or physical damage to self or others. Some examples include but not limited to knives, (pocketknives, Swiss army knives), firearms, clubs, brass knuckles, etc. Items will be confiscated and returned to resident at the time of discharge. Resident #47 On 8/11/25 at 12:35 PM Resident #47 was in bed eating lunch independently. One safety floor mat was observed on resident’s left side and none on the right side (Photo evidence) and no staff was present with the resident. On 8/11/25 at 12:50 PM, the assigned nurse Staff I, Registered Nurse (RN) was notified about the identified concern and stated, When we feed residents we remove one floor mat. The surveyor notified Staff I, Registered Nurse that Resident #47 was observed eating independently and Staff I, RN replied, “I don’t know why the floor mat was not present. On 8/11/25 at 12:50 PM Staff D, Certified Nurse Assistant, was also notified about the identified concern and stated, I removed one floor mat to set [Resident #47] up for lunch. I was called away from another staff member to help and didn’t replace the floor mat. Record review of a demographic sheet revealed Resident #47 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Muscle wasting and atrophy. Record review of an Annual Minimum data set referenced dated 6/2/25 revealed Resident #47 is moderately impaired cognitively and was dependent on Chair/bed-to-chair transfer. Record review of a Fall Evaluation completed on 7/15/25 revealed Resident#47 was at risk for falls. Record review of a Progress note dated 8/3/25 revealed Resident #47 was found lying on floor. Record review of a physician’s order sheet revealed an order dated 8/4/25 directions bilateral floor mattress three times a day each shift. Record review of a Care Plan started on 6/10/25, last reviewed/revised on 8/4/25 revealed Resident #47 was at risk for falls related to: muscle weakness, impaired balance, assistance with transfer and on 08/03/05 Resident #47 observed on floor, no injuries observed and approaches that included: bilateral floor mats as indicated. Record review of a Progress note dated 8/3/25 revealed Resident#47 was found lying on floor. On 8/13/25 at 3:06 PM, the Director of Nursing revealed: The floor mats should be in place when residents are in bed unattended. There is no situation where the floor mats should not be in place while the resident is in bed unattended. Resident #112 On 8/11/25 at 12:51PM Resident #112 was observed in bed. There was one floor mat on the resident's left side (Photo evidence) and no staff present with resident. On 8/11/25 at 12:52 PM the assigned nurse Staff I, RN stated, The Certified Nurse Assistant who assisted [Resident #112] to eat removed the floor mat to assist with lunch and forgot to replace it. I do frequent rounds to monitor. On 8/11/25 at 12:53 PM Staff D, Certified Nurse Assistant was notified about the identified concern and stated, I am assigned to [Resident#112] today. I did not remove the floor mat, and I did not assist the resident for lunch. Staff D then walked away. The Surveyor stayed with Resident #112. Staff I, Registered Nurse approached surveyor and stated, “The Hospice nurse left floor mat after assisting [Resident#112] with lunch and the hospice nurse left the facility.” Record review of Resident #112’s demographic sheet revealed the resident was admitted on [DATE] with diagnosis that included Huntington's disease. Record review of a physician’s order sheet revealed an order dated 2/23/25 directions bilateral floor mattress three times a day. Record review of a Quarterly Minimum data set referenced dated 6/1/25 revealed a Brief Interview for Mental Status score was undetermined and was dependent on Activities of daily living and transfers. Record review of a Fall Evaluation completed on 6/6/25 revealed Resident#112 was at risk for falls. Record review of a Care Plan started on 3/10/25, last reviewed/revised on 7/30/25 indicated Resident #112 had the potential for falls related to: Resident has poor safety awareness, impaired cognition, impaired balance requiring total assistance for transfers and involuntary movements and approaches that included: Bilateral floor mats. Resident #150 On 8/11/25 at 1:20 PM Resident #150 was observed leaving the room with a pack of cigarettes in pants (photogenic evidence). The surveyor interviewed Resident #150 about facility policy for smoking; Resident # 150 stated, I am going to smoke on the patio. I get my cigarettes from the nurse and keep my cigarettes on me for the day and return them at the end of the day. At that time Staff I, RN was notified about the identified concern and stated, [Resident#150] gets cigarettes from staff in the morning and keeps it until the end of the day and return any leftover cigarettes. On 8/11/25 at 1:26 PM Resident #150 was observed on patio smoking. On 8/12/25 at 10:03 AM Resident#150 was taken to the East 2, nursing station by the Administrator, two packs of cigarettes were retrieved from the 7:00 AM to 3:00 PM shift Charge Nurse who took the cigarettes from a locked drawer behind the nursing station. At that time, the East 2’s 7:00 AM to 3:00 PM shift Charge Nurse was interviewed about the facility's smoking protocol and stated, The cigarettes are kept under lock and key. Only a nurse has a key… [Resident#150] returns left over cigarettes at the end of the day. On 8/12/25 at 10:14 AM Resident #150 was escorted back to unit. No cigarettes were returned at that time. Record review of a demographic sheet revealed Resident #150 was admitted on [DATE] with diagnosis that included: Nicotine dependence. Record review of a Quarterly Minimum data set referenced dated 6/19/2025 revealed a Brief Interview for Mental Status score of 2, out of 15 which indicates severe cognitive impairment. Record review of a Care Plan started on 9/30/24, reviewed/revised on 6/23/25 revealed Resident #150 smokes whenever on patio, refuses to wear a smoke protective gown at times and is at risk for self-burn and had approaches that included: Staff will pass out cigarette to resident as needed, staff to closely supervise/assist resident during smoking time, clothing to be checked for holes and changed if any. Record review of a Smoking Assessment completed on 7/8/25 revealed Resident #150 had a Minimal Problem of inappropriately providing smoking materials to others and was determined to be a safe smoker supervisor only. On 8/13/25 at 2:15 PM, the Administrator was notified about the identified concern and stated, The cigarettes should be accounted for, and we should be following our smoking policy. Resident is non complaint.” On 8/13/25 at 2:52 PM, the Risk Manager stated, “I complete investigations and audits. The residents are expected to turn in the cigarettes each time they come upstairs. Even though our policy states all cigarettes should be returned to the unit for [Resident #150] it is not a hazard for him to keep cigarettes in the room because this resident is alert and did not have a lighter.” The Surveyor asked how staff knew no lighter was in the room. No response. Record review of a Policy titled, “Smoking, Vaping, E-Cigarettes &Contraband Revised on 2/1/24 revealed Il. Policy Smoking is prohibited anywhere on JHS property, except for designated areas in the nursing homes. It is prohibited for all employees, visitors, families, volunteers, contracted personnel, vendors or anyone who is not a resident. Smoking is prohibited in any official JHS vehicle. The possession, consumption or sale of alcohol, or contraband on JHS property is prohibited. It is the policy of JHS that items which pose a significant potential danger to Residents, Staff or Visitors be seized and secured by the appropriate department within the facility or law enforcement. SMOKING POLICY: A. Residents shall not keep cigarettes, e-cigarettes, matches nor lighters with them, nor in their rooms.

Based on observations, record review and interviews, the facility failed to properly position an indwelling urinary tubing to facilitate the flow of urine for one (Resident #46) out of one sampled resident with an indwelling urinary catheter, as evidenced by Resident #46's indwelling catheter tubing was positioned above bladder and kinked. This deficient practice prevented the free flowing of urine that would be accumulated in the bladder causing discomfort and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. There were four residents with indwelling urinary catheters residing in the facility at the time of this survey.The findings include.During an observation on 8/11/25 at 1:01 PM, Resident #46 was standing in his room, a tubing was observed protruding from the top of the Resident's shorts and into a drainage bag that was anchored on the walker (photo evidence). Resident #46 revealed he had an indwelling urinary catheter and complained of blood in the urine. Upon further observation the tubing was kinked, and urine did not appear to be flowing freely. On 8/11/25 at 1:05 PM, Staff J, Licensed Practical Nurse (LPN) was notified of the identified concern. Staff J, LPN completed hand hygiene, put on required Personal Protective Equipment (PPE) and readjusted the tubing so it would no longer be kinked.Interview on 8/11/25 at 1:15 PM, Staff J, LPN stated, [Resident #46] has an indwelling urinary catheter that I flush with water daily. I have not flushed it today. This morning the catheter was not kinking because the resident was wearing a gown. I readjusted the tubing, and I educated the resident.Record review of a demographic sheet revealed Resident #46 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Benign Prostatic Hyperplasia (BPH) with lower urinary tract symptoms note: BPH with Obstructive Uropathy and Urinary Tract Infection.Record review of a Significant Change in Status Minimum Data Set (MDS) referenced dated 7/30/25 revealed Resident 46 had no cognitive impairment and required supervision or touching assistance for toileting hygiene and an indwelling catheter.Record review of a Care Plan started on 8/4/25, last reviewed/revised on 8/11/25 revealed Resident #46 requires an indwelling urinary catheter related Benign Prostatic Hyperplasia with Obstructive Uropathy, noted unclamping catheter leg holder and touching his Indwelling catheter at times with approaches that included: resident to not play/touch his Indwelling catheter to avoid dislodgement and/or infection. Reeducate resident not to touch indwelling catheter and to keep it below the level of bladder (resident noted to place catheter above the level).Record review of a July 2025 physician's order sheet revealed [indwelling urinary catheter] care as needed, normal saline flush 30 ml (milliliters) every shift.Interview on 8/13/25 at 3:06 PM, the Director of Nursing revealed for a resident with an indwelling urinary catheter, the best method for positioning is to secure the tubing to the thigh and the bag should be positioned downward because back flow can cause an infection. The Surveyor asked the Director of Nursing (DON) if there was any policy pertaining to the proper positioning of an indwelling urinary catheter and the DON stated: No.On 8/14/25at 2:13 PM, the Registered Nurse, Infection Preventionist revealed ways to prevent Urinary Tract infections in residents with indwelling urinary catheters include positioning the catheter tubing below the level of the bladder.Record review of a policy titled, Urinary Catheter Care dated 6/26/15 revealed POLICY: Catheter care is done by the nurse or nursing assistant routinely twice daily on all residents/patients with indwelling catheters.

Based on observation, record review, and interview, the facility failed to implement infection control measures for three (Residents #57, Resident #98 and Resident #106) out of twenty-one sampled vulnerable Residents, as evidenced by Residents #57 and Resident #98 catheter dignity bags touching the floor; and improper hand hygiene during Resident #106's tracheostomy care. These deficient practices increase the risk for life-threatening infections. The findings included: On 08/12/2025 at 2:02 PM Resident #57's urinary catheter drainage bag was observed in a dignity bag on the floor (photo evidence). Resident #57 Review of the medical records for Resident #57 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to urinary tract infection (UTI). Review of the Physician's Orders Sheet for 06/03/2025 revealed that Resident #57 may use external catheter diagnosis (dx) sacral wound. Record review of Resident #57 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is unknown. Section GG for Functional Abilities documented the resident has impairment to both sides of the upper and lower extremities. Section H for Bladder and Bowel documented Resident #57 bowel was always incontinent. Section I for Active Diagnosis included: Candidiasis, unspecified, Cerebral infarction due to thrombosis of right posterior cerebral artery, Persistent vegetative state, Tracheostomy status, Gastrostomy status, Dependence on respirator [ventilator] status, Urinary Tract Infection (UTI), Pain, unspecified. Record review of Resident #57's Care Plans revealed Resident #57 requires an external catheter and incontinent of bowel related to Multiple wounds. At risk for skin breakdown related to incontinence and UTI. Interventions include - Observe for signs of skin breakdown/irritation and/or decreased blood circulation to penis. Provide care after each incontinent episode, apply skin barrier protector, maintain privacy. Check skin during care, notify provider if any impairment noted. Position bag below level of bladder. Use a catheter strap to reduce pulling. Resident #98 On 08/11/25 at 09:57 AM, Resident #98 urinary catheter drainage bag was observed in a dignity bag on the floor (photo evidence). Review of the medical records for Resident #98 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter. Review of the Physician's Orders Sheet on 07/21/2025 revealed that Resident #98 had an order for External catheter care every shift, diagnosis (Dx): sacral wound. Record review of Resident #98's MDS dated [DATE] revealed: Section for Cognitive Patterns documented the BIMS Score was unknown. Section for Functional Abilities documented the resident is dependent on toileting, showering, upper and lower body dressing and bowel was always incontinent. Section for Active Diagnosis included: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter, Encounter for attention to gastrostomy, Dependence on respirator [ventilator] status, encounter for attention to tracheostomy. Record review of Resident #98's Care Plans revealed Resident #98 is incontinent of bowel and bladder, however, requires an external catheter related to Multiple pressure injuries. At risk for skin breakdown r/t to incontinence and at risk for UTI. Interventions include- Provide total assistance for catheter care. Provide care after each incontinent episode, apply skin barrier protector, maintain privacy. -Check skin during care and notify provider if any impairment noted. Position bag below level of bladder. Use a catheter strap to reduce pulling. Interview on 08/13/2025 at 03:13 PM, the Director of Nursing (DON) revealed the urinary catheter should be secured to the thigh. The tubing should be draining down to prevent backflow. the catheter bag should be hanging off the side of the bed in dignity. the catheter or dignity bag should not touch the floor. if the catheter or dignity bag touch the floor the staff should change it. to prevent this from happening at any other time the staff should make sure it is properly anchored. Interview on 08/14/2025 at 02:45 PM with Staff K, Registered Nurse (RN) stated I have been an RN at this facility for three years. When the patient is lying in bed, the [] catheter should be secured to the inside of the thigh and never touch the floor. It should always be placed in a dignity bag, and neither the catheter nor the bag should ever touch the floor. If it does, I fix it immediately, because urine can flow backward and cause infection. Review of the facility’s policy and procedures tilted Infection Prevention and Control Program 02/06/2025 indicate: the purpose - Develops and implements an ongoing infection prevention and control program (IPCP), to prevent, recognize, and control the onset and spread of infection. Establish facility-wide systems for the prevention, identification, investigation, and control of infections of residents, staff and visitors. Develop and implement written policies and procedures for infection control. Ensure staff handle, store, process and transport all linen and laundry in accordance with national standards. Resident #106 During a Tracheostomy Care observation on 08/11/25 at 09:07 AM for Resident #106, Registered Nurse (Staff F) gathered the supplies, entered Resident # 106's room, identified the resident, performed hand hygiene, donned non-sterile gloves, introduced herself, and informed resident of procedure. Staff F revealed Resident # 106 was receiving oxygen (O2) at 10 liters per minute (lpm). Staff F set up sterile area with tracheostomy supplies, removed non-sterile gloves and donned sterile gloves, suctioned resident with new suction tubing, removed trach gauze, cleaned trach stoma with normal saline, peroxide, and sterile gauze, removed soiled inner cannula, discarded it into a red biohazard bag and inserted a new one, Staff F then removed soiled trach collar and discarded it in red biohazard bag, placed a new trach collar on resident, re-connected oxygen tubing , removed gloves and donned new gloves, discarded all other soiled supplies inside red biohazard bag, removed gloves and gown, exited room, discarded red biohazard bag inside red bin in the soiled utility room, washed hands, and documented care on resident's chart. Review of Resident #106's demographic sheet revealed the resident was admitted on [DATE] with diagnoses that included but not limited to Encounter for Attention to Tracheostomy, Chronic Respiratory Failure, Unspecified whether with hypoxia or hypercapnia, and Chronic Obstructive Pulmonary Disease (COPD). Record Review of Physician's Order Sheet for March 2023 revealed Resident #106 had orders that included but were not limited to: Trach care twice daily and as needed. Record Review of a Quarterly Minimum Data Set (MDS) dated [DATE] Section for Cognitive Patterns revealed a Brief Interview of Mental Status (BIMS) summary score was 0 out of 15 which indicated severe cognitive impairment. The section for Functional Abilities revealed the resident was dependent on Activities of Daily Living (ADLs). The section for Special Treatments revealed the resident was receiving oxygen therapy, tracheostomy care and suctioning, and has received respiratory therapy for 7 days for at least 15 minutes in the last 7 days. Record Review of a care plan dated 03/13/2025, revised 06/12/2025 revealed Resident #106 required oxygen therapy related to Tracheostomy dependent, Chronic respiratory failure, Hypoxia, COPD. Goals: Resident will be monitored for signs of hypoxia. Interventions included but not limited to: Administer oxygen as ordered, HOB (Head of Bed) elevated position for optimal breathing, and monitor/document respiratory status every shift. Interview 08/11/2025 at 09:23 AM, Staff F, Registered Nurse (RN) revealed: To prevent infection while performing trach care, it is important to wash your hands before and after the procedure. Every time you remove your gloves you must wash your hands and then apply new gloves. I did not wash my hands after I removed the gloves because I did not touch any surface after removing the gloves. The infection control protocol while performing trach care is to wash hands before and after care. Interview on 0811/2025 at 10:03 AM, Staff G, Charge Nurse was asked about hand hygiene practices; Staff G , Charge Nurse stated: You need to wash your hands before care, whenever you change gloves, and after completion of care. After you remove soiled gloves, you have to wash your hands regardless of whether you touched any surface or anything else. Interview on 08/13/2025 at 03:18 PM the Director of Nursing (DON) stated: Nurses should be washing hands before and after a procedure. They are required to wash their hands after removing gloves and before donning new gloves, there are no exceptions. Interview on 08/14/2025 at 02:37 PM Infection Preventionist Nurse Manager stated: My number one education is always hand washing. When performing trach care, you make sure you wear your gown and gloves. Anytime you remove anything that is dirty, you need to remove your gloves and wash hands before putting on new gloves. Record Review of the facility Infection Control policy titled Hand Hygiene, dated 02/24/2024, revised 08/12/2025 indicates the following: To ensure that JMLTC has a comprehensive Hand Hygiene policy and that all providers, staff employees, contractors, volunteers, students, patients, and visitors are aware of and knowledgeable about the principles of hand hygiene. Procedure: 5 Moments of Hand Hygiene: Before patient contact Before clean/aseptic procedures After body fluid exposure/risk After touching a patient After touching patient surroundings Glove Usage: a. Gloves use does not replace the need for hand hygiene. Hand hygiene must be performed prior to donning gloves and after glove removal. b. Perform hand hygiene (and glove change) when moving from contaminated body site to a cleaner body site.

Based on observations, record review and interview, the facility failed to implement care plan interventions for one resident (Resident #61) out of eight residents sampled. As evidenced by Resident #61 observed in bed without floor mats in place and out of bed without wearing a helmet. There were 165 residents residing in the facility at the time of survey. The findings included: On 4/01/2024 at 9:36 AM, Resident #61 was observed seated in a wheelchair on the patio near staff. The resident had a splint on the left hand and the left foot was elevated on footrest. On 4/02/2204 at 9:58 AM, Resident #61 was observed self-propelling in wheelchair in the hallway. A splint was on the left hand and the left foot was elevated on the footrest. On 4/03/2024 at 8:34 AM, Resident #61 was observed lying in bed, no bilateral floor mats in place (photo evidence) On 4/04/2024 at 8:37 AM, Resident #61 observed lying in bed, no bilateral floor mats in place (photo evidence) Record review of demographic sheet for revealed Resident #61 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Hemiplegia affecting left dominant side and muscle weakness. Record review of quarterly Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 15 on a scale of 0-15 suggesting the resident is cognitively intact. Section E revealed no indicators of psychosis, rejection of care or wandering behaviors. Section GG for functional status revealed substantial/ maximal assistance for personal hygiene and toileting, dependent for chair to bed transfer, independent to wheel 150 feet in manual wheelchair. Section J for health conditions revealed one fall since admission with injury. Record review of care plan start date 10/05/2023 revised 3/28/2024 indicate the resident is at risk for further falling related to: Use of Psychoactive medication, transfer assistance, poor balance, impaired cognition, wheelchair dependent, seizure disorder, and previous falls. Interventions included: Low riser bed, floor mats as safety measures. Helmet when out of bed. Record review of physician orders revealed 7/03/2018 maintain fall precautions and 7/31/2018 Fall precautions every shift. On 4/04/2024 at 8:40 AM Staff G, Certified Nursing Assistant (CNA) stated: I have been employed at this facility for 3 years and I am assigned to take care of [Resident #61] today. I am involved in the care plan meeting for [Resident #61]. I am not aware that Resident #61 has interventions for floor mats. On 4/04/2024 at 8:44 AM Staff F, CNA stated: I have been employed here for 4 years and I am taking care of [Resident #61] today. I am involved in the care planning for Resident #6]. I was not advised during care planning that [Residnt#61] has interventions for floor mats. On 4/04/2024 at 8:51 AM Staff D, Licensed Practical Nurse (LPN) stated: I am involved in the care planning process for [Resident#61]. There has never been a discussion about residents needing floor mats or helmet. On 4/04/2024 at 8:53 AM Staff E, Registered Nurse, (RN) stated: I am the nursing manager for the unit East 1. Fall precautions are individualized for each resident's needs. I am involved in the care planning for Resident #61. We have a care plan meeting for [Resident #61] quarterly, annually, and as needed; [Resident#61] has an order for fall precaution. We have not discussed floor mats or helmet use in care planning. On 4/04/2024 at 1:52 PM, the Director of Nursing (DON) stated: The care plan interventions for [Resident#61] falls include floor mats and helmet and were not being implemented by staff due to when [Resident#61] improved significantly and doesn't require the floor mats and helmet anymore. When [Resident #61 was admitted she was using those safety devices. Those interventions should have been removed before today. [Resident #61 has been in facility since 2018 and has not had any recent falls. Record review of policy and procedure for Interdisciplinary Care Planning dated 1/10/2024. Purpose To ensure that each resident receives person centered care based on their individualized Plan of Care, the interdisciplinary Team meets on a routine basis and develop/discusses the plan of care. Key Point: Any member of the care team can and should update the plan of care when new information is appropriate and different from what exists at the time.

Based on record review and interview the facility failed to accurately code the Minimum Data Set (MDS) Assessment Section 0 for one (Resident #136) out of four residents reviewed for resident assessment. There were 166 residents residing at the facility at the time of the survey. The findings included: Record review of Resident #136's Admission Minimum Data Set (MDS) dated [DATE] Section O for Special treatments and procedures documented that the resident did not receive any special treatments or procedures. Review of the Physician's Orders Sheet for April 2024 revealed Resident #136 had orders that included but not limited to: Suction Tracheostomy (Trach) as needed and every shift, Trach care every shift and as needed, and Fraction of inspired oxygen (FIO2) at 30% via trach collar every Shift. Further review of the medical records for Resident #136 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and Encounter for attention to tracheostomy. Record review of Resident #136 's Care Plans dated 03/13/2024 documented: Resident has potential for complications related to tracheostomy. Interventions include but are not limited to: Assess lung sounds every shift. Report any wheezes, crackles, or decreased breath sounds. Assist resident to turn, cough, and deep breath every 2-3 hours and as needed. Monitor and report signs of localized infection (localized swelling, redness, pain or tenderness, heat at the infected area, purulent drainage, loss of function). Monitor and report signs of systemic infection (fever, malaise, change in mental status, anorexia, nausea, headache, lymph node tenderness/enlargement). Provide tracheostomy care every shift and as needed. Provide oral hygiene every shift. Use principles of infection control and universal/standard precautions. Interview 04/04/2024 at 07:33 AM. Registered Nurse, Minimum data Set Coordinator (Staff B), was asked about the resident's MDS Admission Assessment section O pertinent data. Staff B stated: I missed that section somehow and I will do a correction right away, we have two MDS coordinators and we have our units that we are responsible for, I am assigned units-east 1, west 2 and south 2, and I am assigned to this resident. When I do my assessment of a resident, I observe the resident, I talk to the staff the CNAs (Certified Nursing Assistants) and the Nurses about the resident before I complete the MDS assessment for the particular resident. Review of the facility's policy and procedure titled Nursing/Treatment-Wound Dressing Changes dated 09/08/2023 indicates: The MDS is used to provide a holistic assessment of each resident to promote optimum quality of care and quality of life. It is also used to identify resident care problems that are addressed in an individualized resident centered care plan, as well as for Medicare reimbursement. It is imperative that all sections are accurately coded by each discipline.

Based on observation, record review and interview the facility failed to obtain a prescribed order for a skin graft dressing change and failed to change the dressing daily per facility protocol for one resident (Resident #31) out of 2 sampled residents. As evidenced by no prescribed orders available for skin graft treatment dressing observed on 04/02/24 on resident anterior left leg initialed and dated 3/30/2024. The findings included: During assessment observation on 04/02/2024 at 08:59 AM Resident #31 was observed with a dressing to the left anterior leg dated 03/30/24, 11-7 PM shift. During observation on 04/03/2024 at 10:58 AM Registered Nurse, Wound Care (Staff C) prepared dressing change supplies, checked the order, entered resident's room, donned gown, washed hands, identified resident, prepared resident for dressing change with the assistance of Registered Nurse (Staff J) washed hands, donned gloves, opened supplies, apply barrier to bed, removed dressing from skin graft sight on anterior left leg, sight observed with redness and dry scabs, washed hands, donned gloves, cleaned area with normal saline x 3, pat dry x 2, washed hands, donned gloves, applied Antibiotic ointment on area and covered with dry dressing dated an initialed 04/03/2023, repositioned resident, discarded supplies in red bag, washed hands, donned gloves, closed red bag, washed hands, took red bag to soiled utility room, discarded red bag in red bin, washed hands, signed off on treatment performed. Review of the medical records for Resident #31 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Pressure ulcer of left hip, stage four (4) Review of the Physician's Orders Sheet for April 2023 revealed Resident #31 had no prescribed order on file for the skin condition dressing treatment to the right anterior leg. Later in the day on 04/02/2024 an order was obtained by Registered Nurse, Wound Care (Staff C) for-Triple Antibiotic ointment; 3.5 milligrams (mg) 400 unit- 5,000 unit/gram; amt (amount): Thin layer; topical. Special Instructions: clean left anterior lateral leg with normal saline, pat dry, apply a thin layer of triple antibiotic ointment and cover with dry dressing daily x 7 days and reassess; diagnosis: open area, once a day. Record review of Resident #31 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented brief interview for mental status score (BIMS) 00 indicating the resident is cognitively impaired. Section GG for Functional Goals and Abilities documented the resident is dependent for care and Section M for Skin conditions documented no other ulcers, wounds, and skin problems. Record review of Resident # 31's Care Plans Reference Date 03/22/2024 documentation include but not limited to- Problem: Resident has a pressure ulcer to: Left Hip . At risk for further skin impairment r/t (related to) impaired mobility and incontinence. 3/21/2024, Resident noted with open area to the left anterior leg. Interventions include, use of pressure relieving mattress and cushions. Heel protectors on and in place, Weekly skin assessment. Report any signs of further skin breakdown daily. Interview on 04/02/2024 at 03:20 PM Staff C stated: I am the primary wound care nurse at the facility, there is no order for any treatment to the left anterior leg for this resident, the resident has a surgical skin graft on the anterior left leg that gets red sometimes and the floor nurses provide treatment as needed, currently there is no order in the system for treatment to the left leg. In this situation we will consult with the Physician (MD), Nurse Practitioner (ARNP). The Interdisciplinary team, dietary, do a wound care evaluation of the site (Left Leg) to see what type of treatment order is required for the resident. The resident's ARNP or the MD would prescribe the order and of course the nurses will provide the treatment. The surveyor informed Staff C that currently the resident has a dressing to his anterior leg dated 3/30/2024. Staff C was asked how often the dressing would need to be changed, Staff C did not respond. Interview on 04/03/2024 at 11:41 AM Staff C stated. I did an assessment of the resident's left anterior leg area yesterday, document the findings, spoke with the resident's ARNP, received a treatment order for the left anterior leg. I communicated with the floor staff about the resident's new order, called the resident's family (dad) to notify him of the changes, and sent dietary a message regarding the open area to the resident's left anterior leg for supplement review. Review of the facility policy and procedure titled Wound Dressing Changes dated 09/08/2023 states: The following information should be recorded in the resident's medical record: The date and time the dressing was changed, the name and title (Or initials) of the individual changing the dressing and the type of dressing used and wound care given.

Ensure oxygen therapy was being provided at an accurate flow rate of oxygen setting for one resident (Resident # 77) out of ten sampled residents. As evidenced by Resident#77 was observed receiving oxygen via nasal cannula at five Liter Per Minute instead of the prescribed three Liters Per Minute. This practice has the potential to have an adverse effect on residents in the facility that requires oxygen therapy. The findings included: On 04/01/2024 at 9:28 AM Resident # 77 observed in bed with oxygen in progress at five Liters Per Minute (LPM) via nasal cannula (N/C). (photo evidence) On 04/02/2024 at 10:07 AM Resident #77 was observed in bed with oxygen in progress at five LPM via N/C. (photo evidence) Record review of demographic face sheet revealed Resident #77 was admitted on [DATE] with diagnosis that included Chronic Obstructive Pulmonary Disease and Respiratory Syncytial Virus Pneumonia. Record review of Quarterly Minimum Data Set (MDS) 2/28/2024 Section C for cognitive status revealed a Brief Interview for Mental Status (BIMS) score of 7 on a scale of 0-15 indicated moderate cognitive impairment. Section GG for functional status revealed setup clean up assistance for eating and dependent for all other Activities of Daily Living (ADL) and transfer. Section J for Health conditions revealed nothing coded. Section O for special treatments not coded. Record review of Care Plan start date 11/30/2023 requires oxygen therapy as needed: COPD Interventions included: Administer oxygen as indicated via N/C. Monitor/document respiratory status every shift. Explain the importance of keeping oxygen at the prescribed setting. Stress more oxygen may not be better. Record review of physician orders revealed 11/18/2022 oxygen at three liters via N/C as needed (PRN) for Shortness of breath (SOB). On 4/02/2024 at 10:22 AM Staff I, Licensed Practical Nurse (LPN) stated [Resident #77] current oxygen order is three LPM via N/C as needed (PRN). Resident #77 usually uses oxygen while in bed due to complaints of shortness of breath. I have not seen any shortness of breath for this resident. The nurse turns on the oxygen for the resident when needed. Resident #77 also notifies staff when he needs assistance for oxygen. On 4/02/2024 at 10:25 AM. The surveyor and Staff I, LPN entered Resident #77's room, Staff I observed the oxygen level. Staff I stated: The oxygen delivery level for [Resident #77] is currently at five LPM and should be at three LPM according to the physician order. I rounded this morning when I started my shift, checked [Resident #77] and the oxygen tubing but did not check the level of oxygen delivery due to the fact it has never been at the wrong level and all staff are aware of the appropriate level. I will do frequent rounding to ensure oxygen therapy is delivered at the prescribed rate and give report to the oncoming shift. I measure the oxygen saturation daily to make sure resident's oxygen level in within normal parameters. On 4/04/2024 at 9:14 AM; Staff E, Registered Nurse (RN) stated: The protocol for administering oxygen PRN is to first check the order, then check the resident's oxygen saturation level or any observation or report of respiratory difficulty and then administer the oxygen as ordered. Oxygen should not be administered above the prescribed rate. [Resident #77] has an order for oxygen at three LPM via N/C as needed. On 4/04/2024 at 9:34 AM, Staff H, Registered Nurse (RN) stated: I am the nursing supervisor for the building. The protocol for administering oxygen is to follow the physician order. There is no time that it should above the doctors order unless it is an emergency, we immediately inform the physician. On 4/04/2024 at 1:27 PM The Director of Nursing (DON) stated: When there is an order for oxygen administration as needed, the nurses are to first verify the order, complete a respiratory assessment, then apply the oxygen according to physician's order. The only time the oxygen would be applied at a higher level then ordered is during an emergency which is temporary, and the physician would be notified. I will investigate the situation to find out if any harm was done to the resident and then consult with the physician. I will also re-educate staff about following doctors' orders and doing more frequent rounds. Record review of Policy and Procedure for Oxygen Administration revised 7/14/2023 revealed Purpose: 1. The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order of facility protocol for oxygen administration. Procedure: Verify physician's order.

Based on observation, interview, and record review the facility failed to follow pharmacy procedures for one out of two carts; as evidenced by Licensed Practical Nurse observed administering medications to Resident #111 in the hallway of the one East unit, next to Medication Cart B. There were 166 residents residing in the facility at the time of the survey. The findings included: On 04/03/2024 at 09:20 AM during medication administration observation with Licensed Practical Nurse (Staff A), the surveyor observed Staff A administering medications to Resident #111 in the 1 East unit hallway, next to Cart B Medication Cart. Review of the medical records for Resident #111 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Guillain-Barre syndrome. Interview on 04/03/2024 at 9:30 AM, Staff A stated: This resident wanted his medication right away because he wanted to go to his activities, I know I was not supposed to give the resident his medications in the hallway, I should have taken the resident to his room. Review of the facility's policy and procedure titled Medication Administration and Observation revision date 07/12/2023 states: All medications shall be ordered by an authorized provider and administered in compliance with community standard nursing policy, while accommodating resident's preference/requests

Based on observation, record review and interview the facility's staff failed to ensure safety measures were implemented to prevent potential hazards and accidents that may cause harm and or injury for one resident (Resident # 1) out of three resident reviewed for accidents as evidenced by the Certified Nursing Assistant (CNA) Staff D failed to use safety measures while providing care to the resident, resulting in the resident falling off the bed and sustaining a fracture to the left leg and laceration to the forehead that required hospitalization . This unsafe practice had the potential to affect any of the twenty-four residents residing in the facility in need of total assistance of one or two staff to receive care during the time of the survey. The findings included: Observation of Resident #1 on 02/22/2023 at 9:56 AM, revealed Resident #1 was lying in bed awake, the resident was noted to be nonverbal but smiled at the surveyor. Resident #1 was noted with sutures to the forehead and right hand was noted to be contracted. The bed was in a low position, bilateral bed rails were up and bilateral mats on the floor. Review of Resident #1's demographic face sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but not limited to, Unspecified intracranial injury without loss of consciousness, subsequent encounter; Laceration without foreign body of other part of head, subsequent encounter; Functional urinary incontinence. Alert **Fall Precautions** Record review of orders dated 02/14/2023 documented: Maintain Fall Precautions every shift. Order dated 02/14/2023 revealed range of motion to bilateral upper and lower extremities every day/shift. Order dated 02/14/2023 documented: Turn and Reposition every 2 hours every shift. Review of the Annual Minimum Data Set (MDS) Section V for Care Area Summary with prior assessment reference dated 01/23/2022 and target date of 04/22/2022 indicated falls was triggered and addressed in care plan. Review of the Quarterly MDS, Section C for Cognitive Patterns dated 01/19/2023 revealed the resident's Brief Interview for Mental Status (BIMS) Summary Score was 00 of 15, indicating the resident was unable to complete the interview. Review of the Quarterly MDS Section G for functional status dated 01/19/2023 revealed the resident needed total dependence with two persons physical assistance for bed mobility and transfer, dressing and toilet use. The resident needed total dependence with one-person's physical assistance for locomotion, eating, personal hygiene and bathing. Review of Resident # 1's care plans revealed a Fall Care Plan initiated on 05/06/2021 with completion target date of 02/03/2022, revealed Resident #1 was totally dependent for transfer with mechanical lift, history of falls, remained at risk for further falling. Goal: Resident risks for fall will be minimized daily through the next review date. Approach: Be sure the mechanical lift was always in good working condition. Fall precautions every shift. Be sure two/three staff personnel were available to assist with transfer to ensure resident's safety. Frequent rounding in room when resident in bed. Keep bed to lowest position and lock the recliner prior to transfer. Always keep the call bell within reach. Answer all call lights promptly. Keep the environment non-cluttered .Physical/Occupational Therapy evaluation as needed. Falls Care Plan initiated on 02/15/2023 revised on 02/15/2023 documented that Resident #1 is resident totally dependent for transfer with mechanical lift, history of falls, remains at risk for further falling; 02/6/2023 resident was found lying on the floor. Goal: Resident risks for falls will be minimized daily through the next review date. Approach: Be sure the mechanical lifter was always in good working condition. Fall precautions every shift. Be sure two/three staff personnel available to assist with transfer to ensure resident's safety. Frequent rounding in room when resident is in bed. Keep bed to the lowest position and lock recliner prior to transfer. Bilateral floor mats. Keep the environment non-cluttered. Keep the call bell within reach. Answer call light promptly. Physical/Occupational therapies evaluation as needed. Review of nurses notes documentation dated 02/06/2023 revealed at approximately 12:52 AM the nurse (Licensed Practical Nurse Staff C) was called to room by both CNAs (Staff D and Staff E), upon entering the room, resident was found lying on the floor in a pool of blood. CNA reported that the resident had just been cleaned and she stepped away to get the lifter and shower bed to prepare the resident for shower. Resident was noted with about 1 1/2 inches laceration to forehead. Pressure was applied to stop the bleeding which was successful. Supervisor notified. Emergency Medical Service was called, and the resident was transported to a local hospital. Review of the hospital records revealed Resident # 1 was admitted to the hospital on 02/06/2023 with admission diagnoses of fall and left femur fracture and discharged from the hospital back to the facility on [DATE]. Further review of the hospital documentation revealed the resident sustained a 3 centimeter hematoma and laceration to the forehead. The X-ray findings dated 02/06/2023 at 02:37 documented an acute displaced fracture to left proximal femur. There is a questionable fracture involving the right superior pubic ramus. Review of the facility's clinical records revealed on 02/14/2023 Resident #1 was readmitted under the care of his Primary Care Physician. Admitting diagnosis to include fall with history. Record review of Adverse Incident report # 607104 dated February 15, 2023, time stamped 6:46:46 PM. Incident Date: 02/06/2023 revealed the Certified Nursing Assistant (CNA) entered the resident's room to provide care to him because he was soiled. He had a large bowel movement, and the resident was also scheduled to have a shower on this day. The CNA admitted to providing care to the resident without assistance. After cleaning the resident, CNA stepped away from the resident's bed to place the soiled towel in a plastic bag which was on the sink in the resident's bathroom. CNA indicated she heard a loud sound and when she looked back the resident was on the floor. CNA stated she forgot to elevate the side rail before stepping away from the bed. Another CNA entered the room and observed the resident on the floor with blood coming from his head. The CNAs called for assistance and the nurse came providing assistance. The assigned nurse on the unit immediately assessed the resident and applied pressure to the laceration on resident's head to stop the bleeding which was successful. The Emergency System was activated. The nurse supervisor was notified of the resident's fall incident. The Nurse Practitioner and the Administrator were informed of the fall incident 02/6/2023. The resident's guardian also was informed of the fall incident. The paramedics arrived at the unit and the resident was transferred via stretcher accompanied by three paramedics to a local hospital for medical treatment. Correction Actions: The investigation revealed that the two employees will benefit from intensive re-educational training in the following areas: 1-Following plan of care to provide care to residents. 2-Proper techniques for transferring residents. 3-Fall safety and prevention. The following interventions were implemented: 1-Nursing staff will monitor residents on all three shifts for signs of pain, discomfort or any other changes observed in the resident's skin integrity. 2-Nurses will medicate the resident for pain as needed. 3-Floor mats were placed at the bedside. 4-The CNA who was in the room during the fall incident received a coaching in regard to the fall incident. 5-Nurse Educator will provide 1:1 intensive re-educational training on: 1-Protocol in providing care to the resident, 2-Proper techniques in transferring residents, and 3-Fall safety and prevention. 6-Facility wide training on Fall Safety and Prevention will be conducted from February 8th to 15th 2023. 7-Facility wide training on Fall Safety and Prevention will be conducted biannually. 8-A random audit was conducted to ensure that the CNAs were working in pairs while providing care and transferring the residents. During an interview, the Risk Manager on 02/22/2023 at 12:00 PM reported, the resident needed to be cleaned because he was soiled. He had a large bowel movement. After cleaning the resident, the CNA stepped away from the bed to place the soiled towel in a plastic bag which was on the sink in the resident's bathroom. The CNA stated that she heard a loud sound and when she looked back the resident was on the floor and blood was coming from his head. The employee forgot to elevate the side rail when she stepped away from the bed which contributed to the resident falling off the bed. Another CNA was outside the resident's room recording the other residents' vital signs. She entered the resident's room after hearing a loud sound and observed the resident on the floor with blood coming from his head and CNA (Staff D) standing over him. Both employees went to the doorway to call the nurse for assistance. Licensed Practical Nurse (LPN) Staff C entered the room and observed the resident lying on the floor with blood coming from his head. She immediately assessed the resident and applied pressure to the laceration on his head to stop the bleeding which was successful. The Administrator and Nurse Practitioner were notified. The Resident's representative was notified (Left message to call back). When the resident arrived at the hospital via emergency 911, we were informed the resident had a fracture in his left leg. The Risk Manager revealed that only an adverse incident was reported because the resident was transferred to the hospital, and he had a fracture and a wound on the forehead. During a telephone interview with Staff C, LPN on 02/22/2023 at 3:09 PM. Staff C reported she was at the nursing station when the CNAs called. She went into the room and found the resident on the floor bleeding from his head. She applied pressure on the forehead and the bleeding stopped. Rescue was called immediately and in 8 minutes they were at the facility. They took care of the resident and transferred him to the hospital. On 02/22/2023 at 3:25 PM, during an interview the Administrator stated they had discussed the incident and it was not considered as neglect, because the CNA went to the bathroom to place the soiled towel in a plastic bag, did not put the bed rails up, and then the resident fell . The CNA stated that she did not do it on purpose. We saw it as a team, like an adverse incident and we reported it like that. On 02/22/2023 at 4:12 PM, during a telephone interview Staff D, CNA revealed that around 1: 00 AM she went to Resident #1's room to prepare him for a shower because he had a large bowel movement, and she had to clean him before. Staff D stated that she put the side rail down, she cleaned the resident, and took up the dirty towel to place in the plastic bag that was in the sink. When she stepped away from the bed the side rail was still down because she forgot to put it up. While she was in the bathroom, she heard a noise and turned around she saw the resident on the floor, and rushed to him. The other CNA Staff E) came in the room, she asked her (Staff E) to call the nurse. The nurse came and assessed the resident and applied pressure to the laceration on forehead of the resident. The supervisor came and the emergency were called. Review of report documentation dated 02/09/2023 by Staff E revealed she was working overtime on the night of the incident and was taking vital signs for the residents and heard a big noise and ran outside. I saw her coming out calling me. I went to the room and found the resident on the floor, then I looked around and I saw the rail bedside of the resident bed was down .I went to call the nurse. During an interview on 03/15/2023 at 10:38 AM, Staff E, CNA reported she takes care of Resident #1 on the morning. Staff E revealed the resident is able to answer when she asked him if he wanted to go to activities, sometimes he prefers to stay in bed watching television. He is a total dependent resident that is very contracted in upper and lower extremities and has to be transferred with a mechanical lift all the times. Record review of Policies and Procedures for Safety, Accident and Supervision of the Residents dated 11/14/2022 revealed Policy: Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Purpose: Each resident will receive adequate supervision and assistive devices to reduce/prevent accidents. Procedures: 3-Employees shall be trained in potential accident hazards and demonstrate competency on how to identify and report accidents hazards, and try to prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accidents hazards for individual residents. 10-Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

Based on record review and interviews, the facility failed to submit an immediate and five day report related to an incident of Abuse/Neglect/Exploitation to the required agencies for one (Resident #1) of three residents reviewed. As evidenced by Staff D failed to use safety measures while providing care to Resident #1 resulting in the resident falling off the bed and sustaining a fracture to the left leg and laceration to the forehead that required hospitalization . There were 169 residents residing in the facility at the time of the survey. The findings included: Observation of Resident #1 on 02/22/2023 at 9:56 AM, revealed Resident #1 was lying in bed awake, the resident was noted to be nonverbal but smiled at the surveyor. Resident #1 was noted with sutures to the forehead and right hand was noted to be contracted. The bed was in a low position, bilateral bed rails were up and bilateral mats on the floor. Review of Resident #1's demographic face sheet indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses include, but not limited to, Unspecified intracranial injury without loss of consciousness, subsequent encounter; Laceration without foreign body of other part of head, subsequent encounter; Functional urinary incontinence. Alert **Fall Precautions** Record review of orders dated 02/14/2023 documented: Maintain Fall Precautions every shift. Order dated 02/14/2023 revealed range of motion to bilateral upper and lower extremities every day/shift. Order dated 02/14/2023 documented: Turn and Reposition every 2 hours every shift. Record review revealed nurse documentation dated 02/06/2023 revealed at approximately 12:52 AM the nurse (Licensed Practical Nurse Staff C) was called to room by both CNAs (Staff D and Staff E), upon entering the room, resident was found lying on the floor in a pool of blood. CNA reported that the resident had just been cleaned and she stepped away to get the lifter and shower bed to prepare the resident for shower. Resident was noted with about 1 1/2 inches laceration to forehead. Pressure was applied to stop the bleeding which was successful. Supervisor notified. Emergency Medical Service was called, and the resident was transported to a local hospital. Records reviewed revealed an Adverse Incident report # 607104 dated February 15, 2023, time stamped 6:46:46 PM. On 02/22/2023 at 12:00 PM, when the Risk Manager was asked about the immediate and five-day reports. The Risk Manager reported only an adverse incident was reported because the resident was transferred to the hospital, and he had a fracture and a wound on the forehead. The Risk manager added that she was going to do the reports now. On 02/22/2023 at 3:25 PM, during an interview the Administrator stated they had discussed the incident and it was not considered as neglect, because the CNA went to the bathroom to place the soiled towel in a plastic bag, did not put the bed rails up, and then the resident fell . The CNA stated that she did not do it on purpose. We saw it as a team, like an adverse incident and we reported it like that. Record review of Policies and Procedures for Reporting Suspicion of a Crime dated 06/10/2022 revealed Policy: It is Jackson Memorial Long-Term Care Center's (JMLTCC) policy to comply with the Elder Justice Act (EJA) about reporting a reasonable suspicion of a crime under Section 115B of the social Security Act, as established by the Patient Protection and Affordable Care Act (ACA)6703(b)(3). Specifically, it is JMLTCC policy to: E-(Note: Facilities are not required to report to either Agency of Healthcare Administration (AHCA) the Police Department under this act, only individuals are required to report. However, facilities may be required to report certain incidents under other Federal, state, and local laws and regulations such as reporting to Social Security Administration (SSA) abuse, neglect or misappropriation. Definitions: Neglect is the failure of a caregiver or fiduciary to provide the goods and services that are necessary to maintain the health or safety of an elder or self-neglect.

Based on observation, interview and record review, the facility failed to store and handle food in accordance with required professional standards for food service as evidenced by, 1) failed to sanitize the thermometer before food temperatures were taken, 2) failed to discard prepared food that was touched by hand during the checking of food temperature; 3) disrepair of the ceiling tile over the food storage, and 4) failed to ensure the kitchen's exhaust vent was kept clean as evidenced by vent noted to be visibly soiled and discolored. These deficient practices have the potential to affect one-hundred and eight residents eating by mouth, out of one-hundred sixty-eight residents living in the facility during this survey. The findings included: Review of the Food Safety Information Services titled Reheating Food dated 1/2003 revealed that to check the food temperature the staff should use a cleaned, sanitized, and calibrated thermometer. On 02/23/21 at 11:21 AM, during food tray line observation, the pureed vegetable (green beans) temperature was 130 degrees Fahrenheit (°F). The staff put the pureed vegetable to be reheated. Staff A,( Cook) checked the pureed green beans temperature and did not sanitize the thermometer before checking the temperature. During the food temperature check, Staff A dropped the thermometer into the pureed green beans and placed his bare hands into the pureed green beans and touched the pureed green beans while he was removing the thermometer. Further observation revealed the pureed green beans was not discarded. On 02/24/21 at 3:25 PM, Staff A, revealed that if the food did not reach the right temperature they would bring the food to the steamer or to the fire until it reached 165 °F. He stated that before checking the food temperature, they had to calibrate the thermometer to 32 °F and sanitize the thermometer. Regarding the day of the food tray line observation, Staff A stated that he sanitized the thermometer after he tested the food temperature of the food on the tray line and he cleaned the thermometer before he put it inside the case and that was the reason he did not sanitize the thermometer again before he tested the pureed green beans that he was reheating. Staff A explained that when he noticed that he dropped the thermometer inside the bowl when he was testing the pureed green beans and his fingers touched the food. He went to the sink to wash the thermometer and he returned to the food tray line area. Staff A stated that if they touched raw meat and touch the cooked meat, they discard the food, this was the Policy that they had, but in this case, the pureed green beans was not supposed to discarded because the food was cooked. Staff A stated that in between services he took the gloves off and at acknowledged that at the time that he touched the food he was not using gloves. Review of the Environmental Services Policy, cleaning procedures revised on 06/14/2019 revealed Housekeeping Department shall take all steps necessary to ensure that all areas of Jackson Memorial Long Term Care Center, including resident rooms and non-resident areas, are maintained in clean and safe homelike environment. Review of the Kitchen Quick Check Inspection form dated 01/26/2021 revealed that the ceiling tile was not included in the check list. On 02/23/21 at 8:34 AM, initial tour of the kitchen accompanied by the Food Service Manager, revealed that the exhaust vent was visibly soiled and discolored. The exhaust vent was located approximately four feet within the area of the ready to eat food. In addition, a hole was observed in the ceiling tile over the food storage (Photography evidence). The Food Service Manager stated that he would call maintenance to fix it and he thinks that the Maintenance does the hard cleaning in the vents twice a year. On 02/25/21 at 3:06 PM, during an interview the Food Service Manager, revealed that Exterior Environmental service was responsible for cleaning the vents and Maintenance was responsible for the replacement of the tiles in kitchen's ceiling. The Food Service Manager stated he believes Maintenance do their rounds. The Food Service Manager acknowledged the hole in the ceiling located in the dry storage area and soiled exhaust vent. The Food Service Director reported that. in the food tray line, staff should always disinfect the thermometer before and after they check the food temperatures. If staff were testing the food temperatures and their hands touched the food, they should discard the food. On 02/25/21 at 3:18 PM the Maintenance Supervisor and Manager for Housekeeping stated that they had a system that any staff could input any complaint for anything that needed Maintenance's attention and rounds are done in the kitchen every Wednesday. They reported that on Tuesday 02/23/21 the Food Service Manager called them to check the hole in the ceiling and they fixed it. They explained that they had a quick check log, but the kitchen ceiling was not part of this check list and they are not used to checking the ceiling tiles. The Manager for Housekeeping stated that they cleaned the exhaust vents once a month and the kitchen's exhaust vent was cleaned in early of January. Later on, the Manager for Housekeeping presented a log that indicated that the vent was cleaned on 02/23/21.

Based on observation, interview, and record review, it was determined that the facility failed to provide residents a safe, clean, comfortable, and homelike environment in 1 of 4 resident areas, as evidenced by rooms observed in disrepair on the facility's 2 West Unit (Rooms 209,210,211,212,213,214, 217 and 221). There were 168 resident residing in the facility at the time of the survey. The findings included: During routine observations of the facility on 02/23/21, 02/24/21, 02/25/21 and environmental tour conducted with the Director of Maintenance, and Director of Housekeeping on 02/26/21 at 11:27 AM the following concerns were noted on the 2 West Unit. Observation of room [ROOM NUMBER] on 02/23/21 at 8:5 AM, revealed the window bed's over bed light had no pull cords. The wooden bathroom cabinet's door and interior shelves were rotted. (Photographic evidence obtained) Observation of room [ROOM NUMBER] on 02/23/21 at 8:57 AM, revealed the window bed's over bed light had no pull cords. The residents' bathroom cabinet door and interior had rotted wood. (Photographic evidence obtained). Observation of room on 211 02/23/21 at 9:09 AM, revealed the over bed lights had no pull cords. The hand washing sink laminated surface was missing and the exposed wood was moist. (Photographic evidence obtained). Observation of room [ROOM NUMBER] on 02/23/21 at 10:20 AM, revealed the over bed lights had no pull cords. there were brown stains on the ceiling tiles in bathroom. (Photographic evidence obtained). Observation of room [ROOM NUMBER] on 02/23/21 at 11:26 AM revealed water stained ceiling tiles in bathroom. (Photographic evidence obtained). Observation of room [ROOM NUMBER] on 02/23/21 at 12:03 PM, revealed the over bed lights had no pull cords. Brown stains were noted on the ceiling tiles in bathroom. (Photographic evidence obtained). Observation of room [ROOM NUMBER] on 02/23/21 at 12:50 PM, revealed the over bed lights had no pull cords. The exhaust fan in the room was rusted exhaust and corroded metal open to the outside. (video taken). There was visible damage noted with grey/green organic matter over the bathroom doorway. The bathroom's door threshold was rusted. (Photographic evidence obtained). On 02/23/21, during the above tour at 12:50 PM the Unit Manger was informed of the findings. The Unit Manager stated that she called maintenance and stated that they (the facility) are working on repairs. Observation of room [ROOM NUMBER] on 02/23/21 at 1:18 PM, revealed the over bed lights had no pull cords. The ceiling in the bathroom was hanging down and below the metal frame, there was visible damage above the bathroom door and the bathroom threshold was rusted out. (Photographic evidence obtained). On 02/26/21 at 12:10 PM all findings and photographic evidence were reviewed with the Administrator, the Director of Maintenance, and the Director of Housekeeping. Review of the Environmental Services Policy, cleaning procedures revised on 06/14/2019 revealed Housekeeping Department shall take all steps necessary to ensure that all areas of Jackson Memorial Long Term Care Center, including resident rooms and non-resident areas, are maintained in clean and safe homelike environment.

Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) was accurately encoded related to range of motion (ROM) for one (resident #48) of twenty eight residents whose assessment were reviewed. There were 168 residents residing in the facility at the time of the survey. The findings included: Observation on 2/23/21 at 12:02 PM revealed Resident #48 in his room in bed. Observation revealed bilateral hand contractures with no splint devices in place. Resident #48 was observed not able to extend his fingers on both hands. Observation on 2/25/21 at 12:16 PM revealed Resident #48 in his room in bed with no hand rolls or splint in place. Record review of the face sheet revealed Resident #48 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the minimum data set (MDS) assessments dated 5/21/20 (annual) and 11/29/20 (quarterly) revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 9, he required extensive to total assistance with activities of daily living (ADLs), had no range of motion (ROM) impairments. The assessment dated [DATE] was coded under special treatments for Restorative Nursing Program (RNP) to provide PROM (Passive Range Of Motion) and AROM (active range of motion). The MDS dated [DATE] was coded under special treatments for the Restorative Nursing Program for splint or brace assistance. Interview with the MDS Coordinator (Staff F) on 2/26/21 at 2:29 PM revealed, Resident #48 had an OT (Occupational Therapy) assessment done on 11/17/20 which reflects flexion contractures to upper extremities including fingers. The OT assessment indicated that the resident refuses to wear hand splits and further treatment. The MDS coordinator stated the contractures should have been coded on the MDS if they were present at the time of the last assessment on 11/29/20.

Based on observation, record review, and interview, the facility failed to develop an individualized care plan for two residents out of twenty eight residents whose care plans were reviewed. ( Resident #21 related to continuous oxygen use and Resident #48 related to contractures management and Range Of Motion (ROM). There were 168 residents residing in the facility at the time of the survey. The findings included: 1.) Observation on 2/23/21 at 9:30 AM revealed Resident #21 in his room in bed. The oxygen meter was set at 2 L/M (liters per minute), but the nasal cannula (NC) was observed not in place. The oxygen tubing and nasal cannula were near Resident #21's mouth. The resident appeared congested. Observation on 2/25/21 at 12:04 PM revealed Resident #21 in his room in bed. The oxygen meter was set at 2 L/M, but the nasal cannula was not in place. The nasal cannula was observed to the right side of Resident #21's nose. Record review of the face sheet revealed Resident #21 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the minimum data sets ((MDS) dated [DATE] (admission) and 2/10/21 (quarterly) revealed Resident #21 had a brief interview for mental status (BIMS,) summary score of 8 indicating the resident is moderately impaired, he required total assistance for activities of daily living (ADLs), the MDS were coded to indicate shortness of breath when lying flat and special treatments included oxygen therapy and suctioning. Review of the care plans revealed Resident #21 did not have a care plan to address the need for continuous oxygen. The Care plans in place included, but were not limited to the following: Resident requires total care with all ADL functions. Approaches included: Administer oxygen via nasal cannula for SOB (Shortness Of Breath) as physician order [REDACTED]. Record review of the physician's orders [REDACTED].#21 had an order for [REDACTED]. Interview with the MDS Coordinator (Staff F) on 2/26/21 at 2:49 PM revealed, Resident # 21 has an order for [REDACTED]. Developing this care plan is the responsibility of the MDS Coordinator. 2.) Observation on 2/23/21 at 12:02 PM revealed Resident #48 in his room in bed. Observation revealed bilateral hand contractures with no splint devices in place. Resident #48 was observed not able to extend his fingers on both hands. Observation on 2/25/21 at 12:16 PM revealed Resident #48 in his room in bed with no hand rolls or splint in place. Record review of the face sheet revealed, Resident #48 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the minimum data set (MDS) assessments dated 5/21/20 (annual) and 11/29/20 (quarterly) revealed resident #48 had a brief interview for mental status (BIMS) score of 9, he required extensive to total assistance with Activities of Daily Living (ADL), had no range of motion (ROM) impairments. The assessment dated [DATE] was coded under special treatments for restorative nursing program (RNP) to provide PROM (Passive Range Of Motion) and AROM (Active Range Of Motion). The MDS dated [DATE] was coded under special treatments for restorative nursing program for splint or brace assistance. Record review of the care plans in the Electronic Health Record (E H R) revealed no care plan in place to address ROM or contractures management. Record review of the Physician order [REDACTED].#48 had an order for [REDACTED]. Interview with the MDS Coordinator (Staff F) on 2/26/21 at 2:29 PM revealed Resident #48 had an OT (Occupational Therapy) assessment done on 11/17/20 which reflects flexion contractures to upper extremities including fingers. The OT assessment indicated resident refuses to wear hand splits and further treatment. The MDS coordinator stated the contractures should have been coded on the MDS if they were present at the time of the last assessment on 11/29/20. If he has contractures he would either have a care plan to address the contractures or should have an ADL care plan that addresses the limitations. Review of the care plans for Resident #48 with Staff F revealed he did not have a care plan developed to address the ROM or contractures.

Based on observation, interviews, record review and review of the facility's policy Interdisciplinary Care Planning, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by an Interdisciplinary Team (IDT) composed of individuals with direct care knowledge of the resident and his/her needs. This impacted 3 of 32 sampled residents (Resident #22, #135, #139). The findings included: During a record review on 02/24/21 Resident # 22's record revealed an admission 11/17/17. Resident #22's [DIAGNOSES REDACTED]. Review of Resident #22's Minimum Data Set (MDS), an annual assessment of 11/12/20 revealed Resident #22 requires total care and is ventilator dependent. Review of Resident #22's IDT Care Conference for 11/19/20 revealed no Registered Nurse with direct care responsibility for the resident, no Certified Nursing Assistant with direct care responsibility for the resident, and no Respiratory Therapist participated in the Care Conference. During a record review on 02/24/21 Resident # 135's record revealed an admission date of [DATE]. Resident #135's [DIAGNOSES REDACTED]. Review of Resident #135's Minimum Data Set (MDS), an annual assessment of 07/15/20 revealed Resident #135 requires an extensive assist of one person for all personal care and is non-ambulatory. Review of Resident #135's IDT Care Conference of 07/21/20 revealed no Registered Nurse with direct care responsibility for the resident, and no Certified Nursing Assistant with direct care responsibility for the resident participated in the Care Conference. During a record review on 02/24/21 Resident # 139's record revealed an admission 01/05/19. Resident #139's [DIAGNOSES REDACTED]. Review of Resident #139's Minimum Data Set (MDS), an annual assessment of 01/17/21 revealed Resident #139 requires total care for all personal care and is non-ambulatory. Review of Resident #139's IDT Care Conference of 01/26/21 revealed no Registered Nurse with direct care responsibility for the resident, and no Certified Nursing Assistant with direct care responsibility for the resident participated in the Care Conference. During an observation of [MEDICAL CONDITION] care on 02/25/21 at 10:20 AM Staff K, a Respiratory Therapist, was asked if she attended IDT Care Conferences for Resident #22, Staff K stated no she does not. Staff K stated that perhaps the Respiratory Therapy Manager attends, but she was not sure. During an interview on 02/25/21 at 11:30 AM the Respiratory Therapy Manager was asked if anyone from his department participated in IDT Care Conferences for ventilator dependent residents, the Respiratory Therapy Manager stated no one from his department participates in the IDT Care Conferences. Review of facility policy Interdisciplinary Care Planning (revised 12/16) revealed Nursing Assistant's input is critical to the care planning process and Involved- any IDT care team member providing any level of service to the patient. During an interview on 02/25/21 at 01:10 PM, Staff F a Registered Nurse and Staff J, Registered Nurse and MDS Coordinators, were asked to review the facility's IDT Care Conference records for sampled Residents #22, Residents #135 and Residents #139. Staff F and Staff J were asked if direct care staff participate in IDT Care Conferences, Staff F stated that sometimes direct care nurses and nursing assistants will participate, but not in these IDT Care Conference. Staff J stated that Respiratory Therapy does not participate in IDT Care Conference for ventilator dependent residents.

Based on observation, interview and record review, the facility failed to provide appropriate care and services for one (Resident #21) of two residents reviewed for respiratory care as evidenced by not ensuring the administration of continuous oxygen as ordered. This had the potential to affect thirty eight residents in the facility receiving respiratory treatments at the time of the survey. The findings included: Observation on 2/23/21 at 9:30 AM revealed Resident #21 in his room in bed and appeared congested but not in distress. The oxygen meter was set at 2 L/M (liters per minute), but the nasal cannula (N/C) was observed not in place. The oxygen tubing and nasal cannula were near Resident #21's mouth. Observation on 2/25/21 at 12:04 PM revealed Resident #21 in his room in bed. The oxygen meter was set at 2 L/M, the nasal cannula was not in place and was observed to the right side of Resident #21's nose. Record review of the face sheet revealed Resident #21 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the minimum data sets ((MDS) dated [DATE] (admission) and 2/10/21 (quarterly) revealed resident #21 had a brief interview for mental status (BIMS,) summary score of 8 indicating cognitive impairment, he required total assistance for activities of daily living (ADL), the MDS coding indicated shortness of breath when lying flat and special treatments included oxygen therapy and suctioning. Review of the Physician Order Sheet (POS) revealed Resident #21 had an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (Staff H) on 2/26/21 at 3:30 PM revealed, Resident # 21 has an order for [REDACTED]. If the C N A (Certified Nursing Assistant) sees that the nasal cannula is not in place they can call the nurse. Since oxygen is considered a medication, the C N A should call the nurse if the nasal cannula is dislodged. We do full vital signs at least once a shift. Staff H reported that Resident #21's oxygen saturation is normally about 95% with oxygen. He is able to dislodge the nasal cannula but, he is not physically able to put it back in place. It would be the responsibility of the nurse to replace the nasal cannula and the C N A would alert the nurse if they see it is dislodged. Review of the facility policy titled Oxygen Therapy dated 6/26/18 revealed: Purpose: To provide uniform procedures for ordering and utilizing oxygen therapy. Procedure: 1. Obtain MD/ARNP order for oxygen therapy. Order must include route liter flow amount or oxygen percentage amount and delivery device/equipment. 7. Document in Nurse's progress: Date/time oxygen therapy initiated. Delivery device e.g. Nasal Cannula, Flow Rate, Abnormal Assessment findings, complications/interventions.

Based on observation, interview, and review of facility policy for Storage of Medication and Security, the facility failed to 1.) dispose of expired medical supplies in 1 of 5 medication storage rooms. 2.) meet the requirement to secure medications in a locked storage area and to limit access to unauthorized personnel. The findings included: 1.) On [DATE] at 1:13 PM Observation of West 2 medication storage room, with Staff E, a Registered Nurse (RN), revealed the Bariatric Tape Measure had a Lot Expiration date of [DATE]. Further observation revealed that there were, BD Pure Hub Disinfecting Cap's (alcohol moistened caps that are used to cover the ends of intravenous catheters) with expiration date of [DATE]. Staff E, RN revealed that at the end of the month there is an inventory performed for medication storage and at that time expired items are removed. 2.) During an observation of emergency medication storage on [DATE] at 10:40 AM with the facility's onsite Pharmacist, it was observed that the facility is storing their emergency medication in an administrative office shared by Staff D, the Staffing Coordinator and Staff C, an Administration Secretary. The Emergency Medication is stored in a 5 drawer file cabinet secured with breakaway plastic ties on the top 4 drawers and the bottom drawer is secured with a padlock (photographic evidence obtained). The Pharmacist stated that the locked bottom drawer is for emergency narcotics, and the top 4 drawers are for all other emergency medication. The Pharmacist was asked if Staff C and Staff D were nurses, he stated no. Review of the facility's policy for Storage of Medication and Security (dated ,[DATE]) with the Pharmacist at 11:50 AM on [DATE], revealed under section II: Access to Medication, only authorized personnel to administer medications shall be allowed access to medication. Medication rooms, carts and medication supplies shall be kept locked at all times. The Pharmacist acknowledged the deficient practice and stated the facility will secure the emergency medications right away. The findings were reviewed with the Director of Nursing (DON) on [DATE] at 2:00 PM, the DON acknowledged that the emergency medication was not secured properly. The DON stated that padlocks had been placed on the file cabinet drawers and only nurses have access to the medications. Photographic evidence of the secured emergency medication was obtained at 2:47 PM on [DATE].

Based on observations, record reviews and interviews, the facility failed to implement an effective Quality Assurance Performance Improvement Plan (QAPI) program to correct and prevent repeated deficiencies in problem prone areas related to safe, clean, and comfortable home like environment (F584). As evidenced by disrepair ceiling tile over the food storage area, exhaust in the kitchen vent noted to be visibly soiled and discolored and resident's rooms observed in disrepair on the facility's 2 West Unit The findings included: During this survey that was conducted on 02/23/2021 to 02/26/2021, repeated deficient practice was identified and cited for Safe Clean Comfortable Home Like Environment (F584) based on 1 of 4 resident areas rooms were observed in disrepair on the facility's 2 West Unit (Rooms 209,210,211,212,213,214, 217 and 221) and disrepair ceiling tile observed in the food storage area and exhaust vent in kitchen noted to be visibly soiled and discolored. Record review of the facility's survey history revealed during the annual survey with an exit date 05/23/2019, deficient practice was cited related to safe/clean/home like environment due to facility's failure to maintain a resident's room in good condition. Review of the facility's correction plan with a completion date of 06/21/2019 indicated : MEASURES TO PREVENT RECURRENCE: 1. EVS manager to Review/revise policy on environmental room cleaning procedures. 2. EVS staff to conduct daily room inspection during room cleaning on the affected unit and report any abnormal odor to manager immediately. 3. Educator to re-in-service all staff on being observant and vigilant and report any abnormal odor in facility to direct supervisor immediately. 4. Room will be renovated to include new flooring and baseboard, new ceiling tiles, fresh painting, and new window treatment. Record review of Quality Assurance Performance Improvement Plan (QAPI) for 2021 revealed the Goals for 2021 are as follows: 1) To Decrease the percentage of pressure ulcers in long term stay residents from 9.8% to 8.8% by December 2021. 2) To increase staff knowledge/skills in hand hygiene and sanitizing from 86% to 100% by December 2021. An interview with the Risk Manager on 02/26/2021 at 2:59 PM revealed all Department Supervisors, Administrator, Medical Director, Physicians, Director of Nursing, Nurse Practitioners, Nurse Managers, Maintenance Department, Environmental Services, Dietician, MDS Department are part of the Quality Assurance Committee and the meetings are held on a monthly basis. The Risk Manager revealed no trends have been identified related to environmental concerns, on the maintenance of the ceiling and the vents. The Housekeeping Department is responsible for cleaning the vents, and certain vents are maintained specifically by the maintenance department. The Director of Nursing and Risk Manager stated that the facility currently does not have a QAPI plan for environmental concerns, but the Housekeeping

Based on observation, interview, and record review, the facility failed to maintain a resident room (room [ROOM NUMBER]) in good condition related to persistent odors identified during observations of the room. There were a total of 170 residents in the facility at the time of this survey. The findings included: Record review of the facility's policy and procedures titled, Cleaning Procedures, dated 09/11/2014, revealed, The Housekeeping Department shall take all steps necessary to insure that all areas of (facility). including resident rooms and non-resident areas, are maintained in excellent sanitary conditions in accordance with high standards. Observation on 05/21/2019 at 10:15 am of room [ROOM NUMBER] revealed that upon entering the residents' room there was a pervasive odor; the resident in the room was not interviewable. At 10:47 am, a certified nursing assistant (CNA) was observed going into the resident's room with a mechanical lifter. Further observation at 11:10 am revealed that there was still an odor in the room. Observation on 05/22/2019 at 1:40 pm of room [ROOM NUMBER] revealed that upon entering the resident's room there was still an odor. Resident #17 was in his bed; the resident appeared to be dressed and groomed appropriately, and there were no odors coming from the resident. However, there was still an odor permeating throughout the room. Interview with the Certified Nursing Assistant (Staff A) on 05/22/2019 at 1:41 pm revealed that she had worked in room [ROOM NUMBER] numerous times and she did not smell anything. Observation and interview on 05/22/2019 at 1:49 pm revealed that in room [ROOM NUMBER], with both Staff A and the nurse manager (Staff B) present. There was an odor in the room, but both staff members stated that they did not smell anything. Observation and interview on 05/22/2019 at 1:55 pm revealed that another State surveyor came to room [ROOM NUMBER] and went inside; she reported that she smelled an odor in the resident's room. Observation and interview on 05/22/2019 at 1:59 pm with the Manager for Environmental Services and Custodial Staff (Staff E) present revealed that in room [ROOM NUMBER] the Manager for Environmental Services did not smell an odor, however, Staff [NAME] stated that she smelled an odor in the room and that she was going to clean it again. Observation and interview on 05/22/2019 at 3:14 pm with the Manager for Environmental Services revealed that in room [ROOM NUMBER] the resident was not in the room; there was still an odor present, but it was not pervasive. The Manager for Environmental Services stated that although her staff member cleaned the resident's room twice, she could still smell something; they were going to have to work on it.

Based on interview, observation and record review, the facility failed to ensure residents were free from accidents that resulted in injury for 2 (R#18 and R#159) of 18 residents whose care plans were reviewed for 1) A failure to follow the interventions for falls as noted on R#18 care plan and 2) Failed to follow a pressure ulcer care plan for one resident (Resident #159) out of 3 residents reviewed for pressure ulcers. This deficient practice has the potential to affect the 23 residents with pressure ulcers in the facility at the time of the survey and all 175 residents residing in the facility at the time of this survey that require the implementation of care plans. The findings include: 1) Record review of resident #18's clinical record revealed, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #18 most recent comprehensive Minimum Data Set (MDS), Annual assessment, with an assessment reference date of 04/05/16 revealed, resident was encoded as total dependence (code 4) with two person physical assist (code 3) for transfers. Review of resident #18's care plan initiated on 04/14/16 for the category of Falls revealed, resident with history of falls and remains at risk for additional falls/injury related to use of psychoactive medication, self mutilation, impaired cognition, agitation, removing arm rest/sliding down in wheelchair. Approaches to include but not limited to: place resident in fall prevention program. Transfer safely with hoyer lift by two people. The care plan was updated on 12/20/16, resident reported she fell while CNA (Certified Nursing Assistant) was transferring her back to bed alone. Complained of pain of right lower extremity. X-ray of right leg negative for fracture. Small bruised area to right knee Review of resident #18's care plan initiated on 04/14/16 for the category of: Activities of Daily Living (ADL) Functional/Rehabilitation Potential revealed, resident is at risk of developing complications related to needing total assistance for all ADLs secondary to impaired cognition and contracture of all extremities. Care plan was last reviewed on 10/13/16. Review of the nurses notes revealed: On 12/20/16 at 10:11am the residents assigned nurse, staff O, documented, resident complained of pain on right shin to supervisor. Nursing supervisor, floor nurse and CNA at bedside. During further investigation, resident states on Monday after the shower the CNA dropped her on the floor while attempting to transfer her to the bed. A skin assessment was done. The resident was noted with a small bluish bruise to the right shin. The alleged incident was reported and further investigation of the alleged incident was currently in progress. At 11:53am, a note by the unit manager, staff P, documented resident complained of pain to her right lower extremity and stated CNA dropped her Monday morning while she was putting her back to bed after receiving a shower. The CNA in question was called and she said she did the transfer without assistance, but the resident did not fall. The Fall protocol was initiated, the ARNP was notified and orders were received, including an X-Ray to the affected extremity. During assessment of the right leg, there was no noticeable injury noted, no swelling, however, the complained that it hurts when the area was touched. CNA in question will be formally counseled for not following facility's protocol regarding safe transfer of residents. At 12:18pm, a note by the resident's assigned nurse, staff O, documented an order was received for a STAT x-ray to right leg to rule out fracture. An order was received to give [MEDICATION NAME] by mouth 650mg every 6 hours for 48 hours then as needed for discomfort. Monitor resident for pain for 72 hours in Medication Administration Record [REDACTED]. The Tylenol 650 mg was given at 12:00pm. The bed was in the lowest position with the call light within reach, and the resident was monitored. At 1:50pm, the resident's pain was reassessed. The resident states pain level 9 out of 10. At 2:12pm, the ARNP was contacted due to the ineffectiveness of the Tylenol. An order was received to give [MEDICATION NAME] 50mg by mouth every 6 hours as needed for moderate pain, a complete blood count (CBC) and comprehensive metabolic panel (CMP) to be drawn in the morning. At 10:55pm, the x-ray results were returned and were relayed to the ARNP, there were no new orders. The [MEDICATION NAME] was given for pain, and was effective upon reassessment. On 12/21/16 at 6:39am, the resident was in bed asleep on rounds and no apparent distress noted. Vital signs were documented as temperature 100, pulse 100, respirations 18, blood pressure 91/62. Upon assessment of the right knee there was a small bruised area noted. The Tylenol 650mg was given every 6 hours. The rechecked pulse was 88, temperature was 97.7. Condition stable. At 8:21am a note by the ARNP for follow up X-ray of left lower extremity (LLE), negative for fracture, will continue with pain monitoring, pain management. At 9:24am, by assigned nurse, the Resident right lower extremity was assessed and a small bluish bruising was noted. The resident complained of right lower extremity pain 8 out of 10. The [MEDICATION NAME] 50mg was given at 0920am. At 10:30 am, the resident's pain level was reassessed. The resident states her right lower extremity pain is 8 out of 10, the medication was ineffective at this time. Vital signs were blood pressure 107/59, pulse 122, respirations 18, temperature 97.2. Awaiting call back from ARNP to notify. At 11:00am, a note by the ARNP revealed a Pulse 122, and pending lab results, and an order for [REDACTED]. At 11:51, the residents labs were reviewed by the doctor (MD), an order was given to transfer the resident to a (nearby acute care hospital name) emergency room due to severe [MEDICAL CONDITION], hemoglobin 6.5 and hematocrit 20.5 At 12:14 the resident noted with anxiety. [MEDICATION NAME] 1mg was given by mouth as ordered at 1210pm. Tylenol was given as ordered for a pain level of 8 out of 10. At 1:08pm, the resident left the unit via ambulance. Anxiety was still noted, the medication was ineffective. The resident still complained of a pain level of 8 out of 10. Review of Physician order [REDACTED].>On 12/20/16 at 11:07am, X-ray to right lower extremity stat. [MEDICATION NAME] 600mg by mouth every 6 hours for 48 hours, then as needed for discomfort. Pain monitoring every shift for 72 hours in MAR. On 12/20/16 at 11:20am, Order clarification: X-ray of right leg to rule out fracture. Pain. On 12/20/16 at 2:10pm, [MEDICATION NAME] 50mg by mouth every 6 hours as needed for moderate pain right lower leg bruising, complete blood count (CBC) and comprehensive metabolic panel (CMP) in the morning on 12/21/16. On 12/21/16 at 11:06am, Give [MEDICATION NAME] 1mg by mouth every 8 hours as needed for anxiety/agitation for 5 days. Resident requires psychiatric evaluation. On 12/21/16 at 11:45AM, Send resident out to (nearby acute care hospital name) emergency room due to severe [MEDICAL CONDITION]. Hemoglobin 6.5, Hematocrit 20.5. Resident #18 was observed on 12/21/16 at 12:16PM in her room in bed, awake, the television (TV) was on, a floor mat was in place, the call light was within reach. The resident was asked how was she feeling, she answered, Not good. When asked, what was wrong she said, my legs. The resident kept pointing at the floor mat on her left side. Interview on 12/21/16 at 12:20PM with resident #18's assigned nurse, staff O, revealed the resident complained of pain to her right lower extremity this morning. At 9:24am she gave [MEDICATION NAME] 15mg to the resident. At 10:24am the pain was still an 8. The doctor was called. Vital signs were taken, her pulse was at 122. The doctor ordered [MEDICATION NAME] 1mg for anxiety and agitation because the resident was getting agitated. Staff O reported, the x-ray was done yesterday with negative findings, the shin area was not swollen, there was only a small bluish discoloration, and it was painful to touch. On 12/21/16 at about 12:58PM resident #18 was observed with the assigned nurse, staff O, in the room. The resident was asked if she knows what month we were in, the resident said something (unable to understand since resident has unclear speech), staff O clarified and said, I don't know. The resident was asked why does her leg hurt, the resident pointed to the floor mat on her left side and said, right there. The resident was asked was there a staff present and where? The resident said something that could not be understood due to her speech impairment. Staff O said, to the resident the name of CNA Q. The resident answered yeah and pointed to the bed next to hers. Resident#18's right leg was observed with staff O present. A round bluish discoloration, about half an inch, was observed on the right shin. The resident started to get restless and agitated, moving her right arm, pointing at her right leg and started saying things that could not be understood by this surveyor or the nurse. The nurse said the two ambulance attendants were outside the room waiting. Interview with unit manager, staff P, on 12/22/2016 at 11:46 AM revealed, she is the manager 8am-4:30pm for this unit (South 2) and West 2 units. Explained on Tuesday morning, a little after 10:00am, during rounds in the unit she went into resident #18's room and saw her in bed. She asked why was she in bed, she is usually out of bed at that time on the 11-7 shift. The resident pointed to her right leg like she was in pain and said CNA Q dropped her. The Nurse manager came out of the room and called resident #18's 7-3 CNA and nurse to come in the room to help her better understand what the resident was saying. Resident #18 has a speech impediment. They went in the room and started to talk to the resident. The resident said the same thing. CNA Q dropped her Monday morning, she used the word drop. They asked some probing questions like when did it happened: she answered that it was after she showered her and was putting her back to bed. The Resident was asked if there was another staff during the transfer, the resident said, no. The residents leg was assessed. The Resident complained of pain upon palpation; no swelling or injury noticed. The Risk Manager was called and notified her. The Resident's nurse called the ARNP. The Risk Manager came up with the Director of Nursing (DON) and they went in the room, and the nurse manager accompanied them. The resident answered all the questions the same way. After that, they called CNA Q. She blatantly denied that the resident had a fall, and said she got assistance in the transfer and gave them another CNA's name. They called that other CNA and said she did not recall assisting CNA Q with the transfer. CNA Q was called back and she admitted she had transferred the resident from the shower chair to bed without a hoyer lift and no assistance. Review of the facility's policy with subject: Body Mechanics, dated 02/08/12 documented a mechanical lifter should be used whenever a patient must be lifted as dead weight. Review of the facility's policy with subject: Use of a Lifter, dated 09/15/16 revealed, it is the policy of the facility to provide transfer of residents who are immobile in a safe and comfortable manner. 1.Carefully plan all lifts and transfers before starting. Always have a second person assist when operating the lift. One person to lift, the second to monitor safety and stabilize sling and lifter. 2) Record review of Resident # 159's face sheet revealed, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the Doctor's order dated 12/22/2016 revealed, weekly skin and heel checks. Record review of the Weekly skin check revealed, it was only completed once since admission on 12/12/2016. Record review of the form revealed, Resident #159 had a sacral wound. Record review of the care plan on Pressure ulcer dated 07/06/2016, revised on 10/05/16, revealed that one of the approaches was weekly skin assessment. During interview with the wound care nurse, Staff H, on 12/22/2016 at 9:57 AM she revealed, Resident #159 should have weekly skin checks done by the nurses on the floor and confirmed that she could find only the one completed on 12/22/2016. In interview with the nurse manager for South 1, Staff I, on 12/22/2016 at 10:16 AM, she revealed, the weekly skin checks were done weekly by the nurses and that the weekly skin checks for Resident # 159 were supposed to be done by the night shift nurse. She confirmed, there was only one weekly skin check completed on 12/22/2016 for Resident #159 since admission. During interview with Staff J on 12/22/16 at 10:46 AM he confirmed, there was only one weekly skin check completed for Resident # 159 on 12/22/2016 since admission on 06/21/2016. On 12/21/2016 at 2:10 PM, observation of the dressing change to the sacral wound for Resident#159 was done with Staff H, a stage 4 pressure ulcer was noted to the sacrum. Cross reference F323.

Based on interview, observation and record review, the facility failed to maintain an accident-free environment for 2 of 6 residents reviewed for incidents with injuries that occurred during 1) the transfer of Resident #18 and 2) Bed Mobility/Assisted Daily Living care provided for Resident #24 which resulted in the resident sustaining a scratch on the forehead. This has the potential to affect all 175 residents residing in the facility at the time of this survey. The findings include: 1) Interview on 12/20/2016 at 12:38 PM with resident#18's assigned nurse, staff O revealed, resident #18 needed a hoyer lift to be transferred and the transfer needed to be done with two CNAs. She explained a STAT x-ray was ordered by the Advanced Registered Nurse Practitioner (ARNP) and they are waiting for the x-ray company to arrive. She gave the resident a Tylenol at 12:00PM. Staff O reported, the Certified Nursing Assistant (CNA) involved in the incident was staff Q and she works 11:00PM-7:00AM and is not here now. Resident #18 was observed on 12/21/16 at 12:16PM in her room in bed, awake, the television (TV) was on, a floor mat was in place, the call light was within reach. The resident was asked how was she feeling, she answered, Not good. When asked, what was wrong she said, my legs. The resident kept pointing at the floor mat on her left side. Further interview on 12/21/16 at 12:20PM with resident #18's assigned nurse, staff O, revealed the resident complained of pain to her right lower extremity this morning. At 9:24am she gave Tramadol 15mg to the resident. At 10:24am the pain was still an 8. The doctor was called. Vital signs were taken, her pulse was at 122. The doctor ordered Ativan 1mg for anxiety and agitation because the resident was getting agitated. Staff O reported, the x-ray was done yesterday with negative findings, the shin area was not swollen, there was only a small bluish discoloration, and it was painful to touch. Two ambulance attendants were observed on 12/21/16 at 12:20PM with a stretcher by resident #18's room. Staff O explained, they came to take the resident to a nearby acute hospital emergency room because of abnormal labs. Staff O reported, resident #18 had labs done this morning. Her hemoglobin, hematocrit, red blood cells and white blood cells were out of range. The doctor was informed and said to send the resident to the hospital. On 12/21/16 at about 12:58PM resident #18 was observed with the assigned nurse, staff O, in the room. The resident was asked if she knows what month we were in, the resident said something (unable to understand since resident has unclear speech), staff O clarified and said, I don't know. The resident was asked why does her leg hurt, the resident pointed to the floor mat on her left side and said, right there. The resident was asked was there a staff present and where? The resident said something that could not be understood due to her speech impairment. Staff O said, to the resident the name of CNA Q. The resident answered yeah and pointed to the bed next to hers. Resident#18's right leg was observed with staff O present. A round bluish discoloration, about half an inch, was observed on the right shin. The resident started to get restless and agitated, moving her right arm, pointing at her right leg and started saying things that could not be understood by this surveyor or the nurse. The nurse said the two ambulance attendants were outside the room waiting. Record review of resident #18's clinical record revealed, the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nontraumatic subdural hemorrhage. Unspecified convulsions. Unspecified psychosis, Nontraumatic sub arachnoid hemorrhage, Personal history of (healed) traumatic fracture and Dementia. Review of resident #18 most recent comprehensive Minimum Data Set (MDS), Annual assessment, with an assessment reference date of 04/05/16 revealed, resident was encoded as total dependence (code 4) with two person physical assist (code 3) for transfers. Record review of the resident's Minimum Data Set ((MDS) dated [DATE], section G, revealed, for personal hygiene, the resident required Total dependence with two + persons physical assist. Review of resident #18's care plan initiated on 04/14/16 for the category of Falls revealed, resident with history of falls and remains at risk for additional falls/injury related to use of psychoactive medication, self mutilation, impaired cognition, agitation, removing arm rest/sliding down in wheelchair. Approaches to include but not limited to: place resident in fall prevention program. Transfer safely with hoyer lift by two people. The care plan was updated on 12/20/16, resident reported she fell while CNA (Certified Nursing Assistant) was transferring her back to bed alone. Complained of pain of right lower extremity. X-ray of right leg negative for fracture. Small bruised area to right knee Review of resident #18's care plan initiated on 04/14/16 for the category of: Activities of Daily Living (ADL) Functional/Rehabilitation Potential revealed, resident is at risk of developing complications related to needing total assistance for all ADLs secondary to impaired cognition and contracture of all extremities. Care plan was last reviewed on 10/13/16. Review of the nurses notes revealed: On 12/19/16 there were no nurses notes. On 12/20/16 at 10:11am the residents assigned nurse, staff O, documented, resident complained of pain on right shin to supervisor. Nursing supervisor, floor nurse and CNA at bedside. During further investigation, resident states on Monday after the shower the CNA dropped her on the floor while attempting to transfer her to the bed. A skin assessment was done. The resident was noted with a small bluish bruise to the right shin. The alleged incident was reported and further investigation of the alleged incident was currently in progress. At 11:53am, a note by the unit manager, staff P, documented resident complained of pain to her right lower extremity and stated CNA dropped her Monday morning while she was putting her back to bed after receiving a shower. The CNA in question was called and she said she did the transfer without assistance, but the resident did not fall. The Fall protocol was initiated, the ARNP was notified and orders were received, including an X-Ray to the affected extremity. During assessment of the right leg, there was no noticeable injury noted, no swelling, however, the complained that it hurts when the area was touched. CNA in question will be formally counseled for not following facility's protocol regarding safe transfer of residents. At 12:18pm, a note by the resident's assigned nurse, staff O, documented an order was received for a STAT x-ray to right leg to rule out fracture. An order was received to give Acetaminophen by mouth 650mg every 6 hours for 48 hours then as needed for discomfort. Monitor resident for pain for 72 hours in Medication Administration Record ( MAR). The resident complained of a pain level of 9 out of 10 to the right shin. The Tylenol 650 mg was given at 12:00pm. The bed was in the lowest position with the call light within reach, and the resident was monitored. At 1:50pm, the resident's pain was reassessed. The resident states pain level 9 out of 10. At 2:12pm, the ARNP was contacted due to the ineffectiveness of the Tylenol. An order was received to give Tramadol 50mg by mouth every 6 hours as needed for moderate pain, a complete blood count (CBC) and comprehensive metabolic panel (CMP) to be drawn in the morning. At 10:55pm, the x-ray results were returned and were relayed to the ARNP, there were no new orders. The Tramadol was given for pain, and was effective upon reassessment. On 12/21/16 at 6:39am, the resident was in bed asleep on rounds and no apparent distress noted. Vital signs were documented as temperature 100, pulse 100, respirations 18, blood pressure 91/62. Upon assessment of the right knee there was a small bruised area noted. The Tylenol 650mg was given every 6 hours. The rechecked pulse was 88, temperature was 97.7. Condition stable. At 8:21am a note by the ARNP for follow up X-ray of left lower extremity (LLE), negative for fracture, will continue with pain monitoring, pain management. At 9:24am, by assigned nurse, the Resident right lower extremity was assessed and a small bluish bruising was noted. The resident complained of right lower extremity pain 8 out of 10. The Tramadol 50mg was given at 0920am. At 10:30 am, the resident's pain level was reassessed. The resident states her right lower extremity pain is 8 out of 10, the medication was ineffective at this time. Vital signs were blood pressure 107/59, pulse 122, respirations 18, temperature 97.2. Awaiting call back from ARNP to notify. At 11:00am, a note by the ARNP revealed a Pulse 122, and pending lab results, and an order for [REDACTED]. The resident required a psychiatric evaluation. At 11:51, the residents labs were reviewed by the doctor (MD), an order was given to transfer the resident to a (nearby acute care hospital name) emergency room due to severe anemia, hemoglobin 6.5 and hematocrit 20.5 At 12:14 the resident noted with anxiety. Ativan 1mg was given by mouth as ordered at 1210pm. Tylenol was given as ordered for a pain level of 8 out of 10. At 1:08pm, the resident left the unit via ambulance. Anxiety was still noted, the medication was ineffective. The resident still complained of a pain level of 8 out of 10. Review of Physician order [REDACTED].>On 12/20/16 at 11:07am, X-ray to right lower extremity stat. Acetaminophen 600mg by mouth every 6 hours for 48 hours, then as needed for discomfort. Pain monitoring every shift for 72 hours in MAR. On 12/20/16 at 11:20am, Order clarification: X-ray of right leg to rule out fracture. Pain. On 12/20/16 at 2:10pm, Tramadol 50mg by mouth every 6 hours as needed for moderate pain right lower leg bruising, complete blood count (CBC) and comprehensive metabolic panel (CMP) in the morning on 12/21/16. On 12/21/16 at 11:06am, Give Ativan 1mg by mouth every 8 hours as needed for anxiety/agitation for 5 days. Resident requires psychiatric evaluation. On 12/21/16 at 11:45AM, Send resident out to (nearby acute care hospital name) emergency room due to severe anemia. Hemoglobin 6.5, Hematocrit 20.5. Review of X-Ray report of Right Tibia/Fibula 2 views with date 12/20/16 documented, Impression: Evidence of old fracture. No acute fracture. Review of December 2016 MAR revealed, resident #18 was monitored for pain starting on 12/20-12/23/16 . Pain documented with a + sign on 12/20/16 for all three shifts and on 12/21/16 during the first shift. Tramadol 50mg tablet, 1 tablet by mouth every 6 hours as needed for moderate pain to right lower leg bruising with start date 12/20/16-open ended was administered on 12/20/16 and 12/21/16. Acetaminophen 325mg tablet, 2 tablets every 6 hours by mouth started on 12/20/16 and stop date 12/22/16 was administered on 12/20/16 and 12/21/16. Pain monitoring to monitor and document (+/0) every shift for swelling, redness, pain associated with right hip/thigh with start date 08/01/16-open ended revealed pain documented as 0 12/01/16-12/20/16 for all 3 shifts and 7-3 shift on 12/21/16. Review of ARNP Progress Notes dated 12/20/16 revealed, the resident was assessed at bedside in regards to reported pain to the right lower extremity. Resident speaks with difficulty, however able to name staff, month and year. Resident stated, CNA dropped me while doing care Monday morning. When questioned, she mentioned the fall and pain to leg resident and stated she reported it to CNA. At this time, resident reports pain to right shin 9/10. Plan of treatment: 1. Pain to right lower extremity: X-ray of extremity ordered, pain medication as ordered, as well as pain monitoring. X-ray results pending. 2.Heart Rate 104, possible due to pain, will reassess when pain medication effective. Review of Fall Risk Assessment revealed: On 12/20/16 Fall Evaluation. Assessment Type: Post Fall Assessment. Does resident have a history of falls in last 3 months? NO. Evaluation: Total Fall Risk Score: 14.00 (score of 10 or higher represents a high risk for falls), level: at risk. Referral: Occupational Therapy (OT), Physical Therapy (PT). Continue current plan of care. Prior Fall Risk Assessment Form (from medical records department) was dated 03/10/11. Resident with history of falls in the past 3 months (3 or more falls). Total Score: 13 (High Risk) Review of the December CNA Flowsheet and interview with unit manager, staff P, on 12/22/2016 at 12:50PM revealed, the staff is documenting the resident is total assist with transfers (code 4) with 1 person assist (code 2) on 11-7 shift on 12/02-12/21/16 and on 7-3 shift on 12/11-12/21/16. Staff P reported, resident #18 needs a hoyer lift to be transferred and that would require 2 staff, They are not documenting it correctly. Review of the document titled, Assignment Sheet South Two 11-7 Shift Two CNAs dated 12/18/16, documented resident #18 is on fall preventions. Under comments it documented 2 CNAs. Review of the Safety Event Summary and Follow-up History, revealed an incident dated 12/20/16 at 10:30am, Severity: Category E (Harm: Minor). Factual Description: Resident stated she was dropped when CNA was transferring her from shower chair back to bed on Monday morning. She complained she was in pain in her right lower extremity. No noticeable injury, no swelling, but complained of pain to touch in that area. ARNP made aware. Interview with unit manager, staff P, on 12/22/2016 at 11:46 AM revealed, she is the manager 8am-4:30pm for this unit (South 2) and West 2 units. Explained on Tuesday morning, a little after 10:00am, during rounds in the unit she went into resident #18's room and saw her in bed. She asked why was she in bed, she is usually out of bed at that time on the 11-7 shift. The resident pointed to her right leg like she was in pain and said CNA Q dropped her. The Nurse manager came out of the room and called resident #18's 7-3 CNA and nurse to come in the room to help her better understand what the resident was saying. Resident #18 has a speech impediment. They went in the room and started to talk to the resident. The resident said the same thing. CNA Q dropped her Monday morning, she used the word drop. They asked some probing questions like when did it happened: she answered that it was after she showered her and was putting her back to bed. The Resident was asked if there was another staff during the transfer, the resident said, no. The residents leg was assessed. The Resident complained of pain upon palpation; no swelling or injury noticed. The Risk Manager was called and notified her. The Resident's nurse called the ARNP. The Risk Manager came up with the Director of Nursing (DON) and they went in the room, and the nurse manager accompanied them. The resident answered all the questions the same way. After that, they called CNA Q. She blatantly denied that the resident had a fall, and said she got assistance in the transfer and gave them another CNA's name. They called that other CNA and said she did not recall assisting CNA Q with the transfer. CNA Q was called back and she admitted she had transferred the resident from the shower chair to bed without a hoyer lift and no assistance. Review of the December 2016 CNA Flowsheet and interview with resident #18 assigned 7-3 CNA, staff R, on 12/22/2016 at 12:53PM revealed, she worked with the resident this past weekend and on Monday. She reported, the resident is total assist with transfer, meaning that the resident should be transferred with 2 CNAs and a hoyer lift, including transfers from the shower chair to bed. All the patients that need total assist are transferred with a hoyer lift. She looked at the December CNA Flowsheet and said the amount of staff used for the transfer was a code 2, she looked at the legend and said 2 means 1 staff. She said, the wrong code was used, it should have been coded a 3 which means 2 staff. She explained, all the transfers she has done for this resident have been with 2 staff and the hoyer lift. She reported, resident#18 did not complain to her about anything on Sunday or Monday. Usually, when she starts her shift the resident is in the geri chair in the dining room by the nurses station. She was off on Tuesday and on Wednesday she had another assignment. Telephone interview with staff Q on 12/23/2016 at 10:27AM revealed, she had resident#18 on Sunday. She was off on Monday and did not have the resident on Tuesday. She gave the resident a shower on Sunday in the bathroom inside the resident's room. When she entered the room to give the resident a shower, at around 4:00am, the resident was awake in bed, did not complain of anything. She asked the resident if she wanted the shower, she said, yes. She went to the restroom, took the shower chair, and put the chair by the bed. Checked and removed the adult brief. Put the resident in a sitting position in bed and transferred her to the chair with the help of the fitted sheet. She said, she lifted the resident by herself. Took her to the shower and gave her a shower, dried her and covered her with a sheet. Then took the resident in the shower chair and put her back to bed. She transferred the resident back to bed by herself. She explained, nothing happened during the transfers, the resident did not complain of any pain or scream or made any noise indicating that she was hurt. No falls happened during care to this resident. She reported, the resident is total care meaning that she is dependent for someone else to do everything for her. She requires 2 CNAs; she is not sure if the resident needs a hoyer lift for transfers. She said, she has used the hoyer lift to weigh her because the transfer is 2 CNAs only. Staff Q confirmed, that morning during those two transfers she did not use a hoyer lift or another CNA to help her and that the transfers were not done according to the protocol and were not safe. She said, she did it by herself because there was no one else available. The nurse was passing meds and the other CNA was helping someone else. She said, she could not wait for the other CNA to finish with her patient because resident #18 wanted the shower at that moment and she starts screaming and yelling if things are not done when she wants them. Review of the facility's policy with subject: Body Mechanics, dated 02/08/12 documented a mechanical lifter should be used whenever a patient must be lifted as dead weight. Review of the facility's policy with subject: Use of a Lifter, dated 09/15/16 revealed, it is the policy of the facility to provide transfer of residents who are immobile in a safe and comfortable manner. 1.Carefully plan all lifts and transfers before starting. Always have a second person assist when operating the lift. One person to lift, the second to monitor safety and stabilize sling and lifter. 2) Record review of Resident #24's face sheet revealed, the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of the progress notes dated 06/10/2016 at 1235 revealed, Hair line scratch to forehead during care. Responsible party made aware. Record review of the Progress Note dated 06/10/2016 at 9:52pm revealed, ice applied as ordered to forehead. triple ABT (antibiotic) ointment to forehead. Record review of the Progress note dated 06/11/2016 at 05:49 pm revealed, Antibiotic (ABT) ointment applied to forehead. Record review of the Progress note dated 06/11/2016 at 11:57am revealed, Forehead injury subsiding and care given. Record review of the Progress note dated 06/11/2016 at 10:33pm revealed, continues on ABT to forehead injury. Record review of the Progress note dated 06/12/2016 at 10:33pm revealed, continues on ABT to forehead injury. Record review of the Progress note dated 06/18/2016 at 2:57pm revealed, forehead healing well. Record review of the Treatment Record (TAR) for the month of June 2016 revealed: -Apply ice to forehead times 24 hours on 06/10/2016. -Clean forehead with NS (normal saline) pat dry and apply triple antibiotic ointment daily times 7 days on 06/10/2016. Record review of the Physician order [REDACTED]. -Apply ice to forehead times 24 hours on 06/10/2016. -Clean forehead with NS pat dry and apply triple antibiotic ointment daily times 7 days on 06/10/2016. During interview with Staff M on 12/22/2016 at 11:56 AM she revealed, she was doing morning care for Resident # 24 with another staff, when the other staff went to the bathroom to discard the water they were using, she turned the resident on his back, and she saw something like a little bleeding in the resident's forehead. She revealed, she called the nurse and reported it right away but she was not sure what caused the bleeding. She also revealed, the nurse came to assess the resident and stated that she was going to notify the family member. During interview with the nurse manager, staff I, on 12/22/2016 at 12:05 PM she revealed, she remembered the incident, two Certified Nursing Assistants (CNAs) were providing care to the resident, and they told her that when they turned the resident, the resident had a scratch on his forehead. She revealed, she called the risk manager and reported it and called the Medical Doctor (MD) for an order for [REDACTED]. During interview with the Risk Manager, Staff N, on 12/22/2016 at 12:33 PM she revealed, an incident happened on June 10, 2016, while both CNAs were giving care to the resident, the CNA reported when they turned him on the left side, he sustained a little superficial skin opening on his forehead. She also revealed, based on their investigation, the resident sustained [REDACTED]. Record review of the Facility's policy on Hygiene-Resident dated 06/26/15 did not mention anything regarding the resident's safety during care. Cross reference F282.

Based on interview and record review, the facility failed to develop a comprehensive care plan regarding safety for its residents going on a Out of the Facility Pass for 3 out of 10 (Residents #1, # 6, and #7) sampled residents reviewed for Out of Facility Passes. The failure to have a safety care plan allowed Resident #1 to be placed at risk for injury. Resident #1 was injured in his wheelchair during a motor vehicle accident and expired. This failure to have a safety care plan placed residents # 6, and #7 at risk for injury. This resident sample includes all 8 residents with current pass privileges at the facility and two closed records from past residents. Cross Reference F323 The findings include: 1. Review of resident #1's demographic face sheet revealed the resident had the following Diagnoses: [REDACTED]. Review of a [DATE] Interdisciplinary Care Plan Team form, labeled "Special CP (care plan) meeting", revealed, it indicated the team explained to resident #1 that they were concerned about his safety while he was out in the community. They explained that his pass privileges would be changed from every day to three times a week and once on Sunday to ensure his safety. The resident was advised, for his safety, he should adhere to the change in pass privileges and comply with doctor's orders. Review of a nursing note dated [DATE] at 5:30 am revealed, while the certified nursing assistant (CNA) was turning resident #1, she noticed the resident had a towel covering the residents left thigh. The towel fell off and the CNA noticed an open wound to the residents left thigh. When the CNA asked resident #1 what had happened, it was reported, the resident bought a taco, heated it up in a microwave, then placed it on his lap. After the CNA reported this to the nurse, the nurse asked the resident what happened and he added this incident happened two days prior while he was out on pass at a local store. The nursing note indicated the resident had a 3rd degree burn to the left thigh measuring 3 cm by 1 cm. Review of the resident's care plans revealed, there was no care plan specific to safety while he was out on pass. The resident's activities care plan noted, the resident displayed poor impulse control and that he went out on pass several times per week, but the care plan did not include interventions specific to the resident's safety while on an out of the facility pass. Interview on [DATE] at 3:07pm with the Director of Nursing (DON) revealed that there was a motorvehicle accident involving one of the facility's residents that was out on pass (resident #1). In order to get pass privelages, residents are assessed by the physician or Assistant Registered Nurse Practitioner (ARNP). They decide who initially gets the passes. Interview with the facility's Director of Nursing (DON) on [DATE] at 4:28pm revealed, resident #1 went out on pass the morning of [DATE] and the police reported, resident #1 was hit by a dump truck around 9:30am, while the traffic light was green, at an intersection near the facility. Interview with the facility's administrator on [DATE] at 10:11am revealed, the news reports said, (resident #1) ran the traffic light and a truck hit him. The administrator reported, the resident had a current out of the facility pass on [DATE], the date he expired as a result the motor vehicle accident. Interview with the DON on [DATE] at 3:21pm revealed, she builds the care plan in the computer and going out on pass is not considered a problem to be care planned. She reported, "if there's a problem that needs intervention, then it should be care planned." 2. Review of resident #6's demographic face sheet revealed, the resident had the following Diagnoses: [REDACTED]. Review of the facility's nursing notes and releases of responsibility for leave of absence (LOA) forms for resident #6 revealed, on [DATE] the resident admitted to having consumed alcohol the prior day while out on pass. On [DATE], the resident returned from a out of the facility pass at 10:00 pm. According to the corresponding LOA form, the resident was scheduled to return at 9:00 pm. On [DATE], according to the LOA form, the resident left the facility at 1:20 pm and returned from pass at 2:55 am despite being scheduled to return at 7:20 pm. According to the nursing notes from that night, upon returning, the resident admitted to having consumed alcoholic drinks at a friend's house, was intoxicated, and fell asleep at a friends house. The resident then made a statement about no longer wanting to live in a nursing home and preferring death to a continued life in a nursing home. A late entry nursing note (written on [DATE] in reference to the [DATE] event) went into further detail by indicating the resident was worried about family health problems and sometimes thought about going into the river with the wheelchair and sinking all the way to the bottom. The LOA form dated [DATE] indicated the resident left the facility at 3:30 pm and did not return until [DATE] at 5:00 am despite being scheduled to return to the facility at 9:30 pm the night before. According to the nursing notes dated [DATE], upon returning, the resident admitted to using cocaine while out on pass. Review of psychiatric assessment documentation dated [DATE] revealed that resident #6 had been depressed and talking about passive death wish. As a result, he was prescribed [MEDICATION NAME] 30mg to be taken everyday at bedtime. Record review of a special care plan meeting note dated [DATE] revealed, the facility met with the resident regarding issues with returning from pass at the allotted time and the residents admitted drug and alcohol consumption. During this meeting the facility staff also addressed the resident's statement about not wanting to live and being unable to cope with family illness. Review of resident #6's care plans revealed, there was no care plan specific to the safety of the resident while out on pass. There was no mention on any care plan of the events outlined above. Interview with Registered Nurse (RN) A on [DATE] at 9:54 am revealed, she was aware of an incident where the resident came back to the facility inebriated after being out on pass. Interview with the facility's Director of Nursing on [DATE] at 3:15pm revealed, she acknowledged that there was not a specific care plan for this resident's safety related to being out on pass. Additionally, she acknowledged that if a resident was leaving the facility and drinking alcohol or doing drugs, it should be noted on the care plan. 3. Record review of resident #7's demographic face sheet revealed the following Diagnoses: [REDACTED]. Additionally, it was noted in physician progress notes [REDACTED].#7 had a past medical history of [REDACTED]. Review of the residents nursing notes and release of responsibility for LOA forms revealed, the LOA form dated [DATE] indicated the resident left the facility at 12:50 pm and returned at 10:30 pm despite being scheduled to return at 6:00 pm. The nursing notes from that night indicate the resident was verbally abusive to staff and had an odor of alcohol after returning to the facility. A [DATE] nursing note indicated the resident was noncompliant with the pass schedule. The LOA form dated [DATE] noted resident #7 left the facility at 11:00 am and did not return until 8:00 pm despite being scheduled to return at 6:00 pm. According to the corresponding nursing note on [DATE], the resident had slurred speech and a strong smell of alcohol upon returning to the facility. The LOA form dated [DATE] indicated the resident left the facility at 1:30 pm and did not return until 5:00 pm despite being scheduled to return at 4:30 pm. According to the corresponding nursing note on [DATE], the resident's breath smelled of alcohol. Review of the interdisciplinary care plan notes dated [DATE] and [DATE] revealed, resident #7 was noted to have a history of using the electric wheelchair to go out into the community three to four times a week and returning to the facility with the smell of alcohol. Review of resident #7's care plans revealed, there was no care plan specific to safety while being out on pass in the community. There was no mention on any care plan about the events outlined above. Interview with Registered Nurse (RN) A on [DATE] at 9:48 am revealed, she was aware of an incident where the resident came back to the facility inebriated after being out on pass. Interview with the facility's Director of Nursing on [DATE] at 3:15pm revealed, she acknowledged that there was not a specific care plan for resident safety related to being out on pass. Additionally, she acknowledged that if a resident was leaving the facility and drinking alcohol or doing drugs, it should be noted on the care plan.

Based on interview and record review, the facility failed to identify hazards and risks then implement interventions to reduce the risk of injury for 3 (residents #1, #6, and #7) out of 10 residents reviewed for safety during pass activity. This is evidenced by staff not consistently signing in and examining residents upon return from pass, allowing residents with proven unsafe behavior the opportunity to continue unsafe behavior without sufficient intervention. Resident #1 was injured in his electric wheelchair during a motor vehicle accident and expired. Cross reference F279. The findings include: Review of the facility's policy and procedure regarding resident passes dated [DATE] revealed, all resident pass requests are subject to review and approval by the physician or Advanced Registered Nurse Practitioner (ARNP) with input by the interdisciplinary team. Passes are approved on a case by case basis and shall be given based on the resident's mental/physical status, physician decision, and family/friends capability for providing adequate supervision and safety of those residents requiring it. Interview on [DATE] at 3:07pm with the Director of Nursing (DON) revealed that, around 9:27am, there was a motorvehicle accident involving one of the facility's residents that was out on pass (resident #1). In order to get pass privileges, residents are assessed by the physician or Assistant Registered Nurse Practitioner (ARNP). They decide who gets passes. Interview on [DATE] at 4:56pm with the facility administrator revealed that, as a result of the incident, they suspended all pass activity temporarily until they review their pass policy for areas of improvement. The facility offered to have, for the residents with pass privelages, their errands to be run by staff to make up for them not being able to go out to get it themselves. 1. Review of resident #1's demographic face sheet revealed the resident had the following Diagnoses: [REDACTED]. Record review revealed a physician's orders [REDACTED].#1 could go out on pass in the community four times a week (Tuesday, Thursday, Saturday, and Sunday). Review of a [DATE] Interdisciplinary Care Plan Team form revealed, it indicated the team explained to the resident that they were concerned about his safety while he was out in the community. They explained that his pass privileges would be changed from every day to three times a week and once on Sunday to ensure his safety. The resident was advised, for his safety, he should adhere to the change in pass privileges and comply with doctor's orders. Review of a nursing note dated [DATE] at 5:30 am revealed, while the certified nursing assistant (CNA) was turning the resident she noticed the resident had a towel covering the residents left thigh. The towel fell off and the CNA noticed an open wound to the residents left thigh. When the CNA asked resident #1 what had happened, it was reported, the resident bought a taco, heated it up in a microwave, then placed it on his lap. After the CNA reported this to the nurse, the nurse asked the resident what happened and he added this incident happened two days prior while he was out on pass at a local store. The nursing note indicated the resident had a 3rd degree burn to the left thigh measuring 3 cm by 1 cm. Record review of Leave of Absence (LOA) forms from [DATE] through [DATE] revealed resident #1 went out on pass into the community 53 times. On 4 of those occasions ([DATE], [DATE], [DATE], [DATE]) there was nothing on the form regarding the time the resident returned to the facility or his condition upon returning. Additionally, there were no corresponding nursing notes from those days indicating the resident was assessed or the residents condition upon returning to the facility from being out on pass. Review of Interdisciplinary Care Plan Team (IDT) documentation form dated [DATE] labeled "Special CP (care plan) meeting" revealed, "IDT explained that CP team is concerned about resident's safety while out in the community....Resident was advised that for his safety he should adhere to pass changes and comply with MD (physician) orders for resident safety." Review of the resident's care plans revealed, there was no care plan specific to safety while he was out on pass. The resident's activities care plan noted, the resident displayed poor impulse control and that he went out on pass several times per week, but the care plan did not include interventions specific to the resident's safety while on an out of the facility pass. Interview with the facility's Director of Nursing (DON) on [DATE] at 4:28pm revealed, resident #1 went out on pass the morning of [DATE] and the police reported, resident #1 was hit by a dump truck at 9:30am, while the traffic light was green, at an intersection near the facility. Interview with the facility's administrator on [DATE] at 10:11am revealed, the news reports said, (resident #1) ran the traffic light and a truck hit him. The administrator reported, the resident had a current out of the facility pass on [DATE], the date he expired as a result the motor vehicle accident. Interview with the ARNP on [DATE] at 10:20 am revealed, resident #1's passes were discussed in [DATE] because the resident was going out into the community daily and any time a resident goes out into the community there is a safety concern. Interview with the DON on [DATE] at 3:21pm revealed, she builds the care plan in the computer and going out on pass is not considered a problem to be care planned. She reported, "if there's a problem that needs intervention, then it should be care planned." 2. Review of resident #6's demographic face sheet revealed, the resident had the following Diagnoses: [REDACTED]. Record review revealed a physician's orders [REDACTED].#6 could go out on pass to the community two times a week for six hours each time as needed. An order dated [DATE] indicated resident #6's pass privileges were placed on hold until further notice. Review of the facility's nursing notes and releases of responsibility for leave of absence (LOA) forms for resident #6 revealed, on [DATE] the resident admitted to having consumed alcohol the prior day while out on pass. On [DATE], the resident returned from a out of the facility pass at 10:00 pm. According to the corresponding LOA form, the resident was scheduled to return at 9:00 pm. On [DATE], according to the LOA form, the resident left the facility at 1:20 pm and returned from pass at 2:55 am despite being scheduled to return at 7:20 pm. According to the nursing notes from that night, upon returning, the resident admitted to having consumed alcoholic drinks at a friend's house, was intoxicated, and fell asleep at a friends house. The resident then made a statement about no longer wanting to live in a nursing home and preferring death to a continued life in a nursing home. A late entry nursing note (written on [DATE] in reference to the [DATE] event) went into further detail by indicating the resident was worried about family health problems and sometimes thought about going into the river with the wheelchair and sinking all the way to the bottom. The LOA form dated [DATE] indicated the resident left the facility at 3:30 pm and did not return until [DATE] at 5:00 am despite being scheduled to return to the facility at 9:30 pm the night before. According to the nursing notes dated [DATE], upon returning, the resident admitted to using cocaine while out on pass. Record review of a special care plan meeting note dated [DATE] revealed, the facility met with the resident regarding issues with returning from pass at the allotted time and the residents admitted drug and alcohol consumption. During this meeting the facility staff also addressed the resident's statement about not wanting to live and being unable to cope with family illness. Review of resident #6's care plans revealed, there was no care plan specific to the safety of the resident while out on pass. There was no mention on any care plan of the events outlined above. Record review of the LOA forms from [DATE] through [DATE] revealed, resident #6 went out on pass into the community 35 times. The resident returned to the facility later than planned 19 times (54% of the time), including 5 times since a [DATE] return to the facility when the resident admitted to using cocaine while being out. Interview with resident #6 on [DATE] at 9:19 am revealed, he acknowledged going out of the facility on pass in his electric wheelchair twice a week. Interview with Registered Nurse (RN) A on [DATE] at 9:54 am revealed, she was aware of an incident where the resident came back to the facility inebriated after being out on pass. Interview with the facility's Director of Nursing on [DATE] at 3:15pm revealed, she acknowledged that there was not a specific care plan for this resident's safety related to being out on pass. Additionally, she acknowledged that if a resident was leaving the facility and drinking alcohol or doing drugs, it should be noted on the care plan. 3. Record review of resident #7's demographic face sheet revealed the following Diagnoses: [REDACTED]. Additionally, it was noted in physician progress notes [REDACTED].#7 had a past medical history of [REDACTED]. Record review of [DATE] physician orders [REDACTED]. Review of the residents nursing notes and release of responsibility for LOA forms revealed, the LOA form dated [DATE] indicated the resident left the facility at 12:50 pm and returned at 10:30 pm despite being scheduled to return at 6:00 pm. The nursing notes from that night indicate the resident was verbally abusive to staff and had an odor of alcohol after returning to the facility. A [DATE] nursing note indicated the resident was noncompliant with the pass schedule. The LOA form dated [DATE] noted resident #7 left the facility at 11:00 am and did not return until 8:00 pm despite being scheduled to return at 6:00 pm. According to the corresponding nursing note on [DATE], the resident had slurred speech and a strong smell of alcohol upon returning to the facility. The LOA form dated [DATE] indicated the resident left the facility at 1:30 pm and did not return until 5:00 pm despite being scheduled to return at 4:30 pm. According to the corresponding nursing note on [DATE], the resident's breath smelled of alcohol. Record review of LOA forms from [DATE] through [DATE] revealed resident #7 went out on pass 158 times. The resident was out on pass on 65% of the days over that time period. The resident returned later than scheduled 78 out of those 158 times, or 49% of the time. Review of the interdisciplinary care plan notes dated [DATE] and [DATE] revealed, resident #7 was noted to have a history of using the electric wheelchair to go out into the community three to four times a week and returning to the facility with the smell of alcohol. Review of resident #7's care plans revealed, there was no care plan specific to safety while being out on pass in the community. There was no mention on any care plan about the events outlined above. Observation on [DATE] at 9:40 am revealed the resident had an electric wheelchair next to the bed. Interview with Registered Nurse (RN) A on [DATE] at 9:48 am revealed, she was aware of an incident where the resident came back to the facility inebriated after being out on pass. Interview with the facility's Director of Nursing on [DATE] at 3:15pm revealed, she acknowledged that there was not a specific care plan for resident safety related to being out on pass. Additionally, she acknowledged that if a resident was leaving the facility and drinking alcohol or doing drugs, it should be noted on the care plan.

Based on record review and interview the facility failed to implement written policies and procedures in regards to the reporting of sexual abuse. This was evident for 1 of 3 sample residents (#2). Findings include: Record review of the facility's "Resident Abuse, Neglect and Exploitation" policy revealed that section E was titled "Investigation & Facility Reporting." The first key point point in the section read, "Upon a complaint or suspected discovery of abuse, neglect, or exploitation, a supervisor must be immediately notified and an investigation initiated immediately. If there is a suspected or actual assault (physically or sexually) FIRST, immediately contact security dispatch at JMH (phone number given) and they will notify the local police department." The second point noted that the "Abuse Coordinators and Administration are to be notified immediately. These are the Administrator, Director of patient Care Services, Shift Supervisor (3-11, 11-7), and Risk Manager." The third key point indicated that "the accused perpetrator of abuse, neglect, or exploitation shall immediately be separated from the victim (...)" Record review of resident #2's demographic face sheet revealed she was admitted on [DATE] and re-admitted on [DATE] with a [DIAGNOSES REDACTED]. Record review of the facility's federal five day report to the Agency for Health Care Administration (AHCA) revealed that an incident occurred on 9/23/12 at 5:15 PM with resident #2. The Certified Nursing Assistant (CNA) observed resident #2's father fondling her breast. The CNA stated she was in shock and that she just stood there and watched incident occurring until the father noticed her watching him. The document also noted that resident #2 "is in a vegetative state due to a [MEDICAL CONDITION] and is unable to speak." According to the document, this incident was not reported until 9/24/12. Interview with the Assistant Director of Nursing (ADON)/Risk Manager (RM) in the presence of the Administrator on 10/2/12 at 12:24 PM revealed that all employees are trained to report any allegation of abuse immediately to their supervisor or to call the abuse hotline. The ADON/RM stated the incident happened on 9/23/12 and that it was reported on 9/24/12. In addition, the ADON/RM stated the CNA saw resident #2's father fondling her breast and that the CNA stated she was in shock and therefore she just stood there and watched incident occurring until the father noticed her watching him. The ADON/RM said that the CNA stated she reported the incident to the charge nurse and the charge nurse did not report it. The ADON/RM stated that, when she found out about the incident, she reported it immediately to AHCA, to the Department of Children & Families (DCF) and to the police. This occurred on 9/24/12. The ADON/RM indicated that the staff could have reported the incident to the supervisor on each shift. The ADON/RM stated that the CNA told her that she reported it to the charge nurse that same day right after it happened. The ADON/RM said that after the CNA reported the incident to the Charge Nurse, her job was finished. The Charge Nurse did not report it right away, but instead, left a message in the ADON/RM's mailbox. She did not get it until the next day (9/24). At that time the ADON/RM stated she had the charge nurse recite what she should have done and she was able to recite it. The ADON/RM went on to state that the facility's security was notified that resident #2's father was not allowed to see her again. A family meeting was held on 9/24/12 with resident #2's mother and sister. They were told about the incident and informed that the father was no longer allowed at the facility. At that time the Director of Nursing (DON) joined the meeting. It was at 12:33 PM. The mother stated the father had done this in the past. During the family meeting the mother revealed the father was homeless for a while and he drinks. The mom stated she told her ex-husband not to visit resident #2 that day but he still went over to the facility. The charge nurse was place on administrative leave. The ADON/RM stated the father was very protective and visited resident #2 every day for the past 2 years by himself as well as with other family members. During the interview with the ADON/RM, the Administrator stated that on the same day (9/24), staff reviewed the Abuse Prohibition policies and procedures. They also held a meeting with upper management. Additionally, the staff was asked how they would react towards a similar witnessed incident and they indicated they would call DCF, call 911, and report the incident. She said, "Prior to the incident we had an in-service about two (2) weeks ago on abuse. I have reviewed the policy about three (3) times since I have been here." Interview with the CNA that observed the incident on 10/2/12 3:38 PM revealed she had been working for the Jackson Health System for [AGE] years and that this was the first time she reported abuse to her supervisor. The CNA said she was on her way from another resident's room when she stopped and looked in resident #2's room. She noticed her father sitting at bottom of bed. She stated that she initially thought "how nice" until she saw his hand moving around under the resident's clothing. She went on, "I told the charge nurse to look in the room to see if she saw anything." She said she did this because she still could not believe what she observed. However, the charge nurse said she looked but did not see anything. The CNA stated, "I wrote the incident report and gave it to her. I asked the charge nurse if she was going to call the supervisor and she said she did not want it all over the building and that she was going to leave a message or send an email with ADON/RM." The CNA also stated that she had abuse training about the week ago. "In training they said you should confront the person. However, having the training and actually seeing it for the first time I could not believe it. I know the facility policy is to report it to the charge nurse, then the charge nurse will tell the supervisor; who will then report it to security and call police. I have to follow the chain."