Every finding on record at La Vida Buena Healthcare

Based on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at increased risk for undesirable side effects (including but not limited to increased drowsiness, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.The findings are:A. Record review of R #1's physician orders revealed the following: 04/24/25: Lorazepam (anti-anxiety medication) 0.5 mg (milligram), as needed every four hours for anxiety. Discontinued 06/27/25.09/12/25: Lorazepam 0.5 mg, as needed every four hours for anxiety. Discontinued 09/17/25.09/17/25: Lorazepam 0.5 mg, as needed every four hours for anxiety. Discontinued 09/26/25.01/05/26: Lorazepam 0.5 mg, as needed every four hours for anxiety. Discontinued 01/06/26.01/06/26: Lorazepam 0.5 mg, as needed every four hours for anxiety. Discontinued 01/19/26.02/27/26: Lorazepam 0.5 mg, as needed every four hours for anxiety. Discontinued 03/02/26.04/24/26: Haldol (antipsychotic medication) 0.5 mg, as needed for behavioral disturbances. Discontinued 05/29/25.11/05/25: Seroquel (an antipsychotic medication) 25 mg, give two times a day for depression. Discontinued 01/05/26.B. Record review of R #1's Electronic Health Record (EHR) revealed R #1's Psychoactive Medication Consent Form was completed on 01/06/26 for the medication Lorazepam no other Medication Consent Form were available or completed for R #1's Seroquel and Haldol or Lorazepam use. C. On 03/09/26 at 12:35 pm during an interview with the Director of Nursing (DON), she confirmed Psychoactive Medication Consent forms should have been completed prior to administering Lorazepam, Haldol and Seroquel to R #1 but that did not occur.

Based on record review and interviews, the facility failed to notify R #1's daughter and the hospice nurse for 1 (R #3) of 3 (R #1, 2 and 3) resident reviewed for falls. This deficient practice is likely to result in family and the hospice not being able advocate for residents and residents being at further risk of injury. The findings are: A. On 03/09/26 at 12:43 pm during an interview with R #1's daughter, she stated that she had received a call from [name of local hospital] on 02/28/26 at 5:30 am and was advised that they needed her permission to treat her mother [R #1]. Daughter further stated that she had not been notified by the facility that her mother had had a fall and had been taken to the hospital. R #1's daughter stated she would have liked to have received a call from the facility about her mother's fall and felt as if they did not care. Daughter was not notified until her mother returned back to the facility from the hospital. B. On 03/09/26 at 4:12 pm during an interview with Hospice Director of Nursing (HDON), she stated the facility had not notified the hospice nurse until after R #1 had returned back to the facility from the emergency room on [DATE]. HDON further stated that at that time hospice nurse had gone to the facility to assess R #1.C. On 03/10/26 at 10:14 am during an interview with Licensed Practical Nurse (LPN) #2, she stated, that she had notified hospice at approximately 9:00 am the morning of 02/28/26 after the fall. (fall occurred between 5:00-5:30 am). LPN #2 further stated that once hospice is notified hospice is responsible of notifying the family it is not the facility's responsibility to notify the family.D. On 03/09/26 at 12:35 pm during an interview with the Director of Nursing (DON) she stated that the facility should notify the family, the physician and hospice if the resident is on hospice. DON was unable to confirm that family or hospice had been notified.

Based on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) and a five day follow up report to the State Survey Agency (SSA) after a fall with injury for 1(R#1) of 1 (R #1) resident reviewed for incidents,This deficient practice is likely to result in the State Survey Agency (SSA) not being aware of facility incidents and being unable to assure residents safety. The findings are:A. On 03/09/26 at 12:43 pm during an interview with R #1's daughter she stated that she received a call from [name of local hospital] informing her that her mother had been brought to the hospital and needed her permission to treat her mother for a laceration she had obtained to her forehead due to a fall at the facility. B. Record review of progress notes dated 02/28/26 at 5:23 pm revealed, R #1 experienced a fall this morning resulting in a 7.0 cm x 2.0 cm (cm-centimeter- unit of measure) laceration to the right side of her forehead. R #1 was transported to [name of local hospital].C. 03/09/26 at 12:40 pm during an interview with the facility Administrator he stated that he was aware of the incident with R #1 and any fall with injury should be reported to the state agency. Administrator confirmed R #1's fall had not been reported to the state agency and should have been.

Based on record review and interview, the facility failed to thoroughly investigate a fall with injury involving 1 (R #1) of 1 (R #1). This deficient practice is likely to result in residents not getting the treatment/care needed if the facility is not thoroughly investigating incidents. The findings are:A. On 03/09/26 at 12:43 pm during an interview with R #1's daughter she stated that she received a call from [name of local hospital] informing her that her mother had been brought to the hospital and needed her permission to treat her mother for a laceration she had obtained to her forehead due to a fall at the facility. B. Record review of progress notes dated 02/28/26 at 5:23 pm revealed, R #1 experienced a fall this morning resulting in a 7.0 cm x 2.0 cm (cm-centimeter- unit of measure) laceration to the right side of her forehead. R #1 was transported to [name of local hospital].C. On 03/09/26 at 12:35 pm during an interview with Director of Nursing (DON) she stated that an investigation had not been conducted for the fall R #1 had on 02/28/26 and was unable to confirm the exact time of incident nor was she able to locate the change in condition for the incident (R #1's fall with injury). DON was also unable to confirm who had witnessed the fall or how it occurred. DON stated that the incident should have been investigated and reported to the State Agency and it was not. D. On 03/10/26 at 3:11 pm during an interview with DON, she stated, The nurse assigned is responsible for notifying family, physician and DON when there is any change of condition including falls with injuries. DON confirmed that she did not conduct an investigation for the R #1's fall and she should have. DON further stated that R #1's medical records was not complete and notes were not through as to what occurred during R #1's incident. E. On 03/10/26 at 10:14 am during an interview with Licensed Practical Nurse (LPN) #2, she stated, that incident with R #1 was not witnessed by her, she heard a loud noise and heard the Certified Nurse Aide (CNA) #1 yelling that R #1 was on the floor. LPN #2 stated that she went around the nurses' station and witnessed R #1 on the floor and had a laceration on her forehead. LPN proceeded to call [name of local hospital] and had R #1 sent out via ambulance to local hospital. LPN #2 stated she had written a progress note in R #1's medical chart as to what she had witnessed. LPN #2 confirmed that she had not conducted an investigation. F. On 03/11/26 at 11:10 am during an interview with Registered Nurse (RN) #1 he stated that he did not witness R #1's fall, RN #2 was giving report to the oncoming nurse and heard the certified Nurse Aide yell and he rushed to witness R #1 on the floor on her side face down and bleeding quite a bit. RN #1 applied gauze to slow down the bleeding and was R #1 returned to her wheelchair and taken to her room and later sent out to [name of local hospital] by the oncoming nurse. RN #1 stated he had not documented incident or what he had witnessed in R #1's medical record.

Based on record review and interview, the facility failed to accurately complete quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments for 1 (R #1) of 3 (R #1, #2, and #3) residents reviewed for assessment accuracy and completion. This deficient practice is likely to result in residents not receiving care and treatment that meet their current needs. The findings are:A. Record review of R #1's electronic health record (EHR) revealed a quarterly MDS assessment for R #1 was due to be completed by 02/16/26.B. On 03/09/26 at 12:35 pm during an interview, the Director of nursing (DON) confirmed the MDS quarterly assessment was due 02/16/26 and it was not completed and it should have been completed by the due date.

Based on record review and interview, the facility failed to ensure that the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) quarterly assessment was electronically transmitted within the required 14-day timeframe for 1 (R #1) out of 3 (R #1, #2, and #3) residents reviewed for MDS transmittal requirement. This deficient practice is likely to hinder the ability of regulatory bodies to oversee resident care and prevents the facility from accurately tracking clinical trends or declines in a resident's condition over time.The findings are: A. Record review of R #1's MDS log revealed the Quarterly Assessment with an Assessment Reference Date (ARD) of 02/16/26 had not been transmitted.B. Record review of the Quarterly Assessment revealed, the assessment remained in Draft (not completed or transmitted) status in the facility's software and had not been encoded or transmitted.C. On 03/09/26 at 12:35 pm during an interview, the Director of nursing (DON) confirmed the MDS quarterly assessment was due 02/16/26 and it was not transmitted electronically. The DON also stated all MDS assessment should be transmitted timely (within the required 14-day timeframe), and it did not happen.

Based on interview and record review, the facility failed to ensure that a comprehensive and accurate assessment was completed for 1 (R #1) out of 3 (R #1, #2, and #3) residents reviewed upon readmission to the facility following an acute care hospital stay. This deficient practice is likely to not accurately calculate the resident's Risk Score for skin breakdown or falls.The findings are:A. Record review of the Electronic Health Record (EHR) revealed no complete head to toe assessment was completed when R #1 returned from the hospital on [DATE].B. On 03/10/26 at 3:17 pm during an interview with the Director of Nursing (DON), she confirmed R #1 was not assessed upon arrival from the hospital on [DATE]. The DON stated all residents sent out to the hospital must be assessed (including head to toe skin assessment) upon arrival/admission to the facility and it did not happen.

Based on record review and interview, the facility failed to report an incident of possible neglect to the State Agency for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for abuse and neglect. If the facility fails to report allegations to the State Agency, then the State Agency is unable to ensure residents are free from abuse and neglect. The findings are:A. On 10/20/25 at 12:00 pm during interview with Director of Nursing (DON), she stated that R #1 had an incident during care. DON stated that on 10/03/25 she became aware that R #1 was complaining of more pain than usual and that her knee was swollen. DON stated she began to investigate and learned that the nurse who was providing care to R #1 on 09/25/25 was moving R #1 about in bed to provide wound care, during this time, the nurse heard a loud pop. DON confirmed the nurse did not report this incident to her (DON) or to the medical provider. DON confirmed the incident was not documented in R #1's medical record. DON stated that her expectation was for any incidents to be reported to administration, documented in the residents medical chart and and an incident report should have been completed. B. Record review of facility's self reports to State Agency dated 09/25/25 to 10/20/25 revealed no incidents had been reported for R #1 during that time period.

Based on record review and interview, the facility failed to notify the facility providers (Nurse Practitioner, Physician, and the facility Wound Care Nurse) and Guardian for 3 (R #'s 4, 9, 15) of 3 (R #'s 4, 9, 15) residents reviewed when:Guardian for R # 4 was not notified of a fall with injury above R #4's right eye on 05/28/25. The facility Registered Nurse Treatment Nurse (Wound Care Nurse) was not notified of R #9's scalp laceration (a tear or ragged cut in skin or flesh) with staples for 24 days after R #9 received scalp staples. Facility providers were not notified of R #15's worsening (becoming worse) pressure ulcer (skin wound) as soon as the wound was identified to be declining, so wound care treatment could be changed. This deficient practice is likely to result in a delay in treatment or inadequate treatment. The findings are: R #4: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE]. B. Record review of R #4's nursing progress notes dated 05/28/25 to 05/29/25 revealed a fall with injury above her right eye that required steri strips (breathable and waterproof bandage strips used to close or tape up wounds). C. On 07/22/25 at 12:25 pm during an interview with R #4’s guardian she stated that she was not made aware of R #4's fall on 05/28/25, and she would have expected the nursing facility staff to notify her. D. On 07/22/25 at 11:45 pm during an interview with Licensed Practical Nurse (LPN) 2, she stated she remembered one incident in May of this year that the guardian for R #4 was not called after a fall. She further stated that R #4’s guardian let her know when she made a follow up call about R #4’s fall that she was not informed about the fall in the first place. E. On 07/23/25 at 12:37 pm during an interview with the Director of Nursing (DON), she stated the nursing facility staff should have notified R #4’s guardian and they did not. R #9: F. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. G. Record review of R #9's emergency room (ER) Discharge Instructions (Orders) dated 06/13/25 revealed R #9 was to have his staples that were located on his head, to close a laceration (a tear or ragged cut in skin or flesh), removed in 7 to 10 days. H. Record review of R #9's nursing progress notes dated 06/13/25 to 06/29/25 revealed the following: 06/13/25 at 12:12 pm: R #9 returned to the facility from the ER where he had staples put into his into his scalp after falling in the facility and sustaining injuries. R #9 returned with orders from the ER doctors to have his staples removed within 7 to 10 days. On call providers were contacted (by nurse writing progress note) and awaiting orders for staple removal. 06/16/25 at 4:56 am: Laceration to R #9's right side of head, laceration was sutured (a stitch or row of stitches holding together the edges of a wound or surgical incision) in the ER. 06/25/25 at 7:04 am: Pending physician orders to remove R #9's stitches. 06/29/25 at 9:00 am: Remove staples from right sides of R #9's scalp. Physician notified of purulent (thick, milky discharge that comes out of a wound meaning infection) drainage and laceration infection. 06/29/25 at 1:07 pm: Nurse removed 4 staples from R #9's scalp as ordered. After staples were removed, R #9's scalp was warm to touch and purulent indicating infection. I. Record review of R #9's physician orders dated 06/29/25 revealed, remove staples from the right side of R #9's scalp one time only. J. On 07/23/25 at 4:09 pm during an interview with the Registered Nurse Treatment Nurse (RNTN), she stated that she was not made aware of R #9's scalp staples until 07/07/25, and she would have expected the facility nursing staff to notify her of R #9's scalp staples as soon as he returned to the facility on [DATE]. K. On 07/24/25 at 9:35 am during an interview with the Nurse Practitioner (NP), she stated the facility nursing staff should have notified the RNTN of R #9's scalp staples as soon as he returned to the facility on [DATE]. The NP also stated that she would expect the RNTN to also ask about R #9's scalp staples. The NP confirmed she expects nursing staff to notify the RNTN as soon as possible and stated, Communication is basic for everything and very important. L. On 07/24/25 at 11:46 am during an interview with the Director of Nursing (DON), she stated the facility nursing staff should have notified the RNTN of R #9's scalp staples as soon as he returned to the facility on [DATE]. R #15: M. Record review of R #15’s face sheet revealed R #15 was admitted into the facility on [DATE] with a Pressure Ulcer of the Sacral Region (area at the bottom of the spine), Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone). N. Record review of R #15’s physician orders dated 04/29/25 revealed, wound to coccyx (tailbone area; base of spine): cleanse with normal saline, cover wound bed with collagen hydrogel (wound care product to create moist environment for healing), pack with normal saline wet gauze, cover with dry dressing. One time a day for wound care. Physician order discontinued on 05/14/25. O. Record review of R #15’s physician orders dated 05/15/25 revealed, wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver (specialized wound dressing to prevent infection) to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care. Physicians order was discontinued on 06/20/25. P. Record review of R #15’s physician orders dated 06/20/25 revealed, wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care. Q. Record review of R #15’s weekly wound progress form (form completed by facility Registered Nurse (RN) Treatment Nurse- Wound Care Nurse) dated 05/28/25 through 07/07/25 revealed the following: 05/28/25: R #15’s coccyx (tailbone area; base of spine) pressure ulcer identified on 04/28/25, was measured to have a length of 5.0 cm (centimeters), width of 5.0 cm, and a depth of 3.3 cm. Notes stated, “Wound has gotten larger.” 06/03/25: R #15’s coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 5.0 cm, and a depth of 3.0 cm. Notes stated, “Wound is healing well.” 06/20/25: R #15’s coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 4.8 cm, and a depth of 2.9 cm. Notes stated, “Wound is healing well.” 06/24/25: R #15’s coccyx pressure ulcer was measured to have a length of 6.0 cm, width of 5.0 cm, and a depth of 2.5 cm. Notes stated, “Wound is healing slowly.” 07/07/25: R #15’s coccyx pressure ulcer was measured to have a length of 6.0 cm, width of 6.0 cm, a depth of 2.0 cm, and 3.0 cm tunneling of the wound. Notes stated, “Necrotic tissue, Wound is healing well. Orders for wounds to be seen by wound clinic sent in.” R #15’s left gluteal fold (horizontal skin crease that forms below the buttocks) pressure ulcer identified on 06/28/25, was measured to have a length of 5.0 cm, width of 6.0 cm, and a depth of 0.1 cm. Notes stated, “Orders for wounds to be seen by wound clinic sent in.” No weekly wound progress form was completed between 06/03/25 through 06/20/25, and 06/24/25 through 07/07/25. R. Record review of R #15’s weekly skin checks completed by facility nursing staff dated 06/06/25 through 07/03/25 revealed the following: 06/06/25: R #15’s coccyx pressure ulcer was not documented. 06/12/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. 06/19/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. 06/25/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. 07/03/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow, shearing left buttocks. 07/11/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. Left buttock (gluteal fold) wound nurse continues to follow. 07/17/25: R #15’s coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. Left buttock (gluteal fold) wound nurse continues to follow. S. Record review of the facility wound report dated 07/23/25 revealed the following for R #15: R #15’s coccyx pressure ulcer was measured to have a length of 6.2 cm, width of 6.1 cm, and a depth of 2.0 cm. R #15’s left gluteal fold pressure ulcer was measured to have a length of 5.20 cm, width of 5.80 cm, and a depth of 0.10 cm. T. Record review of R #15's physician orders dated 07/03/25 revealed, stage 2 wound to left gluteal fold- cleanse with normal saline, pat dry, apply collagen flakes, apply silicone dressing one time a day for wound care. U. Record review of R #15's physician orders dated 07/07/25 revealed, refer to wound clinic STAT (immediately or without delay) for a stage 2 wound to left gluteal fold and pressure ulcer of sacral region (coccyx) stage 4. V. Record review of R #15's physician orders dated 07/21/25 revealed R #15's wound clinic appointment was scheduled for 07/29/25. W. On 07/23/25 at 4:10 pm during an interview with the RNTN, she stated that she did not let the NP know about R #15's worsening coccyx pressure ulcer and left gluteal pressure ulcer until 07/07/25. X. On 07/24/25 at 9:43 am during an interview with the Nurse Practitioner (NP), she stated that she was not informed of R #15's coccyx and left gluteal fold pressure ulcers until 07/07/25. The NP also stated that if she was notified sooner of R #15's worsening coccyx pressure ulcer and left gluteal pressure ulcer, then she would have put in different wound care orders sooner. The NP confirmed she should have been made aware of R #15's worsening coccyx pressure ulcer and left gluteal pressure ulcer sooner. Y. On 07/24/25 at 3:33 pm during an interview with the Medical Director (MD), he stated that his expectation is if a resident's wounds are worsening, like R #15's coccyx pressure ulcer, then he would expect the facility providers to be notified immediately.

Based on record review and interview, the facility failed to make prompt (done without delay; immediate) efforts to resolve resident's grievances for 4 (R #'s 13, 14, 16, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed by:Not responding to grievances that involved allegations of abuse and neglect for several days after the grievance was reported. Failing to educate all nursing staff, including the nursing staff involved, for grievances with allegations of abuse and neglect. If the facility is not ensuring that grievances are responded to in a prompt manner and without delay, then residents are likely at risk of continued/repeat concerns and feeling as though their concerns are unimportant to the facility.The findings are: R #13: A. Record review of R #13's reported facility grievance dated 07/17/25 revealed the following:R #13 stated that Nursing Assistant (NA) #1 answered her call light but stated that she needed to go get more bed sheets and never returned to help R #13. R #13 pressed her call light again, and an unnamed Certified Nursing Assistant (CNA) came in to assist R #13. NA #1 returned to R #13's room and was laughing while the CNA was assisting R #13. Later that day, R #13 was in the shower, and NA #1 came into the shower room and started laughing again. R #13 pressed her call light again later after the shower and NA #1 arrived at her room and told R #13 that she would return to help her, but NA #1 did not return. Facility Response: Facility Nursing staff will be provided education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025. Facility nursing staff will try to schedule employee named by the resident on a different hall, when possible, to minimize the care the employee provides to the resident. B. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.NA #1 was not documented as being present for in-service training. No documentation was available that indicated NA #1 received any in-service/training related to R #13's grievance. C. On 07/23/25 at 10:25 am during an interview with R #13, she stated that she felt humiliated when NA #1 was laughing at her in the shower. R #13 also stated that NA #1 also got mad at R #13's roommate (R #14) for using the call light.R #14: D. Record review of R #14's reported facility grievance dated 07/17/25 revealed the following:Subject: R #14 reported that NA #1 answered her call light. R #14 forgot what she needed because the nursing staff took too long to answer the call light, and NA #1 told R #14 that she should not use the call light if she could not remember what she needed. Facility Response: Facility Nursing staff will be provided with education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025. Facility nursing staff will try to schedule employee named by the resident on a different hall, when possible, to minimize the care the employee provides to the resident. E. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.NA #1 was not documented as being present for in-service training. No documentation was available that indicated NA #1 received any in-service/training related to R #14's grievance. R #16: F. Record review of R #16's reported facility grievance dated 07/16/25 revealed the following:Subject: R #16 does not want CNA #3 working with her because she does not like the way CNA #3 talks to her and treats her. Facility Response: Facility Nursing staff will be provided education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025. Facility nursing staff will try to schedule employee named by the resident on a different hall, when possible, to minimize the care the employee provides to the resident. G. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.CNA #3 was not documented as being present for in-service training. No documentation was available that indicated CNA #3 received any in-service/training related to R #16's grievance.R #17: H. Record review of R #17's reported facility grievance dated 07/18/25 revealed the following:Subject: R #17 got back from dialysis and did not get changed until 12:00 pm. CNA #4 kept passing by R #17 and did not answer R #17's call light. Facility Response: Facility Nursing staff will be provided education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025.I. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.CNA #4 was not documented as being present for in-service training. No documentation was available that indicated CNA #4 received any in-service/training related to R #17's grievance.J. On 07/24/25 at 11:04 am during an interview with the Assistant Director of Nursing (ADON), he stated that he spoke to CNA #3 after R #16 filed a grievance, and he was aware of NA #1 speaking with the Director of Nursing (DON) for R #'s 13 and 14's grievances. The ADON also stated that he has not spoken to CNA #4 about R #17's grievance yet. The ADON confirmed all staff involved in the grievances should have attended the in-service training, and the grievance resolution should have completed sooner than the projected date of 07/25/25. K. On 07/24/25 at 11:57 am during an interview with the DON, she stated that R #'s 13, 14, 16, and 17's grievances should have been handled differently, with the resolutions and education for each grievance being completed sooner than 07/25/25.

Based on record review and interview, the facility failed to report an investigation regarding allegations abuse and neglect within the required timeframe (2 hours) for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances.If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.The findings are: A. Refer to F0610 for related findings. R #13: B. Record review R #13's neglect incident report provided by the facility dated 07/17/25 revealed the following:Details of Incident: During an audit of facility grievances, this incident is being reported that R #13 stated Nursing Assistant (NA) #1 came to change R #13 but left to get supplies and never returned to change R #13. Another staff member came to assist R #13. After Incident Actions: NA #1 was re-educated. Details of Interventions: Investigation is ongoing. Follow-up was reported to the SA on 07/22/25 at 10:34 am. No indication that the neglect incident was reported to the SA within two hours as required. C. On 07/31/25 at 2:16 pm during an interview with the Administrator (ADM), he stated the facility did not identify an allegation of neglect for R #13's grievance dated 07/17/25. The facility identified an allegation of neglect for R #13's grievance dated 07/17/25 several days after the incident occurred during a grievance audit, indicating R #13's neglect grievance dated 07/17/25 was not reported to the SA within two hours as required. The ADM confirmed R #13's neglect incident/grievance should have been submitted to the SA sooner. R #14:D. Record review R #14's incident report provided by the facility dated 07/17/25 revealed the following:Details of Incident: During an audit of facility grievances, this incident is being reported that R #14 stated NA #1 answered the call light, but R #14 forgot what she wanted. NA #1 asked R #14 why she used the call light if she could not remember what she needed. After Incident Actions: NA #1 was re-educated. Details of Interventions: Investigation is ongoing. Follow-up was reported to the SA on 07/22/25 at 10:51 am. No indication that R #14's incident/grievance incident was reported to the SA within two hours as required. E. On 07/31/25 at 2:17 pm during an interview with the ADM, he confirmed R #14's incident/grievance should have been submitted to the SA sooner. R #17: F. Record review of the facility Abuse and Neglect Incident Reports, reviewed on 07/24/25 revealed no abuse and neglect incident report was present for R #17's incident that occurred on 07/18/25. G. On 07/31/25 at 2:18 pm during an interview with the ADM, he confirmed R #17's grievance/incident dated 07/18/25 was not submitted to the SA and should have been because this incident involved allegations of neglect.

Based on record review and interview, the facility failed to complete a thorough investigation and report the investigation findings within five working days, for allegations of abuse and neglect for 3 (R #'s 13, 14, and 17) of 4 (R #'s 13, 14, 16, and 17) residents reviewed for grievances. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.The findings are: R #13: A. Record review of R #13's facility grievance dated 07/17/25 revealed the following:Subject: R #13 stated that Nursing Assistant (NA) #1 answered her call light but stated that she needed to go get more bed sheets and never returned to help R #13. R #13 pressed her call light again, and an unnamed Certified Nursing Assistant (CNA) came in to assist R #13. NA #1 returned to R #13's room and was laughing while the CNA was assisting R #13. Later that day, R #13 was in the shower, and NA #1 came into the shower room and started laughing again. R #13 pressed her call light again later after the shower and NA #1 arrived at her room and told R #13 that she would return to help her, but NA #1 did not return. Facility Response: Facility Nursing staff will be provided with education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025. Facility nursing staff will try to schedule employee named by the resident on a different hall, when possible, to minimize the care the employee provides to the resident. B. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.NA #1 was not documented as being present for in-service training. C. On 07/23/25 at 10:25 am during an interview with R #13, she stated that she felt humiliated when NA #1 was laughing at her in the shower. R #13 also stated that NA #1 also got mad at R #13's roommate (R #14) for using the call light.D. Record review R #13's neglect incident report dated 07/17/25 revealed the following:Details of Incident: During an audit of facility grievances, this incident is being reported that R #13 stated Nursing Assistant (NA) #1 came to change R #13 but left to get supplies and never returned to change R #13. Another staff member came to assist R #13. After Incident Actions: NA #1 was re-educated. Details of Interventions: Investigation is ongoing. Follow-up was reported to the SA on 07/22/25 at 10:34 am. A thorough investigation was not provided for R #13's 07/17/25 incident. E. On 07/31/25 at 2:16 pm during an interview with the Administrator (ADM), he stated R #13's grievance was not identified as an allegation of abuse until the facility completed a grievance audit during the survey. The ADM also stated that while he was out of the facility, he would have expected the facility staff to conduct a thorough abuse investigation, and one was not conducted. R #14: F. Record review of R #14's facility grievance dated 07/17/25 revealed the following:Subject: R #14 reported that NA #1 answered her call light. R #14 forgot what she needed because the nursing staff took too long to answer the call light, and NA #1 asked R #14 why she used the call light if she could not remember what she needed. Facility Response: Facility Nursing staff will be provided education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025. Facility nursing staff will try to schedule employee named by the resident on a different hall, when possible, to minimize the care the employee provides to the resident. G. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.NA #1 was not documented as being present for in-service training. H. Record review R #14's incident report dated 07/17/25 revealed the following:Details of Incident: During an audit of facility grievances, this incident is being reported that R #14 stated NA #1 answered the call light, but R #14 forgot what she wanted. NA #1 asked R #14 why she used the call light if she could not remember what she needed. After Incident Actions: NA #1 was re-educated. Details of Interventions: Investigation is ongoing. Follow-up was reported to the SA on 07/22/25 at 10:51 am. A thorough investigation was not provided for R #14's 07/17/25 incident.I. On 07/31/25 at 2:17 pm during an interview with the ADM, he stated that during the facility grievance audit, it was determined that R #14's grievance was a form of intimidation and should be considered an allegation of abuse. The ADM confirmed a thorough abuse investigation was not completed for R #14's 07/17/25 grievance and should have been. R #17: J. Record review of R #17's facility grievance dated 07/18/25 revealed the following:Subject: R #17 got back from dialysis and did not get changed until 12:00 pm. CNA #4 kept passing by R #17 and did not answer R #17's call light. Facility Response: Facility Nursing staff will be provided education regarding the importance of ensuring all residents are treated with dignity and respect at all times, and education relevant to customer service. Education will be completed by July 25, 2025.K. Record review of facility in-service training dated July 2025 revealed the following: Training Topics: Dementia, Residents Rights, Customer Service, and Assist All Residents in a Timely Manner with a Better Attitude.CNA #4 was not documented as being present for in-service training.L. Record review of the facility abuse and neglect incident reports reviewed on 07/24/25 revealed no abuse and neglect incident report was present for R #17's incident that occurred on 07/18/25. M. On 07/24/25 at 11:05 am during an interview with the Assistant Director of Nursing (ADON), he stated that he spoke to CNA #3 after R #16 filed a grievance, and he was aware of NA #1 speaking with the Director of Nursing (DON) for R #'s 13 and 14's grievances. The ADON also stated that he has not spoken to CNA #4 about R #17's grievance yet. The ADON stated that none of the staff members were suspended for these allegations, and they were only spoken to by the DON and himself. The ADON confirmed that each allegation was a form of abuse and neglect, which meant that each one should have investigated as such, and he was not aware of any investigations taking place. N. On 07/24/25 at 11:58 am during an interview with the DON, she stated that R #'s 13, 14, and 17's grievances should have been investigated as allegation of abuse and neglect, and they were not. The DON also stated that all staff members involved with each allegation should have been suspended during an investigation, but they were not. The DON stated that she was not sure if a thorough investigation was completed for each allegation of abuse or neglect was completed and submitted to the SA within the required timeframe and should have. O. On 07/31/25 at 2:18 pm during an interview with the ADM, he stated a thorough investigation was not completed nor submitted to the SA for R #17's allegation of neglect and should have been.

Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 2 (R #'s 9 and 11) of 2 (R #'s 9 and 11) residents when the facility failed to:Remove R #9's scalp staples within 7 to 10 days as ordered by a physician. Provide physician orders for anticoagulant (blood thinner) complications (bruising, bleeding, pain, swelling, and dizziness) monitoring (daily nursing assessments) for R #11. If the facility is not following physician orders or providing medication monitoring orders, then residents are at risk of adverse outcomes and inadequate monitoring of treatment. The findings are:R #9: A. Record review of R #9's face sheet revealed R #9 was admitted into the facility on [DATE]. B. Record review of R #9's emergency room (ER) Discharge Instructions (Orders) dated 06/13/25 revealed R #9 was to have his staples that were located on his head, to close a laceration (a tear or ragged cut in skin or flesh), removed in 7 to 10 days. C. Record review of R #9's nursing progress notes dated 06/13/25 to 06/29/25 revealed the following:06/13/25: R #9 returned to the facility from the ER where he had staples put into his after falling in the facility and sustaining injuries. R #9 returned with orders from the ER doctors to have his staples removed within 7 to 10 days. On call providers were contacted and awaiting orders for staple removal. 06/16/25: Laceration to R #9's right side of head, laceration was sutured (a stitch or row of stitches holding together the edges of a wound or surgical incision) in the ER. 06/25/25: Pending physician orders to remove R #9's stitches. 06/29/25 at 9:00 am: Remove staples from right sides of R #9's scalp. Physician notified of purulent (thick, milky discharge that comes out of a wound meaning infection) drainage and laceration infection. 06/29/25 at 1:07 pm: Nurse removed 4 staples from R #9's scalp as ordered. After the staples were removed, R #9's scalp was warm to touch and purulent indicating infection. D. Record review of R #9's physician orders dated 06/29/25 revealed, remove staples from the right side of R #9's scalp one time only. E. On 07/21/25 at 4:39 pm during an interview with R #9's daughter, she stated that the facility staff did not know when to take R #9's staples out of his head. R #9's daughter also stated that both her and her brother asked about the removal of R #9's staples on his head, but none of the nursing staff could ever tell them when the staples were to be removed, which resulted in R #9's staples remaining in his head for 16 days. F. On 07/22/25 at 3:08 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated that the facility was trying to get physician orders to remove R #9's head staples from facility providers, but they did not receive an order within the 7 to 10 days. The LPN #1 also stated that she believed R #9's staples were in his head for too long and when she removed the staples, R #9's scalp laceration was infected. G. On 07/23/25 at 11:15 am during an interview with Registered Nurse (RN) #2, she stated R #9's staples were supposed to be removed within 7 to 10 days from 06/13/25 per hospital orders, but the staples were not removed until 16 days after R #9 returned to the facility. H. On 07/24/25 at 9:34 am during an interview with the Nurse Practitioner (NP), she stated that she was made aware of R #9's infected scalp laceration on 06/29/25, but she was surprised because she thought R #9's staples were already removed. I. On 07/24/25 at 11:45 am during an interview with the Director of Nursing (DON), she stated when the facility receives hospital orders, the nurses are to contact a facility provider to see if the facility provider agrees with the hospital recommendation. J. On 07/24/25 at 3:20 pm during an interview with the Medical Director (MD), he stated that he does not think R #9's scalp became infected because the staples were left in too long, but he expects the nursing facility staff to follow hospital orders because those are orders from a physician. The MD confirmed that R #9's hospital order was for R #9's staples to be removed within 7 to 10 days, and the facility should have followed those orders. R #11: K. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. L. Record review of R #11's physician orders dated 02/07/24 revealed R #11 was prescribed Xarelto (anticoagulant) 2.5 mg (milligrams), give one tablet by mouth twice a day related to heart disease. There was no order present for monitoring R #11 for complications (bruising, bleeding, pain, swelling, and dizziness) related to anticoagulant use.M. Record review of R #11's care plan dated 05/06/25 revealed that R #11 received anticoagulant medication related to heart disease. R #11's interventions included the facility staff monitor/document/report to a provider any signs or symptoms of anticoagulant complications. Nursing staff were to review R #11's medication list for adverse interactions as well. N. Record review of R #11's nursing progress notes dated 04/17/25 through 04/20/25 revealed the following: 04/17/25 at 11:40 pm: R #11 was yelling at a Certified Nursing Assistant (CNA) and following the CNA throughout the unit. R #11 proceeded to punch Registered Nurse (RN) #3 in the chest and when RN #3 raised her arm to block R #11's second punch, R #11 lost her balance and fell on the floor while also hitting her head. R #11 refused to let RN #3 get her vitals and complete a post fall assessment. 04/18/25 at 5:52 am: R #11's daughter called requesting a follow-up from R #11's previous fall. The nurse will inform day nurse to call R #11's daughter, facility provider was also notified. 04/18/25 at 8:34 am: R #11 is alert and oriented times one (indicating R #11 was aware of who they are but with confusion) and denied pain or confusion. R #11 has a hematoma (a solid swelling of clotted blood within the tissues) and bruising to left side of face. R #11 being sent to hospital for x-rays. 04/19/25 at 5:46 pm: Bruising spreading throughout face and head for R #11. O. Record review of R #11's Medication Administration Record (MAR) dated 04/01/25 through 04/19/25 revealed R #11 received Xarelto 2.5 mg every day as ordered. P. On 07/24/25 at 3:34 pm during an interview with the Medical Director (MD), he stated that when a resident takes a blood thinning medication such as Xarelto, there should be a physician's order related to staff monitoring for signs and symptoms of anticoagulant medication complications. The MD confirmed R #11 should have had a physician's order for anticoagulant medication monitoring. Q. On 07/24/25 at 3:59 pm during an interview with the Director of Nursing (DON), she confirmed R #11 did not have physician orders for anticoagulant medication monitoring.

Based on record review and interview, the facility failed to provide a program of activities sufficient to meet each resident's capabilities, interests and needs, for 1 (R # 5) of 3 (R #s 1, 2 and 5) residents reviewed for activities. This deficient practice has the potential to cause residents feelings of boredom, isolation and depression. The findings are: A. On 07/22/25 at 11:17 am during an interview with R #5 he stated that he would like to be integrated back into the community. He further stated that there are no facility outings scheduled by the facility and he would like to go outside to walk but he was told he was not to leave the facility without someone accompanying him. R #5 feels frustrated because he is not able to exercise his rights to be able to leave the facility to go to the store or to walk around the facility grounds. B. Record review of Activity assessment dated [DATE] revealed: Page 2 question 7. Go outside for fresh air when the weather is nice: 1) Very Important. C. Record review of Minimum Data Set (MDS-Nursing Resident Assessment and care screening) dated 06/17/25 revealed: Section C-Cognitive Patterns- BIMS score of 15 (brief interview for mental status with scoring 00 through 15. 15 being the highest score- indicating that the individual's cognitive abilities are intact.) D. Record review of R #5's care plan dated 06/21/25 revealed [name of R #5] stated that he went to the store to buy new pair of shoes and returned to the nursing facility. Interventions: encourage resident to let staff know when he wants to go out to purchase items. E. On 07/23/25 at 12:37 pm during an interview with the Director of Nursing (DON) she stated that R #5 was not safe to go out on his own because he had some medical issues that prevented him from being safe and making sound decisions. R #5 is not in agreement that he needs staff to participate with him when he wants to walk to the store or go for a walk. He has not been deemed incompetent. DON further stated that the facility should be able to offer someone to accompany R #5 and that there's not always someone available. DON confirmed R #5 has a BIMS score of 15- cognitively intact. [NAME] further confirmed that there has not been any transportation available for the use of activity outings for the residents in at least 2-3 months. F. On 07/23/25 at 1:15 pm during an interview with the Activities Assistant (AA) she stated R #5 is alert and oriented and able to make his needs known. The AA further stated that R #5 is not allowed to leave the facility because it is not safe and if he were to be seen leaving the front door staff is to bring him back in. The AA further stated that facility outings had not occurred since the facility van had been out of service (2-3 months). G. On 07/23/25 at 11:35 am during an interview with the Activities Director (AD) she stated that the facility van has not been operational for a few months, so they have not been able to take the residents on outings or been able to take them shopping or on rides. When asked about R #5 she stated that he does like to go on outings and likes to go outdoors, but the activities program has not included outings for a while because of the broken van. The AD is hoping to get a van soon to be able to resume the outings and the van rides. H. Record review of the posted July 2025 activity calendar revealed: 6 scheduled outings. All scheduled outing did not occur this month. I. Record review of printed May 2025 activity calendars revealed: 10 scheduled outings. All scheduled outing did not occur this month. J. On 07/23/25 during an interview with R #1 and R #2 they stated that the facility has not had any facility outings for two or three months due to the van not being operational. They both stated that some of the residents are upset about not being able to go on outings. R #2 confirmed that R #5 gets very upset about not being able to go for walks or on outings to the store.

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury/pressure ulcer; skin damage which results from unrelieved pressure on the body) for 1 (R #15) of 1 (R #15) resident reviewed when staff failed to: Monitor for changes in R #15's coccyx (tailbone area; base of spine) pressure ulcer and timely notify the provider (physician and/or Nurse Practitioner) of R #15's pressure ulcer worsening and development of new pressure wound.Document and monitor wound progress (that includes measurements; to track effectiveness of wound care treatments and to prevent the progression of pressure ulcers) for R #15, so any pressure ulcer changes can be managed and/or treated without delay. These deficient practices likely resulted in R #15's pressure ulcer worsening with necrotic tissue (death of cells in tissue due to disease, injury, or failure of the blood supply) which required referral to an out of facility wound care clinic for advanced wound care treatment not available in the facility. The findings are: A. Refer to F0580 for related findings for R #15. B. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE] with a Pressure Ulcer of Sacral Region (area at the bottom of the spine), Stage 4 (deep wounds that may impact muscle, tendons, ligaments, and bone). C. Record review of R #15's physician orders dated 04/29/25 revealed, wound to coccyx cleanse with normal saline, cover wound bed with collagen hydrogel (wound care product to create moist environment for healing), pack with normal saline wet gauze, cover with dry dressing. One time a day for wound care. Physician order discontinued on 05/14/25.D. Record review of R #15's physician orders dated 05/15/25 revealed, wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care. Physicians order was discontinued on 06/20/25.E. Record review of R #15's physician orders dated 06/20/25 revealed, wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care.F. Record review of R #15's Weekly Wound Progress Form (form completed by facility Registered Nurse Treatment Nurse (RNTN)- Wound Care Nurse) dated 04/30/25 through 07/07/25 revealed the following:04/30/25: R #15's coccyx pressure ulcer identified on 04/28/25, was measured to have a length of 5.0 cm (centimeters), width of 3.0 cm, and a depth of 2.2 cm. Notes stated, Wound is healing well.05/06/25: R #15's coccyx pressure ulcer was measured to have a length of 4.5 cm, width of 3.0 cm, and a depth of 2.0 cm. Notes stated, Wound is healing well.05/15/25: R #15's coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 3.2 cm, and a depth of 2.8 cm. Notes stated, Wound has gotten larger, more drainage, and foul odor. Calcium alginate (specialized wound dressing to prevent infection) with silver added to wound order.05/21/25: R #15's coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 3.5 cm, and a depth of 3.0 cm. Notes stated, Wound is healing well. Mo foul odor to the wound.05/28/25: R #15's coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 5.0 cm, and a depth of 3.3 cm. Notes stated, Wound has gotten larger.06/03/25: R #15's coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 5.0 cm, and a depth of 3.0 cm. Notes stated, Wound is healing well.06/20/25: R #15's coccyx pressure ulcer was measured to have a length of 5.0 cm, width of 4.8 cm, and a depth of 2.9 cm. Notes stated, Wound is healing well.06/24/25: R #15's coccyx pressure ulcer was measured to have a length of 6.0 cm, width of 5.0 cm, and a depth of 2.5 cm. Notes stated, Wound is healing slowly.07/07/25 #1: R #15's coccyx pressure ulcer was measured to have a length of 6.0 cm, width of 6.0 cm, a depth of 2.0 cm, and 3.0 cm tunneling of the wound. Notes stated, Necrotic tissue. Orders for wounds to be seen by wound clinic sent in. Wound progress form indicated that R #15's coccyx pressure ulcer grew wider by 1 cm with 3 cm tunneling and necrosis between 06/24/25 and 07/07/25. 07/07/25 #2: R #15's left gluteal fold (horizontal skin crease that forms below the buttocks) pressure ulcer identified on 06/28/25, was measured to have a length of 5.0 cm, width of 6.0 cm, and a depth of 0.1 cm. Notes stated, Orders for wounds to be seen by wound clinic sent in.No weekly wound progress form was completed between 06/03/25 through 06/20/25, and 06/24/25 through 07/07/25. G. Record review of R #15's Weekly Skin Checks (completed by facility nursing staff) dated 05/02/25 through 07/03/25 revealed the following:05/02/25 at 5:23 am: R #15's coccyx pressure ulcer was not documented.05/09/25 at 1:39 am: R #15's coccyx pressure ulcer was healing well and dressed daily. 05/10/25 at 11:41 am: R #15's coccyx pressure ulcer had wound care in progress. 05/29/25 at 11:04 pm: R #15's coccyx pressure ulcer had wound care in place. 06/06/25 at 10:39 am: R #15's coccyx pressure ulcer was not documented.06/12/25 at 5:05 am: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow.06/19/25 at 12:50 am: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow.06/25/25 at 10:05 pm: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow.07/03/25 at 4:31 am: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow, shearing left buttocks (no measurement documented for left buttocks/gluteal fold).07/11/25 at 4:42 am: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. Left buttock (gluteal fold) wound nurse continues to follow.07/17/25 at 11:55 pm: R #15's coccyx pressure ulcer- wound treatment in place and wound care nurse continues to follow. Left buttock (gluteal fold) wound nurse continues to follow.None of R #15's weekly skin checks for this timeframe indicated R #15's coccyx pressure ulcer was declining and becoming worse, with most indicating that the RNTN was responsible for R #15's pressure ulcers/wounds. No weekly skin checks were documented as being completed for R #15 for the dates of 05/11/25 through 05/28/25. H. Record review of R #15's Treatment Administration Record (TAR) dated 06/01/25 through 06/30/25 revealed the following: Order dated 05/15/25: Treatment time of 6:00 am to 6:00 pm- Wound to coccyx: cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care (order was discontinued on 06/20/25); was marked as completed for every day from 06/01/25 through 06/20/25, except for one day on 06/15/25.Order dated 05/15/25: Treatment time PRN (as needed)- Wound to coccyx: cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care (order was discontinued on 06/20/25); was marked as completed one time on 06/19/25 at 2:30 am. Order dated 06/20/25: Treatment time of 6:00 am to 6:00 pm- Wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care; was marked as completed for every day from 06/20/25 through 06/30/25.Order dated 06/20/25: Treatment time of PRN- Wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care; was marked as completed one time on 06/25/25 at 11:00 pm. I. Record review of R #15's nursing progress notes dated 06/25/25 at 11:00 pm, revealed R #15's coccyx pressure ulcer had a bad odor and the dressing was saturated.J. Record review of R #15's nursing progress notes dated 06/28/25 at 7:26 am, revealed R #15 had a new left gluteal fold pressure ulcer that measured to have a length of 1 cm and a width of 0.5 cm with the middle area dark in color. No new orders initiated. No documentation identifying that the Physician was notified. K. Record review of R #15's physician orders dated 07/03/25 revealed, stage 2 (break in the top two layers of skin) wound to left gluteal fold- cleanse with normal saline, pat dry, apply collagen flakes, apply silicone dressing one time a day for wound care. L. Record review of R #15's nursing progress notes dated 07/04/25 through 07/0/25 revealed the following:07/04/25 at 3:09 pm: R #15 was on observation for a change in condition related to the new left gluteal fold pressure injury. R #15's coccyx pressure injury was not documented as being a part of the change in condition.07/06/25 at 5:32 pm: R #15 continues to experience breakdown related to the coccyx and left gluteal fold pressure ulcers. Strong odor was present for wounds. No indication that the facility RNTN or provider was notified. 07/07/25 at 5:43 pm: R #15 has worsening coccyx and left gluteal fold pressure ulcers. The Nurse Practitioner (NP) gave orders to send R #15 to wound clinic. M. Record review of R #15's TAR dated 07/01/25 through 07/22/25 revealed the following: Order dated 06/20/25: Treatment time of 6:00 am to 6:00 pm- Wound to coccyx- cleanse with wound cleanser or normal saline, apply calcium alginate with silver to wound bed, cover with silicone dressing, and monitor for any signs or symptoms of infection every day shift for wound care; was marked as completed for every day from 07/01/25 through 07/22/25, except for one day on 07/12/25.Order dated 07/03/25: Treatment time of 7:00 am- Wound to left gluteal fold- cleanse with normal saline, pat dry, apply collagen flakes, apply silicone dressing one time a day for wound care; was marked as completed for every day from 07/03/25 through 07/22/25, except for one day on 07/12/25.N. Record review of R #15's physician orders dated 07/07/25 revealed, refer to wound clinic STAT (immediately or without delay) for a stage 2 wound to left gluteal fold and pressure ulcer of sacral region (coccyx pressure ulcer that was identified on 04/28/25), stage 4. O. Record review of R #15's physician orders dated 07/21/25 revealed R #15's wound clinic appointment was scheduled for 07/29/25.P. Record review of the facility's wound report dated 07/23/25 revealed the following:R #15's coccyx pressure ulcer was measured to have a length of 6.2 cm, width of 6.1 cm, and a depth of 2.0 cm.R #15's left gluteal fold pressure ulcer was measured to have a length of 5.20 cm, width of 5.80 cm, and a depth of 0.10 cm.Q. On 07/22/25 at 4:11 pm during an interview with an Anonymous Employee (AE), they stated R #15's coccyx pressure ulcer has gotten worse and the facility was not doing anything to improve R #15's coccyx pressure ulcer. R. On 07/22/25 at 11:32 pm during an interview with Licensed Practical Nurse (LPN) #2, she stated R #15's coccyx pressure ulcer has not been healing very well. The LPN #2 also stated the facility nurses are supposed to complete a skin check and document it weekly. S. On 07/22/25 at 5:29 pm during an interview with R #15's Emergency Contact (EC), he stated he was told by the facility that R #15's coccyx pressure ulcer has gotten worse and R #15 developed another pressure ulcer on her left gluteal fold. R #15's EC also stated the facility told him two weeks prior that they needed to send R #15 to the wound clinic, but R #15 still has not been to the wound care clinic. T. On 07/23/25 at 11:08 am during an interview with Registered Nurse (RN) #2, she stated R #15's coccyx pressure ulcer has not been getting smaller. The RN #2 also stated the RNTN is supposed to measure and document residents' wounds at least one time a week. The RN #2 confirmed the facility nurses will treat R #15's wound as ordered and complete weekly skin checks for R #15, but the RNTN is responsible for implementing new wound treatments and measuring R #15's pressure ulcers. U. On 07/23/25 at 4:15 pm during an interview with the RNTN, she stated R #15's coccyx pressure has been declining and now has necrotic tissue present. The RNTN stated she did not tell the NP of R #15's worsening coccyx pressure ulcer and left gluteal fold pressure ulcer until 07/07/25 because she was not in the facility from 06/25/25 to 07/06/25; but the NP wrote an order to send R #15 to the wound care clinic as soon as the NP was made aware of R #15's declining coccyx pressure ulcer on 07/07/25. She was told that the wound care clinic is very behind for outpatient appointments, so R #15's appointment isn't until the end of July (07/29/25). The RNTN confirmed she usually only comes into the facility one day a week and there were weeks when she was unable to enter the facility for wound care management (06/04/25 to 06/19/25 and 06/25/25 to 07/06/25), but she expected the facility nurses to inform her of any changes to resident wounds and document those changes, so she could change wound care treatments as needed. RNTN also confirmed skin checks should be performed weekly by the facility nurses. V. On 07/23/25 at 5:31 pm during an interview with RN #3, she stated she has never assessed or treated R #15's coccyx pressure ulcer because that is done during the day shift. Record review confirmed RN #3 has not provided treatment to R #15's coccyx pressure ulcer, but RN #3 completed one of R #15's weekly skin checks/assessments on 05/02/25. W. On 07/24/25 at 9:42 am during an interview with the NP, she stated that she saw R #15's coccyx pressure ulcer and left gluteal fold pressure ulcer for the first time on 07/07/25 and R #15's coccyx pressure ulcer needs a debridement procedure (medical procedure that involves the removal of dead, damaged, or infected tissue) due to R #15's coccyx pressure ulcer having a lot of necrotic tissue present. The NP also stated that she put in a STAT wound clinic order on 07/07/25, after seeing R #15's coccyx pressure ulcer and left gluteal fold pressure ulcer for the first time, but R #15's appointment at the wound care clinic is not until the end of July due to the wound care clinic not having any immediate availability. The NP stated that R #15's coccyx pressure ulcer treatment has not changed since 06/20/25, and she cannot change the treatment until R #15's coccyx pressure ulcer has the debridement procedure completed. The NP confirmed if she was made aware of R #15's coccyx and left gluteal fold pressure ulcers sooner, she could have sent her to the wound clinic sooner and R #15's coccyx and left gluteal fold pressure ulcers might have improved. X. On 07/24/25 at 11:55 am during an interview with the Director of Nursing (DON), she stated her expectation was the facility floor nurses should be letting providers know of any pressure ulcer changes immediately and the RNTN should have completed R #15's weekly wound progress forms every week and R #15's declining coccyx pressure ulcer should have been addressed sooner than 07/07/25.Y. On 07/24/25 at 3:32 pm during an interview with the Medical Director (MD), he stated his expectation is the facility nursing staff should have notified a facility provider immediately if a wound is worsening. The MD also stated that if R #15's coccyx pressure ulcer declined between 06/24/25 and 07/07/25, then that should have been addressed as a change in condition as soon as possible to prevent further decline and possibly change the wound care treatment. The MD confirmed that he was unaware of the facility nursing schedule, but he would expect the facility nursing staff to routinely communicate and document any changes to R #15's wounds because earlier notifications of worsening wounds is better for overall wound care management and treatments.

Based on interview and record review, the facility failed to utilize Nursing Assistants (NAs) appropriately by using NAs for more than 4 months, on a full-time basis to provide nursing and nursing related services for 2 (NAs #1 and 2) of 3 (NAs #1, 2, and 3) reviewed for staffing.If the facility is staffing NAs for longer than 4 months, then residents are likely to not receive the appropriate care, services and may not meet the needs of all residents.The findings are: NA #1: A. Record review of the facility staffing list reviewed on 07/24/25 revealed NA #1 was hired by the facility on 01/13/25 as a Nurse Aide in Training. B. Record review of the facility staffing schedule dated 07/21/25 through 07/24/25 revealed NA #1 worked on a unit as a Nurse Aide in Training.C. On 07/24/25 at 2:48 pm during an interview with NA #1, she stated that she just became a Certified Nursing Assistant (CNA) about one week ago, but prior to that, she was working at the facility as a Nurse Aide in Training for longer than 120 days. NA #2: D. Record review of the facility staffing list reviewed on 07/24/25 revealed NA #2 was hired by the facility on 10/30/24 as a Nurse Aide in Training. E. On 07/24/25 at 3:57 pm during an interview with the Director of Nursing (DON), she confirmed both NA #1 and NA #2 were working in the facility as NAs for longer than 120 days and they shouldn't have.

Based on record review and interview the facility failed to ensure a resident was treated with respect and dignity for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed for dignity by:1. Not allowing the resident to leave the facility per his preference.2. Re-directing the resident back to the facility when he has wanted to leave to go for a walk or shopping and not offering the resident an alternate solution/plan. This deficient practice created frustration and confusion for the resident because he did not understand why he was unable to leave. The findings are:A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE].B. On 07/22/25 at 10:51 AM- during a phone interview with R #5's Sister she stated He complains about not being able to leave whenever he wants. I was told that he needs someone to sign him out. I don't know what their policy is about him leaving on his own is but he capable of making his own decisions.C. On 07/22/25 at 11:17 AM during an interview with R #5, he stated. There are no outings here at this facility. I can only go outside to the yard/ would like to walk outside the facility. I walked to the store and bought myself tennis shoes and then came back. No one told me anything. But they say I can't leave without someone signing me out now.D. On 07/22/25 at 12:37 PM during an interview with the Director of Nursing (DON), she stated, the facility van has been down for a couple of months it has affected the activity outings, Activity Department is not able to take the residents on facility planned outings. It was reported. He did leave, he went to [name of local store] and bought shoes. If we let him go out on pass it's not safe/ he has a seizures/fall. We want to make sure he is safe. He doesn't want staff going with him. He has not been deemed incompetent. We should be able to offer that someone goes with him. Even after educating him about signing himself out, he didn't sign out when he attempted to go to [name of local store]. He was not allowed to go; he was re-directed and brought back into the facility. DON confirmed R #5 can make his needs known and has a BIMS score of 15 (Brief interview for mental status 00-15 15 being the highest)E. On 07/22/25 at 1:15 PM during an interview with the Activities Assistant (AA) she stated. He (name of R #5) attends activities when he wants. He is alert and oriented. He asks when we are going to the store, we need to watch him because he will take off. He doesn't buy anything but will go for the ride. He doesn't have money sometimes. I do take him on walks when I can, but not lately. He will go out to the front, but we have to watch him because he'll take off. He thinks he's ok but he's not, he can have a seizure at any time. He cannot sign out and go alone to the store. I will stop him and call for help if I see him walking out the door.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #5) of 3 (R #1, 2 and 5) residents reviewed when staff failed to update the care plan to include R #5 not being able to leave the facility independently. This deficient practice is likely to result in residents' preferences and needs not being addressed if care plans are not updated. The findings are: A. On 07/22/25 at 11:17 am during an interview with R #5 he stated that he would like to be integrated back into the community. He further stated that the facility doesn't have any outings scheduled and he would like to go outside to walk but he was told he was not to leave the facility without someone accompanying him. R #5 feels frustrated because he is not able to exercise his rights to be able to leave the facility to go to the store or to walk around the facility grounds. B. Record review of Activity assessment dated [DATE] revealed: Page 2 question 7. Go outside for fresh air when the weather is nice: 1) Very Important C. Record review of R #5's care plan dated 06/21/25 revealed [name of R #5] stated that he went to the store to buy new pair of shoes and returned to the nursing facility. Interventions: encourage resident to let staff know when he wants to go out to purchase items. D. On 07/23/25 at 12:37 pm during an interview with the Director of Nursing (DON) she stated that R #5 was not safe to go out on his own because he had some medical issues that prevented him from being safe and making sound decisions. R #5 is not in agreement that he needs staff to participate with him when he wants to walk to the store or go for a walk. He has not been deemed incompetent. DON further stated that the facility should be able to offer someone to accompany R #5, but the option is not always offered. DON confirmed that R#5's care plan does not state that resident should not be allowed to leave the facility on his own and needs supervision at all times when he leaves the facility.

Based on interview and record review, the facility failed to have competent (aware of each resident's current health status and regular activity) nursing staff that was aware of anticoagulant (blood thinner) use for 1 resident (R #11) of 1 resident's (R #11) reviewed for falls. If nursing staff are not aware of anticoagulant medications taken by residents; then this deficient practice is likely to result in medication administration errors, the lack of monitoring of the resident's condition, delays in treatment or interventions, and increased risk of serious injury or complications such as bleeding, following a fall. The findings are: A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE]. B. Record review of R #11's physician orders dated 02/07/24 revealed R #11 was prescribed Xarelto (anticoagulant) 2.5 mg (milligrams), give one tablet by mouth twice a day related to heart disease.C. Record review of R #11's care plan dated 05/06/25 revealed that R #11 received anticoagulant medication related to heart disease. R #11's interventions included the facility staff monitor/document/report to a provider any signs or symptoms of anticoagulant complications. Nursing staff were to review R #11's medication list for adverse interactions as well. D. Record review of R #11's nursing progress notes dated 04/17/25 through 04/20/25 revealed the following: 04/17/25 at 11:40 pm: R #11 was yelling at a Certified Nursing Assistant (CNA) and following the CNA throughout the unit. R #11 proceeded to punch Registered Nurse (RN) #3 in the chest and when RN #3 raised her arm to block R #11's second punch, R #11 lost her balance and fell on the floor while also hitting her head. R #11 refused to let RN #3 get her vitals and complete a post fall assessment. 04/18/25 at 5:52 am: R #11's daughter called requesting a follow-up from R #11's previous fall. Nurse will inform day nurse to call R #11's daughter, facility provider was also notified. 04/18/25 at 8:34 am: R #11 is alert and oriented times one (indicating R #11 was aware of who they are but with confusion) and denied pain or confusion. R #11 has a hematoma (a solid swelling of clotted blood within the tissues) and bruising to left side of face. R #11 being sent to hospital for x-rays. 04/19/25 at 5:46 pm: Bruising spreading throughout face and head for R #11. E. Record review of R #11's Medication Administration Record (MAR) dated 04/01/25 through 04/19/25 revealed R #11 received Xarelto 2.5 mg every day as ordered. F. On 07/23/25 at 5:35 pm during an interview with Registered Nurse (RN) #3, she stated that when R #11 experienced a fall with her on 04/17/25, she was unaware that R #11 was on an anticoagulant medication. RN #3 also stated that R #11 experienced significant bruising after the fall on 04/17/25 and the amount of bruising on R #11's face looked horrible. RN #3 stated that she would like a list of residents that took an anticoagulant medication so she could be aware of that in case those residents experience a fall. RN #3 confirmed she did not read R #11's care plan and did not know that R #11 took an anticoagulant medication until R #11 fell on [DATE]. G. On 07/24/25 at 9:43 am during an interview with the Nurse Practitioner (NP), she stated that nursing staff should be familiar with the residents and the medications that residents take. The NP confirmed she would expect RN #3 to know that R #11 took an anticoagulant medication. H. On 07/24/25 at 10:26 am during an interview with the Registered Nurse Consultant (RNC), she stated that she would expect the facility nurses to be familiar with the medications that residents take and she would expect that facility nurses would read residents care plans. The RNC confirmed RN #3 should have known about R #11's anticoagulant medication use. I. On 07/24/25 at 3:37 pm during an interview with the Medical Director (MD), he confirmed that he would expect that RN #3 would have known that R #11 was taking an anticoagulant medication prior to R #11's fall on 04/17/25.

Based on record review and interview, the facility failed to promote resident choices for 1 (R #3) of 2 (R #'s 2 and 3) residents reviewed for choices when staff failed to offer R #3 showers per her preference. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE]. B. Record review of R #3's care plan dated 01/28/25, revealed R #3 required Activities of Daily Living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance with baths/showers due to physical and cognitive impairments. C. Record review of the facility's shower schedule revealed R #3's bath/shower days were scheduled for Monday, Wednesday, and Saturday each week. D. Record review of R #3's documentation survey report (ADL tracking form located in the electronic health record- EHR) dated 03/01/25 through 03/31/25 revealed R #3 was offered three (3) baths/showers out of thirteen (13) opportunities. E. Record review of R #3's shower sheets dated 03/01/25 through 03/31/25 revealed R #3 was offered four (4) baths/showers out of thirteen (13) opportunities. F. Record review of R #3's documentation survey report dated 04/01/25 through 04/08/25 revealed R #3 was offered zero (0) baths/showers out of three (3) opportunities. G. Record review of R #3's shower sheets dated 04/01/25 through 04/08/25 revealed R #3 was offered one (1) bath/shower out of three (3) opportunities. H. On 04/07/25 at 3:09 pm, during an interview, the Ombudsman (State Agency Resident Advocate) stated that R #3 told her that she was not receiving enough baths/showers while in the facility. I. On 04/07/25 at 4:57 pm, during an interview with R #3, she stated that the facility switched her from showers to baths and she will often only be offered/given one bath a week. R #3 also stated that she wants more than one bath a week and when she doesn't get that many baths a week, she feels dirty. J. On 04/08/25 at 1:56 pm, during an interview, Licensed Practical Nurse (LPN) #2 stated that she knew R #3 complained about not getting enough baths/showers in the past and she would always try to check on R #3 . LPN #2 confirmed Certified Nursing Assistants (CNAs) documented resident baths/showers on shower sheets and in the residents EHR. K. On 04/08/25 at 2:55 pm, during an interview, Nursing Aide (NA) #1 stated that R #3 will be itchy a lot and so NA #1 will try to offer her a bed bath as often as she can. NA #1 confirmed R #3 complained to her that R #3 was not being offered or given enough baths a week and NA #1 reported R #3's complaint to the nursing staff. L. On 04/08/25 at 3:05 pm, during an interview, LPN #3 stated that R #3 should be offered at least three baths/showers a week unless she requests to have more. M. On 04/08/25 at 5:08 pm, during an interview, the Director of Nursing (DON) confirmed R #3 was not offered enough baths a week and stated that R #3 should be offered/given more baths a week.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for safe transfer when staff did not have two staff present while providing care of a resident. This deficient practice likely resulted in the resident experiencing an injury, pain, discomfort and less than optimal care. A. Record review of R #1's face sheet, dated 11/31/24, revealed R #1 was admitted to facility on 12/04/21 with the following diagnoses: - Unspecified lack of coordination. - Need for assistance with personal care (requires assistance when dressing, transferring positions, meal setup, showers). - History of traumatic brain injury (a sudden and significant injury of the brain). - Dementia (a chronic progressive disease of the brain that causes decline a decline of the memory). B. Record review of R #1's care plan revealed the following: - Initiated on 03/19/24, R #1 continued to be at risk for falls because of his inability to transfer safely. - Initiated on 12/17/21 and revised on 05/20/24, R #1 was at risk for falls, because of inability to transfer safely. R #1 was unaware of his safety needs. - Initiated on 06/01/23 and revised on 07/01/24, R #1 required TWO STAFF WHEN CARING FOR RESIDENT AT ALL TIMES!!!!!! R #1 had cognitive impairment due to head injury and required guidance and cueing throughout the day. C. Record review of R #1's Daily Care Note, dated 08/24/24, revealed a notation by Licensed Practical Nurse (LPN) #1 of a fall in which R #1 was found on the floor of his room. LPN #1 reported R #1 bled from his head and lay in a puddle of blood. R #1 was assessed and noted to have a large hematoma [an area that is swollen and bleeding] with a laceration [a cut of the skin] to his left eyebrow. D. Record review of the facility's investigation documents, dated 08/24/24, for R #1's fall incident revealed a written statement by Certified Nurse Assistant (CNA) #1. She stated she answered R #1's call light, and R #1 told CNA #1 that he needed to be changed (had a soiled brief and needed a change). CNA #1 assisted R #1 to bed, changed him, and then told R #1 that she needed help from another staff to transfer him back to his chair. CNA #1 stated she told R #1 that she was going to get someone to help her transfer him back to his chair. R #1 did not want to sleep in his bed, because he usually slept in his chair. R #1 did not want to wait. He wanted to be transferred right away. CNA #1 stated she did not want to drop the resident that was why she wanted help. R #1 became angry and did not like that CNA #1 wanted to get assistance. R #1 started punching CNA #1 in the arm and told her that he was going to throw himself out of the bed. CNA #1 made sure R #1's bed was in the lowest position and then walked out of the room to let the nurse know what was going on. CNA #1 heard a noise from R #1's room, and she discovered R #1 was on the floor. There were not any other staff present in the room at the time of the incident. E. On 10/31/24 at 12:20 pm during an interview by phone, LPN #2 stated she witnessed CNA #1 enter R #1's room alone. LPN #2 stated she heard R #1 yell at CNA #1 to return him to his wheelchair. LPN #2 stated CNA #1 exited R #1's room, came to the nurse's station, and reported to her (LPN #2) that R #1 scratched her arm. LPN #2 stated CNA #1 returned to R #1's room alone, entered the room, and then exited. CNA #1 returned to the nurse's station and reported to LPN #2 that R #1 fell and was on the floor bleeding. LPN #2 stated she was aware R #1 was a maximal assist transfer (helper does more that half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). LPN #2 advised CNA #1 to fill out an incident report. F. On 10/31/24 at 2:00 pm during interview with Administrator (ADM) and Director of Nursing (DON), they stated they were made aware that R #1 had fallen from his bed. They stated R #1 sustained an injury to his head and required transfer to the hospital. They stated the resident was evaluated and required several sutures (use of sterile string to sew together a wound or cut). They stated they determined that CNA #1 had failed to use proper procedures to transfer R #1. They stated R #1 required a Hoyer lift and two staff to assist him whenever he was transferred from one position to another. They stated CNA #1 failed to use a Hoyer lift or to ask for help from another staff person when she transferred R #1 from his wheelchair to his bed and from his bed back to his wheelchair.

Based on record review and interview, the facility failed to ensure residents received care consistent with professional standards to promote the healing of pressure ulcers (a localized wound caused by prolonged pressure to an area above a prominent bone) for 1 (R #21) of 1 (R #21) resident reviewed when staff: 1. Delayed in implementing new interventions/treatment (antibiotic) when the wound started to deteriorate. 2. Failed to accurately document presence of wound on skin checks/showers sheets and wound staging on reports. 3. Failed to notify provider of changes in the wound. 4. Delayed in getting R #21 an appointment at the Wound Clinic for treatment (seen 21 days after order). These deficient practices likely resulted in the wound significantly worsening for R #21, exposing bone and osteomyelitis (bone infection). The findings are: A. Record review of R #21's face sheet, dated 06/12/24, indicated R #21 was admitted to the facility on [DATE]. B. Record review of R #21's medical record revealed R #21 was admitted with the following diagnoses: 1. Type 2 diabetes mellitus (a condition results from insufficient production of insulin, causing high blood sugar). 2. Unspecified dementia (a group of symptoms that affects memory, thinking and interferes with daily life). 3. Hypertension [high blood pressure in the arteries (vessels that carry blood from the heart to the rest of the body.)] 4. Contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) of the left and right knees and the left and right hip. 5. Muscle weakness (reduction in the power exerted by muscles resulting in an inability to perform a given task on first attempt). C. Record review of R #21's care plan, dated 08/23/19, revealed the following: - R #21 was at risk for skin breakdown (a condition where the skin is damaged or injured) due to bowel and bladder incontinence and decreased mobility. - Interventions: - Daily skin checks. Document results in resident's record. Notify nurse on duty if there is any type of skin break down. - Weekly skin checks. Document results on skin sheet. Notify Medical Doctor (MD) if there is any type of skin break down noted. - Assist and encourage resident to change position every two hours while in bed. - R #21 had wounds: - On 05/22/23: Redness to coccyx (tail bone located at the end of the spine). - On 01/12/24: Re-open area to coccyx. (Wound was facility acquired) - On 05/14/24: Stage 2 (partial thickness loss of skin presenting as a shallow, open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). Interventions: Cleanse wound to coccyx with wound cleanser (an anatomic solution used to rinse or irrigate wounds), apply calazime cream (a skin protectant paste that contains zinc oxide), and cover with dry dressing until healed. D. Record review of R #21's Weekly Pressure Injury Trending Reports revealed the following: - Date of report: 05/15/24. - Wound Type: Pressure Injury. - Wound Location: Coccyx. Acquired in house (developed in the facility). - Date wound identified: 05/12/24. - Stage: 2. - Wound Measurements (Week 2): 2.4 cm length x 1.4 cm width x 0.5 cm depth. - Treatment: Barrier cream (a topical formulation used in industrial applications and as a cosmetic to place a physical barrier between the skin and contaminants that may irritate the skin) with dry dressing (dry absorbent bandage). - Date of Report: 05/22/24. - Wound Type: Pressure Injury. - Wound Location: Coccyx. - Wound Status: Unchanged. - Stage: 2. - Measurements (Week 3): 2.5 cm length x 1.5 cm width x 0.5 cm depth. - Treatment: Unchanged. E. Record review of R #21's Weekly Wound Progress note, dated 05/22/24, revealed R #21 had one wound on her coccyx. Staff documented the wound was a skin tear (a type of injury where the skin is torn from the body) with odor present. The wound had 100 percent (%) red and black granulation tissue (a type of connective tissue that forms on the surface of a wound during the healing process) present, and the wound measured 2.5 centimeters (cm) in length by (x) 1.5 cm in width x 0.5 cm in depth. F. Record review of R #21's Physician Orders revealed the following: - Order, dated 05/21/24, referral to Wound Clinic for unstageable pressure injury to coccyx. - Order, dated 05/21/24, Pro-Stat oral liquid (concentrated liquid protein). Give 30 milliliters (ml) by mouth two times daily. - Order, dated 05/22/24, zinc oral tablet (supplement taken by mouth to support the immune system), 50 milligrams (mg). Give one tablet by mouth once daily. G. Record review of R #21's progress notes revealed staff documented the following: - On 05/15/24, resident had new pressure sore to coccyx. It was healing well with red granulation tissue. Was cleaned and dressed as ordered. Resident tolerated well. - On 05/19/24, wound to coccyx tunneled (through layers of the skin) with a strong foul odor. Blood and wound drainage on dressing. Informed Director of Nursing (DON). Wound treatment done as ordered. - On 05/21/24, wound to coccyx with foul odor. Will notify Wound Care Nurse (WCRN) this morning. - On 05/21/24, resident complained of pain to coccyx. Cleaned area and gave as needed (PRN) pain medication. Will continue to monitor throughout the shift. - On 05/22/24, wound to coccyx continued with foul odor. - On 05/22/24, resident had a new pressure sore to coccyx. It was healing well with red granulation tissue but does have a foul odor. Was cleaned and dressed as ordered. Resident tolerated well. Wound clinic referral made. H. Record review of R #21's Physicians Note, dated 05/27/24, revealed the resident's wound was worsening, and the resident waited for an appointment at the Wound Care Center. Wound had slough (a type of necrotic tissue that accumulates on the surface of a wound) per photos. Physician recommended change wound dressing to Santyl (name of ointment; removes dead tissue from wounds so they can start to heal). I. Record review of R #21's Weekly Pressure Injury Trending Reports revealed the following: - Date of Report: 05/28/24. - Wound Type: Pressure Injury. - Wound Location: Coccyx. - Wound Status: Unchanged. - Stage: 2. - Measurements (Week 4): 6.0 cm length x 4.0 cm width x 4.9 cm depth. - Treatment: Unchanged. - Date of Report: 06/04/24. - Wound Type: Pressure Injury. - Wound Location: Coccyx. - Wound Status: Unchanged. - Stage: 2. - Measurements (Week 5): 6.0 cm length x 4.2 cm width x 4.5 cm depth. - Treatment: Unchanged . J. Record review of R #21's shower sheets revealed staff documented the following: - 05/01/24: No new conditions. - 05/08/24: No new conditions. - 05/10/24: Skin check (staff observed skin for any abnormalities including wounds or signs of breakdown). - 05/15/24: No new conditions. - 05/17/24: Open area reported with coccyx area circled on shower sheet. - 05/22/24: No new skin conditions. - 05/31/24: No new skin conditions. K. Record review of R #21's Physician Orders revealed the following: - Order, dated 05/28/24, wound culture (a small sample of a substance from patient's body to test for bacteria) with sensitivity (test that determines what antibiotic can kill a certain bacteria). Diagnosis: Worsening wound to coccyx with foul odor. - Order, dated 06/02/24, cleanse wound to coccyx with wound cleanser and pat dry. Apply Santyl to slough, pack with a wet to dry dressing, apply barrier cream to edges of wound, cover with a dry dressing, change daily and as needed (PRN). - Order, dated 06/02/24, reposition resident from right side to left side while in bed. Avoid placing resident on coccyx to promote healing. - Order, dated 06/03/24, refer to hospice for wound to coccyx and decline in condition. - Order, dated 06/10/24, Santyl external ointment, 250 unit/gram (g). - Order, dated 06/11/24, stage 4 [a full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dark dead tissue) may be present on some parts of the wound bed] sacral pressure ulcer with exposed bone. Bone sent for culture (cx; a sample taken from the body used to diagnose infection) at wound care. Patient referred to emergency room (ER) for surgical consult, IV antibiotics, case management consult for discussion of goals of care, and possible palliative care consult. L. Record review of R #21's progress notes revealed staff documented the following: - On 05/28/24, spoke with Nurse Practitioner (NP) and received order for Bactrim DS (medication used to treat bacterial infection) twice a day (BID) for 10 days. Pending appointment with wound clinic. Wound care provided daily and as needed. Daughter/Power of Attorney (POA; the authority to act for another person) notified of antibiotic therapy (ABT; taking an antibiotic to resolve infection) and wound. The daughter to visit this evening. Doctor (Dr.) visited yesterday and was updated on wound. He gave an order for hospice evaluation. Will speak with daughter and plan further care. - On 05/29/24, resident had pressure sore to coccyx. It was healing well with red granulation tissue, slough, and eschar. The wound had a foul odor. Was cleaned and dressed as ordered. Resident tolerated well. Wound clinic referral made. - On 05/29/24, resident continued on ABT for wound. Adverse effects were not noted. Wound culture results still pending and awaiting wound clinic appointment date at this time. - On 05/30/24, wound to coccyx continued with foul odor. Continued on Bactrim DS without adverse side effects. - On 05/30/24, resident tolerated wound care well. A discharge present on wound dressing and a foul odor. Resident on antibiotics for wound. - On 06/01/24, resident tolerated wound care well. Drainage and odor present to wound. Resident was on antibiotics. - On 06/02/24, wound treatment done to coccyx. Resident tolerated well, without complaints of pain or discomfort. Dressing had drainage and odor noted. - On 06/02/24, resident remained on antibiotics for wound to coccyx. Resident on Bactrim DS BID for 10 days. Wound culture sent to hospital on 5/28/24. - On 06/05/24, resident continued on antibiotic treatment for wound. Adverse effects were not noted. Wound culture results still pending. Wound clinic appointment on 6/11/24. - On 06/07/24, resident was alert and without pain or discomfort. Wound care completed, and resident tolerated well. Drainage to bandage and odor present. On antibiotic for wound. - On 06/08/24, resident tolerated wound care well. Drainage to bandage present. Odor present. Resident on antibiotics for wound. - On 06/11/24, resident had an appointment with the hospital wound clinic this morning at 7:45 am. Transported via facility van and accompanied by staff. Daughter met resident at appointment. Wound clinic staff spoke with daughters about hospice/palliative care versus aggressive treatment. Daughters wanted to send resident to the ER for further evaluation and management of wound. Per note from wound clinic, bone sent for culture wound care. Resident referred to the ER for surgical consult and intravenous (IV; inserted in the vein) antibiotics. Case management consult for discussion of goals of care and possible palliative care consult. M. Record review of R #21's Electronic Health Record (EHR) revealed a note from the hospital wound clinic, dated 06/11/24. Stage 4 sacral (tailbone) pressure ulcer with exposed bone. Bone sent for culture and wound care. Patient referred to ER for surgical consult and IV antibiotics. N. On 06/12/24 at 2:02 pm during interview with the Wound Care Nurse (WCRN), she stated she first saw the R #21's stage 2 pressure injury to coccyx on 05/22/24, and it had a foul odor, and the Family Nurse Practitioner (FNP) saw the wound the same day. She stated she expected antibiotic therapy to be ordered on [05/22/24]. The WCRN stated she sent a wound culture to the hospital, but she was not sure if it came back. WCRN stated that there was a period of time when she was pulled to work the floor and wasn't able to update wound reports and review the wounds. WCRN also stated she would have expected the provider to order the ABT when foul smell was identified. O. On 06/13/24 at 10:43 am during an interview with Certified Nurse Aide (CNA) #1, he stated he was aware R #21 had a pressure injury to her coccyx, and it had a foul odor. He was aware of the odor from the wound, because he assisted the nurses with positioning the resident for bandage changes. CNA #1 stated skin checks were done on all residents on 05/10/24. He stated CNAs checked for and documented any new skin conditions. He stated the CNAs alerted the nurse when they found a skin issue, and they documented it on the shower sheet. He stated the CNAs always reported any discoloration, anything that looked out of the normal, a mole, and dry skin. CNA #1 stated they did skin checks at random times. He stated if the nurses found a pressure wound on someone in an area, then they checked the other residents in the area. P. On 06/13/24 at 11:31 am during an interview with CNA #6, she stated the CNAs documented everything they saw during a shower on each resident's shower sheet. Q. On 06/13/24 at 12:41 pm during an interview with the DON and the Regional Nurse Coordinator (RNC), they stated it was expected staff would take action sooner to assess the wound and inform the provider of condition of wound. After reviewing the progress note entered on 05/19/24, the DON confirmed it was her expectation that the nurse report changes to the provider and document how the wound was being treated. The DON stated the resident's record did not contain documentation on the progression of the wound. The DON stated sometimes a foul-smelling wound was a sign of an infection. She stated staff perform skin checks weekly as a skin assessment performed by the nurse. The DON stated staff fill out [document what we see] shower sheets according to the nurses' preference. She stated staff needed training on documenting on the progress of the wound and all actions taken in the resident's record. R. On 06/13/24 at 1:49 pm during an interview with the Family Nurse Practitioner (FNP), she stated the first time she saw R #21's wound it had a bad smell. She described the wound as necrotic (dead tissue). She stated she never saw the results from the wound culture she ordered on 05/28/24. The FNP stated if staff would have informed her of the change in R #21's wound then she would have suggested that R #21 go to the wound clinic sooner. She stated she expected the facility to call the 24 hour on-call provider to inform them of any change of condition so appropriate action could be taken. The FNP stated staff should have considered the changes in the resident's wound to be a change of condition.

Based on observation, record review, and interview the facility failed to ensure that 1 (R #1) of 3 (R #1, 26 and 42) residents reviewed for wounds was free from neglect when: 1. A wound on R #1's toe was identified in [DATE] but no wound care orders were implemented nor was the wound being monitored until [DATE]. 2. The ill fitting shoes which likely cause the toe wound was still available for R #1 to wear. 3. Ordered antibiotics were not administered when infection was identified. This deficient practice likely resulted in R #1's amputation of his toe. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Type II Diabetes Mellitus w/o (without) complications [a disease in which your blood glucose, or blood sugar, levels are too high.] 2. Unspecified Dementia [a term used to describe a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life.] 3. PTSD [Post Traumatic Stress Disorder: mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it. Symptoms may include flashback.] 4. Compression of Brain [a serious and potentially life-threatening condition which produces increased pressure on the brain.] 5. Traumatic Subdural Hemorrhage w/o loss of consciousness [a type of bleed inside your head. It's a type of bleed that occurs within your skull but outside the actual brain tissue.] 6. Major Depressive Disorder [a persistent feeling of sadness and loss of interest.] 7. History of Methicillin Susceptible Staphylococcus Aureus Infection (MSSA) [a type of bacteria that's resistant to a number of widely used antibiotics.] B. Record review of R #1's Visit Notes from Foot and Ankle Specialists dated [DATE] revealed that R #1 had a HKT lesion [an area of rough or patchy skin that feels different from the surrounding skin] to PIPJ [proximal interphalangeal joint (PIPJ) is a bicondylar, synovial, hinge joint] of the right 2nd digit [second toe from big toe on the right foot]. It was debrided [a procedure to remove infected/dead tissue from a wound] without complications. The initial reason for the visit was to provide routine nail care. C. Record review of Progress Notes in eMAR (electronic Medication Administration Record) does not reflect the visit on [DATE]. D. Record review of Weekly Skin Checks from [DATE] until [DATE] did not identify any wounds or open areas on R #1's body. E. Record review of Progress Notes dated [DATE] revealed nurses note which stated Resident has an open area with redness surrounding to his (R) 2nd digit toe. Saturday night ([DATE]), night nurse notified provider of this condition. Today ([DATE]) on day shift provider gave orders to start resident on Keflex [medication used to treat a wide variety of bacterial infections] 500 mg [milligrams] TID [three times a day] for seven days and provide Epsom salt soaks q [every] shift also for seven days. F. Record review of Visit note from Foot and Ankle Specialists dated [DATE] revealed Hyperkeratosis (a thickening of the outer layer of the skin) noted at right dorsal 2nd digit PIPJ. Wound measures 0.4 cm [centimeters] length x 0.3 cm width x 0.3 cm depth Deepest wound base noted bone and joint. (This indicates that the infection has reached the bone) Purulent drainage [thick consistency] noted at this time. G. Record review of Progress Notes dated [DATE] revealed nurses note labeled F/U [follow up] open area R (right) Foot, 2nd toe. Stated Rsd .[resident] Continues with small open area to R foot, 2nd toe. Rsd. had appt with [Name of Dr.] at Foot and Ankle this morning. Returned with new orders for daily wound care (TAO) [triple antibiotic anointment] and Band-Aid, doxycycline [used to treat a wide variety of bacterial infections] 100 mg BID [twice a day] x [time] 7 days, STAT [without delay : immediately] referrals to Circulate Vascular (Name of imaging service), X-ray Company (Name of imaging service and Name of imaging service. Symptoms: right second digit [toe] osteomyelitis [an infection in a bone] with cellulitis [a common, potentially serious bacterial skin infection]. H. Record review of Wound Report dated [DATE] revealed Right Foot, 2nd digit deep Tissue Injury measures 0.5 cm x 1.0 cm, INH [in house acquired] no drainage or sign of infection. I. Record review of Visit note from Foot and Ankle Specialists dated [DATE] reveled Patient comes to us today to follow up with pain in the right foot 2nd toe ulcer. The pain has been present for 1 month. Wound measures 0.4 x 0.3 x cm. Purulent drainage noted at this time. Maintain current treatment plan. Orders given include: Continue Neosporin(antibiotic ointment) & Band aide, Finish doxycycline, CT Scan (a computed tomography scan allows doctors to see inside your body. It uses a combination of X-rays and a computer to create pictures of your organs, bones, and other tissues) for OM [Osteomyelitis a bacterial infection in the bone]. J. Record review of progress notes dated [DATE] did not reflect any notes pertaining to the outcome of the visit or physician's orders following R #1's visit at Foot and Ankle Specialists on [DATE]. K. Record review of Weekly Wound assessment dated [DATE] stated wound to right foot, top of 2nd toe measures 0.2 cm x 0.2 cm. No signs of infection, no drainage. L. Record review of Visit Note from Foot and Ankle Specialists dated [DATE] revealed Wound measures 0.5 x 0.1 x 0.3 cm deepest wound base noted bone and joint purulent drainage noted at this time. Positive probe to bone. Orders received: Continue PO [oral] antibiotics, Needs Right 2nd toe CT, Plan for toe amputation after revascularization (a procedure that can restore blood flow in blocked arteries or veins.) M. Record review of Foot and Ankle Specialist order dated [DATE] identified continue PO antibiotics. Handwritten note dated [DATE] on the order form revealed Notified MD. N. Record review of progress notes from [DATE] do not reflect R #1's visit to Foot and Ankle Specialists on [DATE] or any orders received from physician. O. Record review of eMAR dated [DATE] to [DATE] reflected that resident (R #1) received one dose of doxycycline on [DATE]. According to the eMAR resident did not receive any further antibiotic treatment. P. Record review of Visit Note from Foot and Ankle Specialists dated [DATE] revealed Patient comes to us today to follow up with pain in the right foot 2nd digit toe ulcer. The pain has been present for 2 months. Plan for amputation [surgical removal of all or a portion of a limb] on [DATE] at surgical facility, discussed possible need for further surgery. Will see for post op (after operation). Q. On [DATE] at 9:07 am during interview with R #1's Primary Care Physician [PCP] when asked about R #1's wound to right 2nd toe he [PCP] stated It was infected, I can't say for sure for how long, it was necrotic [dead tissue]. He [R #1] was referred to the podiatrist [foot doctor]. (R #1 was referred to the foot doctor on [DATE].) We did not communicate directly, but I reviewed his [foot doctor's] notes and approved the orders I agreed with. (antibiotics and wound care.) R. On [DATE] at 12:33 pm during interview with Director of Nursing [DON] it was confirmed that Nurse Aides will inform the nurse on duty verbally of any skin conditions but do not document them. S. On [DATE] at 11:24 am during interview with R #1's daughter #1 [D #1] she stated The nurse called, he [R #1] was showering from what I recall, they called me and it was a female nurse. They were showering him, he had hit his toe and they were going to check it to see if it was broken or what was going on because he had hit it pretty hard. From there it got infected. (Unable to provide specific date) About a week after the call he [R #1] went to the foot doctor. I didn't see the toe until I met him [R #1] at [Foot and Ankle Specialist]'s office for the second visit ([DATE]). He [Foot and Ankle Specialist] said it was infected and that the infection had already hit the bone. It was swollen, red and purple, and it had a hole in it. During interview with D #1, she was asked how R #1's amputation of the 2nd right toe has affected his life she replied I think he was depressed, he puts his head down, he wouldn't talk. He was relieved it wasn't all four toes but overall he was sad because he didn't understand why it had happened. T. On [DATE] at 1:32 pm during interview with R #1's Daughter #2 (D #2), she stated My sister [D #1] got a call from the facility and they told her that in the shower he supposedly hit his toe. They were going to take him for X-rays to see if he broke it. When I saw it bandaged, I asked the wound nurse so what's going on with my dads toe? Because they had it wrapped up. I was told it looks fine. (Unable to recall exact date of occurrence). When asked if she saw the wound bandaged or the wound being treated she replied No. I didn't see it treated, I did see it wrapped. The foot doctor had to put a slit ( a small incision) to check to see how far the infection was going (referring to the Probe to bone test on [DATE]), it (right second toe) wasn't hurting him [R #1] at the time, because he had no feeling in the toe because the tissue had already died . When asked What happened with the antibiotic therapy [Doxycycline]? D # 2 replied I'm not sure, there was no follow up. I asked isn't he [R #1] supposed to be on antibiotics? I was told he finished them. He started the antibiotics at the first visit with the foot doctor. At the 3rd visit on [DATE], they were ordered to continue. Several weeks passed before he ( R #1) saw the foot doctor again. When he saw him [R #1] he [the foot doctor] said he[ R #1] should be on antibiotics, the toe needed to be amputated and he [the foot doctor] was really concerned that the infection could spread. U. On [DATE] at 3:57 pm during an interview with Wound Care Nurse [WCRN] she stated His [R #1] family brought him some tennis shoes, the toe rubbed on the top of the shoes. We took the shoes away but he [R #1] would find them and put them back on. We gave him slippers. On [DATE] and stored his tennis shoes in his room closet. He was started on antibiotics, it [right second toe] was irritated and had redness, PCP (Primary Care Physician) approved the orders from [Physician #1] and we followed the treatments. They [residents] come back from the foot doctor with progress notes and we scan them into the eMAR under Miscellaneous Orders. She further stated that there was no antibiotic therapy ordered. V. On [DATE] at 4:19 pm during interview with Certified Nurse Aide #1 [CNA #1] she stated. All I know is he [R #1] had gone to have it [ 2nd right toe] checked and the doctor [the foot doctor] wanted to have it removed (his toe). The nurses would tell us not to let him have the tennis shoe and to put on his slippers instead. W. On [DATE] at 11:07 am during interview with CNA #2, she stated she helped R #1 with showering and dressing and she helped dry his feet and put on his shoes. He (R #1) is given a choice of either his black tennis shoes or his slippers, those black tennis shoes are his favorite shoes. He can choose which shoes his wants to wear we honor his preference. He had a bandage on his toe (Right 2nd toe) so CNA #1 didn't see his toe and therefore was unable to describe the appearance of his toe. CNA #2 further stated that R #1 would tell her they were going to cut off his toe because it wasn't working, he was upset about it. X. On [DATE] at 11:37 am during interview with WCRN when asked, what kind of shoes did he [R #1] have that were rubbing on his toe? WCRN stated. Black tennis shoes, he doesn't have them anymore, at least I don't think he has them anymore. Y. On [DATE] at 11:45 am during interview with CNA #2 when asked when the last time she saw R #1 wearing the black tennis shoes? She stated I think it was last week. Z. On [DATE] at 11:55 am during interview with D #1, when asked if R #1 still has the black shoes that were rubbing on his toe she stated Yes. I wasn't told they were rubbing on the top of his foot. He was wearing them the last time I visited him, a few days ago. AA. On [DATE] at 1:29 pm D #1 sent a photo of R #1 wearing the black tennis shoes. The photo was received to Surveyors phone and it was confirmed with D #1 that these were the same black tennis shoes that R #1 has had that had caused the injury to the right 2nd toe. BB. On [DATE] at 9:54 am during interview with PCP he stated Initially, from what I recall, it [right second toe] was swollen and red, it looked infected, it had cellulitis ([DATE]). The next time I saw it was when it was gangrenous (is death of body tissue due to a lack of blood flow or a serious bacterial infection). The change would have occurred within ,d+[DATE] weeks. Somewhere around that timeframe. When asked At what time were you informed about the amputation? he replied From what I can recall, it was ,d+[DATE] weeks prior to the procedure [[DATE]] it may have been sooner than that. When asked Did the facility communicate with you that there was a second order for antibiotics? he replied No, I don't recall being informed of that. When asked Would you have expected communication on this? he replied Yes, they [the facility] usually notify me of any new orders. When asked Who is responsible for treatment and monitoring of this wound? he replied The wound nurse and staff nurse are the ones who carry out the treatments and monitor the wound. CC. On [DATE] at 10:25 am during an interview with Foot and Ankle Specialist he stated that R #1 had a corn on his right 2nd toe and that it was related to friction and he [R #1] had some tenderness to the area. When asked, Could it have been related to an ill fitting shoe? He stated. Yes. It could have been. When asked How many times he had seen R #1? He replied The first and last time I saw him was in [DATE]. That was when they [the facility] flipped out on me (facility was upset because he was reporting the facility for neglect). In fact, that was the last time I saw any of those residents The nursing home stopped sending patients to me because I called them out a couple of times for various things that had come up. That made me feel even worse, but I have an ethical duty to report things like that. Patients were coming to me with infections to the point where I had to send them to the ED [Emergency Department]. These findings resulted in Immediate Jeopardy being identified. The facility Administrator was notified of the Immediate Jeopardy on [DATE] at 3:21 pm. The Administrator and the Director of Nursing (DON) were notified at this time. The plan of removal was received and accepted on [DATE]. Implementation of the Plan of Removal was validated onsite through observation and interview. The Plan of Removal Included: 1. The facility will audit all appointments to ensure all records are received by facility and follow up with the family to the recommendations of all MD appointments and copies are given to the facility. Educate transportation staff and nursing staff. 2. The Transportation department will enter a note on all documentation provided and given to the medical records department on each resident and note if none was received by MD office. Educate transportation staff and nursing staff. 3. Request the notes from any MD office appointment if facility does not receive them for any reason. Educate transportation staff and nursing staff. 4. Resident R #1 will have a full head to toe assessment today [DATE]. 5. Assistant Director of Nursing [ADON] will immediately audit all skin checks and ensure they are up to date. Skin issues will be reported and documented today. 6. All appointments will be audited by nurse and followed up by DON and ADON. Staff education will be provided to the transportation and nursing staff. 7. All skin issues (bruises, scratches, rashes, lesions, wounds, and surgical wounds) will be added to the wound report and will be reported by the wound nurse the MD and followed up by the DON currently completed [DATE]. 8. All residents will have a skin assessment as soon as possible, notify any change of condition, facility will notify the resident physician, and resident's POA (Power of Attorney)/responsible party. The facility will implement any treatment ordered by the physician. Any new condition will be reported to the wound nurse for follow up on wound report. Director of Nursing and Assistant Director of Nursing will follow up on all skin conditions. All plan of removal correction plans will be completed by [DATE]

Based on record review and interview, the facility failed to ensure that 1 (R #52) of 1 (R #52) received treatment and care in accordance with professional standards of practice. This deficient practice is likely to result in resident experiencing delayed treatment or a change in condition. The findings are: Resident #52 A. On 03/01/22 at 9:04 am during an interview with R #52, he stated, I have been having right shoulder pain on and off for a couple of weeks, but it has been getting worse in the last week. I have been unable to move it very much cause, it hurts so bad. I have let the nurse know and the nurse gave me some Tylenol (medication used for pain relief), and put on this patch ([MEDICATION(S)] patch- a patch used to help relieve pain-numbs your nerves in a specific area of body) and it would help for a while and then the pain would start all over again. I have told several of the nurses that I would like to get an X-ray (an image or picture of a certain body part) done because I want to know why it (right shoulder) hurts so bad, and I want to know why they haven't taken me to get an X-ray before the pain got this bad. I am unable to sleep at night and it is getting harder to do things for myself (perform his activities of daily living care- dressing, transferring, eating, bathing). I have not fallen or anything like that, but, they just don't listen to me here. I think they do not believe me when I tell them how bad it (right shoulder) hurts. I want to get out of here so I can go get it checked out myself with my Doctor or at the hospital. B. Record review of Facesheet revealed R #52 was admitted on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] Peritonitis (inflammation of the membrane lining the abdominal wall) Degeneration of nervous system due to alcohol (process of decline or getting worse) Disorientation (the condition of having lost one's sense of time, place or identity) Alcoholic liver disease (disease caused by heavy use of alcohol- the process in which the liver breaks down alcohol) Alcoholic [CONDITION(S)] of liver without ascites (disease that causes liver to become stiff, swollen and unable to function properly) C. Record review of Physicians orders dated 12/09/22 revealed: Active order #1 Acetaminophen Suppository 650 mg (milligrams) Insert 1 suppository rectally every 4 hours as needed for pain; elevated temperature, fever greater than 100 (degrees) Active order #2 Acetaminophen tablet 500 mg, give 2 tablets by mouth every 4 hours as needed for pain; elevated temperature, fever greater than 100 (max.(maximum) dose 3,000 mg per 24 hours) Active order #3 dated 02/28/22 [MEDICATION(S)] Patch Apply to right upper arm topically one time a day for Pain for 2 Days 5% patch, remove after 12 hours and remove per schedule C. Record review of Medication Administration Note dated 02/27/22 revealed two (2) Acetaminophen (medication used to relieve pain) Tablets 500 mg were administered at 9:23 am for right shoulder pain. Findings of Record review of Medication Administration Note. D. Record review of Medication Administration Note dated 03/02/22 at 7:18 am revealed two (2) Acetaminophen Tablets 500 mg were administered for pain to right shoulder. E. Record review of Medication Administration Note dated 03/02/22 at 2:04 pm revealed two (2) Acetaminophen Tablets 500 mg were administered for pain to right shoulder. F. Record review of Medication Administration Note dated 03/03/22 at 00:57 (12:57) am revealed two (2) Acetaminophen Tablets 500 mg were administered for pain to right shoulder pain. G. Record review of Medication Administration Noted dated 03/03/22 revealed two (2) Acetaminophen Tablets 500 mg were administered at 14:05 (2:05 pm) given for pain. H. Record review of Medication Administration Note dated 02/13/22 revealed two (2) Acetaminophen tablet 500 mg were administered at 2049 (8:49 pm) for complaints of pain to right shoulder I. Record review of Medication Administration Note dated 02/16/22 revealed two (2) Acetaminophen tablet 500 mg were administered at 1326 (1:26 pm) for complaints of shoulder pain J. Record review of skilled evaluation note dated 02/27/22 revealed vocal (R #52) complaints of pain. Pain description: Achiness-RUE (right upper extremities--upper limbs) reports that pain occurs daily. Doctor was notified and [MEDICATION(S)] Patch to LUE QD (daily) for pain. K. Record review of nurses notes dated 03/01/22 at 5:57 am revealed, Resident (R #52) did have complaints of pain to right shoulder. PRN (as needed) Tylenol administered with effective results. New order for [MEDICATION(S)] patch daily x (times) 3 days for pain to right shoulder started as well. L. On 03/02/22 at 11:35 am during interview with the Director of Nursing (DON), when asked what the process was when a resident complained of pain, DON stated, Typically the nurses will assess the pain and will administer a PRN (as needed) medication and if that does not work or if the resident continues to complain of the same pain, the nurse will notify the doctor and he will give us some kind of an order, we will try new order and then re-assess. If they (residents) need something more the physician will order something else, or try other interventions. If nurse or the resident feel that they need an X-ray the nurse will notify the doctor and he will give us an order to send the resident out for the X-ray. Typically if they (resident) request it (X-ray) we will send them for one. They (nurses) should have sent him [R #52] out for an X-ray to see where the pain was coming from. DON was not sure if the nurses had reported the pain to the Doctor. DON stated, that the Doctor should have been notified if the resident was still complaining of pain with no relief and also if the resident had requested to be taken for an X-ray. M. On 03/03/22 at 8:14 am during an interview with Certified Occupational Therapist (COTA), she stated, He (R#52) complains about pain in his right shoulder, it has been about a week to a week and half that he has been complaining of that shoulder pain. I asked him if he had told the nurse about it and he stated he had and he had asked them if they could take him to get an X-ray. He comes in to the therapy room and I put biofreeze (a topical ointment used to soothe minor pain). He says it helps him and he says he does not know what is causing the pain. N. On 03/03/22 at 11:54 am during an interview with the Physician, he stated, It [R #52's shoulder pain] is not an emergent (urgent, unexpected occurrence) thing. I like to do my homework; I like to treat residents here in the facility. Anyone else would send them out and put it on another Doctor to figure out what is wrong, but I don't like to give my work to other Doctors. I like to figure it out myself. I was called about his shoulder pain at some point. I am not sure when I got the call because I did not document it. I get calls about his pains all the time. I treat all his pains the same way, he complains about constant pain. I think the nurse told me he had some pain to his shoulder and she said R #52 had told her (nurse) that it had been ongoing since he received his COVID vaccine (vaccine used to prepare the body's immune system to protect against COVID-19- [an infectious disease caused by the [CONDITION(S)]-CoV-2 virus, that can cause symptoms that vary from unnoticeable to life threatening]) months ago. (Resident has not had a COVID vaccine) He further stated that he would have liked for him [R #52] to have been sent out if the pain was on-going and he would have expected for them [facility staff] to let him [Physician] know that the pain medications he was being given were not working or that the pain continues. Physician also stated that there are many residents that have pain after the vaccine and that kind of pain is an easy fix but he was not told of the continued pain. Physician confirmed that he had not seen R #52 for his right shoulder pain. O. Record review of Imaging Report from [name of local hospital] dated 03/03/22 revealed abnormal alignment at the [MEDICATION(S)] ligature joint consistent with Grade 3 AC separation ( a tearing of the joint and ligaments connecting the shoulder blade and collar bone) Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 ( R #33) of 1 (R #33) residents reviewed for timely Urinary Tract Infection ([CONDITION(S)]) medication and treatment. This deficient practice is likely to result in residents not receiving the appropriate medical care as needed, leading to an exacerbation (to make worse) of current medical conditions. The findings are: A. Record review of R #33's Hospital Discharge Instructions dated 02/09/22 revealed the following: 1. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. [MEDICATION(S)] [antibiotic] 500 mg [Milligram] Oral tablet- Take 1 tablet by ORAL route every 12 hours for 10 days. 3. [MEDICATION(S)] Z-Pak [antibiotic] 250 mg Oral Tablet- Take 1 tablet by ORAL route as directed for 5 days Day 1 - take two (2) tablets one time. Day 2, 3, 4 , 5 take one (1) tablet once daily. B. Record review of R #33's Nurse Progress notes dated 02/10/22 at 5:59 am revealed, Resident ready to be discharged back to the facility. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] [antibiotic] 1 gm [gram] was given to resident along with [MEDICATION(S)] [Narcotic pain medication] for pain relief. Discharge orders also stated that previous order for [MEDICATION(S)] could be used for pain. Prescription for [MEDICATION(S)] and Zpac were sent to [Name of local store], will have day nurse follow up with getting these medications. Resident will need a new prescription for [MEDICATION(S)], MD [Medical Doctor] notified of this and awaiting reply. Resident arrived back to facility at approximately 0545 [5:45 am], in pleasant mood and no complaints of pain or discomfort. C. Record review of R #33's Nurse Progress notes dated 02/12/22 at 6:23 am revealed, Note Text: Informed provider no order for antibiotics have yet been entered per [Local Hospital] to treat [CONDITION(S)] and PNA. All reports had been sent to provider. Informed day nurse for follow-up on orders for treatment. D. Record review of R #33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . E. Record review of R #33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Give 500 mg by mouth every 12 hours for ANTIBIOTIC for 10 Administration Days Note- med unavailable nurse notified. F. Record review of R #33's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . nurse notified. G. Record review of Nurse progress note dated 02/14/22 at 3:14 am revealed, Note Text: Follow up: Resident on follow up for antibiotic therapy, has started Zpac for PNA, first dose administered with no adverse reactions present. No respiratory concerns this shift, lung sounds are clear and resident denies having trouble breathing. Continuous oxygen at 2 liters per minute, oxygen saturation at 90% [percent]. Antibiotic for [CONDITION(S)] not started and is not available in the E-kit, (an automated medication dispensing system) order sent to [Name of local pharmacy]. Resident will start medication as soon as it is delivered. Resident denies having any urinary symptoms at this time. H. Record review of R #33's MAR progress note dated 02/14/22 at 7:09 am revealed, Note Text: [MEDICATION(S)] Tablet 500 MG-Give 500 mg by mouth every 12 hours for ANTIBIOTIC for 10 Days- Med unavailable. I. Record review of R #33's Nurse progress note dated 02/14/22 at 12:28 pm revealed, [MEDICATION(S)] delivered by pharmacy and to be started tonight, was ordered for [CONDITION(S)]. Resident denies urinary symptoms at this time. J. On 03/03/22 at 3:25 pm during an interview with the Director of Nursing (DON) stated, We are having issues with our pharmacy and it [R #33's antibiotic order] is partially their [pharmacy] fault and they [pharmacy] kept saying that it [R #33's antibiotics] wasn't in stock. It was discussed with him [Facility Medical Director (FMD)] whether or not she [R #33] should be started on another medication. If he (FMD) felt like it would be more detrimental (cause harm) to start her on another medication [antibiotic], we wouldn't do that. I don't see anything [change of antibiotic order]. DON confirmed R #33 went three days without antibiotics to treat her [CONDITION(S)] and R #33 should not have.

Based on record review, observation, and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R # 33) of 2 (R # 33, 52) residents reviewed for pain. This deficient practice likely resulted in R #33 experiencing significant (long) periods of pain without sufficient relief. The findings are: Findings for R #33: A. Record review of R #33's face sheet revealed R #33 was admitted into the facility on [DATE]. B. Record review of R #33's Physician History and Physical dated 06/04/21 revealed, Chief Complaint- Patient being admitted to facility following a R [Right] sided [CONDITION(S)] [[CONDITION(S)]- Stroke]. Patient with residual left sided weakness. Past History- [CONDITION(S)] [[CONDITION(S)]- a group of lung diseases that block airflow and make it difficult to breathe], DMII [Diabetes Mellitus type 2], Depression, RLS [Restless Leg Syndrome], [CONDITION(S)] OA [[CONDITION(S)]], L [Left] hip pain. C. On 03/01/22 at 10:46 am during an interview with R #33, she stated. I have pain from top to bottom (top of my head to the bottom of my feet). They only give me one pain pill in the morning and it doesn't help. I got pain medication that helped me at the hospital and I was not in so much pain. I have asked the nurses here to give me that medication ([MEDICATION(S)]-Narcotic pain medication) but they tell me they can't cause there is not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . D. Record review of R #33's Nurses Progress notes dated 02/07/22 at 4:43 pm revealed, Note Text: Resident was sent out for fall that occurred in dinning area during dinner. At the time of fall, no injuries present and resident did have complaints of slight tenderness. PRN (as needed) Tylenol (pain reliever) was administered by day shift with no relief. At the time that this nurse received report, resident stated she had severe pain to left side of body and head and requested she be sent out. MD (Medical Doctor) was notified and resident was sent to [name of local hospital] via EMS (Emergency Medical Services) transportation. At approximately 2300 (11:00 pm), [name of local hospital staff] from [name of local hospital] called and gave report [update on residents condition to facility] she stated that resident (R #33) was ready to come back with no fractures or other concerns. When resident arrived to facility discharge papers stated she had a pubis fracture (a break of the ring of bones that connect your spine to the hips). This nurse spoke to ER (emergency room ) Doctor and he stated that initial X-ray showed no fractures so he did a MRI (an image obtained by magnetic resonance imaging) and that revealed said fracture [current pelvic fracture], [name of facility medical director] notified of residents current diagnosis, no new orders at this time. Resident arrived at facility via van accompanied by staff at 2340 (11:40 pm), resident with complaints of pain but in good spirits. Follow up with DO (Doctor of Osteopathic Medicine) in 5-6 days, Reason: Continuance of Care. E. Record review of R #33's Nurses Progress note follow-up dated 02/08/22 at 6:02 am revealed, Resident is post ER for fall that occurred on 02/07/22, old pubis fracture noted. Reported that resident did not have any complaints of pain until dinner time and was requesting to see [Name of Facility Medical Director]. This nurse spoke to resident in a calm manner and asked what was her urgency to see the doctor. Resident stated that she wanted to discuss the pain she is having to left side of body, neck and bilateral feet. This nurse explained to resident that it was late in the day and that doctor would not be in at this time. At first resident did not want to cooperate, after administering PRN [MEDICATION(S)] and applying ordered [MEDICATION(S)] [ordered 12/30/21 and used to relieve pain] resident agreed to lay down. PRN [MEDICATION(S)] administered with effective results [reduced pain]. F. Record review of R #33's Hospital Discharge Instructions dated 02/09/22 revealed, Please fill [MEDICATION(S)] [Narcotic pain medication] prescription patient got at last ER [emergency room ] visit to help treat the pain patient has from recent pelvic fracture. G. Record review of R #33's Nurses Progress notes dated 02/10/22 at 4:53 am revealed, Note Text: Follow up: Resident on follow up for fall without visible injuries, was sent out and old pelvic fracture was noted. Reported that during the day shift, resident was pleasant with no behaviors, pain or discomfort. At the beginning of this shift, resident was assisted to bed and began having complaints of severe pain to neck, LUE [Left Upper Extremities], BLE [Bilateral Lower Extremities] and bilateral feet. Scheduled [MEDICATION(S)] cream applied [[MEDICATION(S)] cream ordered on 12/30/21], PRN [MEDICATION(S)] and PRN Tylenol administered with no relief. Ice and heat alternated and resident repositioned to assist in pain relief, all methods ineffective. Resident began hitting herself on the head and stating that she wanted to die. Due to increase in pain with no relief and resident hitting herself, resident was sent out to [Name of local hospital] to be evaluated and treated. Resident transported via EMS [Emergency Medical Services]. MD will be notified before shift is over. H. On 03/03/22 at 9:41 am during an interview with Registered Nurse (RN) #2, she stated, She (R #33) was sent out [to local hospital] because nothing was working for her pain. She was hitting herself and she stated that she 'couldn't take it no more and she wanted to end her life.' It was told to me [by facility staff] that it was an old fracture and it was discussed with [name of facility Medical Director] as an old fracture. I couldn't find it myself (documentation of an old fracture in the medical chart). I give her Tylenol every night and I made a note to the doctor to give her something else. I do believe I requested pain medication before she was sent out (to hospital) after the fall. I will say [to the Facility Medical Director/R #33 physician] the resident was asking for something stronger and if he [Facility Medical Director] wants to prescribe something. I know I asked for something stronger for her [R #33] because she was in so much pain. I want him [Facility Medical Director] to do something for her [reason to call] or to advise me to send her out. He [Facility Medical Director] told me to send her out [to the hospital on 02/09/22]. As far as [R #33's pain] being managed, the only thing she had was Biofreeze for pain or if she [R #33] requested Tylenol [ordered on 12/23/21]. I would ask her (R#33) if she had more pain at night and she said she had pain all day but they never gave her anything. In talking to the Facility Medical Director, he told me, he was more concerned with her mental status because she was on [MEDICATION(S)] [Narcotic pain medication used to treat pain, PRN (as needed) 50 mg every 24 hours ordered on 01/17/22 and discontinued on 02/14/22, Scheduled 50 mg 1 time a day ordered on 02/14/22 ].As far as the pain, that's something every night with her [R #33] left side. The night when I sent here out was because nothing was helping her, at that time, she was already on the [MEDICATION(S)]. The day of the fall she had excruciating (intensely painful) pain. I. Record review of R #33's Nurses Progress note dated 02/10/22 at 5:59 am revealed, Discharge orders also stated that previous order for [MEDICATION(S)] could be used for pain. Prescription for [MEDICATION(S)] [antibiotic medication] and Zpac [antibiotic medication] were sent to [Name of local store], will have day nurse follow up with getting these medications. Resident will need a new prescription for [MEDICATION(S)] (medication used to treat pain), MD notified of this and awaiting reply. Resident arrived back to facility at approximately 0545 [ 5:45 am], in pleasant mood and no complaints of pain or discomfort. J. Record review of R #33's Nurses Progress note dated 02/12/22 at 3:09 am revealed, Note Text: Resident very very demanding .Stated she got some 'good pills' while at hospital and she slept well. Stated she was going to keep ringing so she can be sent to hospital. Resident has refused to eat dinner . [CONDITION(S)]-resident stated she wanted something to eat and asked to warm up soup, in which I did and she did not eat. Resident did eat two cookies with some juice. Resident noncompliant with meals. Resident also has personal tube of medicated muscle rub and request to be applied (constantly-does not care about the orders nor the instructions-Will take control by ringing bell). Resident kept calling to be taken to toilet, however unable to assist with transfer, Resident 2 person assistance. Resident is very heavy (dead wt) for transfers. Stated the RX [prescription] Cep not effective. Resident stated apply the ointment 2x [two times] day not effective. Has pain, PRN administered. Stated not effective, at this time resident appears to be sleeping. K. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet by mouth at bedtime related to PAIN L. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . M. On 03/03/22 at 11:57 am during an interview with the Facility Medical Director (FMD), he stated, I was told about it [R #33's discharge prescription for [MEDICATION(S)]], but I got the prescription and I disagreed with it because she [R #33] was on [MEDICATION(S)]. I look at it [ER prescriptions] and review and will disagree with it, but I'm not sure if I'm supposed to document that [disagreement with ER prescriptions]. Since we made that increase [[MEDICATION(S)]- 100 mg (milligram) twice a day ordered on 01/03/22, and 600 mg once a day ordered on 12/30/21] and scheduled [MEDICATION(S)]], I haven't heard anything [R #33 complaints of pain]. Tylenol is a lot safer than putting her [R #33] on a lot of opiates [a drug derived from or related to [MEDICATION(S)]] and flooding her with opiates. We spoke with the family and we confirmed with family that it [Pelvic fracture] was old and I should have put that in my notes. She was seen in the ER and they determined it was an old fracture. FMD confirmed previous pelvic fracture was not noted on R #33's 06/04/21 History and Physical, but he was informed by the family of previous injury but did not document it.

Based on observation, record review and interview, the facility failed to ensure that 2 (R # 1 and 2) of 8 (R # 1, 2, 3, 4, 5, 6, 7, 8) resident reviewed for needing 2 person physical assist with bed positioning and accidents, were provided the treatment and care needed to maintain the highest practicable physical well-being by: 1. Not ensuring R #1 was properly positioned and repositioned in bed, likely resulting in a arm fracture. 2. Not ensuring that R #2 was appropriately assessed for injury following a fall, that was later diagnosed as multiple rib fractures. These deficient practices likely resulted in resident pain and serious bodily injury. The findings are: Findings for R #1: A. Record review of the Face Sheet dated 10/20/17 revealed [DIAGNOSES REDACTED]. and [MEDICAL CONDITION] (loss of ability to understand or express speech, caused by brain damage). B. Record review of Care Plan dated 10/20/17 revealed the following problem area: Focus: (Name of R #1) has contractures to right elbow and may experience some discomfort due to pain. Goals: Will maintain current Activities of Daily Living (ADLs) and pain/discomfort will be reviewed with medication used. Intervention: Observe for signs and symptoms (S/S) of pain such as facial grimaces. He may be unable to verbalize pain. Attempt other interventions such as positioning, massage. etc. Observe for S/S of increased pain/discomfort- assess resident for possible causes other than contractures. Use sheet for transfers. C. Record review of Nursing Notes revealed: 1. 10/15/17 07:00 (7:00 am) Called to resident's room by CNA (Certified Nurse Aide) stating resident is having pain to right arm. CNA states, resident was found this morning in supine position (laying on back) with right arm under his back. States when resident was turned over and arm brought to chest she noticed his facial grimacing. Resident known to swing arms, unable to move right arm. When arm moved facial grimacing and guarding noted. Shoulders asymmetrical with right shoulder raised. Unable to perform ROM (Range of Motion) to right arm without resident having signs of pain. Resident sent to ER (emergency room ) for further evaluation to area. Power of Attorney (POA), notified of residents status and transfer to ER via ambulance. Called in report to ER. 2. 10/15/17 09:43 (9:43 am) Received call from ER nurse stating resident is ready for discharge. States resident has dislocation to right shoulder and complete fracture to humerus (upper arm bone). Will return with sling. Needs follow-up appointment made with (Name of Physician). Will call tomorrow AM. Returned with order for [MEDICATION NAME] (pain medication) 10/325 milligram (mg). Discoloration now noted to right shoulder, blue in color. Swelling noted to affected area, ice pack applied. Sister, removed sling from right arm, states she does not believe it will help while he is laying down. Resident will continue to be monitored. 3. 10/15/17 09:47 (9:47 am) Social Worker (SW) was in talking to family and observed that family was feeding resident pudding. Resident was not sitting up and appeared to be at a less that 45 degree angle. Nurse notified and nurse raised bed to prevent any possible aspiration. 4. 10/15/17 19:00 (7:00 pm) Right shoulder is discolored and area is swollen, Sister removed sling. 5. 10/16/17 10:30 (am) During assessment this AM, rales (sic) (abnormal lung sound) heard throughout resident's lung fields. Secretions heard in airway, unable to expectorate (cough) successfully. Resident appears drowsy, however continues with s/s of pain to right arm. Facial grimacing and moaning noted when arm touched or moved. 6. 10/21/17 04:49 (4:49 am) Admission Note: Patient arrived to facility via ambulance at approximately 2145 (8:45 pm), Physician notified of arrival all meds (medications) clarified by day nurse. Resident anxious and alert and oriented. Hand grips unequal due to fracture to right arm. Resident transferred to bed by sister and Emergency Medical Technicians (EMT)'s. Transfers and changes done while stabilizing right arm. Large bruising to right extremity, mostly elbow area, swelling also noted. Ice applied per family's request, no signs of pain or discomfort noted. Self inflicted scratches to left abdomen, dry, intact with no signs of infection. Bruise to left arm from previous IV (intravenous: in the vein) insertion site. Unable to obtain measurements, no other skin conditions noted. Will continue to monitor this shift. 7. 10/21/17 17:01 (5:01 pm) Resident (Rsd) calm for most of the day grimacing seems to be in pain and answers yes and no questions when asked. Right shoulder remains swollen and bruised, kept immobile no weight bearing. 8. 10/22/17 04:37 (4:37 am) Follow up skilled: Fracture to right extremity/antibiotic therapy. Resident complaint with care and medications. Facial grimacing noted and showed signs of pain, PRN [MEDICATION NAME] (pain medication)administered. Right extremity continues with swelling and bruising. Changes done while keeping right extremity stabilized. Resident non compliant with oxygen while awake, able to keep oxygen on while asleep and head of bed elevated, no signs of shortness of breath. Receiving antibiotic with no adverse reactions noted. Frequent rounds done to ensure safety. D. Record review of Hospital #2 Imaging Report dated 10/16/17 revealed Right Humeral Fracture, comminuted (producing multiple bone splinters) and displaced (a traumatic bone break in which two ends of a fractured bone are separated and out of their normal positions). E. On 11/14/17 at 2:06 pm during an interview with Social Services Director (SSD), she confirmed that she completed the investigation related to R #1's fracture on 10/15/17. She stated (Name of CNA #1) found him (R #1) laying on his right side with his arm stuck behind his back; he was trying to get it out so she moved him onto his back and moved his arm placing it on top of him, that's when she noticed he was grimacing in pain. It is believed he was repositioned and laid on his arm. She further stated He cannot roll or turn on his own. They positioned him incorrectly, that's how this (fracture) happened. F. On 11/14/17 at 2:19 pm during an interview with CNA #1 she stated, The morning I found him (10/15/17) when his arm was broken the pillows were tucked behind him and his arm was behind his back. He cannot roll or turn himself. They (Night CNAs) had to have turned him and not seen where his arm was. He's a two person assist and it was about 7:15 or 7:30 am when we went in to get him up and changed. When I moved his arm from back to front, he was making facial expressions that he was hurting. (Name of CNA #2) gave me report at 6:00 that morning, but he (CNA #2) didn't tell me when he had last changed him, it could have been anywhere from 4:30 to 5:30 am. G. On 11/16/17 at 8:32 am during an interview with Licensed Practical Nurse (LPN) #2 she stated I went and assessed him (10/15/17) he had facial grimacing, the area around his shoulder was raised. Then (Name of CNA #1) called me back in when she took his shirt completely off, the shoulder was raised swollen and had a ball. So I sent him out to the hospital. The report I was given from the hospital said it was a complete fracture. She further stated No, he cannot turn himself from side to side. He can reach out and grab things but its more like swinging not an intentional grasp. There is no way he could place his hand behind his back. That day the CNA (CNA #1) came and got me right away, we noticed it right at the beginning of our shift (day shift: 6 am to 6 pm). If he had been like that since the afternoon or evening before (10/14/17) he would have been in so much pain and the night staff would have noticed. LPN #2 confirmed that R #1 is able to recognize pain and indicate that he is in pain. H. On 11/15/17 at 11:15 am during an interview with CNA #3 she stated (Name of R #1) was being his usual self that night (shift of 10/14/17 to 10/15/17). He was spitting at us and trying to kick us. (Name of CNA #2) and I changed him at 12:00 am and checked on him again at 2:00 am, the final change was at 5:30 am. That night he was in a good mood and let us move him from one side to the other to change him. I was on his left so we rolled him toward me first then towards (Name of CNA #2) to pull the brief under him. We left him on his right side after we changed him, I'm pretty sure. We could have moved him wrong or something, I don't really remember. I. On 11/15/17 at 12:45 pm during an interview with the sister (S) #1 of R #1 she stated No, (Name of R #1) can't turn himself on his side, he has to be placed that way. When something happens to him here, they tell us they are investigating but then all they come back with is 'He's combative that's how he got hurt.' This last time he was in a lot of pain. There is no way he could have turned himself on his side and gotten his arm stuck behind him. J. Record review of physician's orders [REDACTED].> 1. 10/21/17: Non-weight bearing to Right Upper Extremity (RUE) two times a day related to Other fracture of upper end of humerus, 2. 10/23/17: Occupational Therapy (OT) clarification: OT evaluation completed. OT 5 times a week for 60 days for Activities of Daily Living (ADL) retraining, therapy and modalities as needed (PRN). Recommend bed sheet transfer only with 3 person assist with RUE stabilized next to body. Gentle passive range of motion (PROM) to right shoulder and right elbow to maintain joint integrity and for hygiene and dressing skills. 3. 10/27/17: New Ortho Medical Doctor (MD) orders for right shoulder gentle pendulum PROM. Patient is referred to Restorative Nursing Program for right shoulder gentle pendulum exercises 7 times a week for 30 days. Discontinue sling, continue with 3 person bed sheet transfer with RUE stabilized and supported at all times. Finding for R #2: K. Record review of the Care Plan for R #2 revealed the following problem areas: 1. 06/08/16 (Name of R #2) is at risk for falls because of inability to transfer safely and is unaware of safety needs. Falls identified on 06/08/16, 07/02/16, 08/11/16, 09/07/16, 09/11/16, 03/19/17 and 05/12/17. 2. 06/15/16 (Name of R #2) has cognitive impairment due to dementia and requires guidance and cueing throughout the day. 3. 06/15/16 (Name of R #2) is at risk for skin breakdown due to B&B (bowel and bladder) incontinence and decreased mobility. 4. Resident has a [DIAGNOSES REDACTED]. 5. resident sustained [REDACTED]. L. Record review of the Hospital Imaging Report dated 06/19/17 revealed that R #2's bone density values were consistent with [MEDICAL CONDITION] (disease where decreased bone strength increases the risk of broken bones). M. Record review of the Progress Notes for R #2 dated 10/06/17 (Friday) reveals At approximately 0130 (1:30 am) call light sounded at (R #2 and R #19's room). Upon entering room, resident (R #19) stated that he rang the call for roommate (R #2). Nurse and CNA (Initials for CNA #4) looked over at the other residents (R #2) bed and saw that resident's bed and saw that resident's legs were dangling over the bed and resident was holding on to rail. Resident stated he wanted to go to bathroom. Assisted resident with toileting and then assisted back to bed. Resident did not want to go to bed and was kicking off blankets. Resident kept stating that he wanted to get up. Resident up at nurses station complaining of pain to right rib cage, no tenderness or bruising noted. PRN (as needed) Tylenol (pain reliever) administered with positive results. N. Record review of the Facility Incident Report dated 10/09/17 revealed On 10/08/17 resident had continued to complain of right side pain and was taken to the ER where it was found (Name of R #2) to have sustained 6 rib fractures. O. On 11/14/17 at 1:39 pm during interview with the Administrator, she stated I talked to (Name of CNA #4) and asked him if anything had happened (on 10/06/17 with R #2). He said that (Name of R #2) had a fall. His roommate, (Name of R #19) pulled the call light between 1:00 and 1:30 (am) and when he (CNA #4) pulled the curtain, he saw (Name of R #2) was stuck between the transfer bar and the mattress. It took 2 people to unstick him from the side rail. He told (Name of Registered Nurse (RN) #2) and she helped him get unstuck. She documented that he had had a fall. We (Administrator and SSD) would have been expected to be called and we would have had him looked at. He (R #2) complained of pain the rest of the night. The nurses did not notify anyone about the pain or the incident (until 10/09/17). I found it to be a serious incident and he (former Director of Nursing (DON)) did not grasp that is was a very serious incident (when informed on 10/09/17). He put no systems in place for the nurses to notify about any incidences. P. On 11/14/17 at 3:27 pm during interview with Licensed Practical Nurse (LPN) #1, she stated I was working on Saturday (10/07/17). He (R #2) was complaining of right side pain. I gave him Tylenol ([MEDICATION NAME]: pain reliever). On Sunday, his son was stating that he (R #2) was complaining of pain and he wanted him sent out to the hospital, so I sent him out. Per LPN #1, she stated that R #2's son demanded that she send R #2 to the hospital or he was going to (send him to the hospital). Q. On 11/20/17 at 10:49 am during interview with POA #2, he stated They never notified me that he (R #2) was dangling on the bed. POA #2 confirmed that he was not informed about the incident on 10/06/17 until Sunday (10/08/17) when he requested that R #2 be sent out to the hospital. R. Record review of the Medication Administration Records (MAR) for R #2 dated 09/01/17 until 10/10/17 revealed that he received Tylenol 650 mg (milligrams) twice on 09/26/17 (pain not rated on pain scale) and 10/06/17 for pain in right rib cage- pain scale (1-10, least to greatest self assessment of pain) 4/10, and then 4 times on 10/07/17 (pain not rated on pain scale).

Based on observation, record review and interview, the facility failed to ensure that residents are free from accidents for 2 (R # 1 and 2) of 8 (R # 1, 2, 3, 4, 5, 6, 7, 8) residents reviewed for needing 2 person physical assist with bed positioning and accidents, by: 1. Not ensuring R #1 was properly positioned and repositioned in bed, likely resulting in a arm fracture. 2. Not ensuring that R #2's mattress appropriately fit the bed frame to prevent risk for entrapment. These deficient practices likely resulted in resident pain and serious bodily injury. The findings are: Findings for R #1: A. Record review of the Face Sheet dated 10/20/17 revealed [DIAGNOSES REDACTED].) and Aphasia (loss of ability to understand or express speech, caused by brain damage). B. Record review of Care Plan dated 10/20/17 revealed the following problem area: Focus: (Name of R #1) has contractures to right elbow and may experience some discomfort due to pain. Goals: Will maintain current ADLs and pain/discomfort will be reviewed with medication used. Intervention: Observe for signs and symptoms (S/S) of pain such as facial grimaces. He may be unable to verbalize pain. Attempt other interventions such as positioning, massage. etc. Observe for S/S of increased pain/discomfort- assess resident for possible causes other than contractures. Use sheet for transfers. C. Record review of Nursing Notes revealed: 1. 10/15/17 07:00 (7:00 am) Called to resident's room by CNA (Certified Nurse Aide) stating resident is having pain to right arm. CNA states, resident was found this morning in supine position (laying on back) with right arm under his back. States when resident was turned over and arm brought to chest she noticed his facial grimacing. Resident known to swing arms, unable to move right arm. When arm moved facial grimacing and guarding noted. Shoulders asymmetrical with right shoulder raised. Unable to perform ROM (Range of Motion) to right arm without resident having signs of pain. Resident sent to ER (emergency room ) for further evaluation to area. Power of Attorney (POA), notified of residents status and transfer to ER via ambulance. Called in report to ER. 2. 10/15/17 09:43 (9:43 am) Received call from ER nurse stating resident is ready for discharge. States resident has dislocation to right shoulder and complete fracture to humerus (upper arm bone). Will return with sling. Needs follow-up appointment made with (Name of Physician). Will call tomorrow AM. Returned with order for norco (pain medication) 10/325 milligram (mg). Discoloration now noted to right shoulder, blue in color. Swelling noted to affected area, ice pack applied. Sister, removed sling from right arm, states she does not believe it will help while he is laying down. Resident will continue to be monitored. 3. 10/15/17 09:47 (9:47 am) Social Worker (SW) was in talking to family and observed that family was feeding resident pudding. Resident was not sitting up and appeared to be at a less that 45 degree angle. Nurse notified and nurse raised bed to prevent any possible aspiration. 4. 10/15/17 19:00 (7:00 pm) Right shoulder is discolored and area is swollen, Sister removed sling. 5. 10/16/17 10:30 (am) During assessment this AM, rales (sic) (abnormal lung sound) heard throughout resident's lung fields. Secretions heard in airway, unable to expectorate (cough) successfully. Resident appears drowsy, however continues with s/s of pain to right arm. Facial grimacing and moaning noted when arm touched or moved. 6. 10/21/17 04:49 (4:49 am) Admission Note: Patient arrived to facility via ambulance at approximately 2145 (8:45 pm), Physician notified of arrival all meds (medications) clarified by day nurse. Resident anxious and alert and oriented. Hand grips unequal due to fracture to right arm. Resident transferred to bed by sister and Emergency Medical Technicians (EMT)'s. Transfers and changes done while stabilizing right arm. Large bruising to right extremity, mostly elbow area, swelling also noted. Ice applied per family's request, no signs of pain or discomfort noted. Self inflicted scratches to left abdomen, dry, intact with no signs of infection. Bruise to left arm from previous IV (intravenous: in the vein) insertion site. Unable to obtain measurements, no other skin conditions noted. Will continue to monitor this shift. 7. 10/21/17 17:01 (5:01 pm) Resident (Rsd) calm for most of the day grimacing seems to be in pain and answers yes and no questions when asked. Right shoulder remains swollen and bruised, kept immobile no weight bearing. 8. 10/22/17 04:37 (4:37 am) Follow up skilled: Fracture to right extremity/antibiotic therapy. Resident complaint with care and medications. Facial grimacing noted and showed signs of pain, PRN Lortab (pain medication)administered. Right extremity continues with swelling and bruising. Changes done while keeping right extremity stabilized. Resident non compliant with oxygen while awake, able to keep oxygen on while asleep and head of bed elevated, no signs of shortness of breath. Receiving antibiotic with no adverse reactions noted. Frequent rounds done to ensure safety. D. Record review of Hospital #2 Imaging Report dated 10/16/17 revealed Right Humeral Fracture, comminuted (producing multiple bone splinters) and displaced (a traumatic bone break in which two ends of a fractured bone are separated and out of their normal positions). E. On 11/14/17 at 2:06 pm during an interview with Social Services Director (SSD), she confirmed that she completed the investigation related to R #1's fracture. She stated that on 10/15/17, (Name of CNA #1) found him (R #1) laying on his right side with his arm stuck behind his back; he was trying to get it out so she moved him onto his back and moved his arm placing it on top of him, that's when she noticed he was grimacing in pain. It is believed he was repositioned and laid on his arm. She further stated He cannot roll or turn on his own. They positioned him incorrectly, that's how this (fracture) happened. F. On 11/14/17 at 2:19 pm during an interview with CNA #1 she stated, The morning I found him (10/15/17) when his arm was broken the pillows were tucked behind him and his arm was behind his back. He cannot roll or turn himself. They (Night CNAs) had to have turned him and not seen where his arm was. He's a two person assist and it was about 7:15 or 7:30 am when we went in to get him up and changed. When I moved his arm from back to front, he was making facial expressions that he was hurting. (Name of CNA #2) gave me report at 6:00 that morning, but he (CNA #2) didn't tell me when he had last changed him, it could have been anywhere from 4:30 to 5:30 am. G. On 11/16/17 at 8:32 am during an interview with Licensed Practical Nurse (LPN) #2 she stated I went and assessed him (10/15/17) he had facial grimacing, the area around his shoulder was raised. Then (Name of CNA #1) called me back in when she took his shirt completely off, the shoulder was raised swollen and had a ball. So I sent him out to the hospital. The report I was given from the hospital said it was a complete fracture. She further stated No, he cannot turn himself from side to side. He can reach out and grab things but its more like swinging not an intentional grasp. There is no way he could place his hand behind his back. That day the CNA (CNA #1) came and got me right away, she we noticed it right at the beginning of our shift (day shift: 6 am to 6 pm) If he had been like that since the afternoon or evening before (10/14/17) he would have been in so much pain and the night staff would have noticed. LPN #2 confirmed that R #1 is able to recognize pain and indicate that he is in pain. H. On 11/15/17 at 11:15 am during an interview with CNA #3 she stated (Name of R #1) was being his usual self that night (shift of 10/14/17 to 10/15/17). He was spitting at us and trying to kick us. (Name of CNA #2) and I changed him at 12:00 am and checked on him again at 2:00 am, the final change was at 5:30 am. That night he was in a good mood and let us move him from one side to the other to change him. I was on his left so we rolled him toward me first then towards (Name of CNA #2) to pull the brief under him. We left him on his right side after we changed him, I'm pretty sure. We could have moved him wrong or something, I don't really remember. I. On 11/15/17 at 12:45 pm during an interview with the sister (S) #1 of R #1 she stated No, (Name of R #1) can't turn himself on his side, he has to be placed that way. When something happens to him here, they tell us they are investigating but then all they come back with is 'He's combative that's how he got hurt.' This last time he was in a lot of pain. There is no way he could have turned himself on his side and gotten his arm stuck behind him. J. Record review of physician's orders [REDACTED].> 1. 10/21/17: Non-weight bearing to Right Upper Extremity (RUE) two times a day related to Other fracture of upper end of humerus, 2. 10/23/17: Occupational Therapy (OT) clarification: OT evaluation completed. OT 5 times a week for 60 days for Activities of Daily Living (ADL) retraining, therapy and modalities as needed (PRN). Recommend bed sheet transfer only with 3 person assist with RUE stabilized next to body. Gentle passive range of motion (PROM) to right shoulder and right elbow to maintain joint integrity and for hygiene and dressing skills. 3. 10/27/17: New Ortho Medical Doctor (MD) orders for right shoulder gentle pendulum PROM. Patient is referred to Restorative Nursing Program for right shoulder gentle pendulum exercises 7 times a week for 30 days. Discontinue sling, continue with 3 person bed sheet transfer with RUE stabilized and supported at all times. Findings for R #2: K. Record review of the Care Plan for R #2 revealed the following problem areas: 1. 06/08/16 (Name of R #2) is at risk for falls because of inability to transfer safely and is unaware of safety needs. Falls identified on 06/08/16, 07/02/16, 08/11/16, 09/07/16, 09/11/16, 03/19/17 and 05/12/17. 2. 06/15/16 (Name of R #2) has cognitive impairment due to dementia and requires guidance and cueing throughout the day. 3. 06/15/17 (Name of R #2) is at risk for skin breakdown due to B&B (bowel and bladder) incontinence and decreased mobility. 4. 06/15/17 Resident has a [DIAGNOSES REDACTED]. 5. resident sustained [REDACTED]. L. Record review of the Progress Notes for R #2 dated 10/06/17 (Friday) reveals At approximately 0130 (1:30 am) call light sounded at (R #2 and R #19's room). Upon entering room, resident (R #19) stated that he rang the call for roommate (R #2). Nurse and CNA (Initials for CNA #4) looked over at the other residents (R #2) bed and saw that resident's bed and saw that resident's legs were dangling over the bed and resident was holding on to rail. Resident stated he wanted to go to bathroom. Assisted resident with toileting and then assisted back to bed. Resident did not want to go to bed and was kicking off blankets. Resident kept stating that he wanted to get up. Resident up at nurses station complaining of pain to right rib cage, no tenderness or bruising noted. PRN (as needed) Tylenol (pain reliever) administered with positive results. M. Record review of the Facility Incident Report dated 10/09/17 revealed On 10/08/17 resident had continued to complain of right side pain and was taken to the ER where it was found (Name of R #2) to have sustained 6 rib fractures. N. On 11/14/17 at 1:39 pm during interview with the Administrator, she stated I talked to (Name of CNA #4) and asked him if anything had happened (on 10/06/17 with R #2). He said that (Name of R #2) had a fall. His roommate, (Name of R #19) pulled the call light between 1 and 1:30 (am) and when he (CNA #4) pulled the curtain, he saw (Name of R #2) was stuck between the transfer bar and the mattress. It took 2 people to unstick him from the side rail. He told (Name of RN (Registered Nurse) #2) and she helped him get unstuck. She documented that he had had a fall. O. On 11/15/17 at 11:00 am during an interview with the Administrator she stated. I went to the room after the incident to get some understanding about how the incident occurred. The bed was against the wall on the left side, foot of the bed towards the door, the bed that was being used is a Liberty Bed (bed brand); the transfer bar is different than the others in the facility (shorter positioning bar, rising 6 inches above mattress). The headboard was not installed properly leaving a big gap at the top of the bed allowing the mattress to move a lot. P. On 11/20/17 at 11:13 am during an interview with the Maintenance Director (MD), regarding R #2, he stated I saw that after the incident that there was an adjustment on the head board (R #2's bed); there was a big gap on the head of the bed but not on the side. I tested it myself, the mattresses would move when I sat on the bed.

During multiple observations, R #100 and 106 were observed smoking outside the front of the facility without any staff intervention. Record review of the Smoking Policy and Smoking Audit Tool assessments revealed that these residents should only smoke under supervision. These deficient practices resulted in Immediate Jeopardy (IJ) being called on 05/27/16 at 11:46 am. The Maintenance Director, Director of Social Services and Assistant Director of Nursing were notified at this time. A Plan of Removal (POR) was submitted on 06/01/16 at 3:56 pm and rejected. A second POR was submitted and rejected on 06/02/16 at 11:59 am. A third POR was submitted and approved on 06/02/16 at 2:45 pm. The scope and severity was decreased from a level 4, K to a level 2, E. The Plan of Removal included: 1. Updating the Facility's Smoking Policy to include: a. If residents are assessed to be safe, they have the right to be an independent smoker. b. If residents are assessed to be unsafe, they are prohibited from keeping smoking materials and must give materials to staff. Unsafe smokers must wear a smoking apron if not smoking electronic cigarettes. c. The facility will post smoking times at the nurses' station and staff will accompany those residents and supervise them at the designated times. d. Violations of the policy can result in written warnings or confiscation of smoking material. 2. An update on current residents who smoke: a. One resident was discharged home. b. One resident was assessed as a safe smoker and can choose to be non-compliant with the policy. In this case, the resident's physician and family will be notified and he will sign an Informed Consent form. c. Two residents were assessed as unsafe smokers. One elected to use a facility provided electronic cigarette under supervision. The other resident does not have cigarettes and continues to be non-compliant with the policy and now has a wanderguard placed on his wheelchair. d. The facility will do a Smoking Assessment on these residents quarterly to identify changes in smoking safety and will continue to educate residents on the smoking policy. 3. A new process for future residents: a. Future residents who are smokers are assessed as safe or unsafe. The facility will alert the resident of the policy and offer an electronic cigarette. b. For future residents who are considered safe to smoke, they can choose to be non-compliant with the policy and smoke anytime at their own risk as long as they sign an Informed Consent form. The physician and family will also be notified and the facility will complete a Smoking Assessment quarterly to determine changes in residents' smoking safety. c. For future residents who are considered unsafe to smoke, if they choose to be non-compliant the facility will inform the physician and family. The facility will also attempt to educate the resident of the policy, control smoking material, and begin warning the resident or confiscating material as appropriate. A wanderguard may also be implemented if appropriate to alert the facility when residents are leaving the building to go smoke. Based on record review, observation and interview, the facility failed ensure that each resident received adequate supervision to prevent accidents for 2 ( R #100 and 106) of 4 ( R #5, 94, 100 and 106) residents reviewed for smoking by not providing adequate supervision to residents who have been assessed as being unsafe smokers. This deficient practice is likely to result in residents who smoke experiencing burns, fire related explosions and ignition of their clothing. The findings are: A. Record review of the facility's Smoking Policy dated 03/23/16 revealed For those Residents admitted before March 23, 2016, who were previously identified as a current smoker, the State requires the facility to allow their continued smoking for the rest of the Resident's current admission and those Residents are permitted to do so (smoke) under staff supervision. B. Record review of R #100's Smoking Audit Tool dated 03/25/16 revealed R #100 requires supervision while smoking. C. Record review of R #106's Smoking Audit Tool dated 03/25/16 revealed R #106 requires a smoking apron and supervision while smoking due to dexterity issues. D. On 05/25/16 at 6:31pm and 05/26/16 at 3:26pm during random observation, R #100 was smoking in the front driveway of the facility alone without supervision. E. On 05/26/16 at 3:07pm during random observation, R #106 was in front of the facility smoking two cigarettes at one time without staff supervision. R #106 was not wearing a smoking apron and had visible burn holes on the left leg of his sweatpants. F. On 05/26/16 at 3:26pm during interview, R #100 confirmed that he is always outside alone as he smokes and staff does not supervise him. G. On 05/26/16 at 7:27pm during random observation, R #106 was smoking in front of the facility approximately 10 feet from the front door without staff supervision. R #106 was also not wearing a smoking apron. H. On 05/27/16 at 9:35 am during interview, R #106 was asked if he has been burnt while smoking and stated Yes, but it's nothing to worry about. I have burnt my fingers and pants but it's nothing big. R #106 confirmed he goes out when he desires and never has staff supervision. I. On 05/27/16 at 9:45 am during interview with the Maintenance Director (MD). he explained that the facility bought e-cigarettes (electronic cigarettes- handheld smoking devices that vaporize flavored liquid with nicotine) for all smokers in March 2016 and decided to be a smoke free facility allowing only those residents who were grandfathered in to smoke e-cigarettes. He also explained activities runs the program and they have scheduled times for residents who are compliant. He expressed concern by saying, We don't know what to do with the (non-compliant smokers (smokers who refuse to use the e-cigarettes and continue to smoke cigarettes)). When asked how the policy worked at the time of implementation he answered, They all wanted it (switch to e-cigarettes). When we started (transitioning from cigarettes to e-cigarettes), it didn't work. All (residents) started migrating outside. When asked what the facility is doing to ensure the residents' safety while smoking he answered, If staff see them out there, especially my staff (housekeeping), they're supposed to stay out (outside) and watch them. When asked why the Smoking Policy was changed, the MD responded I think that where it started off was manpower. We were really low (on staff). Hard time keeping staff. At that time, it (providing smoking supervision) was taking a tax on the staff. J. On 05/27/16 at 10:03 am during interview with Director of Social Services (DSS), she confirmed that regardless of the policy, residents go outside when they'd like and it's out of the facility's control at this time. When asked about R #106's ability to smoke safely unattended she answered, I don't feel he's safe to smoke by himself. He has holes in his clothes. He has cognitive loss, he's not safe. When asked how the smoking process works she answered, They smoke out here in the front. They're supposed to sign themselves out if they smoke. I don't know how that helps, maybe relieve us of liability. (After they sign out) And then they wheel themselves out and they'll smoke. The nurse would then tell someone to go watch. K. On 05/27/16 at 10:37 am during random interview, Licensed Practical Nurse (LPN) #6 was asked if she was ever asked to supervise smokers outside. she responded, I have never been told to provide supervision. L. On 05/27/16 at 10:37 am during random interview, Certified Nursing Assistant (CNA) #10 confirmed she has never been asked to provide smoking supervision. M. On 05/27/16 at 10:38 am during random interview, Housekeeper (HK) #1 was asked about smoking supervision and answered, Lately no, I have not been given instruction to watch (smokers). HK #1 confirmed she has regularly seen three to four residents smoking alone out front (of the building) before. N. On 05/27/16 at 10:40 am during interview with HK #2, he denied ever being asked to supervise smokers and confirmed that he has seen residents out front smoking unsupervised. O. On 05/27/16 at 10:43 am during interview with HK #3, she denied ever being asked to supervise residents if she saw them outside smoking. P. On 05/27/16 at 10:44 am during interview, R #100 was outside alone smoking. He stated, I've been out here about 20 minutes. I come out maybe 2-3 times a day. When asked if staff try to supervise him he stated, They don't try to stop me or supervise me. R #100 confirmed that he has never signed himself out prior to smoking outside. Q. On 05/27/16 at 10:46 am during interview, the (Van Driver) VD was outside unloading the van and confirmed seeing residents out front smoking regularly and stated, Once in a while they have staff with them, I think. The VD denied ever being asked to supervise residents if he sees them smoking out front.

Based on record review, observation, and interview, the facility failed to ensure that residents received the necessary care and services to attain or maintain their highest practicable physical and psychosocial well-being for 2 ( R #49 and 79) of 2 ( R #49 and 79) residents reviewed during random observation, by administering a rectal suppository in R #49's vagina, which likely resulted in pain and by refusing to open the shower room door for R #79 who has difficulty breathing, which likely resulted in R #79 to experience extreme shortness of breath and anxiety. The findings are: Findings related to R #49: A. Record review of the Progress Notes for R #49 dated 05/06/16 revealed Rsd (resident) was requesting a rectal suppository for constipation, and requested that a female nurse administer the suppository. Asked Rsd if she would prefer to lie down or stand up: she refused to lay down. Rsd became impatient while standing and said she could not stand anymore and began moving, that was when suppository was inserted vaginally unknowingly. Rsd later had complaints of a burning sensation to her vagina. Offered rsd Tylenol to help relieve the sensation and apologized, educated rsd that the burning will go away and everything will return to normal. notified MD and POA (Power of Attorney). Signed by Licensed Practical Nurse (LPN) #7. B. Record review of the Medication Administration Record [REDACTED]. Written in the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. C. On 05/31/16 at 3:08 pm during interview with the Assistant Director of Nursing (ADON), she stated (Name of LPN # 7) came in and let me know what happened (inserting the suppository into R #49's vagina instead of the rectum). We told her to follow the process and let the physician know and POA (Power of Attorney) know. Later, she (R #49) was complaining about burning. I know that she (LPN #7) gave her (R #49) some medication for pain. She (R #49) seemed fine after the situation The ADON confirmed that she personally never assessed of talked to R #49 following the situation. When asked if LPN #7 received any disciplinary action or training after the incident, she stated Not that I can recall. We (ADON and Director of Nursing (DON)) both talked to her (LPN #7) about that and she said she'd never do that again (allow a resident to stand up when administering a rectal suppository). D. On 05/31/16 at 4:32 pm during interview with the DON, she confirmed that she never spoke to R #49 following the incident but she did talk to LPN #7. The DON confirmed that no education was provided to LPN #7 following the incident. When asked if R #49 experienced any harm, she stated I don't believe so. The DON confirmed that the medication error was not reported to the State because We knew what had happened and there was no harm. When asked if it is alright to administer a rectal suppository while a resident is standing, she responded I don't know. I think it's not the norm (normal). I think that because the two holes are close together it's possible to not know which hole it goes in. When asked if this is something a nurse would know, she stated It's pretty easy to tell if it's put in the right way. E. On 06/01/16 at 8:59 am during interview with R #49, when asked about the suppository, she stated That girl (LPN #7) that gave it to me, she took to the bathroom, cause I didn't want to lay down. She put it in my vagina instead of my rectum. It burned so bad. It was one of the worst things that happened to me while I was here. It (pain) lasted about a couple days. I got some paper towels wet and tried to clean it. She was in such a hurry. She apologized. R #49 confirmed that she was offered Tylenol but she declined It doesn't do anything for me. To relieve the pain, she stated They were suppose to give me a [MEDICATION NAME] but they never did (it was offered but no one came to give it). R #49 stated I think it ([MEDICATION NAME]) would have helped (pain). When asked to rate her pain on a scale of 1 to 10, with 10 being the worst pain, she stated About 10. The pain was the whole time after she stuck it in. She wasn't paying attention to what she was doing. I thought she knew (what she was doing) but she didn't. F. On 06/08/16 at 1:40 pm during interview with LPN #7 regarding administering the suppository to R #49, she stated that there was another nurse on the floor (male) (LPN #8). The resident was requesting female nurse (to give her the suppository). I had never given her (R #49) a suppository before. LPN #7 explained that R #49 refused to lay down and asked if she could stand up instead and while LPN #7 was opening the package, R #49 told her to hurry up so she put the suppository in. LPN #7 confirmed that she did not know that she put the suppository in R #49's vagina until LPN #8 told her about an hour later. He (LPN #8) pulled me aside to tell me. I went and apologized to her at that point. I offered her Tylenol. She was complaining of a burning sensation. LPN #7 confirmed that R #49 refused that Tylenol and there was no other pain medication to offer her. I offered for one of the CNAs to help clean her up. LPN #7 explained that she informed the ADON of the incident and there was no counseling/training/reprimand offered to her following the incident. Surveyor: Vigil, Martha Findings related to R #79: G. On 05/26/16 at 8:19 pm during observation and interview, R #79 was seen hurriedly walking out of the shower room reaching toward the nurses station. He was extremely short of breath (SOB) and anxious stating, She (Certified Nurse Aide (CNA) #1) wouldn't leave the door open, I can't breathe. I told her (to open the door) and she said the inspectors were here and they couldn't leave the door open. R #79 sat in a chair at the nurses station and continued speaking with SOB. H. On 05/26/16 at 8:22 pm during observation, the DON told CNA #1 to take R # 79 to his room and give him a treatment (breathing treatment). CNA #1 walked CNA #79 back to his room and closed the door. I. On 05/26/16 at 8:26 pm during interview with the DON, she stated He is like that all the time. He gets anxious and complains. J. On 05/27/16 at 9:00 am during interview with R# 79, he stated I get anxiety when I shower. I have to walk to the shower and I have trouble breathing. R #79 stated that he prefers to shower at night because there are less people around and he can leave the door open. R #79 stated, I tell them (CNAs) how to shower me and the they don't understand. I ask them to leave the door open, because it gets too hot and I cant breathe and I get very anxious. R #79 stated Last night I asked the CNA (CNA #1) to leave the door open and she said she couldn't because the inspectors were here. K. On 05/27/16 at 10:05 am during interview with CNA #1, she confirmed that R #79 asked her to open the door in the shower room. She stated I saw that he was short of breath and I turned up his oxygen to 3 lpm (liters per minute) . It is usually at 2 lpm. He asked me to open the door twice and I could not leave to ask the nurse if it would be ok. I turned on the fan . I had never showered him before and I didn't know about the door. L. On 05/31/16 at 10:03 am during interview with R #79, regarding his shower the other evening, he said I had trouble breathing. I had a lot of trouble breathing. I have [MEDICAL CONDITION] (chronic obstruction [MEDICAL CONDITION] disease: progress lung disease that makes it difficult to breathe). The only way I feel good is when I lay down. I have to have the window open to get some air. I have been here 2 years already. I've had trouble breathing in the shower cause the heater is on and the humidity. I ask them to open the door one foot. The other night she (CNA #1) closed it (door)cause the inspectors were there. I thought I was going to faint. I saw white, like when it's snowing. I felt my head going. They (staff) all know it, that I can't breathe. They shower me. It takes 5- 10 minutes. I tell them to shower me as quick as possible. I get terrible anxiety. The girl (CNA #1) that showered me told me that there was nothing in the record about keeping the door open. M. Record review of the Care Plan for R #79 dated 04/28/14 revealed (Name of R #79) has Oxygen Therapy and is at risk for [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues). Interventions included Monitor fo s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed); Respirations, pulse, oximetry (method for monitoring a person's oxygen saturation), increased heart rate ([MEDICAL CONDITION], restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapse or closure of a lung), hemoptysis (cough up blood), cough, pleuritic (inflammation) pain, accessory muscle usage, skin color. The Care Plan did not identify any interventions related to showering R #79.Vital signs record was not available.

Based on record review and interview, the facility failed to develop a care plan to include weight loss and interventions for 3 (R #66, 79 and 117) of 6 (R #25, 63, 66, 70, 79 and 117) residents reviewed for nutrition, wound care, and during random observation. This deficient practice is likely to result in staff being unaware of resident care and needs. The findings are: Findings related to R #117: A. Record review of Dietary note dated 03/14/16 reveals weight below IWR (Ideal Weight Range). Continue Regular Diet which provides adequate calories and protein to promote weight gain. Registered Dietician (RD) will monitor nutritional status. B. Record review of RD Dietary Note dated 3/25/16 revealed: WEIGHT WARNING. Rsd (resident's) weight has been decreasing since admit. Weight: 135# (pounds) below IWR: 155-189#, BMI (Body Mass Index) 18.8. Receives Regular Diet. Added super cereal with breakfast and large portions with meals for additional calories to prevent weight loss/promote weight gain. Current interventions provide adequate calories and protein to meet needs. C. Record review of the residents Care Plan dated 03/14/16 reveals no dietary care plan had been developed. D. On 05/31/16 at 10:14 am during an interview with Minimum Data Set Coordinator (MDS) she stated. No Care Plan was developed for R #117. I have to talk to Point Click Care (electronic records) cause some of the dietary care plans did not show up (in the residents' medial record). Findings related to R # 79: E. On 05/26/16 at 8:19 pm during observation and interview, R #79 was seen hurriedly walking out of the shower room reaching toward the nurses station. He was extremely short of breath (SOB) and anxious stating, She (Certified Nurse Aide (CNA) #1) wouldn't leave the door open, I can't breathe. I told her (to open the door) and she said the inspectors were here and they couldn't leave the door open. R #79 sat in a chair at the nurses station and continued speaking with SOB. F. On 05/26/16 at 8:22 pm during observation, the Director of Nursing (DON) told CNA #1 to take R # 79 to his room and give him a treatment (breathing treatment). CNA #1 walked CNA #79 back to his room and closed the door. G. On 05/26/16 at 8:26 pm during interview with the DON, she stated He is like that all the time. He gets anxious and complains. H. On 05/27/16 at 9:00 am during interview with R# 79, he stated I get anxiety when I shower. I have to walk to the shower and I have trouble breathing. R #79 stated that he prefers to shower at night because there are less people around and he can leave the door open. R #79 stated, I tell them (CNAs) how to shower me and the they don't understand. I ask them to leave the door open, because it gets too hot and I cant breathe and I get very anxious. R #79 stated Last night I asked the CNA (CNA #1) to leave the door open and she said she couldn't because the inspectors were here. I. On 05/27/16 at 10:05 am during interview with CNA #1, she confirmed that R #79 asked her to open the door in the shower room. She stated I saw that he was short of breath and I turned up his oxygen to 3 lpm (liters per minute) . It is usually at 2 lpm. He asked me to open the door twice and I could not leave to ask the nurse if it would be ok. I turned on the fan. I had never showered him before and I didn't know about the door. J. On 05/31/16 at 10:03 am during interview with R #79, regarding his shower the other evening, he said I had trouble breathing. I had a lot of trouble breathing. I have [MEDICAL CONDITION] (chronic obstruction [MEDICAL CONDITION] disease: progress lung disease that makes it difficult to breathe). The only way I feel good is when I lay down. I have to have the window open to get some air. I have been here 2 years already. I've had trouble breathing in the shower cause the heater is on and the humidity. I ask them to open the door one foot. The other night she (CNA #1) closed it (door)cause the inspectors were there. I thought I was going to faint. I saw white, like when it's snowing. I felt my head going. They (staff) all know it, that I can't breathe. They shower me. It takes 5- 10 minutes. I tell them to shower me as quick as possible. I get terrible anxiety. The girl (CNA #1) that showered me told me that there was nothing in the record about keeping the door open. K. Record review of the Care Plan for R #79 dated 04/28/14 revealed (Name of R #79) has Oxygen Therapy and is at risk for [MEDICAL CONDITION] (deficiency in the amount of oxygen reaching the tissues). Interventions included Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed); Respirations, pulse, oximetry (method for monitoring a person's oxygen saturation), increased heart rate ([MEDICAL CONDITION], restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (collapse or closure of a lung), hemoptysis (cough up blood), cough, pleuritic (inflammation) pain, accessory muscle usage, skin color. The Care Plan did not identify any interventions related to showering R #79. L. On 06/08/16 at 2:32 pm during interview with the Minimum Data Set (MDS) Coordinator, she confirmed that she was recently made aware that R #79 does not like to have the shower room door closed during his showers. She stated I wouldn't have known this unless someone told me. That would be something that should be care planned. MDS Coordinator confirmed that the information from the care plan is passed onto the CNAs from the nurses. She confirmed that no interventions regarding R #79's shower preferences are listed on the Care Plan. Findings related to R #66: M. On 05/31/16 at 10:05 am during observation of wound care, R # 66 has a skin tear laceration 1 1/2 inches superficial open redness without swelling on her left forearm N. On 05/31/16 at 10:13 am during interview with Registered Nurse (RN) #2, she confirmed that R #66 has a skin tear that is not being treated. O. Record review of the Care Plan for R #66 dated 03/15/16 revelaed resident sustained [REDACTED]. No other skin tears were identified on the Care Plan. P. On 06/01/16 at 3:00 pm during interview with the MDS Coordinator, she confirmed that she was recently made aware of the skin tear on R #66's left forearm, however the care plan has not been updated to reflect this new skin tear.

The facility failed to ensure that residents remained free from mistreatment and potential abuse by not: 1. Identifying resident complaints of mistreatment as potential abuse. 2. Ensuring that residents were protected from further potential mistreatment/abuse from CNA #3 by having her/him continue to work with residents after a complaint of mistreatment was made. 3. Honoring R #90's request to not have CNA #3 work with him by allowing CNA #3 to shower R #90 on 02/08/15. 4. Ensuring that the corrective action of having another staff member shower residents with CNA #3 was followed. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity K, being identified at the facility on 03/04/15 at 7:39 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/04/15 at 9:00 pm. The plan of removal, interventions included: 1. Terminating CNA #3. 2. Implementing a log to track grievances and those involved. 3. Establishing a look back period to ensure employee performance meets the facility's corrective action standards. 4. Re-educating all staff on immediately reporting grievances. At this time, the scope and severity was lowered to an E. Based on record review and interview, the facility failed to ensure that 4 (R #49, 64, 67 and 90) of 4 (R #49, 64, 67 and 90) residents reviewed for abuse remained free of mistreatment from CNA #3 by: 1. Not identifying resident complaints of mistreatment as potential abuse. 2. Not ensuring that residents were protected from further potential mistreatment/abuse from CNA #3. 3. Not honoring R #90's request to not have CNA #3 work with him. 4. Allowing CNA #3 to shower residents alone. This deficient practice likely resulted in continued mistreatment of [REDACTED].#3. The findings are: A. Record review of Corrective Action From dated 10/28/14 revealed that CNA #3 was given a verbal warning because of family/resident complaint that water was too hot during shower. Action Required: CNA not to work with resident per family request. Maintenance to rule out any shower function issues. CNA advised of residents complaint of temp (temperature) on water to address immediately. B. On 03/04/15 at 6:22 pm during interview with the Director of Nursing (DON), she confirmed that the complaint on 10/28/14 was regarding R #48. E. Record review of Corrective Action Form for CNA #3, dated 12/05/14 revealed that this was a final written warning and suspension dates: 12/11/14 & 12/12/14. The reason for suspension was because of, Multiple complaints from residents about employees attitude. The action required was, Employee must be professional and courteous at all times. Employee must watch residents rights video before next scheduled shift. Employee sent home for the day. F. Record review of Grievance/Complaint Report dated 01/16/15 revealed a grievance from R #90 about CNA #3 that included the following, CNA (#3) very rough during shower, resident upset and has hurt feelings. Does not want her to work with him again. States he asked her to not be rough and she replied 'I know what I am doing'. Documentation of Facility Follow-Up revealed that ADON and Director of Social Services (DOSS), Met with CNA (#3) , advised she is to have another CNA at all times while showering any resident as a resolution and indicated that the grievance was resolved. G. Record review of Bathing in Point-Click Care (electronic charting system)dated 02/08/15 revealed that CNA #3 had documented giving R #90 a shower. H. On 03/04/15 at 11:24 am during an interview with the DOSS, when asked if the R #64 has complained about the way staff was treating her, she stated, She (R #64)has had complaints, but did not want to do a formal grievance and the Assistant Director of Nursing (ADON) and DON have had discussions with the staff and have resolved them. When asked if there were specific staff members that she has had problems with, she stated, There have been a few staff members, (name if CNA #2), (name if CNA #3) , (name if CNA #4), and there was one (name if CNA #5), and when we brought (name of CNA #5) in she had not been on the hall or working with her that day. When asked when these complaints occurred, she stated, More from October to December (2014) and they kinda just stopped. I would ask her if she would want to do a grievance and she would say no, and asked if she wanted us to talk to staff and she said yes and we would bring them in and talk with them. When asked if this was documented anywhere, she confirmed that it had not been documented. When asked if there was a point that she asked staff not to work with her, and she confirmed that (name of CNA #3) was the only one. When asked when CNA #3 worked, she stated, Days and at the end of the week. When asked if there was corrective action documentation, she called the DON and stated that she was looking for it. She added, If we felt we needed to do corrective action, we have on staff. When asked if she had done corrective action on anyone, she stated, The DON and ADON have and I don't recall who. I. On 03/04/15 at 12:10 am during an interview with the DON, she stated, There is no write up for any employee corrective action (in regards to R #64). She had an issues with (Name of CNA #3) and did not want her to shower her or work with her, and we moved her from this unit (B) to unit (A) (speaking about CNA #3). (Name of R #64) should have two people with her for showers. That is documented in the Social Services. J. On 03/04/15 at 3:46 pm during an interview with R #90, when asked if he could tell me what happened with the CNA #3 he stated, That lady? She was pretty rough. She was pushing me around and she was rough. I didn't like the idea and she was pushing me around. I talked to staff. I went to the people (staff) about 2 months ago. I don't like to be treated like that. You have to treat the people kind. I am not a horse or an animal. When asked if CNA #3 has worked with him since that incident, he confirmed that CNA #3 has showered him since he told told staff that he did not want her to work with him. Resident #90 stated, I want them to keep her away. I don't want to see her. K. On 03/04/15 at 5:14 pm during interview with R #49, she confirmed that CNA #3 showered her, and when resident told her the water was too hot, CNA #3 turned up the hot water. Resident confirmed that she was scared and became tearful, exhibiting a pained expression on her face. L. On 03/04/15 at 5:27 pm during interview with the DON, when asked who is your abuse coordinator, she stated, Social Services, she doesn't usually do the whole process. Usually (name of ADON) and myself help with it. Usually, if she pulls up what she documented, one of us know what's going on. It would be me if she is not here. There have been two self-reports since she has been gone and I have done both. M. On 03/04/15 at 5:42 pm during an interview with RN #3, when asked if CNA #3 showers residents alone, she stated, She has never asked me for help. I think so, unless her partner is there to help her or not. It depends on who she is showering. N. On 03/04/15 in the evening, during interview with CNA #8, when asked if she has worked with CNA #3, she confirmed that she has not. When asked if any residents have complained about CNA #3, she stated, Yes, (name of R #67). He's gone now. Just said she was really rough with him, that she pulled him up and twisted him too hard when she was putting him in the chair. He never complains. Maybe it was October (2014). He was talking to his daughter and the daughter was really upset. When asked if she told anyone about this when R #67 reported it to her, she stated, He didn't tell me about it. But it gets around pretty quick here. O. On 03/04/15 at 6:22 pm during interview with the DON and the Administrator (ADM), when the DON was asked what is the resident grievance process, she stated, The complaint would first go to the nurse and if it can be taken care of right away and fixed it wouldn't come to us. Sometimes a resident will make an allegation and it will go to somebody, me or (Name of DOSS). If they don't want to talk to the nurse, we will see what the concern was, then it will go from there. 1. The ADM stated, (Name of DOSS) will be involved because she's the abuse coordinator. If it's someone being mean to them (resident) or actual abuse then (Name of DOSS). Now that she is not here, it is me (ADM). If there is a complaint about a specific employee then we send them home for a specific issue. (Name of DOSS) would interview the resident and we would find out from there. Interview other residents and other staff. Did you see anything, or hear anything? Depending upon what we are hearing from the resident. 2. When the DON was asked, what do you do when resident makes a complaint about a specific employee, she stated, Removing the employee that the complaint was about from the resident, wing or facility. At least while we interview and determine if anything needs to happen further. Sometimes there is just a complaint and there wasn't abuse going on. They may sometimes say that they don't want to work with a certain staff, but it's not abuse. We would ask them why. A lot of times they won't give you a reason. We remove the staff and don't assign those residents. If they give us something, we look into it further, but sometimes we don't get anything. We remove the staff member and it's done from there. It's rescheduling. 3. The ADM stated, If we would get another complaint from another resident, then we have something. We would do another investigation. 4. When the ADM was asked what would be reportable, he stated, That goes through me too. If this individual handles me roughly, that gets reported and we do an investigation. 5. When the DON was asked who begins the investigation, she stated, That would get documented first on whoever got it. The DOSS would start and document. 6. When the DON was asked about the Corrective Action Form date 12/05/14 regarding Multiple complaints from residents about employee (CNA #3) attitude she stated, Since there was a previous complaint with the shower, and then complaints later on. We had her watch Resident's Rights video. And her (CNA #3) attitude, basically they (the residents) were giving her (CNA #3) direction on how they (the residents) wanted to be taken care of and she (CNA #3) wasn't responding. I talked to her (CNA #3), basically about resident rights and routines. They want to keep them the same as possible. She felt she was doing her job and getting the task done. 7. When the DON was asked what R #49's complaint on 10/28/14 and R #64's complaint of CNA #3 was regarding, she stated, (Name of R #49) was about the water. Complaints from (Name of R #64), her complaint was that she didn't want her (CNA #3) to work with her. Her (CNA #3) and another CNA had provided her (R # 64) care and she said she didn't want to work with her (CNA #3). She's been working weekends part time and there hasn't been any issues since she watched the videos and she worked with me. When the DON was asked to give details about R #90's complaint on 01/16/14, she stated, I thought her (R #64) and his (R #90) were simultaneous.(Name of R #49) had a complaint and then (Name of R #64) had a complaint. (Name of R #64)'s complaint was 'I don't want her (CNA #3) to take care of me.' She (CNA #3) moved to another hall. Then, (Name of R #90) had a complaint. (Name of DOSS) talked to (Name of R #90) about this. I didn't meet with (Name of R #64) about her complaint. P. Record review of Policies and Procedures on Abuse Prevention Program dated August 2006 revealed Our abuse prevention program provides policies and procedures that govern, at a minimum: .c. Identification of occurrences and patterns of potential mistreatment/abuse.h. An ongoing review and analysis of abuse incidence; and i. The implementation of changes to prevent further occurrences of abuse. Q. Record review of Policies and Procedures on Preventing Resident Abuse dated April 2014 revealed Our abuse prevention/intervention program includes, but is not necessarily limited to the following:.i. Monitoring the staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents about giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.);.q. encouraging all personal, residents, family members, visitors, etc, to report any signs or suspected incidents of abuse to the facility management immediately. R. Record review of Policies and Procedures on Abuse Investigations dated April 2014 revealed 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.4. The individual conducting the investigation will, as minimum; a. review the completed documentation forms; b. review the resident's medical record to determine events leading up to the incident; c. interview the person (s) reporting the incident; d. interview any witnesses to the incident; e. interview the resident (as medically appropriate); f. interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. interview the resident's roommate, family members, and visitors; i. interview other residents to whom the accused employee provides care or services; and j. review all events leading up to the alleged incident.

The facility failed to ensure that residents remained free from mistreatment and potential abuse by not: 1. Identifying resident complaints of mistreatment as potential abuse. 2. Ensuring that residents were protected from further potential mistreatment/abuse from CNA #3 by having her/him continue to work with residents after a complaint of mistreatment was made. 3. Honoring R #90's request to not have CNA #3 work with him by allowing CNA #3 to shower R #90 on 02/08/15. 4. Ensuring that the corrective action of having another staff member shower residents with CNA #3 was followed. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity K, being identified at the facility on 03/04/15 at 7:39 pm. The facility took corrective action by providing an acceptable Plan of Removal on 03/04/15 at 9:00 pm. The plan of removal, interventions included: 1. Terminating CNA #3. 2. Implementing a log to track grievances and those involved. 3. Establishing a look back period to ensure employee performance meets the facility's corrective action standards. 4. Re-educating all staff on immediately reporting grievances. At this time, the scope and severity was lowered to an E. Based on record review and interview, the facility failed implement their policies and procedures on mistreatment of [REDACTED].#49, 64, 67 and 90) of 4 (R #49, 64, 67 and 90) residents reviewed for abuse remained free of mistreatment from CNA #3 by: 1. Not identifying resident complaints of mistreatment as potential abuse. 2. Not ensuring that residents were protected from further potential mistreatment/abuse from CNA #3. 3. Not honoring R #90's request to not have CNA #3 work with him. 4. Allowing CNA #3 to shower residents alone. This deficient practice likely resulted in continued mistreatment of [REDACTED].#3. The findings are: A. Record review of Corrective Action From dated 10/28/14 revealed that CNA #3 was given a verbal warning because of family/resident complaint that water was too hot during shower. Action Required: CNA not to work with resident per family request. Maintenance to rule out any shower function issues. CNA advised of residents complaint of temp (temperature) on water to address immediately. B. On 03/04/15 at 6:22 pm during interview with the Director of Nursing (DON), she confirmed that the complaint on 10/28/14 was regarding R #48. E. Record review of Corrective Action Form for CNA #3, dated 12/05/14 revealed that this was a final written warning and suspension dates: 12/11/14 & 12/12/14. The reason for suspension was because of, Multiple complaints from residents about employees attitude. The action required was, Employee must be professional and courteous at all times. Employee must watch residents rights video before next scheduled shift. Employee sent home for the day. F. Record review of Grievance/Complaint Report dated 01/16/15 revealed a grievance from R #90 about CNA #3 that included the following, CNA (#3) very rough during shower, resident upset and has hurt feelings. Does not want her to work with him again. States he asked her to not be rough and she replied 'I know what I am doing'. Documentation of Facility Follow-Up revealed that ADON and Director of Social Services (DOSS), Met with CNA (#3) , advised she is to have another CNA at all times while showering any resident as a resolution and indicated that the grievance was resolved. G. Record review of Bathing in Point-Click Care (electronic charting system)dated 02/08/15 revealed that CNA #3 had documented giving R #90 a shower. H. On 03/04/15 at 11:24 am during an interview with the DOSS, when asked if the R #64 has complained about the way staff was treating her, she stated, She (R #64)has had complaints, but did not want to do a formal grievance and the Assistant Director of Nursing (ADON) and DON have had discussions with the staff and have resolved them. When asked if there were specific staff members that she has had problems with, she stated, There have been a few staff members, (name if CNA #2), (name if CNA #3) , (name if CNA #4), and there was one (name if CNA #5), and when we brought (name of CNA #5) in she had not been on the hall or working with her that day. When asked when these complaints occurred, she stated, More from October to December (2014) and they kinda just stopped. I would ask her if she would want to do a grievance and she would say no, and asked if she wanted us to talk to staff and she said yes and we would bring them in and talk with them. When asked if this was documented anywhere, she confirmed that it had not been documented. When asked if there was a point that she asked staff not to work with her, and she confirmed that (name of CNA #3) was the only one. When asked when CNA #3 worked, she stated, Days and at the end of the week. When asked if there was corrective action documentation, she called the DON and stated that she was looking for it. She added, If we felt we needed to do corrective action, we have on staff. When asked if she had done corrective action on anyone, she stated, The DON and ADON have and I don't recall who. I. On 03/04/15 at 12:10 am during an interview with the DON, she stated, There is no write up for any employee corrective action (in regards to R #64). She had an issues with (Name of CNA #3) and did not want her to shower her or work with her, and we moved her from this unit (B) to unit (A) (speaking about CNA #3). (Name of R #64) should have two people with her for showers. That is documented in the Social Services. J. On 03/04/15 at 3:46 pm during an interview with R #90, when asked if he could tell me what happened with the CNA #3 he stated, That lady? She was pretty rough. She was pushing me around and she was rough. I didn't like the idea and she was pushing me around. I talked to staff. I went to the people (staff) about 2 months ago. I don't like to be treated like that. You have to treat the people kind. I am not a horse or an animal. When asked if CNA #3 has worked with him since that incident, he confirmed that CNA #3 has showered him since he told told staff that he did not want her to work with him. Resident #90 stated, I want them to keep her away. I don't want to see her. K. On 03/04/15 at 5:14 pm during interview with R #49, she confirmed that CNA #3 showered her, and when resident told her the water was too hot, CNA #3 turned up the hot water. Resident confirmed that she was scared and became tearful, exhibiting a pained expression on her face. L. On 03/04/15 at 5:27 pm during interview with the DON, when asked who is your abuse coordinator, she stated, Social Services, she doesn't usually do the whole process. Usually (name of ADON) and myself help with it. Usually, if she pulls up what she documented, one of us know what's going on. It would be me if she is not here. There have been two self-reports since she has been gone and I have done both. M. On 03/04/15 at 5:42 pm during an interview with RN #3, when asked if CNA #3 showers residents alone, she stated, She has never asked me for help. I think so, unless her partner is there to help her or not. It depends on who she is showering. N. On 03/04/15 in the evening, during interview with CNA #8, when asked if she has worked with CNA #3, she confirmed that she has not. When asked if any residents have complained about CNA #3, she stated, Yes, (name of R #67). He's gone now. Just said she was really rough with him, that she pulled him up and twisted him too hard when she was putting him in the chair. He never complains. Maybe it was October (2014). He was talking to his daughter and the daughter was really upset. When asked if she told anyone about this when R #67 reported it to her, she stated, He didn't tell me about it. But it gets around pretty quick here. O. On 03/04/15 at 6:22 pm during interview with the DON and the Administrator (ADM), when the DON was asked what is the resident grievance process, she stated, The complaint would first go to the nurse and if it can be taken care of right away and fixed it wouldn't come to us. Sometimes a resident will make an allegation and it will go to somebody, me or (Name of DOSS). If they don't want to talk to the nurse, we will see what the concern was, then it will go from there. 1. The ADM stated, (Name of DOSS) will be involved because she's the abuse coordinator. If it's someone being mean to them (resident) or actual abuse then (Name of DOSS). Now that she is not here, it is me (ADM). If there is a complaint about a specific employee then we send them home for a specific issue. (Name of DOSS) would interview the resident and we would find out from there. Interview other residents and other staff. Did you see anything, or hear anything? Depending upon what we are hearing from the resident. 2. When the DON was asked, what do you do when resident makes a complaint about a specific employee, she stated, Removing the employee that the complaint was about from the resident, wing or facility. At least while we interview and determine if anything needs to happen further. Sometimes there is just a complaint and there wasn't abuse going on. They may sometimes say that they don't want to work with a certain staff, but it's not abuse. We would ask them why. A lot of times they won't give you a reason. We remove the staff and don't assign those residents. If they give us something, we look into it further, but sometimes we don't get anything. We remove the staff member and it's done from there. It's rescheduling. 3. The ADM stated, If we would get another complaint from another resident, then we have something. We would do another investigation. 4. When the ADM was asked what would be reportable, he stated, That goes through me too. If this individual handles me roughly, that gets reported and we do an investigation. 5. When the DON was asked who begins the investigation, she stated, That would get documented first on whoever got it. The DOSS would start and document. 6. When the DON was asked about the Corrective Action Form date 12/05/14 regarding Multiple complaints from residents about employee (CNA #3) attitude she stated, Since there was a previous complaint with the shower, and then complaints later on. We had her watch Resident's Rights video. And her (CNA #3) attitude, basically they (the residents) were giving her (CNA #3) direction on how they (the residents) wanted to be taken care of and she (CNA #3) wasn't responding. I talked to her (CNA #3), basically about resident rights and routines. They want to keep them the same as possible. She felt she was doing her job and getting the task done. 7. When the DON was asked what R #49's complaint on 10/28/14 and R #64's complaint of CNA #3 was regarding, she stated, (Name of R #49) was about the water. Complaints from (Name of R #64), her complaint was that she didn't want her (CNA #3) to work with her. Her (CNA #3) and another CNA had provided her (R # 64) care and she said she didn't want to work with her (CNA #3). She's been working weekends part time and there hasn't been any issues since she watched the videos and she worked with me. When the DON was asked to give details about R #90's complaint on 01/16/14, she stated, I thought her (R #64) and his (R #90) were simultaneous.(Name of R #49) had a complaint and then (Name of R #64) had a complaint. (Name of R #64)'s complaint was 'I don't want her (CNA #3) to take care of me.' She (CNA #3) moved to another hall. Then, (Name of R #90) had a complaint. (Name of DOSS) talked to (Name of R #90) about this. I didn't meet with (Name of R #64) about her complaint. P. Record review of Policies and Procedures on Abuse Prevention Program dated August 2006 revealed Our abuse prevention program provides policies and procedures that govern, at a minimum: .c. Identification of occurrences and patterns of potential mistreatment/abuse.h. An ongoing review and analysis of abuse incidence; and i. The implementation of changes to prevent further occurrences of abuse. Q. Record review of Policies and Procedures on Preventing Resident Abuse dated April 2014 revealed Our abuse prevention/intervention program includes, but is not necessarily limited to the following:.i. Monitoring the staff on all shifts to identify inappropriate behaviors toward residents (e.g., using derogatory language, rough handling of residents, ignoring residents about giving care, directing residents who need toileting assistance to urinate or defecate in their clothing/beds, etc.);.q. encouraging all personal, residents, family members, visitors, etc, to report any signs or suspected incidents of abuse to the facility management immediately. R. Record review of Policies and Procedures on Abuse Investigations dated April 2014 revealed 1. Should an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.4. The individual conducting the investigation will, as minimum; a. review the completed documentation forms; b. review the resident's medical record to determine events leading up to the incident; c. interview the person (s) reporting the incident; d. interview any witnesses to the incident; e. interview the resident (as medically appropriate); f. interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition; g. interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. interview the resident's roommate, family members, and visitors; i. interview other residents to whom the accused employee provides care or services; and j. review all events leading up to the alleged incident.

REPEAT DEFICIENCY The facility failed to ensure that Resident #52 received appropriate medical care and pain management after sustaining a fall in the facility on 11/02/12 which resulted in a left [MEDICAL CONDITION]. R #52 was left in the facility in pain from 11/02/12 at 2:00 pm until 11/04/12 at 5:29 pm when he was sent to the hospital for X-rays which confirmed a left [MEDICAL CONDITION] upon admission. This resulted in an Immediate Jeopardy (IJ) being identified on 11/29/12 at 4:30 pm. The administrator was notified of the findings for the IJ on 11/30/12 at 11:30 am. The facility took corrective action by providing an acceptable Plan of Removal on 11/30/12 at 3:00 pm. The scope and severity was lowered to a scope and severity of G after the facility submitted their Plan of Removal. The Plan of Removal indicated that the facility action plan was to include: 1. Immediate In-Service on 11/30/12 at 2:00 pm regarding education on Fall Management Policies and Procedures and definition of a fall for all Clinical management team to include, Administrator, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Admissions Director, MDS Coordinator and Social worker, nursing staff and therapy department. Clinical staff will be in-serviced before their next assigned shift or will not be able to return to work until training and education has been completed. All clinical team will be in-serviced on the above by 5:00 pm on Tuesday, December 4, 2012. In-service and education will be provided by the Director of Nursing and Staff Development Educator. 2. Nursing staff will immediately assess resident for injury after a fall in the same location as where resident is found (if resident is found on floor the resident will remain on floor). Resident is not to be moved until assessment is complete and there are no signs of injury noted. If signs are noted during assessment, nursing staff to make resident comfortable in current place and immediately phone 911 for transfer to hospital for medical assessment if needed. 3. Resident's physician will be contacted immediately regarding any falls or injuries. 4. Resident's family will be contacted immediately if resident has any signs of injury or must be transferred to the hospital for care. 5. During Normal business hours, families may be contacted for all incidents, after business hours it is the responsibility of the oncoming day shift nurse to contact the family and communicate incident to the family member. 6. Internal incident report will be created with documentation on a progress note for the medical record. 7. Incident reports will be reviewed in morning Clinical Management meeting Monday through Friday's which includes, Administrator, Director of Nursing, Asst. Director of Nursing, MDS Coordinator, Staff Development Coordinator, RN Admissions Director and Occupational Therapist. 8. Weekend incident will be reported to Weekend Supervisor, during the hours of 9:00 am to 6:00 pm, she is to contact and report each incident to the Nurse Manager on call for review and follow up if needed effective 11/30/12. 9. Nurses are to contact on-call Nurse Manager to report any falls or injuries that may occur after normal business hours effective immediately on 11/30/12. 10. Resident will immediately be placed on 72 hour follow up, "Hot Rack" following any fall or injury. This will include resident assessment, vital signs, skin assessment and pain assessment and proper pain management with documentation of follow up in the medical record. 11. A Fall Risk Assessment will be completed immediately upon a residents fall. Assessment will be utilized to create measures of safety and develop interventions to assist fall committee with Care Plan and fall prevention planning. Fall Committee Chair, Director of Nursing will update Falls Committee logs. Care plans will be updated by the Asst. Director of Nursing, MDS Coordinator during meetings effective immediately 11/30/12. 12. The Fall Committee will review, track and trend reports of resident falls documented on established Resident Fall Log to review and revise risk, interventions and follow-up on resident care plan on a weekly basis. Map tracking of facility will be implemented on 11/30/12 of all new falls and injuries. Documentation will be completed by Fall Committee and will be filed in the Fall Committee binder for reference. 13. The DON/Designee chair of Fall Committee will report tracking and trending of falls and safety interventions for fall prevention in the monthly QAPI meeting effective immediately 11/30/12. 14. Administrator/designee will meet with Director of Nursing weekly to review fall tracking and trending to ensure policy and procedures are followed effective immediately, 11/30/12. Based on interview and record review the facility failed to provide 1 resident (#52) of 9 residents ( #8, #11, #30, #51, #52, #60, #61, #62 & #87) reviewed with medical care to include pain management due to a left [MEDICAL CONDITION] sustained in the facility on 11/02/12. R #52 remained in the facility in pain with limited range of motion to his left leg for 2 days before he was sent to the hospital for X-rays. The hospital confirmed R #52 had a left [MEDICAL CONDITION] upon admit. This deficient practice likely caused actual harm to R #52 by pain and suffering and had the potential to affect all 9 residents since the nursing staff did not follow the facilities protocol for a significant change in condition or protocol for resident falls. The findings are: A. Record review of the hospital's history & physical dated 11/04/12 for R #52 revealed the following: Chief Complaint: Left hip pain for 2 days prior to admission. [AGE] year old male admitted due to left [MEDICAL CONDITION]. B. Record review of hospital's discharge summary dated 11/08/12 revealed the following: Resident not a good candidate for surgery per the Orthopedic surgeon, he did have pain which was controlled with narcotic [MEDICATION NAME]. C. On 11/27/12 at 4:40 pm, during an interview with the Director of Nursing (DON) when asked if the incident regarding R #52 on 11/02/12 was a fall she replied: "Yes." When asked if nursing should have made notes every shift to follow up on R #52 since he did have a change in condition and pain, she said: "Yes." The DON confirmed there was not any documentation in the medical record after the fall until 2 days later when Registered Nurse (RN) #2 documented sending R #52 to the hospital for X-rays due to pain in left hip unrelieved by Tylenol and unable to bear weight on left leg per RN #2's call to the physician. D. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed being on duty on 11/02/12 when R #52 sustained a fall. LPN #2 said she found Certified Nurse Assistant (CNA) #5 on the floor with the R #52 "sitting in her lap with his bottom on the ground and his legs underneath the bed." LPN #2 said: (Name of R #52) didn't have any complaints of pain and he had full range of motion (ROM), we transferred him from the floor to the wheelchair and then to the bed and he could stand and assist us." When asked again about no pain she said: "He complained of a little bit of pain to his left hip." When asked about protocol after a fall LPN #2 said: "We watch him through out the day for pain and guarding (involuntary action to protect an area from pain), usually we watch him for 72 hours." LPN #2 confirmed she did not pull his chart and put it in the rack for nursing to follow up. LPN #2 said: "Thinking about it now I should have notified the doctor since he complained of pain to his hip. I did an incident report (internal) just in case since I really didn't consider this a fall." LPN #2 confirmed an assessment should have been completed, a skin check and a pain assessment and it should be documented in the progress notes. When asked if she notified the family she said "No." E. Record review of R #52's monthly standing orders dated 11/01/12 for the month revealed the following: Notify the doctor (MD) during office hours of a fall without injury. F. Record review of R #52's fall risk assessment dated [DATE] scored this resident as high risk for falls (10). G. On 11/28/12 at 11:12 am, during an interview with the Social Worker (SW) she confirmed as the facilities abuse coordinator she was responsible for incident reports. The SW confirmed she wasn't aware of the fall regarding R #52 until 11/05/12 when he was admitted to the hospital with [REDACTED].#52 she said: "It was late due to we didn't consider it a actual fall then he began to have pain so I thought we needed to report it." H. Record review of R #52's Minimum Data Sheet ((MDS) dated [DATE] for a discharge to acute care revealed the following:" Section J1800- Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent?" The Minimum Data Sheet Coordinator (MDSC) marked the answer as "No." Section G for Functional status the MDSC scored R #52's transfer status as extensive assistance-resident involved in activity, staff provide weight-bearing support. I. Record review of R #52's MDS dated [DATE] revealed the following: "Type of assessment significant change in status assessment. Section G for Functional status the MDSC scored R #52's transfer status as total dependence-full staff performance every time during entire 7-day period. Section I for Active [DIAGNOSES REDACTED]. The MDS did not contain a [DIAGNOSES REDACTED]. J. On 11/28/12 at 2:40 pm, during an interview with the Minimum Data Sheet Coordinator (MDSC) she confirmed completing a discharge MDS on R #52 when he was discharged to the hospital on [DATE]. The MDSC then completed a re-entry MDS upon R #52's return to the facility on [DATE]. The MDSC said the MDS only showed his return and the fall and fracture would be on the MDS dated [DATE] for a significant change in condition. The MDSC then said the fall for R #52 with fracture was not documented on the MDS only the fall incurred on 11/16/12. When asked why this assessment was not accurate of R #52's condition she replied: I didn't really understand the question." The MDSC confirmed she did not complete the MDS to capture the current condition of R #52 to include his fall and [MEDICAL CONDITION] incurred on 11/02/12. K. On 11/28/12 at 3:05 pm, during an interview with Certified Nurse Assistant (CNA) #5 she confirmed she was with R #52 when he fell . CNA #5 demonstrated the fall and said: "When I stood him up originally he grunted in pain and then his legs gave out. I turned to lay him on the bed and he was sliding off so I grabbed his gait belt and pulled him up and he landed on top of me on the floor. I had to push him over to the right so I could reach the call lite for help." CNA #5 said: " He clearly was in a lot of pain, he was just grunting and groaning and not able to bare weight, he couldn't even help scoot himself in the bed. His left leg couldn't move at all, I had to move him. That is not his usual, he is usually easy to transfer with one person and I have worked with him for months. (Name of LPN #2) and I put him in his wheelchair from the floor and let him sit for a moment since he was hurting and very short of breath, we let him rest then we transferred him to bed." L. Record review of R #52's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s fall. M. On 11/29/12 at 9:17 am, during an interview with RN #2 he said: "That Sunday (11/04/12) morning the CNA's went to get him up and he was unable to bare weight, he was complaining of pain to the left hip so I called the doctor and alerted him of the pain and that Tylenol was not effective so he said to send him to X-ray. I couldn't find any incident reports in the system about the fall, no verbal reports, nothing on the 24 hour report and nothing was in the nurses notes." I didn't even do a transfer since he was just going out for X-rays and I didn't expect for him to be admitted ." N. On 11/29/12 at 3:03 pm, during an interview with CNA #4, he confirmed he worked all the weekend (November 2nd & 3rd, 2012) of the incident with this resident. CNA #4 said: "He was in a lot of pain for 3 or 4 days, it was really bad. Sunday the pain continued and the nurse then sent him out. We couldn't move him at all. He kept his hands on his left hip and was moaning and groaning and complaining of pain. He was really hurting." O. On 11/29/12 at 3:08 pm, during an interview with Registered Nurse (RN) #1 she confirmed working with R # 52 on 11/03/12 the day after his fall. RN #1 said she was not told by LPN #2 about the fall and confirmed there was not a nursing note or assessment in the record regarding the incident. RN #1 said R # 52 complained of pain all over that day and she gave him Tylenol. RN # 1 confirmed she did not document any assessment of R #52 to include a pain assessment or even a physical assessment. P. Record Review of R #52's nursing/progress notes contained the following: Nursing progress note with late entry date of 11/05/12 at 7:04 pm (3 days after the fall) and after R #52 was diagnosed with [REDACTED]. Documentation was: "Nurse noticed call light above resident door was on, nurse went to resident's room. Found resident leaning againt CNA (Inititals of CNA) legs/sitting on floor. CNA states she was transferring resident to bed from wheelchair (w/c) when resident became weak and started to fall to floor. CNA attempted to break fall assisting resident gently to floor in sitting position. Assisted resident to bed, resident able to bare weight and help during transfer. Full range of motion (ROM) to all extremities, no bruising, redness or swelling noted.No open areas. Resident complained of slight pain to left leg/knee area. Will continue to monitor." Q. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she said: "I put a late entry in the chart on Saturday, 11/03/12. When asked why she did that she said: "That day (Friday 11/02/12) was crazy. I did an internal incident report too." When asked if that was normal procedure for her she said: "I was worried in case something was wrong. Yes, it bothered me. This incident was very unusual for him, he always helps out with transfers and I felt like something was wrong." LPN #2 said she alerted the nurse coming on duty the day of the fall and confirmed she did not document anything on the 24 hour report. LPN #2 then confirmed that R #52 was moaning and groaning in pain when her and CNA #5 put him to bed and that he could not move his left leg at all. When asked why the incident was not documented in the record she said: "I didn't think this was going to turn out as such a big deal." R. Record review of the Policies and procedures for Abuse Investigations, Resident Rights-Appendix B from Operational Policy and Procedures Manual, received from the Administrator on 11/30/12 at 3:00 pm with revised date December 2006, states: 1. Policy Statement, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management." 2. Policy Interpretation and Implementation, item 3 (Three), which states, "The individual conducting the investigation will, at a minimum: a. Review the resident's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; e. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; f. Interview the resident's roommate, family members, and visitors; g. Review all events leading up to the alleged incident." 3. All occurrences of abuse, neglect, mistreatment, injuries of unknown source will be analyzed by the quality assessment and assurance committee to determine if system changes need to be made.

Based on interview and record review, the facility failed to implement their policy and procedures for abuse investigations, neglect and injuries of unknown source for 3 residents (#8, #52, & #87) of 9 residents (#8, #11, #30, #51, #52, #60, #61, #62, & #87) reviewed. This deficient practice is likely to have caused actual harm to R #52 and had the potential to likely cause harm to residents (#8, #11, #30, #51, #60, #62, & #87) who where at risk of falls and fractures since the facility did not complete a thorough investigation to explore the possible causes and how to prevent the incident from re-occurring. The findings are: A. Record review of the Policies and procedures for Abuse Investigations, Resident Rights-Appendix B from Operational Policy and Procedures Manual, received from the Administrator on 11/30/12 at 3:00 pm with revised date December 2006, states: 1. Policy Statement, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management." 2. Policy Interpretation and Implementation, item 3 (Three), which states, "The individual conducting the investigation will, at a minimum: a. Review the resident's medical record to determine events leading up to the incident; b. Interview the person(s) reporting the incident; c. Interview any witnesses to the incident; d. Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition; e. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; f. Interview the resident's roommate, family members, and visitors; g. Review all events leading up to the alleged incident." 3. All occurrences of abuse, neglect, mistreatment, injuries of unknown source will be analyzed by the quality assessment and assurance committee to determine if system changes need to be made. B. Record review of Nursing/Progress notes for R #8 dated 11/24/12 by Licensed Practical Nurse (LPN) #4 revealed: At 9:15 pm resident was found on right side of bed on floor laying on left side. Resident has floor mat in place with resident on other side of mat on floor. Resident has skin tear to left elbow. C. Record review of the reportable incidents received from the Social Worker (SW) on 11/27/12, dated 2012 was negative for documented reported incidents to the State Agency (SA) for R #8. D. On 12/05/12 at 6:10 pm, during an interview with Licensed Practical Nurse (LPN) #4 regarding the 11/24/12 fall and injury of unknown source sustained by R #8, LPN #4 confirmed that no injury of unknown source was referred for reporting to SA within 24 hours. E. On 12/06/12 at 9:50 am, during an interview with the Director of Nursing (DON) regarding the 11/24/12 incident for R #8, the DON confirmed that the injury of unknown source associated with the 11/24/12 incident for R #8 was not reported to the SA.within 24 hours and that no investigation of the incident was done or reported to the SA within 5 (five) working days of the incident. F. Record review of the hospital's history & physical dated 11/04/12 for R #52 revealed the following: Chief Complaint: Left hip pain for 2 days prior to admission. [AGE] year old male admitted due to left [MEDICAL CONDITION]. G. On 11/27/12 at 4:40 pm, during an interview with the Director of Nursing (DON) when asked if the incident regarding R #52 on 11/02/12 was a fall she replied: "Yes." When asked if nursing should have made notes every shift to follow up on R #52 since he did have a change in condition and pain, she said: "Yes." The DON confirmed there was not any documentation in the medical record after the fall until 2 days later when Registered Nurse (RN) #2 documented sending R #52 to the hospital for X-rays due to pain in left hip unrelieved by Tylenol and unable to bear weight on left leg per RN #2's call to the physician. H. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed being on duty on 11/02/12 when R #52 sustained a fall. L When asked about protocol after a fall LPN #2 said: "We watch him through out the day for pain and guarding (involuntary action to protect an area from pain), usually we watch him for 72 hours." LPN #2 confirmed she did not pull his chart and put it in the rack for nursing to follow up. LPN #2 said: "Thinking about it now I should have notified the doctor since he complained of pain to his hip. I did an incident report (internal) just in case since I really didn't consider this a fall." LPN #2 confirmed an assessment should have been completed, a skin check and a pain assessment and it should be documented in the progress notes. When asked if she notified the family she said "No." I. On 11/28/12 at 11:12 am, during an interview with the Social Worker (SW) she confirmed as the facilities abuse coordinator she was responsible for incident reports. The SW confirmed she wasn't aware of the fall regarding R #52 until 11/05/12 when he was admitted to the hospital with [REDACTED].#52 she said: "It was late due to we didn't consider it a actual fall then he began to have pain so I thought we needed to report it." J. On 11/28/12 at 3:05 pm, during an interview with Certified Nurse Assistant (CNA) #5 she confirmed she was with R #52 when he fell . CNA #5 demonstrated the fall and said: "When I stood him up originally he grunted in pain and then his legs gave out. I turned to lay him on the bed and he was sliding off so I grabbed his gait belt and pulled him up and he landed on top of me on the floor. I had to push him over to the right so I could reach the call lite for help." CNA #5 said: " He clearly was in a lot of pain, he was just grunting and groaning and not able to bare weight, he couldn't even help scoot himself in the bed. His left leg couldn't move at all, I had to move him. That is not his usual, he is usually easy to transfer with one person and I have worked with him for months. (Name of LPN #2) and I put him in his wheelchair from the floor and let him sit for a moment since he was hurting and very short of breath, we let him rest then we transferred him to bed." K. On 11/29/12 at 9:17 am, during an interview with RN #2 he said: "That Sunday (11/04/12) morning the CNA's went to get him up and he was unable to bare weight, he was complaining of pain to the left hip so I called the doctor and alerted him of the pain and that Tylenol was not effective so he said to send him to X-ray. I couldn't find any incident reports in the system about the fall, no verbal reports, nothing on the 24 hour report and nothing was in the nurses notes." I didn't even do a transfer since he was just going out for X-rays and I didn't expect for him to be admitted ." L. On 11/29/12 at 3:03 pm, during an interview with CNA #4, he confirmed he worked all the weekend (November 2nd & 3rd, 2012) of the incident with this resident. CNA #4 said: "He was in a lot of pain for 3 or 4 days, it was really bad. Sunday the pain continued and the nurse then sent him out. We couldn't move him at all. He kept his hands on his left hip and was moaning and groaning and complaining of pain. He was really hurting." M. On 11/29/12 at 3:08 pm, during an interview with Registered Nurse (RN) #1 she confirmed working with R # 52 on 11/03/12 the day after his fall. RN #1 said she was not told by LPN #2 about the fall and confirmed there was not a nursing note or assessment in the record regarding the incident. RN #1 said R # 52 complained of pain all over that day and she gave him Tylenol. RN # 1 confirmed she did not document any assessment of R #52 to include a pain assessment or even a physical assessment. N. Record Review of R #52's nursing/progress notes contained the following: Nursing progress note with late entry date of 11/05/12 at 7:04 pm (3 days after the fall) and after R #52 was diagnosed with [REDACTED]. Documentation was: "Nurse noticed call light above resident door was on, nurse went to resident's room. Found resident leaning againt CNA (Inititals of CNA) legs/sitting on floor. CNA states she was transferring resident to bed from wheelchair (w/c) when resident became weak and started to fall to floor. CNA attempted to break fall assisting resident gently to floor in sitting position. Assisted resident to bed, resident able to bare weight and help during transfer. Full range of motion (ROM) to all extremities, no bruising, redness or swelling noted.No open areas. Resident complained of slight pain to left leg/knee area. Will continue to monitor." O. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she said: "I put a late entry in the chart on Saturday, 11/03/12. When asked why she did that she said: "That day (Friday 11/02/12) was crazy. I did an internal incident report too." When asked if that was normal procedure for her she said: "I was worried in case something was wrong. Yes, it bothered me. This incident was very unusual for him, he always helps out with transfers and I felt like something was wrong." LPN #2 said she alerted the nurse coming on duty the day of the fall and confirmed she did not document anything on the 24 hour report. LPN #2 then confirmed that R #52 was moaning and groaning in pain when her and CNA #5 put him to bed and that he could not move his left leg at all. When asked why the incident was not documented in the record she said: "I didn't think this was going to turn out as such a big deal."

Repeat deficiency Based on record review and interview, administration failed to manage the facility in order to prevent system failure as evidenced by; 1. Failure to complete nursing assessment accurately. 2. Failure to follow their policies and procedures regarding notification of the physician and family after resident falls. 3. Failure to perform pain and fall re/assessments after a resident has experienced a fall. This deficient practice presents a risk of harm to all 86 resident listed on the resident census record provided by the Director of Nursing (DON) on 11/27/12 who may be inappropriately assessed and receive inappropriate overall medical care. The findings are: 1. Failure to complete nursing assessment accurately. A. Record Review of R #52's nursing/progress notes contained the following: Nursing progress note with created date of 11/05/12 (3 days after the fall) and after R #52 was diagnosed with [REDACTED]. B. On 11/27/12 at 4:04 pm, during an interview with the DON she was asked if the incident on R #52 on 11/02/12 was a fall she replied: "Yes." When asked what the facility protocol was for nursing regarding this incident she said an assessment of the resident which could be documented in the progress notes if not on an actual nursing assessment, a skin check, pain assessment and a fall assessment. C. On 11/27/12 at 4:40 pm, during an interview with the Director of Nursing (DON) when asked if the incident regarding R #52 on 11/02/12 was a fall she replied: "Yes." When asked if nursing should have made notes every shift to follow up on R #52 since he did have a change in condition and pain, she said: "Yes." The DON confirmed there was not any documentation in the medical record after the fall until 2 days later when Registered Nurse (RN) #2 documented sending R #52 to the hospital for X-rays due to pain in left hip unrelieved by Tylenol and unable to bear weight on left leg per RN #2's call to the physician. D. On 11/28/12 at 3:05 pm, during an interview with Certified Nurse Assistant (CNA) #5 she confirmed she was with R #52 when he fell . CNA #5 demonstrated the fall and said: "When I stood him up originally he grunted in pain and then his legs gave out. I turned to lay him on the bed and he was sliding off so I grabbed his gait belt and pulled him up and he landed on top of me on the floor. I had to push him over to the right so I could reach the call lite for help." CNA #5 said: "He clearly was in a lot of pain, he was just grunting and groaning and not able to bare weight, he couldn't even help scoot himself in the bed. His left leg couldn't move at all, I had to move him. That is not his usual, he is usually easy to transfer with one person and I have worked with him for months. (Name of LPN #2) and I put him in his wheelchair from the floor and let him sit for a moment since he was hurting and very short of breath, we let him rest then we transferred him to bed." E. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed being on duty on 11/02/12 when R #52 sustained a fall. LPN #2 said she found Certified Nurse Assistant (CNA) #5 on the floor with the R #52 "sitting in her lap with his bottom on the ground and his legs underneath the bed. "LPN #2 said: (Name of R #52) didn't have any complaints of pain and he had full range of motion (ROM), we transferred him from the floor to the wheelchair and then to the bed and he could stand and assist us." When asked again about no pain she said: "He complained of a little bit of pain to his left hip." When asked about protocol after a fall LPN #2 said: "We watch him through out the day for pain and guarding, usually we watch him for 72 hours. LPN #2 confirmed she did not pull his chart and put it in the rack for nursing to follow up. LPN #2 said: "Thinking about it now I should have notified the doctor since he complained of pain to his hip. I did an incident report (internal) just in case since I really didn't consider this a fall." LPN #2 confirmed an assessment should have been completed, a skin check and a pain assessment and it should be documented in the progress notes. When asked if she notified the family she said "No." F. On 11/29/12 at 9:17 am, during an interview with RN #2 he said: "That Sunday (11/04/12) morning the CNA's went to get him up and he was unable to bare weight, he was complaining of pain to the left hip so I called the doctor and alerted him of the pain and that Tylenol was not effective so he said to send him to X-ray. I couldn't find any incident reports in the system about the fall, no verbal reports, nothing on the 24 hour report and nothing was in the nurses notes. "When asked if he notified the family RN #2 said: "I didn't yet because no results yet from X-ray. I didn't even do a transfer since he was just going out for X-rays and I didn't expect for him to be admitted ." G. On 11/29/12 at 3:03 pm, during an interview with CNA #4 he confirmed he worked all the weekend (11/02/12 & 11/03/12) of the incident with this resident. CNA #4 said: "He was in a lot of pain for 3 or 4 days, it was really bad. Sunday the pain continued and the nurse then sent him out. We couldn't move him at all. He kept his hands on his left hip and was moaning and groaning and complaining of pain. He was really hurting." H. On 11/29/12 at 3:08 pm, during an interview with Registered Nurse (RN) #1 she confirmed working with R # 52 on 11/03/12 the day after his fall. RN #1 said she was not told by LPN #2 about the fall and confirmed there was not a nursing note or assessment in the record regarding the incident. RN #1 said R # 52 complained of pain all over that day and she gave him Tylenol. RN # 1 confirmed she did not document any assessment of R #52 to include a pain assessment or even a physical assessment. RN #1 said: "He kept complaining of pain all over." RN #1 confirmed she did not notify R #52's physician or family about his change in condition. I. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she said: "I put a late entry in the chart on Saturday, 11/03/12. When asked why she did that she said: "That day (Friday 11/02/12) was crazy. I did an internal incident report too." When asked if that was normal procedure for her she said: "I was worried in case something was wrong. Yes, it bothered me. This incident was very unusual for him, he always helps out with transfers and I felt like something was wrong." LPN #2 said she alerted the nurse coming on duty the day of the fall and confirmed she did not document anything on the 24 hour report. LPN #2 then confirmed that R #52 was moaning and groaning in pain when her and CNA #5 put him to bed and that he could not move his left leg at all. When asked why the incident was not documented in the record she said: "I didn't think this was going to turn out as such a big deal." J. Record review of the fall/accident/incident log received by the Director of Nursing (DON) revealed for R # 62 shows 2 falls in the last 3 months (08/2012 - 11/2012). Progress notes dated 8/26/12 & 11/19/12 both indicate that R # 62 had a fall. (8/26/12 reports R # 62 rolled out of bed onto the floor) & (11/23/12 reports that R #62 was found on mat next to his bed). These two falls were in-accurately reported on the Monthly Nursing Assessments that were completed on 09/22/12 & 11/22/12 under section # 8-A (has the resident fallen since the previous assessment?) Both Nursing assessments were marked "No." 1. On 12/05/12 at 10:30 am during interview, the DON explained that the Monthly Nursing Assessments are completed by an assigned nurse for that month. The DON acknowledged that Licensed Practical Nurse (LPN) # 9 did not complete section # 8 (falls in the past 30 days) accurately by marking "no" for falls since resident # 62 fell on [DATE]. 2. On 12/05/12 at 10:30 am during interview with the DON also acknowledged that the Monthly Nursing assessment completed on 11/22/12 by RN #4 indicated "no" in section # 8-A; however, R #62 had a reported fall on 11/19/12 in the Progress notes. The Assistant Director of Nursing (ADON) was present during interview and did re-confirm that the assessment was completed in-accurately. 3. On 12/05/12 at 10:30 am during interview, Registered Nurse #4 explained the reason the monthly nursing assessment was done inaccurately is " that I get so use to daily assessments and it talks about falls in the last 24 hours which is different than the monthly assessment which asks about falls in the last 30 days, I must have overlooked it. I will work on this " . K. On 12/05/12 at 10:30 am during interview, the DON confirmed that a Monthly Nursing Assessment for 10/2012 was never completed for R #62. L. On 12/05/12 at 4:05 pm, during an interview with LPN #4 she confirmed that she was the nurse assigned to care for R #61 when the resident fell on [DATE]. LPN #4 stated that after R #61 fell on [DATE] she informed the physician the next morning, 11/24/12. When LPN #4 was informed that no nursing notes were found regarding an initial assessment or any action taken on her behalf after R #61 fell on [DATE] she stated, " I honestly don't remember if I made any notes. " When LPN #4 was asked if she informed the family about the resident's fall she stated, "That is the responsibility of the day-shift nurse." M. On 12/05/12 at 6:10 pm, during an interview with LPN #4 regarding a fall sustained by R #8 on 11/24/12, LPN #4 confirmed that there was no documentation of physician or family notification in the medical record. 2. Failure to follow their policies and procedures regarding notification of the physician and family after resident falls. N. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed working the day of 11/02/12 when R #52 fell when asked if she notified the physician and the family she said: "No, thinking about it now, I should have notified the doctor since he complained of pain to his hip." O. On 11/28/12 at 11:12 am, during an interview with the Social Worker (SW) she confirmed she completed the incident report regarding R #52's fall on 11/05/12. Wen asked why the section on the report to notify the physician and the family was blank she said: "It's the nurse's responsibility to notify the doctor and the family." During the interview the SW stated that she wasn't aware of the fall regarding R #52 until 11/05/12 when he was admitted to the hospital with [REDACTED].#52 she said: "It was late due to we didn't consider it a actual fall then he began to have pain so I thought we needed to report it." The SW confirmed it was nursing's responsibility to notify the physician and the resident's family. P. Record review of R #52's Minimum Data Sheet ((MDS) dated [DATE] for a discharge to acute care revealed the following: "Section J1800- Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent?" The Minimum Data Sheet Coordinator (MDSC) marked the answer as "No." Section G for Functional status the MDSC scored R #52's transfer status as extensive assistance-resident involved in activity, staff provide weight-bearing support. Q. Record review of R #52's MDS dated [DATE] revealed the following: "Type of assessment significant change in status assessment. Section G for Functional status the MDSC scored R #52's transfer status as total dependence-full staff performance every time during entire 7-day period. Section I for Active [DIAGNOSES REDACTED]. The MDS did not contain a [DIAGNOSES REDACTED]. R. On 11/28/12 at 2:40 pm, during an interview with the MDSC she confirmed completing a discharge MDS on R #52 when he was discharged to the hospital on [DATE]. The MDSC then completed a re-entry MDS upon R #52's return to the facility on [DATE]. The MDSC said the MDS only showed his return and the fall and fracture would be on the MDS dated [DATE] for a significant change in condition. The MDSC then said the fall for R #52 with fracture was not documented on the MDS only the fall incurred on 11/16/12. When asked why this assessment was not accurate of R #52's condition she replied: I didn't really understand the question." The MDSC confirmed she did not complete the MDS to capture the current condition of R #52 to include his fall and [MEDICAL CONDITION] incurred on 11/02/12. S. On 11/29/12 at 9:17 am, during an interview with RN #2 he confirmed he was the nurse who alerted the physician of R #52's pain and inability to bare weight. When asked if he notified the family he said: "I didn't yet because no results from the X-ray. He was just going out for X-rays and I didn't expect for him to be admitted ." T. Record review of R #52's monthly standing orders dated 11/01/12 for the month of November revealed the following: Notify the doctor (MD) during office hours of a fall without injury. U. On 12/04/12 at 4:38 pm, during an interview with the ADON she confirmed that R #60 incurred a skin tear of unknown origin on 11/17/12 and the nursing staff did not assess the wound and document it in the medical record. The ADON confirmed a 72 hour follow up was protocol for all injuries/accidents and falls in the facility. The ADON confirmed there wasn't a follow up after R #60's skin tear and and that the nursing staff did not notify the physician or the family/POA. V. On 12/05/12, at 3:16 pm, during an interview with the DON, she stated, "The Policy and Procedure on what happens after a fall is immediately the nurse on duty, on each shift, has to do a fall assessment, pain assessment and skin check, even on the graveyard shift. That nurse is responsible." W. On 12/06/12 at 9:50 am, during an interview with the DON regarding the 10/27/12 fall noted on the fall log for R #8, the DON confirmed that there was no documentation of physician or family notification in the medical record, that a fall incident documented in the medical record on 10/27/12 and that there is no nursing assessment of R #8 as a result of the fall, documented in the medical record. 3. Failure to perform pain and fall re/assessments after a resident has experienced a fall. X. Record review of R #52's Minimum Data Sheet ((MDS) dated [DATE] for a discharge to acute care revealed the following:" Section J1800- Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent?" The Minimum Data Sheet Coordinator (MDSC) marked the answer as "No." Section G for Functional status the MDSC scored R #52's transfer status as extensive assistance-resident involved in activity, staff provide weight-bearing support. Y. Record review of the hospital history & physical dated 11/04/12 for R #52 revealed the following: "Chief Complaint-Left hip pain 2 days prior to admission. Hospital Admission Diagnosis: [REDACTED]. Z. Record review of an incident report dated 11/05/12 on R #52, completed by the Social Worker (SW) documented "Injuries of unknown origin" and described a witnessed fall. Incident report for R #60 documented a skin tear that was found by staff. AA. Record review of R #52's MDS dated [DATE] revealed the following: "Type of assessment significant change in status assessment. Section G for Functional status the MDSC scored R #52's transfer status as total dependence-full staff performance every time during entire 7-day period. Section I for Active [DIAGNOSES REDACTED]. The MDS did not contain a [DIAGNOSES REDACTED]. BB. Record review of the facilities fall/accident/incident log received by the DON on 11/27/12 at 12:00 pm revealed the following: R # 52 transfer/positioning incident on 11/02/12. R #60 transfer/positioning incident on 11/17/12. CC. On 11/27/12 at 4:04 pm, during an interview with the DON she confirmed that physician for R #52 was not notified of a fall sustained on 11/02/12 until 11/04/12 when orders were given by the physician to send R #52 to the hospital for X-rays. he DON also confirmed that R #52's family/Power of Attorney (POA) wasn't notified of the fall or hospital transfer until 11/05/12. DD. Record review of the facility Assessments Special Note, dated 11/28/12, indicated Next Assessment Due: Pain Management Tool (3.0): 109 days overdue-08/17/12. EE. On 11/28/12 at 2:40 pm, during an interview with the MDSC she confirmed completing a discharge MDS on R #52 when he was discharged to the hospital on [DATE]. The MDSC then completed a re-entry MDS upon R #52's return to the facility on [DATE]. The MDSC said the MDS only showed his return and the fall and fracture would be on the MDS dated [DATE] for a significant change in condition. The MDSC then said the fall for R #52 with fracture was not documented on the MDS only the fall incurred on 11/16/12. When asked why this assessment was not accurate of R #52's condition she replied: I didn't really understand the question." The MDS confirmed she did not complete the MDS to capture the current condition of R #52 to include his fall and [MEDICAL CONDITION] incurred on 11/02/12. During the interview the MDSC was also asked why the significant change in status MDS was created for R #52 dated 11/18/12 she said:"Due to his fall and fracture." The MDSC confirmed she captured another fall incurred by R #52 on the MDS dated [DATE] and that this MDS and the discharge MDS dated [DATE] did not capture R #52's fall and fracture. The MDSC confirmed the significant change in status should have been completed accurately when R #52 returned from the hospital and the discharge MDS should have reflected the fall R #52 had on 11/02/12. The MDSC verbalized not really understanding some of the MDS questions and that was the reason for the inaccuracy. FF. On 11/28/12 at 9:20 am, during an interview with LPN #2 she confirmed she was on duty when R #52 fell . When asked what should have happened after R #52 fell she said: "A full nursing assessment should have been completed, a skin check and a pain assessment and it should at least be in the progress notes as far as the assessment." LPN #2 confirmed she did not complete the assessments and document it in the residents chart. GG. On 11/29/12 at 9:50 am, during an interview with the MDSC, she confirmed that no nursing notes regarding an initial nursing assessment, pain assessment, skin assessment or fall risk re-assessment were made as a result of the fall that occurred on 11/23/12. HH. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she confirmed that R # 52 had a fall while she was on duty on 11/02/12. II. On 12/05/12 at 9:05 am, during an interview with the DON, she confirmed that the facility had not been routinely informing the physician regarding falls without injury, performing pain, skin or fall risk re-assessments after residents experienced a fall, including falls without injury. JJ. On 12/06/12 8:14 am, during an interview, LPN #5 stated she was on duty 11/21/12 when R #11 fell . When asked if she completed a Fall Risk Assessment and Pain Assessment on R #11 after he fell on [DATE], she stated "No. I just did the documentation in the Nurses Notes and did not think this was necessary. He had no injuries." KK. On 12/06/12, at 10:15 am, during an interview with the ADON she confirmed that the facility had not performed a skin assessment or fall risk re-assessment during the 72-hour follow up for R #61. LL. On 12/06/12 at 2:32 pm, during an interview, LPN #6 stated "I did not know about the need to do a Falls Risk, Pain and Skin Assessment right after a fall." Regarding R #11's fall on 11/04/12, she revealed "the fall was not documented." She could not explain why a Fall Risk Assessment was not done until 11/10/12. LPN #6 revealed she did a Late Entry for the 11/04/12 fall, on 11/10/12 and stated "I cannot explain why this was late, but it should have been done on 11/04/12." She stated "No Falls Risk Assessment, Pain Assessment or Skin Assessment was done immediately after the fall. I didn't do a pain assessment or skin check. I did a Falls Risk Assessment on 11/10/12 (six days late) and agree it was done late."

REPEAT DEFICIENCY Based on record review and interview the facility failed to maintain complete and accurate clinical records for 6 (Resident (R) #8, #11, #52, #60, #61 & #62) out of 9 (R #8, #11, #30, #51, #52, #60, #61, #62 & #87) reviewed residents by not properly updating nursing notes, not capturing residents' falls on the Minimum Data Set (MDS), not documenting physician/family notification regarding falls, resident fall risk re-assessments or pain/skin assessments after a fall of a resident. This deficient practice likely caused harm to R #52 as a result of being medically neglected after sustaining a broken hip from a fall and had the potential to harm all 86 residents in the facility, according to the resident census record provided by the Director of Nursing (DON) on 11/27/12 at 11:15 am, as a result of the facility's failure to communicate the accurate medical status/needs of residents amongst clinical staff. The findings are: Resident # 52 & # 60 A. Record review of the hospital's history & physical dated 11/04/12 for R #52 revealed the following: Chief Complaint: Left hip pain for 2 days prior to admission. [AGE] year old male admitted due to left [MEDICAL CONDITION]. B. On 11/27/12 at 4:40 pm, during an interview with the Director of Nursing (DON) when asked if the incident regarding R #52 on 11/02/12 was a fall she replied: "Yes." When asked if nursing should have made notes every shift to follow up on R #52 since he did have a change in condition and pain, she said: "Yes." The DON confirmed there was not any documentation in the medical record after the fall until 2 days later when Registered Nurse (RN) #2 documented sending R #52 to the hospital for X-rays due to pain in left hip unrelieved by Tylenol and unable to bear weight on left leg per RN #2's call to the physician. C. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed being on duty on 11/02/12 when R #52 sustained a fall. LPN #2 said: (Name of R #52) didn't have any complaints of pain and he had full range of motion (ROM), we transferred him from the floor to the wheelchair and then to the bed and he could stand and assist us." When asked again about no pain she said: "He complained of a little bit of pain to his left hip." When asked about protocol after a fall LPN #2 said: "We watch him through out the day for pain and guarding, usually we watch him for 72 hours. LPN #2 confirmed she did not pull his chart and put it in the rack for nursing to follow up. LPN #2 said: "Thinking about it now I should have notified the doctor since he complained of pain to his hip. I did an incident report (internal) just in case since I really didn't consider this a fall." LPN #2 confirmed an assessment should have been completed, a skin check and a pain assessment and it should be documented in the progress notes. D. On 11/28/12 at 11:12 am, during an interview with the Social Worker (SW) she confirmed as the facilities abuse coordinator she was responsible for incident reports. The SW confirmed she wasn't aware of the fall regarding R #52 until 11/05/12 when he was admitted to the hospital with [REDACTED].#52 she said: "It was late due to we didn't consider it a actual fall then he began to have pain so I thought we needed to report it." The SW confirmed it was nursing's responsibility to notify the physician and the resident's family. E. Record review of R #52's Minimum Data Sheet ((MDS) dated [DATE] for a discharge to acute care revealed the following:" Section J1800- Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent?" The Minimum Data Sheet Coordinator (MDSC) marked the answer as "No." Section G for Functional status the MDSC scored R #52's transfer status as extensive assistance-resident involved in activity, staff provide weight-bearing support. F. Record review of R #52's MDS dated [DATE] revealed the following: "Type of assessment significant change in status assessment. Section G for Functional status the MDSC scored R #52's transfer status as total dependence-full staff performance every time during entire 7-day period. Section I for Active [DIAGNOSES REDACTED]. The MDS did not contain a [DIAGNOSES REDACTED]. G. On 11/28/12 at 2:40 pm, during an interview with the MDSC she confirmed completing a discharge MDS on R #52 when he was discharged to the hospital on [DATE]. The MDSC then completed a re-entry MDS upon R #52's return to the facility on [DATE]. The MDSC said the MDS only showed his return and the fall and fracture would be on the MDS dated [DATE] for a significant change in condition. The MDSC then said the fall for R #52 with fracture was not documented on the MDS only the fall incurred on 11/16/12. When asked why this assessment was not accurate of R #52's condition she replied: I didn't really understand the question." The MDSC confirmed she did not complete the MDS to capture the current condition of R #52 to include his fall and [MEDICAL CONDITION] incurred on 11/02/12. H. Record review of R #52's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s fall. I. On 11/29/12 at 9:17 am, during an interview with RN #2 he said: "That Sunday morning the CNA's went to get him up and he was unable to bare weight, he was complaining of pain to the left hip so I called the doctor and alerted him of the pain and that Tylenol was not effective so he said to send him to X-ray. I couldn't find any incident reports in the system about the fall, no verbal reports, nothing on the 24 hour report and nothing was in the nurses notes. J. On 11/29/12 at 3:08 pm, during an interview with RN #1 she confirmed working with R #52 on 11/03/12 the day after his fall. RN #1 said she was not told by LPN #2 about the fall and confirmed there was not a nursing note or assessment in the record regarding the incident. RN #1 said R # 52 complained of pain all over that day and she gave him Tylenol. RN # 1 confirmed she did not document any assessment of R #52 to include a pain assessment or even a physical assessment. K. Record Review of R #52's nursing/progress notes contained the following: Nursing progress note with created date of 11/05/12 (3 days after the fall) and after R #52 was diagnosed with [REDACTED]. L. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she said:"I put a late entry in the chart on Saturday, 11/03/12. When asked why she did that she said: "That day (Friday 11/02/12) was crazy. I did an internal incident report too." When asked if that was normal procedure for her she said: "I was worried in case something was wrong. Yes, it bothered me. This incident was very unusual for him, he always helps out with transfers and I felt like something was wrong." LPN #2 said she alerted the nurse coming on duty the day of the fall and confirmed she did not document anything on the 24 hour report. LPN #2 then confirmed that R #52 was moaning and groaning in pain when her and CNA #5 put him to bed and that he could not move his left leg at all. When asked why the incident was not documented in the record she said: "I didn't think this was going to turn out as such a big deal." Resident # 11 M. On 12/05/12 at 2:52 pm, during an interview, LPN #3 stated, "No Pain Assessments were done after (Name of R #11)'s falls on 11/04/12 and 11/21/12. The Pain Assessment I did on 12/04/12 was a quarterly assessment and not due to either the fall on 11/04/12 or 11/21/12. After a fall, I now realize nursing needs to do a fall risk assessment, a pain assessment and a skin assessment." N. On 12/06/12 8:14 am, during an interview, LPN #5 stated she was on duty 11/21/12 when R #11 fell . When asked if she completed a Fall Risk Assessment and Pain Assessment on R #11 after he fell on [DATE], she stated "No. I just did the documentation in the Nurses Notes and did not think this was necessary. He had no injuries." O. On 12/06/12 at 2:32 pm, during an interview, LPN #6 stated "I did not know about the need to do a Falls Risk, Pain and Skin Assessment right after a fall." Regarding R #11's fall on 11/04/12, she revealed "the fall was not documented." She could not explain why a Fall Risk Assessment was not done until 11/10/12. LPN #6 revealed she did a Late Entry for the 11/04/12 fall, on 11/10/12 and stated "I cannot explain why this was late, but it should have been done on 11/04/12." She stated "No Falls Risk Assessment, Pain Assessment or Skin Assessment was done immediately after the fall. I didn't do a pain assessment or skin check. I did a Falls Risk Assessment on 11/10/12 (six days late) and agree it was done late." Resident # 61 P. On 11/29/12 at 9:50 am, during an interview with the MDSC, she confirmed that no nursing notes regarding an initial nursing assessment, pain assessment, skin assessment or fall risk re-assessment were made regarding a fall that R #61 endured on 11/23/12. Q. On 11/29/12 at 9:50 am, during an interview with the MDSC, she confirmed that no nursing notes regarding an initial nursing assessment, pain assessment, skin assessment or fall risk re-assessment were made as a result of the fall that occurred on 11/23/12. R. On 12/06/12, at 10:15 am, during an interview with the Assistant Director of Nursing she confirmed that the facility had not performed a skin assessment or fall risk re-assessment during the 72-hour follow up for R #61. Resident # 62 S. Record review of the fall/accident/incident log received by the DON on 11/27/12 at 12:00 pm for R #62 shows 2 falls in the last 3 months (08/2012- 11/2012). Progress notes dated 8/26/12 & 11/19/12 both indicate that R #62 had a fall. (8/26/12 reports R #62 rolled out of bed onto the floor) & (11/23/12 reports that R # 62 was found on mat next to his bed). These two falls were in-accurately reported on the Monthly Nursing Assessments that were completed on 09/22/12 & 11/22/12 under section # 8-A (has the resident fallen since the previous assessment?) Both Nursing assessments were marked "No." 1. On 12/5/12 at 10:30 am during interview, the DON explained that the Monthly Nursing Assessments are completed by an assigned nurse for that month. The DON acknowledged that LPN # 9 did not complete section #8 (falls in the past 30 days) accurately by marking "no" for falls since resident #62 fell on [DATE]. 2. On 12/05/12 at 10:30 am during interviewwith the DON also acknowledged that the Monthly Nursing assessment completed on 11/22/12 by RN #4 indicated "no" in section # 8-A; however, R #62 had a reported fall on 11/19/12 in the Progress notes. The ADON was present during interview and did re-confirm that the assessment was completed in-accurately. 3. On 12/05/12 at 10:30 am during interview, RN # 4 explained the reason the monthly nursing assessment was done inaccurately is "that I get so use to daily assessments and it talks about falls in the last 24 hours which is different than the monthly assessment which asks about falls in the last 30 days, I must have overlooked it. I will work on this." T. On 12/05/12 at 10:30 am during interview, the DON confirmed that a Monthly Nursing Assessment for 10/2012 was never completed for R #62. Resident # 8 U. Record review of the facility provided fall log recieved from the DON revealed that R #8 sustained 2 (two) falls dated 10/27/12 (without injury) and 11/24/12 (with injury). V. Record review of the Nursing/Progress notes for R #8 dated 10/27/12 and 11/24/12 revealed that there was no documentation in the medical record of physician or family notification. W. On 12/05/12 at 6:10 pm, during an interview with LPN #4 regarding the 11/24/12 fall, LPN #4 confirmed that there was no documentation of physician or family notification in the medical record. X. On 12/06/12 at 9:50 am, during an interview with the DON regarding the 10/27/12 and 11/24/12 incidents for R # 8, the DON confirmed that there was no documentation of physician or family notification in the medical record.

REPEAT DEFICIENCY Based on record review and interview the facility failed to provide 1 resident (R #52,) of 9 (#8, #11, #30, #51, #52, #60, #61, #62, & #87) residents reviewed the necessary care and services based on his needs regarding a significant change in condition after sustaining a fall and fracture in the facility on 11/02/12. This deficient practice likely caused actual harm to R #52 since the facility failed to notify R #52's physician to seek medical care and the family of the incident so they could make informed decisions when the incident occurred. The resident was in pain and lost function in his left leg for 2 days prior to being seen by a physician at the emergency room (ER) who diagnosed R #52 with a left [MEDICAL CONDITION] upon admission. This deficient practice is likely to cause harm to all 9 residents reviewed since the facility did not follow their own policy and procedure for falls and change in condition. The findings are: A. Record review of the hospital's history & physical dated 11/04/12 for R #52 revealed the following: Chief Complaint: Left hip pain for 2 days prior to admission. [AGE] year old male admitted due to left [MEDICAL CONDITION]. B. Record review of hospital's discharge summary dated 11/08/12 revealed the following: Resident not a good candidate for surgery per the Orthopedic surgeon, he did have pain which was controlled with narcotic [MEDICATION NAME]. C. On 11/27/12 at 4:40 pm, during an interview with the Director of Nursing (DON) when asked if the incident regarding R #52 on 11/02/12 was a fall she replied: "Yes." When asked if nursing should have made notes every shift to follow up on R #52 since he did have a change in condition and pain, she said: "Yes." The DON confirmed there was not any documentation in the medical record after the fall until 2 days later when Registered Nurse (RN) #2 documented sending R #52 to the hospital for X-rays due to pain in left hip unrelieved by Tylenol and unable to bear weight on left leg per RN #2's call to the physician. D. On 11/28/12 at 9:20 am, during an interview with Licensed Practical Nurse (LPN) #2 she confirmed being on duty on 11/02/12 when R #52 sustained a fall. LPN #2 said she found Certified Nurse Assistant (CNA) #5 on the floor with the R #52 "sitting in her lap with his bottom on the ground and his legs underneath the bed. " LPN #2 said: (Name of R #52) didn't have any complaints of pain and he had full range of motion (ROM), we transferred him from the floor to the wheelchair and then to the bed and he could stand and assist us." When asked again about no pain she said: "He complained of a little bit of pain to his left hip." When asked about protocol after a fall LPN #2 said: "We watch him through out the day for pain and guarding (involuntary action to protect an area of pain), usually we watch him for 72 hours. LPN #2 confirmed she did not pull his chart and put it in the rack for nursing to follow up. LPN #2 said: "Thinking about it now I should have notified the doctor since he complained of pain to his hip. I did an incident report (internal) just in case since I really didn't consider this a fall." LPN #2 confirmed an assessment should have been completed, a skin check and a pain assessment and it should be documented in the progress notes. When asked if she notified the family she said "No." E. Record review of R #52's monthly standing orders dated 11/01/12 for the month of November revealed the following: Notify the doctor (MD) during office hours of a fall without injury. F. Record review of R #52's fall risk assessment dated [DATE] scored this resident as high risk for falls (10). G. On 11/28/12 at 11:12 am, during an interview with the Social Worker (SW) she confirmed as the facilities abuse coordinator she was responsible for incident reports. The SW confirmed she wasn't aware of the fall regarding R #52 until 11/05/12 when he was admitted to the hospital with [REDACTED].#52 she said: "It was late due to we didn't consider it a actual fall then he began to have pain so I thought we needed to report it." The SW confirmed it was nursing's responsibility to notify the physician and the resident's family. H. Record review of R #52's Minimum Data Sheet ((MDS) dated [DATE] for a discharge to acute care revealed the following:" Section J1800- Has the resident had any falls since admission/entry or reentry or the prior assessment, whichever is more recent?" The Minimum Data Sheet Coordinator (MDSC) marked the answer as "No." Section G for Functional status the MDSC scored R #52's transfer status as extensive assistance-resident involved in activity, staff provide weight-bearing support. I. Record review of R #52's MDS dated [DATE] revealed the following: "Type of assessment significant change in status assessment. Section G for Functional status the MDSC scored R #52's transfer status as total dependence-full staff performance every time during entire 7-day period. Section I for Active [DIAGNOSES REDACTED]. The MDS did not contain a [DIAGNOSES REDACTED]. J. On 11/28/12 at 2:40 pm, during an interview with the Minimum Data Sheet Coordinator (MDSC) she confirmed completing a discharge MDS on R #52 when he was discharged to the hospital on [DATE]. The MDSC then completed a re-entry MDS upon R #52's return to the facility on [DATE]. The MDSC said the MDS only showed his return and the fall and fracture would be on the MDS dated [DATE] for a significant change in condition. The MDSC then said the fall for R #52 with fracture was not documented on the MDS only the fall incurred on 11/16/12. When asked why this assessment was not accurate of R #52's condition she replied: I didn't really understand the question." The MDSC confirmed she did not complete the MDS to capture the current condition of R #52 to include his fall and [MEDICAL CONDITION] incurred on 11/02/12. K. On 11/28/12 at 3:05 pm, during an interview with Certified Nurse Assistant (CNA) #5 she confirmed she was with R #52 when he fell . CNA #5 demonstrated the fall and said: "When I stood him up originally he grunted in pain and then his legs gave out. I turned to lay him on the bed and he was sliding off so I grabbed his gait belt and pulled him up and he landed on top of me on the floor. I had to push him over to the right so I could reach the call lite for help." CNA #5 said: " He clearly was in a lot of pain, he was just grunting and groaning and not able to bare weight, he couldn't even help scoot himself in the bed. His left leg couldn't move at all, I had to move him. That is not his usual, he is usually easy to transfer with one person and I have worked with him for months. (Name of LPN #2) and I put him in his wheelchair from the floor and let him sit for a moment since he was hurting and very short of breath, we let him rest then we transferred him to bed." L. Record review of R #52's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s fall. M. On 11/29/12 at 9:17 am, during an interview with RN #2 he said: "That Sunday morning the CNA's went to get him up and he was unable to bare weight, he was complaining of pain to the left hip so I called the doctor and alerted him of the pain and that Tylenol was not effective so he said to send him to X-ray. I couldn't find any incident reports in the system about the fall, no verbal reports, nothing on the 24 hour report and nothing was in the nurses notes." When asked if he notified the family RN #2 said: "I didn't yet because no results yet from X-ray. I didn't even do a transfer since he was just going out for X-rays and I didn't expect for him to be admitted ." N. On 11/29/12 at 3:03 pm, during an interview with CNA #4, he confirmed he worked all the weekend of the incident with this resident. CNA #4 said: "He was in a lot of pain for 3 or 4 days, it was really bad. Sunday the pain continued and the nurse then sent him out. We couldn't move him at all. He kept his hands on his left hip and was moaning and groaning and complaining of pain. He was really hurting." O. On 11/29/12 at 3:08 pm, during an interview with Registered Nurse (RN) #1 she confirmed working with R # 52 on 11/03/12 the day after his fall. RN #1 said she was not told by LPN #2 about the fall and confirmed there was not a nursing note or assessment in the record regarding the incident. RN #1 said R # 52 complained of pain all over that day and she gave him Tylenol. RN # 1 confirmed she did not document any assessment of R #52 to include a pain assessment or even a physical assessment. P. Record Review of R #52's nursing/progress notes contained the following: Nursing progress note with created date of 11/05/12 (3 days after the fall) and after R #52 was diagnosed with [REDACTED]. Q. On 11/30/12 at 5:18 pm, during an interview with LPN #2 she said:"I put a late entry in the chart on Saturday, 11/03/12. When asked why she did that she said: "That day (Friday 11/02/12) was crazy. I did an internal incident report too." When asked if that was normal procedure for her she said: "I was worried in case something was wrong. Yes, it bothered me. This incident was very unusual for him, he always helps out with transfers and I felt like something was wrong." LPN #2 said she alerted the nurse coming on duty the day of the fall and confirmed she did not document anything on the 24 hour report. LPN #2 then confirmed that R #52 was moaning and groaning in pain when her and CNA #5 put him to bed and that he could not move his left leg at all. When asked why the incident was not documented in the record she said: "I didn't think this was going to turn out as such a big deal."

The facility failed to ensure that Resident #7 was free from physical harm since she wore a seat belt restraint and had a history of [REDACTED]. This deficient practice had the potential to affect all 19 residents who have restraints per a list of residents with restraints revised from the Director of Nursing received on 09/06/12. This resulted in a Immediate Jeopardy (IJ) being identified on 08/24/12 at 12:45 pm. The Administrator was notified of the findings for the IJ on 08/24/12 at 2:20 pm. The facility took corrective action by providing an acceptable Plan of Removal on 08/24/12 at 5:15 pm. The scope and severity was lowered to a scope and severity of H after the facility submitted their Plan of Removal. The Plan of Removal indicated that the facility action plan was to: 1. Discontinue seat belt restraint immediately for R #7, physician orders [REDACTED]. Resident has agreed to remove seatbelt restraint. Resident provided with anti-thrust seat cushion on her wheelchair (w/c). 2. R #7 to continue with Occupational Therapy (OT) services 1-3 times a week, focus will be w/c positioning, transfers and safety. OT will place resident on Restorative Aide 2 times daily for 60 days for proper w/c positioning with anti-thrust w/c cushion. Restorative Aide 3 times a week for 60 days for strengthening with standing balance and transfers. 3. Resident's room will be moved closer to nurses station if she allows and 15 minute checks by staff will be implemented and documented to ensure resident safety. Floor staff from residents unit which includes CNA's, activities, and nurses will perform 15 minute checks for 14 days. 4. Residents with restraints will be monitored every 2 hours which will include observation, release and reposition. Restraint monitoring forms will be created and filed in the treatment books for proper follow up and documentation by 08/24/12 at 7:00 pm. Staff in facility will be trained on restraint monitoring forms by DON/ADON/SDC on 08/24/12 at 7:00 pm. All other staff members will be called in to facility for training that will be completed by 08/25/12 at 3:00 pm. 5. Restraint orders from doctors will include type of restraint, duration of restraint with a stop date, medical diagnosis, parameters for use, frequency of need to check restraint (minimum every 2 hours) and removal schedule. ODD, DON, ADON, SDC will audit all residents with restraints and ensure all orders are as stated above by 08/27/12 at 3:00 pm. 6. Residents will be re-evaluated on monthly basis for any used restraints to determine continue need for their use; residents care plan will indicate the continued use of the restraint. Clinical management team which includes, DON, ADON, SDC, OT, MDS Coordinator. Restraint committee will be created by 08/27/12 at 5:00 pm. All members of clinical management will be on Restraint Committee. 7. Physicians will be provided with a notice from DON/ADON informing them of any restraints being used on their residents with recommendations of decreasing restraint or discontinuing completely. Notices will be sent out on a quarterly bases. Notices will be completed for entire facility by 08/27/12 at 5:00 pm. 8. CNA In-service will be completed for all CNA's regarding proper use of restraints. CNA's in facility will be trained by 08/24/12 by 7:00 pm by the DON, ADON, SDC and OT. Remainder of CNA's will be trained by 08/25/12 at 3:00 pm as they will be called in to be trained on proper use of restraints. Based on interview and record review the facility failed to provide an environment free of accidents by not monitoring falls and restraints which resulted in 1 ( R #7) resident out of 19 (R #4, #7, #9, #10, #11, #12, #13, #14, # 15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) residents with restraints according to the revised list of residents with restraints obtained from the DON on 09/06/12 which resulted in R #7 sliding down in her wheelchair and her seat belt restraint was caught around her neck causing a reddened area. This deficient practice had the potential to cause harm and even death to any of the 19 residents with restraints since staff were not applying the restraints correctly and not monitoring them at a minimum of every 2 hours and checking the restraints for placement and releasing them. The findings are: A. Record review of an internal resident incident/accident investigation worksheet dated 07/26/12 revealed the following: (Name of R #7) had a witnessed fall on 07/26/12 at 5:40 am in the main dining room. Witnessed fall of resident out of wheelchair. Resident yelling for help upon arrival resident found with seat belt at neck area where she had slid down in the wheelchair. Resident did not hit head or receive any injuries. Reddened area noted to neck area. Under the restraint information on the worksheet Licensed Practical Nurse (LPN) # 3 left the section blank. Resident stated she was opening shades to window was the description of activity when incident occurred. Under environmental section it was noted seat belt to wheelchair as a safety intervention. B. Record review of R #7's care plan documented she was at risk for falls but it was never revised for new interventions after falls. The care plan was initiated on 10/11/11 and hand written notes read: Continue with goals and approaches and signed off by nursing. C. Record review of complaint intake form # received by the state agency revealed the following concern:(Name of R #7) slid out of her wheelchair on 07/25/12 early in the morning and she had her seat belt around her neck. Very concerned for her safety since staff pick her up about 20 times a day and her wheelchair is unsafe for her. This has been reported to the DON and the facility hasn't addressed her safety issues. It was reported the facility had 6 falls in a 7 day time span and 3 of the 4 falls happened over the weekend and they were sent to the hospital. The complaintant reported this issue since another resident (#1) had just sustained a fall with injury to her head and was found dead by the staff. Complaintant worried about residents safety in the facility. D. On 08/24/12 at 7:44 am, during an interview with Registered Nurse (RN) #1 she confirmed that R #7 had a history of [REDACTED]. RN #1 said that R #7 said she was trying to open the shades on the window in the dining room when she slid and the seat belt restraint was around her neck due to sliding down in her chair. RN #1 confirmed that R #7 has to be repositioned due to sliding down in wheelchair several times a day. E. On 08/24/12 at 8:40 am, during an interview with the Assistant Director of Nursing (ADON) she confirmed that R #7 had a history of [REDACTED]. Asked why in dining room so early in the morning and she said the resident propels herself early in the morning to the dining room. The ADON confirmed that a temporary care plan wasn't completed after the fall and said the staff should have since a follow up was needed due to a witnessed fall and that is their protocol. The ADON confirmed that new interventions to prevent sliding down in her chair were not implemented. F. Observations of residents on 08/24/12 at 4:20 pm, residents were all sitting in wheelchairs by the A-wing nursing station waiting to be escorted to the dining room for dinner. Checked all the residents at station and this is what was observed, 7 (#27, #10, #11, #12, #13, #2 & #14) residents with restraints in place. 1 resident (#27) was able to remove the seat belt restraint on command, the others were not able to do so. Out of 7 restraints checked only 1 restraint was properly fitting and 1 was a Geri-chair. The 5 seat belt restraints were so loose they were laying in the residents laps so if the resident was to slid down in their chair the restraint could easily be caught around their neck. G. On 08/22/12 at 11:20 am, during an interview with the Director of Nursing (DON) she was asked how many falls she had as of this date for the month. The DON was not able to answer this question. Asked the DON to see her fall log and she said she didn't have one. Asked the DON how she could track and trend falls in the facility and she said: "It's discussed at stand up meetings and I document follow up. I tell the Quality Assurance team the number of falls." The DON confirmed she wasn't able to give me any documentation on fall tracking or trending to reduce the number of falls in the facility. H. On 08/24/12 at 10:06 am, during an interview with the ADON she was asked how the facility tracked and documented on residents with restraints. The ADON said: "restraints aren't checked and released and no documentation of 2 hour releases." The ADON said there was an incident management track system in the computer for risk management but she didn't know how to access any information in the system. The ADON confirmed the facility did not have any type of restraint documentation form. I . On 08/24/12 at 10:14 am, during an interview with LPN #2 she confirmed there was no restraint tracking or documentation in the facility. J. On 08/24/12 at 10:55 am, during an interview with Registered Nurse (RN) # 1 she confirmed the facility did not have any restraint forms or documentation to chart restraint checks, safety, releases, etc. K. On 08/24/12 at 11:05 am, during an interview with the DON she confirmed the care plans for R #1,#2 & #7 were not revised with new interventions after having falls in the facility to include injuries. The DON said she usually doesn't attend care plan meetings. The DON said: "I only go to care plan meetings if something is very important. Asked the DON about residents with repeat falls and injuries was important and she said: "Yes." The DON confirmed the facility did not have any form of restraint documentation, no measures to reduce restraints, etc. The DON confirmed she was not aware of all the federal regulations. The DON confirmed that the 802 was up to date regarding falls, fractures and restraints. L. On 08/24/12 at 4:20 pm 9 additional residents (R #2,#4,#10,#11,#12,#13,#14, #18 & #19) were observed wearing restraints whose names were not on the list the DON provided after an Immediate Jeopardy was called in the building at 2:20 pm this day. The DON confirmed the 672 and the 802 forms received from the Administrator on 08/22/12 were not up to date and reflective of actual resident care needs. The DON agreed lack of documentation in the facility was a systems failure. M. Record review of the facilities policy and procedures for restraints dated 7/2009 revealed the following: Medical symptoms that warrant the use of restraints will be documented in the resident's medical record, ongoing assessments, and care plan. The physician's orders [REDACTED]. The facility will engage in a systematic and gradual process towards reducing any restraints. New restraint orders-complete restraint assessment and if appropriate then obtain order for type of restraint, duration (time frame) to be utilized, medical diagnosis/symptom for use, parameters for use (including release schedule), frequency of checking and removal schedule. The facility did not follow their own policy and procedure for restraints.

Based on interview and record review the facility failed to monitor physical restraints which resulted in 1 resident (R #7) out of 19 (#4, #7 , #9, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) residents with restraints according to the revised list obtained from the Director of Nursing (DON) on 09/06/12 to slide down/fall in her wheelchair and the seat belt restraint was around her neck. The facility did not have specific medical symptoms for use of restraints, no tracking documentation as to length of time the restraint was to be used, schedule to check restraints for proper placement, release, reposition, and no documentation as to gradual reduction for the use of restraints. This deficient practice had the potential to cause harm and even death to any of the 19 residents with restraints since staff were not applying the restraints correctly and not monitoring them at a minimum of every 2 hours and checking the restraints for placement and releasing them. The findings are: A. Record review of the facilities policy and procedures for restraints dated 07/2009 revealed the following: Medical symptoms that warrant the use of restraints will be documented in the resident's medical record, ongoing assessments, and care plan. The physician's orders [REDACTED]. The facility will engage in a systematic and gradual process towards reducing any restraints. New restraint orders-complete restraint assessment and if appropriate then obtain order for type of restraint, duration (time frame) to be utilized, medical diagnosis/symptom for use, parameters for use (including release schedule), frequency of checking and removal schedule. B. Record review of an internal resident incident/accident investigation worksheet dated 07/26/12 revealed the following: (Name of R #7) had a witnessed fall on 07/26/12 at 5:40 am in the main dining room. Witnessed fall of resident out of wheelchair. Resident yelling for help upon arrival resident found with seat belt at neck area where she had slid down in the wheelchair. Resident did not hit head or receive any injuries. Reddened area noted to neck area. Under the restraint information on the worksheet Licensed Practical Nurse (LPN) # 3 left the section blank. Resident stated she was opening shades to window was the description of activity when incident occurred. Under environmental section it was noted seat belt to wheelchair as a safety intervention. C. Record review of complaint intake form # received by the state agency revealed the following concern: (Name of R # 7) slid out of her wheelchair on 07/25/12 early in the morning and she had her seat belt around her neck. Very concerned for her safety since staff pick her up about 20 times a day and her wheelchair is unsafe for her. This has been reported to the DON and the facility hasn't addressed her safety issues. It was reported the facility had 6 falls in a 7 day time span and 3 of the 4 falls happened over the weekend and they were sent to the hospital. The complainant reported this issue since another resident (# 1) had just sustained a fall with injury to her head and was found dead by the staff. Complainant worried about residents safety in the facility. D. On 08/24/12 at 7:44 am, during an interview with Registered Nurse (RN) #1 she confirmed that R # 7 had a history of [REDACTED]. RN # 1 said that R # 7 said she was trying to open the shades on the window in the dining room when she slid and the seat belt restraint was around her neck due to sliding down in her chair. RN # 1 confirmed that R # 7 has to be repositioned due to sliding down in wheelchair several times a day. E. Observations of residents on 08/24/12 at 4:20 pm, residents were all sitting in wheelchairs by the A-wing nursing station waiting to be escorted to the dining room for dinner. Checked all the residents at station and this is what was observed, 7 residents (# 27, #10, #11, #12, #13, # 2 & #14) with restraints in place. One resident ( # 27) was able to remove the seat belt restraint on command, the others were not able to do so. Out of these 7 restraints checked, only 1 restraint was properly fitting and 1 was a Geri-chair (recliner). The 5 seat belt restraints were very loose and were laying in the residents laps. F. On 08/24/12 at 10:06 am, during an interview with the Assistant Director of Nursing (ADON) she was asked how the facility tracked and documented on residents with restraints. The ADON said: "restraints aren't checked and released and no documentation of 2 hour releases." The ADON said there was an incident management track system in the computer for risk management but she didn't know how to access any information in the system. The ADON confirmed the facility did not have any type of restraint documentation form. G . On 08/24/12 at 10:14 am, during an interview with LPN # 2 she confirmed there was no restraint tracking or documentation in the facility. H. On 08/24/12 at 10:55 am, during an interview with Registered Nurse (RN) # 1 she confirmed the facility did not have any restraint forms or documentation to chart restraint checks, safety, releases, etc. I. On 08/24/12 at 11:05 am, during an interview with the DON she confirmed the facility did not have any form of restraint documentation, no measures to reduce restraints, etc. The DON confirmed she was not aware of all the federal regulations. The DON confirmed that the 802 (Resident Matrix/Roster) was up to date regarding falls, fractures and restraints. L. On 08/24/12 at 4:20 pm, 9 additional residents (#2, #4, #10, #11, #12,#13, #14, #18 & #19) were observed wearing restraints whose names were not on the list the DON provided after an Immediate Jeopardy was called in the building at 2:20 pm this day or the 672 (Resident Census and Conditions of Residents) and 802 forms provided by the Administrator on 08/22/12. The DON confirmed the 672 and the 802 forms were not up to date and reflective of actual resident care needs. The DON agreed when questioned that the lack of documentation in the facility was a systems failure.

Based on interview and record review, the facility failed to revise care plans to include new interventions for 3 (#1, #2, & #7) of 6 ( #1, #2, #3, #4, #5 & #7) residents reviewed with history of falls, repeat falls and falls with injury. This deficient practice had the potential to affect all 55 residents identified as high risk for falls by the Director of Nursing (DON) on 09/07/12. The findings are: A. Record review of incident reports over the last 4 months revealed that R #1 had repeat falls and the last fall reported on 07/23/12 the facility found R #1 dead on the floor with lacerations to her head, R #2 had falls with injury to include a broken leg, and R #7 had repeat falls (sliding down in wheelchair) with one resulting in a seat belt restraint around her neck. B. Record review of R #1's care plan revealed: (Name of resident) is at risk for falls related to decreased mobility and inability to self-transfer/ambulate on her own. Focus area initiated on 02/01/12. Goals: (Name of resident) will be free of falls through the review date: Target date was 04/30/12 and was updated on 05/03/12 to continue with same goals and approaches. C. Record review of R #2's care plan revealed: (Name of resident) is unable to ambulate on her own and is at risk for falls. She uses wheelchair for primary locomotion. She also has poor vision with a [DIAGNOSES REDACTED]. Focus area initiated on 04/27/12. Goals: (Name of resident) will not sustain any injuries due to falls. Target date was 07/26/12. Problem added on 07/23/12 to care plan (Name of resident) has a [MEDICAL CONDITION] was lined out and above the knee fracture was written in and is at risk for pain and limited Range of Motion. Goals remained the same. Approaches: Added cast care, check toes for circulation and report cyanosis (blue discoloration) or cold toes. Geri-chair for comfort and positioning due to cast. D. Record review of R #7's care plan revealed: (Name of resident) is at risk for falls because of her inability to transfer safely and her unawareness of her safety needs. She also has a [MEDICAL CONDITION] disorder. Focus area initiated on 10/11/11. Goals: (Name of resident) will not sustain any injuries due to falls. Inititated date 10/11/11 and target date of 01/09/12. Interventions remained the same as inititated on 10/11/11 with review dates of 04/30/12 and 06/28/12 to continue with the same goals and approaches. E. Record review of an internal incident report dated 07/26/12 revealed: R #7 had a witnessed fall out of her wheelchair. Resident yelling for help and upon arrival and resident was found with seat belt restraint at neck area due to sliding down in her wheelchair. F. On 08/24/12 at 7:44 am, during an interview with Registered Nurse (RN) #1 she confirmed that R #7 had a history of [REDACTED]. RN #1 said that R #7 said she was trying to open the shades on the window in the dining room when she slid and the seat belt restraint was around her neck due to sliding down in her chair. G. On 08/24/12 at 8:40 am, during an interview with the Assistant Director of Nursing (ADON) she confirmed that R #7 had a history of [REDACTED]. Asked why in dining room so early in the morning and she said the resident propels herself early in the morning to the dining room. The ADON confirmed that a temporary care plan wasn't completed after the fall and said the staff should have followed up since it was a witnessed fall and that is protocol. The ADON confirmed that new interventions to prevent sliding down in her chair were not implemented. H. On 08/24/12 at 10:06 am, during an interview with the ADON she confirmed that R #1, R #2 , & R #7's care plans did not contain any new interventions to prevent further falls, falls not documented on the care plans and the falls were reported during their stand up meetings and documented on the 24 hour reports. Asked the ADON who is responsible for making these updates and she replied: (Name of the MDS Cooridinator) (MDSC).

The facility administration failed to prevent system failures with regards to residents and their specific care needs. This deficient practice had the potential to affect all 88 residents (per the Administrator census form received on 08/22/12) residing in the facility since systems failures identified included the lack of tracking and trending falls, tracking and monitoring residents with restraints, resident specific care needs not communicated to Centers for Medicaid Medicare Systems (CMS) on the 802 ( Resident care/census matrix form) and incident managment system failure to report and investigate injuries of unknown origin and failure to follow their own policy and procedure. The findings are: As Evidenced by: The facility failed to ensure that Resident #7 was free from physical harm since she wore a seat belt restraint and had a history of [REDACTED]. This deficient practice had the potential to affect all 19 residents who have restraints per a list of residents with restraints revised from the Director of Nursing received on 09/06/12.See F323 The facility failed to monitor physical restraints which resulted in 1 resident (R #7) out of 19 (#4, #7 , #9, #10, #11, #12, #13, #14, #15, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26) residents with restraints according to the revised list obtained from the Director of Nursing (DON) on 09/06/12 to slide down/fall in her wheelchair and the seat belt restraint was around her neck. The facility did not have specific medical symptoms for use of restraints, no tracking documentation as to length of time the restraint was to be used, schedule to check restraints for proper placement, release, reposition, and no documentation as to gradual reduction for the use of restraints. This deficient practice had the potential to cause harm and even death to any of the 19 residents with restraints since staff were not applying the restraints correctly and not monitoring them at a minimum of every 2 hours and checking the restraints for placement and releasing them. The findings are: See F221 The facility failed to accurately document and keep records up to date reflecting a current picture of resident care and facilities documentation such as tracking and trending of resident falls, physical restraints for safety checks, release and repositioning, accurate resident care issues and follow up to medications given on an as needed basis. This deficient practice is a systems failure and has the potential to affect all 88 residents residing in the facility per the census form received from the Administrator on 08/22/12. The facility failed to implement their policy and procedure for abuse and neglect for 2 residents (R #1 & #15) of 68 incident reports reviewed. This deficient practice had the potential to likely cause harm to all 88 residents per the census form received from the Administrator on 08/22/12 by not reporting, not completing a thorough investigation and not protecting R #15 during an investigation due to a report of brusing of unknown origin. The findings are: See F224 The facility failed to complete a thorough investigation of 1 resident's (R #1) fall and death to the incident management division within 5 days of the incident. The facility also failed to report bruising of unknown origin for 1 resident (R #15) resident to the incident management division within 24 hours and an investigative report to identify possible causes. This deficient practice had the potential to likely to cause harm to all 55 residents identified as high risk for falls per the Director of Nursing (DON) on 09/07/12 by not identifying possible causes of fall and unknown bruising to further protect all residents at risk and provide a safer environment. The findings are: See F225 The facility failed to implement their policy and procedure for abuse, and neglect of residents for 2 residents (R #1 & #15) of 68 incident reports reviewed. This deficient practice had the potential to likely cause harm to all residents identified on the census form received from the Administrator on 08/22/12 by not reporting, completing a thorough investigation by protecting the residents from harm when an investigation is in process and when the possibility of abuse or neglect has been identified. The findings are: See F226 Based on record review and interview, the facility failed to provide effective and efficient administration to attain the highest practicable physical, mental and psychosocial well-being for 1 (R #6) of 4 (R #6, #9, #10, #17) sampled residents who had pneumonia, by implementing isolation precaution measures for R #6, without an accurate assessment or written Physician Order authorizing its medical necessity. This deficient practice had the potential to harm R #6 and other residents who may be improperly assessed for requiring isolation precaution measures. The findings are: A. Review of R #6's Admission Record indicated admission date of [DATE] with Diagnoses: [REDACTED]. B. Review of R #6's Regional Hospital History and Physical dated 03/16/12 indicated hypertension, [MEDICAL CONDITIONS], dementia, urinary incontinence, history of [MEDICAL CONDITIONS] ([MEDICAL CONDITION]). C. Review of R #6's facility Care Plan dated 01/12/12 indicated focus: at risk for falls related to unaware of safety needs and confusion; focus: oxygen therapy related to [MEDICAL CONDITION] (inadequate oxygen in body tissue); focus: complications of asthma; focus: at risk for constipation due to immobility; focus: bowel incontinence related to dementia. D. On 08/22/12 at 9:47 am, during an interview, Registered Nurse (RN) #1 stated that the policy and procedure regarding precaution measures requires "the head of the bed up, monitor vitals, the bed needs to be lowered with head on elevation if someone is a fall risk. Have to wear a mask, gown and gloves. A sign on the door. The door must be closed." E. On 08/22/12 at 4:00 pm, during an interview, Licensed Practical Nurse (LPN) #1 revealed the following: 1. She oversees supervision of the entire facility including the Memory Care Unit on weekends. 2. "Residents get checked by CNA's every (2) two hours, unless someone needs more on a PRN basis. 3. "Doors in the Memory Care Unit should not be closed." F. On 08/22/12 at 4:12 pm, during a second interview, LPN #1 revealed the following: 1. On 03/24/12, R #6 was on respiratory precautions. There was a lot of confusion with staff and questions came up as to why this policy had been implemented. 2. "The bed was not lowered all the way down which (Name of R #6) needs because she is a fall risk. 3. "The door was closed due to the precautions." 4. The room was hot, maybe over 90 degrees, which is not a good situation for someone who takes medication, is on oxygen (which emits more heat) and is at risk for dehydration and has [MEDICAL CONDITION] disorder." 5. "When I viewed the Chart, there was no order for respiratory precautions from the doctor." 6. "I called to ask the physician, why we are doing precautions for (Name of R #6)." The doctor stated he never ordered it and then deleted (D/C'ed) the order. 7. She told R #6's family "if (Name of R #6) falls I would hope somebody passes by. It's possible that if she fell (during a two-hour check) she might be laying there for some time until someone finds her." The family got very upset. G. On 08/23/12 at 8:12 am, during an interview, LPN #3 revealed the following: 1. "On 03/24, I was there in the morning. They had (Name of R #6) in isolation due to respiratory issues. Someone came to me and expressed concern. I looked for the doctor's order and could not find it. There were no written orders for precautions." 2. "I am aware (Name of R #6) uses a mat due to being a fall risk also a lowered bed. Part of my responsibility is to ensure beds are lowered and mats are in place." She could not recall if the bed was lowered or if the mat was at bedside. 3. "It's possible if someone falls, they won't be seen right away. R #6's family was very upset." H. Review of R #6's Medical Chart confirmed there was no physician order regarding isolation precautions for R #6. I. Review of R #6's Physician Order dated 03/25/12 indicated "D/C (discontinued) respiratory precautions." J. Review of R #6's facility admission orders is free from [MEDICAL CONDITION] (TB) and other communicable diseases with no need for isolation--primary Diagnosis: [REDACTED]. K. Review of the facility Nursing Policy and Procedures (P&P) for Isolation-Airborne, dated 03/2006, revealed the following: 1. Page NP-I-28 indicated "as soon as possible the resident's physician will issue written orders for airborne isolation. Procedure: verify the order for airborne isolation. 2. Page NP-I-29, #9.I. indicated "when protective measures(PRs) are required leave room, close door. 3. Page NP-I-29, #9.J. "document isolation or precautions on resident record." 4. Page NP-I-32 indicated "as soon as possible the resident's physician will issue written orders for respiratory isolation or special precautionary measures." L. On 08/23/12 at 1:44 pm, during an interview, Certified Nurse Assistant (CNA) #8 stated on 03/24/12 he was on the 2:00 pm-10:00 pm shift. "I had to do precaution measures. Gowns, gloves and masks were outside the door. The staff weren't sure why they had to do precautions for R #6." M. On 08/24/12 at 8:17 am, during an interview, RN #1 stated that on 03/24/12 LPN #1 came to ask her about precautions for (Name of R #6). "We looked at the Chart and there was nothing about precautions and no physician orders. My supervisor LPN #1 made the call for isolation precautions mid-morning on 03/24/12. Both of us placed the gowns, masks and gloves outside the door. The door was closed. Those rooms are usually hot. On 03/25/12 it was determined R #6 wasn't supposed to be on precautions. I agree we needed physician orders for the precaution measures." N. On 08/24/12 at 8:34 am, during an interview, CNA #9 stated that on 03/24/12 they started (R #6's) precautions. "Sometimes the nurse tells us about isolation precaution. Other times we see the door closed with stuff outside the door (gloves, masks, gowns). All of a sudden they (precautions) are off and find out they were not necessary. This happened two times with (Name of R #6)." She stated that when R #6 came back from the hospital "we did precautions but there were no doctors orders. We go according to what the Charge Nurse says. The door was closed." CNA #9 stated on 03/25/12 the precautions were lifted. CNA #9 heard from LPN #1 the order was D/C'ed and the family was angry that she was on precautions for no reason and it was the second time it happened with no doctor's orders. CNA #9 stated that the Employee Handbook addresses precautions and also addresses the door has to be closed. O. On 08/24/12 at 3:55 pm, during an interview, Environmental Assistant (EDA) stated that on 03/22/12 the facility Central Thermostat is set at 75 to 79 degrees, not to exceed 81 degrees. There is no separate thermostat in the Memory Care Unit. "It is possible with an oxygen machine and door closed, it went up to 90 degrees or more. We do not keep a log with heat setting checks." P. On 08/24/12 at 5:30 pm, during an interview, the Director of Nursing (DON) stated the facility policy is that the admitting nurse would have had to call the doctor for orders before doing respiratory precautions. Regarding R #6, "heat could have caused problems. Anyone with [MEDICAL CONDITION] we try to keep in a cooler room. Raised temperature in a room can cause a [MEDICAL CONDITION]. I was not aware isolation precaution orders were d/c'ed."

Based on record review, observation and interview the facility failed to provide pain relief and assistive devices for comfort for one of two sampled residents (#9) on hospice services. This deficient practice had the potential to affect two residents (CMS-672) receiving hospice care. The findings are: A. Record review of May 2010 physicians orders for Resident #9 revealed the resident was admitted to hospice services on 05/13/10 with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. B. Record review of the care plan dated 04/02/10 for Resident #9 revealed that staff were supposed to monitor Resident #9 for signs and symptoms of pain such as "facial grimacing, crying, etc." The care plan also instructed the staff to administer pain medications and if not effective to notify the physician. 1. On 09/30/10, the care plan was updated with instructions that Resident #9 was now on scheduled pain medication due to recent issues of pain. 2. The resident needed to wear a right hand splint while sitting in his wheelchair for comfort and to prevent further decline in status. The resident also needed to wear a right elbow protector to prevent skin breakdown. C. On 10/06/10 at 12:20 pm, during observation and interview, Resident #9 was observed sitting in his wheelchair with a grimace on his face. His right hand was contracted and laying on his lapboard. There was no splint to his right hand and no elbow protector to his right elbow. Resident #9 was asked if he was in pain. He nodded his head "yes" and pointed to his right arm. D. Record review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E. On 10/07/10 at 9:45 am, during observation and interview, Resident #9 was observed in bed positioned on his right side. He had a grimace on face. Resident #9 was asked if he was having pain in his right arm. He stated "Yes" and began to cry. F. On 10/07/10 at 9:45 am, during interview, Registered Nurse (RN) #1 verified that [MEDICATION NAME] was given at 8:00 am. She stated "I will give the [MEDICATION NAME] time to kick in. I will check on him and if needed I will give him some Tylenol." G. On 10/07/10 at 11:25 am, during observation and interview, Resident #9 was observed in his wheelchair with a grimace on his face. There was no splint to his right hand or elbow protector to his right elbow. Resident #9 was asked if the nurse gave him something for pain and he nodded "yes." He was then asked if it helped and he nodded "No." H. Record review of the October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation of the effectiveness of the pain medication. I. On 10/08/10 at 8:10 am, during interview, Hospice RN #1 stated, "The nurses here are either lazy or afraid of giving pain medications." Hospice RN #1 confirmed that Resident #9 was not being properly assessed for pain and said "They (facility nurses) don't think the resident is in pain, but then we (Hospice RN's) see something different." J. On 10/08/10 at 11:20 am and 2:33 pm, during interview, RN #1 admitted to not being aware that Resident #9 was supposed to wear a splint to his right hand and wear a right elbow protector while he was up in his wheelchair. RN #1 stated, "He came from B wing and I really don't know much about him." When asked how long ago the resident moved to A wing from B wing RN #1 stated, "I think it was about 4 months ago." K. On 10/08/10 at 11:20, during an interview, the Director of Nursing (DON) stated that she was not sure how they coordinated care with the hospice companies. When asked whether or not Resident #9 had a contracture, the DON stated "I would think so by looking at him but I really haven't assessed him." She also stated "I'm aware that the nurses are weak with pain assessments." The DON confirmed that RN #1 did not document results of the as needed Tylenol. She also confirmed the lack of nursing notes with regards to pain and the lack of pain assessments for Resident #9. L. On 10/08/10 at 11:58 am, during an interview, Certified Nursing Assistant (CNA) #1 stated "Yeah, I used to put a splint on him (Resident #9) and another CNA told me that they (facility) stopped it." CNA #1 was asked if she spoke with her nurse and she replied, "It was a couple of months ago. I don't remember what nurse, but she didn't know anything anyway." When asked if Resident #9 experienced pain during transferring, CNA #1 stated, "He is always in pain, so it's hard to tell."