Every finding on record at Lake Hills Healthcare Center

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 6 of 6 (Resident #2, Resident #5, Resident #6, Resident #7, Resident #8, and Resident #9) residents reviewed for comprehensive person-centered care plans. For Resident #2, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measurable objectives as identified and written in the focus areas of care plan as: risk for complications r/t allergies to Gemfibrozil, Celexa, Effexor, and Seroquel, use of left side 1/4 grab bar for increased mobility while in bed, plans to remain in a long term in facility, little or no activity involvement, ADL self-care performance deficit, behavior problem r/t to attention seeking, Hyperlipidemia, Hypertension, Impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's, Diabetes Mellitus, Fall risk, GERD, diuretic therapy r/t hypertension, and pain. For Resident #5, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives as identified and written in the focus areas of the care plan as: seasonal allergies, no known allergies to medication/foods, plans to remain in a long term in facility, ADL self-care performance deficit r/t disease process, Hypertension, impaired cognitive function/dementia or impaired thoughts processes r/t Encephalopathy, HLD, GERD, risk for adverse reaction r/t Polypharmacy (simultaneous use of five or more medication by a single individual), pain medication therapy, use of antidepressant medication, Parkinson's Disease, Seizure Disorder, Chronic pain r/t toxic encephalopathy, shortness of breath r/t COPD, and oxygen therapy. For Resident #6, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives as identified and written in the focus areas of the care plan as: seasonal allergies, use of grab rail to turn and reposition, behaviors related to use of nebulizer machine, plans to remain in a long term in facility, allergic reaction to Bactrim, ADL self-care performance deficit r/t dementia and weakness, impaired cognitive function or impaired thoughts r/t dementia, GERD, use of antidepressants for depression, pain medication therapy, and oxygen therapy. For Resident #7, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives as identified and written in the focus areas of the care plan as: independence with ADLs, allergies to aspirin, penicillin, and vancomycin, plans to remain in a long term in facility, Hypertension, impaired cognitive function/dementia or impaired thoughts processes r/t alcoholic dementia, risk for falls, GERD, Diuretic therapy, and Parkinson's Disease. For Resident #8, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives as identified and written in the focus of the care plan as: no known allergies, ADL deficit, Hypertension, Heart failure, fluid overload r/t cirrhosis of the liver, heart failure, and Chronic viral Hepatitis C, Diuretic therapy, and pain medication therapy. For Resident #9, the facility failed to develop a comprehensive person-centered care plan based on assessed needs with measured objectives as identified and written in the focus areas of the care plan as: allergies to Lithium and Buspirone, plans to remain in a long term in facility, ADL self-care performance deficit r/t activity intolerance, impaired circulation r/t Hyperlipidemia, Congestive heart failure, impaired cognitive function/dementia or impaired thoughts processes r/t dementia, Diabetes mellitus, Edema, use of anti-anxiety medication, issues with diet/obesity, and oxygen absorption. These failures could place residents at risk for not receiving care and services to meet their needs and deficits.Findings included: 1. Record review of Resident #2's Face Sheet, dated 07/07/2026, revealed a [AGE] year-old male, with an initial admission date 09/24/2024. Resident #2's diagnoses included Complete Traumatic Amputation of left great toe, Osteomyelitis (an infection and inflammation of the bone or bone marrow caused by bacteria or fungi), Type II Diabetes Mellitus (a chronic condition where your body either resists the effects of insulin or does not produce enough to maintain normal glucose levels), Schizoaffective disorder (a chronic mental condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, including mania or depression), Essential (primary) hypertension (high blood pressure), Gastro-esophageal Reflux Disease (chronic condition where stomach acid flows back into the esophagus causing persisting heartburn, regurgitation, chest pain, and damage to the esophageal lining), and Hyperlipidemia (abnormally high levels of lipids (fats), such as cholesterol or triglycerides in the blood which increase the risk of heart disease). Record review of Resident #2s Quarterly MDS assessment, dated 07/09/2026, revealed Resident #2 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #2 Care Plan, with a recent review date of 04/22/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: The resident will not have complications secondary to allegories/sensitives through next review period (risk for complications r/t allergies to Gemfibrozil, Celexa, Effexor, and Seroquel), Resident will have increased mobility thru the next review date (use of 1/4 grab bar), [Resident] will continue to adjust psychosocially to transitioning to long-term care services this review date (remaining in long-term facility), Resident will remain independent with bed mobility with use of assist bars (requirement of assist bars to bed for mobility and transfers), Resident will express satisfaction with type of activities and level of activity involvement when asked through the review date (little or no interest to participate), Resident will maintain current level of function through the review date (ADL self-care performance deficit r/t unsteady gait/balance), Resident will have fewer episodes (resident has a behavior problem r/t attention seeking), Resident will be free from s/sx of complications of poor circulation through the review date (Hyperlipidemia), Resident will remain free of complications related to hypertension through the review date (Hypertension), Resident will be able to communicate basic needs on a daily basis through the review period (impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's), Resident will have no complications related to diabetes through the next review date (Diabetes Mellitus), Resident will be free from fall through the next review date (moderate risk of falls r/t gait/balance problems), Resident will remain free from discomfort, complications, or s/sx related to dx of GERD through review date (GERD), Resident will be free of any discomfort or adverse side effects of diuretic therapy through review date (diuretic therapy for hypertension), Resident will not have discomfort relate to side effects of analgesia through the next review date (pain). 2. Record review of Resident #5's Facesheet, dated 07/08/2026, revealed a [AGE] year-old female, with an initial admission date of 07/2/2023. Resident #5's diagnoses included Epileptic seizures (a sudden, abnormal electrical surge in the brain causing altered behavior, movements, or awareness), GERD (chronic condition where stomach acid flows back into the esophagus causing persisting heartburn, regurgitation, chest pain, and damage to the esophageal lining), Chronic Obstructive Pulmonary Disease (progressive, preventable inflammatory lung disease causing restricted airflow and breathing difficulties), Obesity (a chronic, relapsing disease characterized by excessive body fat accumulation that presents significant health risks), Hyperlipidemia (abnormally high levels of lipids (fats), such as cholesterol or triglycerides in the blood which increase the risk of heart disease), and Schizoaffective Disorder (a chronic mental condition characterized by a combination of schizophrenia symptoms such as hallucinations or delusions and mood disorder symptoms, including mania or depression). Record review of Resident #5's Quarterly MDS assessment, dated 07/04/2026, revealed Resident #5 had a BIMS score of 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #5's primary medical condition was Medically Complex Conditions, as I0020 was coded 13. Record review of Resident #5's Care Plan, with a recent review of date of 02/04/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: Resident will have a decrease in s/s of allergies (seasonal allergies), [Resident] will continue to be free allergies to medication/foods through next review period (no known allergies to medication/foods), [Resident] will continue to adjust psychosocially to transitioning to long term care services through this review period (remain in the nursing facility), Resident will improve current level of function in ADLs through the review date (ADL deficit), Resident will remain free from s/s of hypertension through the review date, Resident will improve current level of cognition function through the review date (dementia r/t Encephalopathy), Resident will be free from complications of cardiac problems through the review date (HLD), Resident will remain free from discomfort, complications, or s/s of GERD through the next review date, Resident will be free of adverse drug reactions through the next review date (Polypharmacy), Resident will be free of any discomfort or adverse side effects from pain medication through the review date (medication therapy), Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date (use of antidepressants), Resident will remain free of further s/s, discomfort or complications related to Parkinson's disease through review date, Resident will be free from injury from seizure activity (Seizure Disorder), Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date (Encephalopathy), Resident will have no complications related to SOB through the review date (COPD), and Resident will have no s/s of poor oxygen absorption through the review date (oxygen therapy). 3. Record review of Resident #6's Face Sheet, dated 07/09/2026, revealed a [AGE] year-old female, with an initial admission date into the facility of 06/22/2026. Resident #6's diagnoses included Acute Respiratory Failure with Hypoxia (a life-threatening emergency where the lungs cannot adequately transfer oxygen to the bloodstream), Dementia in other diseases classified elsewhere (symptoms that indicated a severe, progressive decline in cognitive abilities such as memory, thinking, and reasoning, that impair a person's ability to live and function independently), Major Depressive Disorder (a serious mental health condition characterized by a persistent low mood and loss of interest in activities), Chronic Obstructive Pulmonary Disease (progressive, preventable inflammatory lung disease causing restricted airflow and breathing difficulties), and GERD (chronic condition where stomach acid flows back into the esophagus causing persisting heartburn, regurgitation, chest pain, and damage to the esophageal lining). Record review of Resident #6's admission MDS, dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #6's primary medical condition was Debility, Cardiorespiratory Conditions, as I0020 was coded 12. Record review of Resident #6's Care Plan, with recent review of date of 04/07/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: [Resident] will report s/s of allergies (seasonal allergies), [Resident] will remain with the ability to use grab bars while turning and repositioning (use of grab bars), Resident will be free from complications to nebulizer in bed, [Resident] will continue to adjust psychosocially to transitioning to long term care services through this review date (remain in the nursing facility), [Resident] will not have complications secondary to allergies/sensitivities through the next review period, Resident will maintain current level of function in through review date (as written in care plan) (ADL deficit), Resident will maintain current level of cognitive function through the review date (cognitive function r/t dementia), Resident will remain free from discomfort, complications, or s/s related to Dx of GERD, Resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date, Resident will be free from any discomfort or adverse side effects from pain medication through the review date (pain medication therapy), and Resident will have no s/s of poor oxygen absorption through the review date (oxygen therapy). 4. Record review for Resident #7's Face Sheet, dated 07/09/2026, revealed a [AGE] year-old male, with an admission date of 10/09/2025. Resident #7's diagnoses included Parkinson's Disease (a progressive neurological disorder caused by the loss of dopamine-producing neurons in the brain), Alcoholic Myopathy (a muscle disease caused by chronic alcohol misuse or binge drinking), Essential (primary) hypertension (high blood pressure), and GERD (chronic condition where stomach acid flows back into the esophagus causing persisting heartburn, regurgitation, chest pain, and damage to the esophageal lining). Record review of Resident #7's Annual MDS assessment, dated 06/05/2026, revealed Resident #7 had a BIMS score of 12, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #7's primary medical condition was Non-Traumatic Brain Dysfunction, as I0020 was coded 02. Record review of Resident #7's Care Plan, with recent review of date of 03/27/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: Resident will remain independent with no declines (ADLs), Resident will not have complications secondary to allergies/sensitivities through the next review period (allergies r/t aspirin, penicillin, vancomycin), [Resident] will continue to adjust psychosocially to transitioning to long term care services through this review period (remain in the nursing facility), Resident will remain free of complications related to hypertension through review date, Resident will be able to communicate basic on a daily basis through the review date (Alcoholic dementia), Resident will be free of minor injury through the review date (fall risk), Resident will remain free from discomfort, complications, or s/s related to Dx of GERD through the review date, Resident will remain free from discomfort or adverse side effects of diuretic therapy through the review date, and Resident will remain free of further s/s, and discomfort or complications related to Parkinson's disease through the review date. 5. Record review of Resident #8's Face Sheet, dated 07/09/2026, revealed a [AGE] year-old male, with an admission date of 02/23/2026. Resident #8's diagnoses included Cerebral infarction (occurs when a blood vessel in the brain is blocked by a clot or narrowed by plaque), Major depressive disorder (a serious mental health condition characterized by a persistent low mood and a loss of interest in activities), Chronic Viral Hepatitis C (a blood-borne infection that causes long-term liver inflammation), Essential (primary) hypertension (high blood pressure), Heart failure, and Hepatic encephalopathy (a decline in brain function caused by severe liver disease). Record review of Resident #8's Quarterly MDS assessment, dated 06/03/2026, revealed Resident #8 had a BIMS score of 12, which indicated moderate cognitive impairment. Section I - Active Diagnoses revealed Resident #8's primary medical condition was Stroke, as I0020 was coded 01. Record review of Resident #8's Care Plan, with recent review of date of 03/11/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: Resident will continue to have no known allergies (NKA), Resident will maintain current level of function through the review date (ADL deficit), Resident will remain free of complications related to hypertension through review date, Resident's electrolyte levels will be within normal limits through the review date (heart failure), Resident will comply with diet and/or fluid restrictions daily through review date (heart failure), Resident will remain free from discomfort or adverse side effects of diuretic therapy through the review date, Resident will be free from any discomfort or adverse side effects from pain medication through the review date (use of Tramadol) 6. Record review of Resident #9's Face Sheet, dated 07/08/2026, revealed a [AGE] year-old female with an original admission date of 04/30/2025. Resident #9's diagnoses included Type II Diabetes, Morbid obesity (a chronic, relapsing disease characterized by excessive body fat accumulation that presents significant health risks), Hyperlipidemia (abnormally high levels of lipids (fats), such as cholesterol or triglycerides in the blood which increase the risk of heart disease), Anxiety Disorder, Obstructive sleep apnea (a disorder where the throat muscles repeatedly relax during sleep, blocking the airway and causing pauses in breathing), Essential (primary) hypertension (high blood pressure), and Chronic congestive heart failure (chronic, progressive condition where the heart cannot pump blood efficiently enough to meet the body's needs). Record review of Resident #9's Annual MDS assessment, dated 05/01/2026, revealed Resident #9 had a BIMS score of 15, which indicated intact cognitive response. Section I - Active Diagnoses revealed Resident #9's primary medical condition was Medically Complex Conditions, as I0020 was coded 13. Record review of Resident #9's Care Plan, with recent review of date of 02/20/2026, revealed objectives that lacked the ability to be evaluated, quantified, and measured as written in the care plan: [Resident] will continue to adjust psychosocially to transitioning to long term care services through this review period (remain in the nursing facility), Resident will improve level of function through review date; Resident will be able to independently perform all ADLs with no falls or declines, Resident will be free from s/s of complications of poor circulation through the review date (Hyperlipidemia), Resident will be free of peripheral edema through the review date, Resident will be free from s/s of complications related to hypertension through the review date, Resident will be able to communicate basic on a daily basis through the review date (cognitive function/dementia), Resident will have no complications related to diabetes through the review date, Resident will be free from discomfort or adverse side effects of diuretic therapy through the review date (Edema), Resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date, Resident will tolerate therapeutic diet through the review date, and Resident will have no s/s of poor oxygen absorption through the review date (CHF). During an interview of 07/09/2026 at 11:32 a.m., the Social Worker said she was not responsible for the development of resident objectives in the care plans. The Social Worker said the MDS Coordinator completed the MDS assessment and entered the information into the care plan. The Social Worker said the MDS Coordinator developed the objectives. The Social Worker said she attended the IDT meetings, but the MDS Coordinator data enter the information into the assessment during the meeting. During an interview on 07/09/2026 at 2:10 p.m., the Administrator said he was not responsible for the objective in the care plan. The Administrator said the MDS Coordinator was responsible for the development of the objectives and goals. The Administrator said the MDS Coordinator and nursing staff had the responsibility of developing the goals and objectives. During an interview of 07/10/2026 at 9:34 a.m., the MDS Coordinator said she was responsible for the residents' care plans and development of the focus areas and objectives. The MDS Coordinator said the focus areas, objectives, and interventions were a template that populated based on what was inputted into computer from the MDS assessment. The MDS Coordinator said nursing staff would come to her to add additional information to the care plan. The MDS Coordinator agreed that some of objectives in the residents' care plans were not person-centered and measurable. The MDS Coordinator said the objectives should be person-centered because every person was different. The MDS Coordinator said in her opinion the issue was the template. The MDS Coordinator said objectives should be measurable to see if the person was making progress and received the correct services. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 10/2022 (reviewed 06/02/2025), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for one [Dietary Manager] of one kitchen staff reviewed for food and nutrition services. The dietary manager failed to have the appropriate license, certification, or qualifications to function as the food service supervisor.This failure could place residents, who consume food prepared from the kitchen, at increased risk of food borne illness and not receiving adequate nutrition.Findings included:Record review on 06/24/26 at 1:20 pm, of the Dietary Manager's employee file revealed a hire date of 09/05/25. There was no documentation evidence for a Dietary Manager Certificate found in the file.In an interview on 06/24/26 at 1:37 pm, the Dietary Manager said she completed the courses for Dietary Manager certification in 2021 but never tested. She said she was not currently enrolled to be tested. She said she had been employed as the Dietary Manger at the facility since September 2025. In an interview on 06/24/26 at 1:40 pm, the Administrator said he was not aware of the Dietary Manager not being certified. He said she would be scheduled to be tested. He said he did not know of any potential negative outcomes of the Dietary Manager not being certified because she was being supervised by a Dietician. The Administrator stated the Dietician did not work at the facility full time. Record review of the Dietary Manager job description, dated April 2017, revealed the following [in part]: Qualifications: The requirements listed below are representative of the knowledge, skill, and/or ability required.Education and/or Experience: High school diploma or equivalent. Successful completion or current enrollment in course approved by the Dietary Manager Association.Record review of the FDA Food Code 2022, revealed the following [in part]: Chapter 2 Management and Personnel. 2-102.11 Demonstration. Based on the risks to the food operation, during inspections and upon request the person in charge shall demonstrate to the regulatory authority knowledge of foodborne disease prevent, application of the hazard analysis and critical control point principles, and the requirements of this code. The person in charge shall demonstrate this knowledge by: (B) Being a certified food protection manager who has shown proficiency of required information though passing a test that is part of an accredited program.2-102.12 Certified Food Protection Manager. (A) The person in charge shall be a certified food protection manager who has shown proficiency of required information through passing a test that is part of an accredited program.

Based on observation, interview, and record review, the facility failed to ensure drugs, biologicals and medical supplies used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 3 medication carts (Medication Cart A and Medication Cart B) reviewed for pharmacy services. The facility failed to ensure the following: 1. All medications and supplies stored in Medication Cart B were not discarded past their expiration date. 2. The Change-of-Shift Record of Controlled Substances Log for the Medication Cart B was not missing signatures verifying that the narcotics counts on that cart were verified as correct at the change of each shift for 15 days during the month of June of 2026 by the oncoming and off going Nurse These failures could place residents at risk of ineffective therapeutic response to medications, drug diversion, a potential and a decline in health . The findings included: During an observation of Med Cart B on 6/24/26 at 9:50 a.m., three expired medications were found in the cart. The expired medications were: Melatonin 1 mg expiration date on bottle 6/18/26, oyster shell Calcium500 mg expired 1/26 ( it was marked opened on 6/22/26 on the outside of the bottle with a black marker), bottle of a medication Allergy Relief with and expiration date of 5/26. Record review of the Control Drug Card Count Sheets for June 2026 on Med cart B revealed the sheets were missing signatures for the following dates and shifts:- 6/1/26 Nurse on 6:00 p.m.- 6/2/26 Nurse off 6:00 a.m.; Nurse off 6:00 p.m.; Nurse off 6:00 a.m. Nurse on 6:00 p.m.- 6/3/26 Nurse off 6:00 p.m.; Nurse on 6:00 a.m.; Nurse on 6:00 p.m. and- 6/4/26 Nurse on 6:00 a.m. and Nurse off 6:00 P.m.- 6/5/26 Nurse on 6 :00 a.m. and Nurse off 6:00 a.m.- 6/7/26 Nurse on 6 :00 a.m. and Nurse off 6:00 a.m.- 6/10/26 Nurse off 6 p.m.- 6/11/26 Nurse on 6 a.m.- 6/14/26 Nurse on 6 a.m.- 6/15/26 Nurse off 6:00 p.m.- 6/16/26 Nurse on 6 a.m.- 6/16/26 Nurse on 6 a.m.- 6/17/26 Nurse on 6 a.m.- 6/19/26 Nurse off 6:00 a.m.- 6/20/26 Nurse on and off 6:00 a.m. to 6:00 p.m. , Nurse 6:00 Pm on- 6/21/26 Nurse on 6:00 A.M. Nurse on and Nurse off at 6:00 p.m. During an interview on 6/24/26 at 10:01 AM, CMA I stated staff should be signing in and out on the Controlled Drug Card Count Sheets when taking possession of the medication cart to indicate that the count was correct, and had been counted by the oncoming and off going nurses at the change of each shift. He said it was the responsibility of each person that accepted the cart to monitor the sign in sheets to ensure they have been signed. He stated that the medication carts were supposed to be checked on Mondays to ensure that all over-the-counter and prescription drugs were not expired. He stated expired medications were to be pulled at that time and taken to the ADON or DON for destruction. He stated failure to remove expired medications could result in the resident not receiving the intended dosage of a medication or the desired intended therapeutic effect. During an interview with CMA D on 6/24/26 at 10:30 AM, she stated nurses were to count drugs at the beginning and end of their shift, with the oncoming nurse, and both shifts should sign the log signifying that they accepted the count of the narcotics as correct, and they are accepting responsibility for the contents of the cart. She stated failure to do so could result in drug diversion. During an interview with the Director of Nurses (DON) on 06/24/26 at 11:00 a.m., the DON stated the nurses were responsible for checking the medication carts and medication rooms for expired medications on a routine basis. She stated they should check for medications needing label changes daily. She stated it was the nurse's responsibility to check the label before medication administration, and notify the pharmacy and the physician of incomplete administration orders. She stated the rate of administration should be on the label of IV medications before it was administered. She stated failure to do either of these things could result in a med error and the resident not receiving the intended therapeutic effect of medication, or too much medication over a short period of time. She stated she would have expected the rate to be on the label before the first dose of the medication was given. Record review of the facility's policy titled Medication Administration revised 3/5/26, stated the following in part: PurposeTo ensure medications are prepared and administered, and documented safely, accurately, and in accordance with prescribed orders and accepted nursing standards of practice.Check the medication label three times before administration, Confirm the right resident, the right medication, the right dose, the right time, right route and right documentation. Multi dose containers are dated when they are opened. If medication preparation questions arise, nursing staff consult the pharmacy provider. Check expiration or beyond use dates before administering. Record review of the facility's policy titled Controlled Substances dated 3/5/26 stated in part: Nursing staff count controlled medication inventory at the end of the shift. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 (Resident #44) of 8 residents reviewed for nursing services.The facility did not provide incontinent care for Resident #44's for 54 minutes. This failure could place residents at risk who were dependent on staff for toileting at risk for embarrassment, rashes, infection, discomfort, and skin breakdown.Findings include:Record review of Resident #44's admission Record, dated 06/23/2026 revealed a [AGE] year-old female, admitted to the facility on [DATE]. She had a primary diagnosis of displaced Tri malleolar fracture of left lower leg (ankle fracture) and additional diagnosis of difficulty in walking, unsteadiness of feet and history of falling. Record review of the Minimum Data Set (MDS) admission assessment, dated 06/18/2026 reveled Resident #44 had a BIMS score of 15 (cognitively intact). Section GG for toileting and hygiene revealed the resident required substantial/maximal assistance. In an interview and observation on 06/22/2026 at 10:51 am, it was noted outside of the Resident #44's room, her call light was on above the door. Resident #44 and a family member were in the resident's room. Resident #44 and her family member voiced they were upset and angry, stating that the resident was non-weight bearing and could not get up on her on own. She pushed her call light, and had been waiting for an hour for assistance to go to the bathroom. She said she finally called a family member to come up to the facility to put her on the bed pan. The family member said she had received a call from Resident #44, stating that she needed to use the bathroom, but no one responded and she needed help. She came up to the facility to assist the resident. The family member said she helped clean up the resident after her bowel movement. She said no one ever came into the room to check on the resident. Resident #44 and the family member said that this happened one time before in the past. In an interview on 06/22/2026 at 10:55 am, CNA D was walking in the hallway and said if a resident pushed a call light, it lights up outside of the resident's room and alarms at the nurse's station. She said she was currently assisting another resident at that time. In an interview and observation on 06/22/2026 at 10:57 am, RN E was sitting at the nurse's station. RN E said when a resident pressed a call light, it lights up outside of the hallway at the resident's room and alarms at the nurse's station. She said the call light system was working currently. It was observed/noted the alarm was sounding. She said the call light system shows how long it has been since a call light was pushed. An observation on 06/22/2026 at 10:59 am, revealed Resident #44's call light had a time of 54 minutes since it had been pushed. RN E said she would go check on the resident. In a follow-up interview on 06/22/2026 at 2:30 pm, RN E said anyone who heard the call lights go off should answer it. She stated she did not realize it was going off. She said she did not know why the call light had not been answered. In an interview on 06/24/2026 at 11:42 am, LVN F and CMA G said everyone was supposed to answer the call lights. In an interview on 06/24/2026 at 11:42 am, the DON and ADON said the facility had a new call light system for approximately a week, and the alarm had a different sound than the previous one. The DON said any staff who hears or sees a call light is responsible for answering the call. They did not know why it took 54 minutes for Resident #44's call light to be answered. The DON said 5 minutes would be a good response time for call lights to be answered. Nurse staffing was reviewed for 06/22/2026 which revealed 1 RN, 2 LVNs, 7 CNAs, and 2 CMAs on duty at that time. The ADON said the minimum number of CNAs would be 4, but they had 7 at that time. The DON said a potential negative outcome would be serious if a resident would have fallen or gotten hurt and needed immediate attention.In an interview on 06/24/2026 at 12:00 pm, the Administrator and Corporate Nurse Officer stated it was their expectation that anyone who heard or sees a call light goes off, should answer it. He said a response time of 54 minutes was not normal for the facility. He said he had not received any complaints about call lights not being answered in a timely manner from residents or their representatives. Record review of facility policy Answering the Call Light, dated as revised in September 2022, revealed the following [in part]: Purpose: The purpose of this procedure is to ensure timely responses to the resident's request and needs. Steps in the procedure:1. Answer the resident call system immediately.

Based on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 (Resident #77) reviewed for medication accuracy. The facility failed to ensure Resident # 77's IV Antibiotic medication (in Med Cart A) was properly labeled with the prescribed infusion rate. This failure could place residents at risk of not receiving the therapeutic benefit biologicals used for testing and treatment of residents.The findings included: Record review of Resident #77's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Urinary Tract Infection (a bacterial infection in any part of the urinary system to include the bladder, kidneys, ureters or urethra) Record review of Resident #77's active physician orders revealed she had an order for Cefepime HCl Solution Reconstituted 2 GM - Give 2 gram intravenously every 12 hours for Infection related to urinary tract infection site not specified for 5 days, with a start date of 06/19/2026. Record review of Resident #77's EMAR revealed she had an order for Cefepime HCl Solution Reconstituted 2 GM - Give 2 gram intravenously every 12 hours for Infection related to urinary tract infection site not specified for 5 Days start Date 06/19/2026. She had received 6 doses of the medication since 6/19/26. During an observation, interview, and record review with RN H of medication administration on Med Cart A on 6/23/26 at 7:50 a.m., RN H removed an antibiotic (Cefepime) from her medication cart, and was comparing the medication to the electronic medication administration record on her computer. She stated she was unable to administer the medication without clarifying the order with the physician and the Pharmacy. She stated the medication was not labeled with the rate of administration for the IV antibiotic. She stated the flow rate was needed to ensure the proper therapeutic dose, and could affect absorption and side effects from the medication. Review of the IV bag labeling revealed the following instructions on the label: Cefepime 2 GM/50ml Give 2 GM intravenously every 12 hours for infection related to urinary tract for 5 days. The label showed a dispensed date of 6/19/26. RN H reviewed Resident # 77's MAR at that time, and confirmed Resident # 77 had received 6 Doses of the medication Cefepime. During an interview with the Director of Nurses (DON) on 06/24/26 at 11:00 a.m., the DON stated the nurses were responsible for checking the medication carts and medication rooms for expired medications on a routine basis. She stated they should check for medications needing label changes daily. She stated it was the nurse's responsibility to check the label before medication administration, and notify the pharmacy and the physician of incomplete administration orders. She stated the rate of administration should be on the label of IV medications before it was administered. She stated failure to do either of these things could result in a med error and the resident not receiving the intended therapeutic effect of medication, or too much medication over a short period of time. She stated she would have expected the rate to be on the label before the first dose of the medication was given.Record review of the facility's policy titled Medication Administration revised 3/5/26, stated the following in part: PurposeTo ensure medications are prepared and administered, and documented safely, accurately, and in accordance with prescribed orders and accepted nursing standards of practice.Check the medication label three times before administration, Confirm the right resident, the right medication, the right dose, the right time, right route and right documentation. Multi dose containers are dated when they are opened. If medication preparation questions arise, nursing staff consult the pharmacy provider. Check expiration or beyond use dates before administering.

Based on interview and record review, the facility failed to not use any individual working in the facility as a nurse aide for more than four months on a full-time basis unless that individual has completed a training and competency evaluation program for 2 (Caregiver HA A and Caregiver HA D) of 4 Caregiver Hospitality Aides reviewed for nursing services.The facility failed to ensure Caregiver HA A and Caregiver HA D were certified within four months of their hire date. This failure could place residents at risk for receiving inappropriate care from individuals whose skill level was unknown. Findings included:Record review on 02/07/2026 of the facility's employee files revealed: -Caregiver HA A was hired 08/06/2025 and worked full time. An employability status check, dated 08/06/2025, indicated Caregiver HA A and had no CNA certification.-Caregiver HA D was hired 07/30/2025 and was currently working full time. An employability status check, dated 07/29/2025, indicated Caregiver HA D had no CNA certification.During an interview on 02/07/2026 at 2:49 PM, Caregiver HA D stated she performed incontinent care without a CNA or nurse at bedside. She stated she had taken courses but had not taken the test. Caregiver HA D stated if a person did not know how to care for a resident, the harm could be the resident was not taken care of to the full extent they should have been. During an interview on 02/07/2026 at 6:10 PM, Caregiver HA A stated he performed sit to stand transfers with residents. He stated there was only one other CNA at night, and if busy with other residents he would go get another HA to help him do incontinent care (change briefs) and transfer residents, if needed. He stated he used to work at another facility and the DON showed him how to transfer residents and perform incontinent care, but he was not certified. During an interview on 02/09/2026 at 3:00 PM the DON stated the HAs did not have competency check-off lists. She stated they had not been doing incontinent care or transfers. The DON stated HAs were not supposed to do peri-care, or transfers. She stated that HAs could not do anything that involved touching the residents as they were not certified. The DON stated her expectations for HAs was for them to be removed from the floor until their clinical portion of classes were obtained and completed. She stated the floor nurses and the ADMN monitored the HA's classes and certifications as well as making sure there was a CNA or nurse with them while performing certain tasks. The DON stated she felt it was a system failure between nurses and staff The DON stated there was a potential of harm to residents because they were possibly provided incorrect procedures. During an interview on 2/09/2026 at 3:47 PM the ADMN stated there were no competency check-off lists for any of their Caregiver HAs. He stated he did not know why the HAs were not checked off. The ADMN stated the HAs were not allowed to provide direct care unless they had their clinicals or they were paired with a nurse or CNA. He stated the staff performing direct care should have their certification within four months of hire. The ADMN stated his expectations, going forward, was no uncertified staff could work the floor and would be given a 4-month window. He stated if their clinicals were done, and had not been certified, they would not return to work until they were registered. The ADMN stated the failure occurred in a lot of different ways but stated he should not have trusted the situation was being handled. He stated there was a potential of harm to residents who received care from an HA, but since they were not certified and could have possibly given residents improper care. Record review of documents provided by the DON titled Job Description with a date of 03/2020 revealed: Position Title: Hospitality Aid, Reports to: Director of Nursing Job Summary: the Hospitality Aide performs non-nursing, non-direct care duties under the supervision of licensed nursing personnel and assists in maintaining a positive physical, social and psychological environment for residents. Job Responsibilities: Answer call lights, make unoccupied beds, pass fresh drinking water and deliver snacks, take menu/orders from residents, Serve/deliver food trays., Remove food trays, assist with feeding non-choking or non-aspiration risk residents, assist residents with preparing food as needed, assist residents in wheelchairs to/from events, 1-on-1 with residents who have behavioral challenges or need socialization, Provide personal care, such as combing hair or washing face and hands, assist resident with putting on and removing glasses and hearing aids, stay with resident while in the bathroom to. To do other tasks while waiting to transfer, Complete errands for residents, Read mail and write letters for residents per residence request, and supplies, Transport soiled linen containers, Restock supplies including stock linen carts, Cleaning over bed tables and bedside stands, Inventory of personal items upon admission. And update as needed, label and store personal items, clean Whirlpool tub after in between residents, store or hang clean laundry items in resident rooms., ensure treatment and nurses stations are clean and in order. And all nursing stations are stocked with necessary forms. Drawers and files are organized, Assist in facilitating a designated activity, other duties as assigned.

Based on observation, interviews and record review the facility failed to ensure the environment was as free of accident hazards was possible and each resident receives adequate supervision to prevent accidents for 1 of 21 resident (Resident #55) reviewed for accidents and hazards, in that: On 03/20/2025 at about 9:30pm, Resident #55 was able to get out of a window in a common room on the secure unit without staff's knowledge, pull off 3 wood fence pickets and leave the premises. Facility staff were not aware Resident #55 was not in the building until he was returned by law enforcement at approximately 01:00 AM on 03/21/2025. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 04/02/2025 at 3:37 PM. The Immediate Jeopardy began on 03/20/2025 and ended on 03/24/2025. The facility had corrected the non-compliance before the survey began. The failure placed residents at risk for weather exposure, injury, hospitalization and/or death. Findings included: Review of Resident #55's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of dementia, late onset Alzheimer's disease, anxiety, bipolar disorder, high blood pressure, non-insulin dependent diabetes mellitus, and psychosis. Review of Resident #55's Quarterly MDS dated [DATE] revealed in Section C Cognitive Patterns, subsection C0500 BIMS Score Summary, the resident scored 3 out of 15 indicating severe cognitive impairment. Section E - Behavior, subsection E0900 - Wandering, Prescence & Frequency, Has the resident wandered? 1. Behavior of this type occurred 1 to 3 days was selected. Review of Resident #55's physicians orders dated 02/26/25 revealed an order May reside on secure unit r/t Dx: (diagnoses) Dementia, Bipolar disorder, Anxiety. Review of Resident #55's Comprehensive Care Plan dated 03/04/25 and reviewed/revised 03/21/25 revealed Focus: I have been evaluated as a wandering risk r/t specify: decreased safety awareness, confusion, wandering behavior [Resident] resides on the secure unit. [Resident] has a history of elopement from other prior facilities. [Resident] carries around a bed roll packs bag to leave everyday. Date initiated 03/21/25. Goal: I will remain free of injuries associated with wandering behaviors thru this review period with a target date of 06/10/2025. Interventions/Tasks: attempt to redirect resident when packing items and remind resident he resides in facility. Check my location frequently. Encourage me to participate in activities of my preference. Engage me in diversional activities when indicated. Observe me for s/s of agitation, pacing, repetitive verbalization of wanting to leave/go home, restlessness, report increased behaviors to nurses for further interventions. Offer resident the ability to call his family when behaviors are occurring. Provide me re-orientation as needed. Focus: [Resident] has a behavior problem AEB resident eloped out of a window, through a privacy fence which he ripped fence panels off of, and was found walking the streets. Date initiated 03/21/25. Goal: [Resident] will remain in facility without further elopements. Interventions/Tasks: ADMNister medications as ordered. Monitor for side effects and effectiveness. Anticipate and meet The resident's needs. Caregivers to provide the opportunity for positive interaction, attention. Stop and talk with him/her as passing by. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Monitor resident whereabouts frequently to ensure not attempting to elope. Provide a program of activities that is of interest and accommodates residents status. During an observation on 04/01/2025 at 02:13 PM, revealed Resident #55 was sitting in the common room on the secure unit working on a diamond painting project with a staff member present recording resident's activity every 15 minutes. During an observation on 04/01/2025 at 02:15 PM, revealed the windows in the common room on the secure unit, had window stops secured which allowed the window to raise 6 or less. During an observation on 04/02/25 at 07:00 AM, revealed a new gate with a keypad and doorbell noted along the fence surrounding the secure area. There were no bowed, cracked or loose pickets noted around the secure area. On the east side of the facility, an old gate was open, and the fence was missing 2 pickets, but with no access to the secured area. On the south side of the facility the gate was open, but with no access to the secure unit. Observation of the road in front of facility revealed a speed limit of 30. During a telephone interview on 04/02/25 at 08:21 AM, Resident #55's Guardian stated she was assigned to Resident #55 2 weeks ago. She stated the current facility was the 3rd facility the resident has been admitted to in the past month or so. The Guardian stated she felt the facility addressed the elopement appropriately and she was fine with every 15-minute checks instead of 1:1. She stated she had talk with Resident #55's family member in who resided in another state about relocating him closer, but the family member was not able to care for him. The Guardian explained Resident #55 was living with a family member in another city but was repeatedly being found and returned by law enforcement. The guardian stated the problem was not the facility but the system. She stated the facility communicated with her very well. She stated the facility was working overtime to keep the resident safe but he was cognizant enough to develop a plan and carry it out. The Guardian had offered to purchase and install window alarms but was waiting on decision from facility. She stated the window stops were on the windows prior to the elopement but were placed higher than they were. The Guardian stated the maintenance man immediately lowered the stops after the elopement. She stated the facility was not failing, or had an issue of poor care, it was the archaic system. During an observation on 04/02/25 at 08:20 PM, revealed one nurse and one CNA were present on the secure unit. During an interview on 04/02/25 at 08:20 PM, LVN G stated he was on duty the night of the elopement. He stated as soon as they were made aware of the elopement, a head count was done, doors were checked, and the outside perimeter was checked. LVN G explained he discovered the pickets missing in the wood fence outside the windows in the common room. He also noted the window in the common room was open and indicated with hands approximately 8. He stated he thought it was interesting that the resident chose fence pickets between the 2 windows in the common room. The fence pickets removed by Resident #55 were not visible when looking straight out either window. LVN G stated he did not hear any unusual noises the evening of the incident. LVN G explained Resident #55 received a sandwich at approx. 9:00 PM, ate it at the nurse's station then walked down the hall towards his room. LVN G stated he gave the Resident #55 his evening and the resident stated he was going to bed. The nurse observed the resident enter his room and shut the door. He stated since the roommate had already received his PM meds, the nurse did not enter the room again until doing the head count. LVN G explained they tried to not wake the roommate (in bed A) because he became agitated. He stated the CNA working on the night of the incident was new to the unit. He stated the usual CNA had called in sick. LVN G stated the replacement CNA had trained for almost 2 shifts. He explained the Activity Director was assisting on the unit until approximately 9:00 PM. LVN G stated when Resident #55 returned, he was wearing a long sleeve shirt, pants, shoes and was carrying his blanket roll. LVN G stated policy was to conduct rounds every 2 hours. LVN G stated Resident #55 made verbal statements about leaving but did not actively exit seek. He stated he did not feel the incident was a facility failure, measures were in place to prevent elopement such as keypad locks on all the exit doors, screws or stops in all the windows to limit height they could be raised, a 6' wood privacy fence around the courtyard and walk-way bordering the unit. LVN G stated he was told the resident was found on the access road. When asked how to get to the access road he stated a turn left or right onto a nearby street would get there. No one knew which direction the resident took. LVN G stated an elopement drill was done after the incident and the following week. He stated Resident #55 was put on 1:1 supervision with every 15-minute activity documentation. He stated in-services were done on elopement and every 2-hour rounds. LVN G stated the census on the secure unit the night of incident was 21. During a telephone interview on 04/02/25 at 08:49 PM, the local county Sherriff's Deputy stated she received the first call about the resident walking along the side of the road sometime after 9:00 PM on 03/20/25. The Deputy stated she interviewed him at the time and considered it a consensual stop. She stated the resident seemed cognizant and he explained to her that he was going to his family member's. The Deputy stated the resident was alert, oriented, answered questions appropriately, there were no signs of distress, and his walking ability was steady. She saw no reason to investigate further. The Deputy stated she received a 2nd call at approximately 11:00 PM about a man walking along the roadside a couple miles from the facility. She stated the resident appeared more altered but again was able to tell his name and that he was going to his family member's house. She explained that she called EMS to assess and checked the resident's driver's license for flags. She explained flags were put on the DL for situations like dementia. She stated the resident had no emergency contact information on him or linked to his DL. She contacted the address on his DL, no one knew who he was. She then made a report to APS. The Deputy stated APS told her they had information in bits and pieces on the resident d/t all the times he left his family member's house and was returned by law enforcement. She explained APS also stated the resident had been in other places but had left each of them several times. The Deputy stated she checked the missing person's report, but the resident's name was not listed. She stated EMS checked the resident, obtained a full set of vital signs, and determined he was in perfect health. She stated EMS reported his body temperature was normal. The Deputy stated she then decided to take him to the sheriff's department while trying to find out where he needed to be. She stated she finally reached his family, but they were not able to tell her where he was supposed to be. She explained one family member told her he was supposed to be in a nursing home 124 miles north. She stated she had other officers calling different facilities in surrounding counties. She stated one county reported notes on the resident that he lived with his [family member]. The deputy stated the resident was with her from 11:00 PM until she returned him to the facility. She described his reaction upon returning was pleasant, no behavior or statement of distress, only stated he wanted to see his family member that lived by the base. The deputy stated once inside the building the resident knew exactly how to get to his room. The Deputy stated when she located the resident, he was appropriately dressed and was carrying a bed roll with snacks so he was prepared. She stated the resident was not walking in the roadway either time, he was well off to the side. Review of weatherspark.com (https://weatherspark.com/h/d/7167/2025/3/20/Historical-Weather-on-Thursday-March-20-2025-in-Brownwood-Texas-United-States#metar-22-55) revealed the weather on 03/20/2025 at 10:55 pm, was 48.4 F, with no precipitation. During an observation on 04/02/25 between 09:00 PM and 09:20 PM of the road in front of the facility revealed 4 vehicles traveling south and 3 vehicles traveling north. During an interview on 04/03/25 at 05:51 AM CNA H stated she was scheduled to work the night of the incident but was sick. She stated she worked 2 partial shifts with the CNA that covered for her. CNA H stated training on elopement prevention included on-line modules and in-services. She explained training monitored by HR. CNA H stated the night of the incident, HR called her and had her participate in the elopement drill via phone. She explained the effect on residents of failing to provide training would be bad. She stated staff was trained to not give out the door codes and methods to block a resident from attempting escape without antagonizing the resident. She stated elopement drills were done for both day and night shifts. CNA H stated the best training to prevent elopement was to know the residents. During an interview on 04/03/25 at 08:43 AM, the Administrator stated staff call-ins were covered by PRN staff or having one of the 3 CNAs assigned to the front hall to float to the secure unit. She stated every 2-hour rounds were not done on Resident #55 because staff knew if the resident and/or his roommate were woken up by staff, they became agitated and were up all night. She stated because both residents in the room were independent, staff avoided irritating them. She stated her expectations were for rounds to be done every 2 hours but also wanted to keep in mind resident rights and preferences. She stated a few residents on other halls specifically requested not to be bothered. The Administrator stated policy was for law enforcement to be called when a resident was discovered missing, an eyes on count done, and the facility and perimeter checked. Review of the facility policy titled Wanderer Management, Monitoring System & Resident Elopement Protocol dated reviewed 01/2023 revealed 1. If a resident is noted to be missing, the following must be initiated immediately: Notify the Administrator/designee immediately. Perform a complete search of the interior of the building. This should include every room, including bathrooms, break rooms, storage rooms, closets, etc., Initiate an external search outside of the building, including the facility grounds and community, on foot and by vehicle. Interview staff to determine who may have seen the resident last and try to determine when they may have been seen last, including what they were wearing, etc. Notify local law enforcement and provide them with a complete description of the individual. Notify the resident's family and physician. Call area hospitals, bus stations, train stations, grocery stores, liquor stores, etc. Notify state agency per state law. Notify other nearby nursing homes. Postscript added to end of policy: Education: Staff to physically see and check on patients every 2 hours to ensure safety. The facility implemented the following corrections prior to survey entrance on 04/01/2025. The facility was evaluated to be in past noncompliance based on the corrections implemented prior to entrance. The following records of interventions were reviewed: 1. Record review of 1:1 supervision and every 15 minute activity documentation of Resident #55 revealed supervision began on 03/21/25 and was ongoing. 2. Record review revealed the facility conducted elopement policy and every 2-hour resident checks in-services. Documentation of interviews with multiple staff members on their knowledge of elopement procedures and every 2-hour resident checks was on file. 3. Record review of the facilities An elopement drill revealed an elopement drill was conducted on 03/21/2025 and again on 03/28/2025. 4. Record review of maintenance records on 04/03/25 revealed the door to the secure unit and outside fence gate lock codes were changed on 03/24/2025. 5. Record review of maintenance documentation revealed the broken fence pickets were replaced, and all pickets were reinforced with screws on 03/21/2025. 6. An Ad hoc committee (a temporary group formed to address a specific issue or task) was created to evaluate effectiveness of interventions weekly for 8 weeks. Meetings were conducted on 03/21/2025 and again on 03/28/2025. 7. Residents with wandering/elopement risks were to be reviewed for risk potential daily for 30 days. Documented reviews began 03/22/2025 and were conducted daily.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed in that: The facility's kitchen staff failed to clean the kitchen as directed by daily cleaning lists. The facility's kitchen staff failed to store food properly. The facility's kitchen staff failed to remove expired food from the refrigerator. The facility's kitchen staff failed to keep clean and dirty dishes separated during meal service. The facility's kitchen staff failed to cover drinks that were placed on delivery trays and sent to the hall during meal service. These failures placed residents at risk for food borne illness and cross-contamination. Findings included: During observation on [DATE] beginning at 9:10 AM the following was noted: 1. A box of [NAME] biscuits in the freezer #1 was soiled with an orange liquid. 2. Crumbs and an unknown soiled substance was at the bottom of refrigerator #1. 3. Crumbs and an unknown dried substance was on a shelf containing plastic lids and napkins. 4. The bottom shelf of the food prep table contained clean pans. Wax paper underneath the clean pans contained dried cooked food, crumbs, and was soiled with an unknown substance. 5. Behind the stove contained dirt, dust, and dried food. 6. Walls were noted to be soiled with dried liquid. 7. The door leading to the dining room was soiled with dirt and unknown substances. 8. The ice machine was soiled with unknown dried liquids. 9. Upside down pans beneath the food prep tables were noted to have dried food sitting in the rim of the pan. 10. The cleaning checklist had not been completed since February of 2025. The cleaning check list for February 2025 was incomplete. 11. A bag containing sliced cheese was open to air in refrigerator #1. 12. A bag containing cookies was left open to air in the food storage area. 13. A bag containing cereal was left open to air in the food preparation area of the kitchen. 14. Peach cobbler found in refrigerator #1 had an expiration date of [DATE]. During an interview with the DM on [DATE] at 11:45 AM, she reported her first day on the job was Friday ([DATE]). The facility had not had a dietary manager for about a month. She continued to say the last cleaning log that was completed was from February 2025. She was in the process of putting together a new log. In the meantime, she had been instructing kitchen staff on what needed to be cleaned. During an interview with the Administrator on [DATE] at 9:32 AM, she reported the facility went 3 weeks without a dietary manager. She stated, I was in charge of the kitchen while she was gone. I don't know if cleaning lists were being completed or not. I know we were doing cleaning every day. It's just a really old kitchen. It's hard to make it look pretty. We came in Sunday ([DATE]) and worked a lot on cleaning. We have a verbal action plan in place to come in a clean. When asked what negative outcomes could occur if proper cleaning was not completed, she stated, There is a potential for illness. During an interview with the DM on [DATE] at 8:25 AM, she reported that she reviewed the policy on cleaning. The policy stated that the manager came up with the cleaning schedule and monitored if it's being completed. She stated that illness could occur if the kitchen was not cleaned properly. During an interview on [DATE] at 2:25 PM, the DM stated that all food being stored must be sealed and dated when opened. It was everyone's job to monitor for that. If left open to air food could go bad or develop bacteria that could cause illness. During an interview on [DATE] at 2:20 AM, the DA reported that opened food was to be stored in two-gallon bags, dated, and sealed. If left open to air it could get stale, grow mold, and get bugs. Serving food that was left open to air could cause residents to get sick. She continued to say its everyone's responsibility to ensure bags were sealed properly. During an interview on [DATE] at 2:25 PM, the DM stated it was everyone's responsibility to check for expired food daily and throw it out. If that was not done, it could get served out and everyone could get sick. During an interview on [DATE] at 2:20 AM, the DA reported everyone was responsible for checking the refrigerator and storage area for expired food daily. Failure to do so could allow the food to be served. That could cause residents to get sick. During observation on [DATE] at 11:56 AM, the following was noted: 1. The [NAME] was observed removing used lids from the steam table and returning them to racks containing clean pans underneath a food preparation table. During an interview with the DM on [DATE] at 11:56 AM, she reported that it was not standard practice for kitchen staff to remove used lids off the steam table and return them to racks with clean pans. She stated, No. That is not supposed to happen. That causes cross contamination and can cause illness. During observation on [DATE] at 12:33 PM, the following was noted: 1. Trays being delivered down hall 300 contained glasses of tea that were not covered with plastic lids. During an interview with the DM on [DATE] at 12:41 PM, she reported if drinks and food were being sent to the hall, they must be covered. If not covered particles and dust could get in the drink causing illness. During an interview with the Administrator on [DATE] at 12:42 PM, she reported there was not a specific policy that stated drinks must be covered; however, that was the expectation. She was aware of the issue and had put together an in-service for staff. Record review of the policy titled Sanitization revealed [in part]: -Policy Statement The food service area shall be maintained in a clean and sanitary manner. -Policy Interpretation and Implementation 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Record review of the daily dietary start up tool provided by the Dietary Manager revealed [in part]: 1. Storage Room: All items sealed. 2. Freezer: All foods sealed. 3. Refrigerator: All items sealed. 4. Daily Cleaning schedule - initialed and completed. 5. Weekly Cleaning schedule - initialed and completed. 6. Post weekly cleaning schedule. Record review of the Cook's Deep Cleaning List for February 2025 revealed [in part]: 1. Clean under prep tables. 2. Clean behind stove. 3. Change paper under prep tables. Record review of the new Daily Cleaning List created by the Dietary Manager revealed [in part]: 1. Work tables/shelves after each use. 2. Prep area/shelves after each use. 3. Shelves/underneath shelves. 4. Reach in cooler - shelving clean daily. 5. Inside/outside clean daily 6. Ice machine - inside ice guard and outside

Based on observation, interview and record review, the facility failed to promptly notify the resident's physician when there was radiology results outside of clinical reference range for 1 of 5 residents (Resident #17) reviewed for physician notification of radiology results. The facility failed to promptly notify Resident #17's physician by phone per facility protocol on 02/12/25 when x-ray results falling outside of clinical reference ranges reflected Resident #17 had a right femur fracture This failure could place residents at risk of a delay in medical treatment and could result in not receiving appropriate care and interventions. The findings included: Record review of Resident #17's face sheet dated 04/03/2025 revealed an [AGE] year-old female admitted on [DATE] with diagnoses which included: Schizoaffective disorder (mental health condition), major depressive disorder (mental health condition), hypothyroidism (an underactive thyroid), unspecified dementia (cognitive decline), hypertension (high blood pressure), osteoporosis (weakened bones), iron deficiency anemia (body does not have enough iron for healthy red blood cell production), gastro-esophageal reflux disease without esophagitis (reflux without inflammation or damage to the esophageal lining). Record review of Resident #17's quarterly MDS dated [DATE] revealed a BIMS score of 00 which indicated a severe cognitive impairment and required extensive assistance and/or two plus persons physical assist for ADL care. Record review of Resident #17's care plan report dated 02/09/2025 revealed focus areas that included moderate risk for falls related to confusion, gait/balance problems, psychoactive drug use as well as impaired cognitive function/dementia or impaired thought processes related to dementia. Record review of Resident #17's care plan report dated 03/11/2025 revealed added focus areas of has had an actual fall and lists dates of falls as 02/26/24, 04/01/24, 04/19/24, 06/24/24, 11/01/24 (all with no injury), 02/04/25 (with abrasion to right knee), and 02/10/25 (fall with late onset right hip fracture resulting in hospital stay). Record review of Resident #17's progress notes revealed: 02/10/25 at 01:08 AM, RN A noted Resident #17 was found lying in the floor, she was assisted back to bed after being assessed with noted hip bruising. The MD (on call), DON, and family were notified. 02/11/25 at 03:38 AM, LVN B noted Resident #17 was up in her wheelchair, eyes open, respirations even and unlabored, denied any pain or discomfort, and refused help to get back in bed. 02/11/25 at 01:18 PM, RN C noted in a Weekly Skin Observations Summary [in part]: Skin Condition Site(s) / Description(s): Face - forehead (bruise), Right trochanter (hip) - bruise, Other (specify) - right side (bruise) Skin condition(s) requires no treatment/dressing. Monitoring ongoing. Treatment/Care Plan Status: Skin condition(s) were not resolved. Continue current treatment plan. Education/Training Provided was described as: staff informed to round on resident every 2 hours and monitor the sides with bruising and to assess her to prevent anymore falls. Turning and repositioning outcome: The resident allowed clinician to reposition them for pressure redistribution and comfort. The resident was also left clean and dry. Referrals and/or additional notes if applicable: the nurse was notified of the resident, x-ray to be ordered. 02/11/25 at 03:34 PM, LVN D noted a portable x-ray bilateral (both sides) hip 3 views and cervical 2-3 view, due to post fall pain. 02/12/25 at 00:59 AM(12:59AM), RN A noted the x-ray results were received, and faxed to the MD for review. Xray report reflected: Impression: 2. Mildly displaced fracture of the right femoral neck(upper long bone of leg). 02/12/25 at 09:24 AM, RN C noted in a Weekly Wound Observation Summary Note [in part]: The resident allowed clinician to reposition them for pressure redistribution and comfort. No new referrals / consultations were needed currently. 02/12/25 at 10:27 AM, the ADON noted they called and spoke with receptionist at MD's office related to fracture report and increased pain to right hip. The MD ordered to send the resident to the ER to eval and treat. 02/12/25 at 04:55 PM, the ADON noted they called and spoke with the ER. The resident admitted for a fracture from ortho. Record review of Resident #17's Hospital Notes dated 02/12/25 - 02/16/25 revealed: Resident #17 underwent a right hip arthroplasty(joint replacement) to repair the fracture. In an observation of Resident #17 on 04/02/25 at 8:20 AM, revealed the resident was lying in bed stated, I'm good, then closed her eyes and turned over towards the wall. Hydration at bedside, the call light was within reach, the fall mat was on the floor by the bed, and the bed was in a low position. In an interview on 04/03/25 at 11:10 AM, the DON stated he was unsure what took place or what was going on at the time but that when it was brought to his attention the morning of 2/12/25, that the physician was not called with the x-ray results report that night. He stated he and the ADON completed an in-service over the phone with RN A, that reporting abnormal x-rays and labs to the MD, DON, and RR with all critical/abnormal findings must be done by phone. He further stated that for no reason should abnormal results be faxed. At that time the DON provided the policy for Fall Prevention Program and Medication Orders. The DON stated those were the only policies he had for falls and orders/reporting to physicians. In an interview on 04/03/25 at 01:26 PM, LVN E stated the process for reporting an abnormal x-ray or lab report was to call the ordering physician immediately. She stated when a resident fell , the nurse did a head toe assessment making sure the resident was ok, a neuro check was done at that time and then every 30 min for 4 hours and then every hour for 4 hours. After the assessment, if at night, call the DON, family, and MD to inform of the incident and receive any orders the MD adds. She stated if the MD ordered an x-ray, the nurse placed the order in the computer, called the mobile x-ray provider to complete the order, then once the report was back call the MD with the results especially if they were positive for a fracture, or if a lab level was abnormal. She further stated that was the expectation. She also stated an adverse outcome, if a positive x-ray was reported and not immediately reported, could be the resident suffered in pain for a prolonged period of time and didn't get the care needed, also if staff did not know of the fracture, staff would do ADL's and activities with the resident like normal. In a telephone interview on 04/03/25 at 4:28 PM, the MD for the facility stated the expectation when a resident fell was, he was immediately contacted via call or text, and informed if there was an injury or no injury. He stated the adverse outcome in the situation was the delay in care from the time the x-ray was done, the day after the fall, to the time he was notified of the fracture the next day 02/12/2025. He further stated when he was notified of the fall it was reported as no injury therefore an x-ray was not ordered at that time. An attempt for phone interview on 04/03/25, at 4:40 PM and 5:15 PM to contact RN A and was unsuccessful. Unable to reach her with two attempts and voicemails were left. In an interview on 04/04/25 at 8:10 AM, the ADON stated she called the MD's office on 02/12/25 as soon as she was made aware with the report of Resident #17's hip fracture. She stated the expectation of the nurses when an abnormal lab or x-ray came across the fax was to call the MD and speak to them directly. She further stated an adverse outcome was a delay in care. In a record review of the facility policy labeled Fall Prevention Program last reviewed date 06/10/2024 reflected [in part]: #5 If a fall occurs, the following will be done: k. If the resident with dementia sustains a fall, in addition to the nursing assessment, the facility will also prioritize diagnostics such as STAT x-ray/transfer to the ER for appropriate investigation and intervention. In an interview on 4/4/25 at 9:45 AM , the ADMN stated there was no further documentation or evidence to provide.

Based on interview and record review the facility failed to provide an activities program directed by a qualified professional for 1 of 1 activity directors (AD) reviewed for qualifications. The facility failed to ensure the AD was a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident. The findings included: Record review of the AD's employee file revealed the AD took the position on 06/03/2024, and evidence of training beginning 02/13/2025 as a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. Record review revealed once the course was done (May 2025), it would have been almost a year since being hired to be certified. During an interview on 04/03/2025 at 11:23 AM, the AD stated she was hired 8 months ago. She stated she had no prior experience nor prior SW experience. The AD stated she did not have her AD certification upon hire. She stated she was supposed to have started her certification in October of 2024, but the company changed the course they used which in turn pushed them back to January 2025. The AD stated the ADMN stated to her when hired, she needed to get certified as soon as possible. She stated she felt there was no harm to the residents. During an interview on 04/03/2025 at 1:08 PM, the ADMN stated she had never been told the time frame but assumed during the first year. She stated she worked with the AD as a CNA and felt with her leading the residents in attending AD events was enough to be hired for the position. The ADMN stated it was HR who monitored the certifications and the paperwork for staff members. She stated her expectations would be for AD to have her certification within a year of being hired. She stated she did not feel there was a failure nor a negative impact to residents. During an interview on 04/03/2025 at 5:01 PM, HR stated there was not a check off list for the AD staff member's hiring. She stated she was unaware of her certification status. Record review of the AD's application dated 08 May 2024 with an updated date of 03 June 2024, revealed: License and Education: Valid professional license or certification-yes License /certification: (was unanswered) License/number: (was unanswered) Issuing Organization: (was unanswered) State: (was unanswered) Issue date: (was unanswered) Expiration date: (was unanswered) Record Review of the facility Activity Director's job application agreement dated and signed on 08 May 2024 revealed: I understand that, if hired, (a) I am required to abide by all rules and regulations . Record review of the facility's job description for Activity Director signed on 6/3/24 revealed, I will perform the duties and responsibilities of that position and further agree to conform to the rules and regulation

Based on observation, interview, and record review the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 of 1 medication rooms reviewed for medication labeling and storage. The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. These failures could place residents at risk of misappropriation of medications. Findings Included: Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS Section I - Active Diagnoses revealed resident had seizure disorder or epilepsy and anxiety disorder. Record review of Resident #3's care plan dated 01/23/2025 revealed Resident #3 had seizures. Further review of care plan revealed interventions for seizures included to give medications as ordered, monitor/document effectiveness and side effects, use half side rails with seizure pads added to resident bed for safety, and to document seizure activity. Record review of Resident #3's electronic physician orders dated 01/21/2025 revealed one time order for Ativan (lorazepam) 2mg/ml inject 2mg IM (intramuscularly) one time only for anxiety. Further review revealed an electronic physician order dated 01/14/2025 lorazepam injection 1mg IM every 5 minutes prn anxiety. Record review of Resident #3's nursing progress notes which indicated that resident received 4 doses of Ativan (lorazepam) IM on 1/21/2025. Further review of nursing progress notes indicated Resident #3 received 1 dose of Ativan (lorazepam) IM on 1/22/2025 at 5:08 p.m. Record review of Resident #3's narcotic count sheet titled controlled substance record indicated 4 doses of lorazepam were administered on 1/21/2025. There was no evidence that 1 dose of lorazepam had been administered on 1/22/2025. During an observation and interview on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a sealed bag of lorazepam vials for Resident #3 inside of the controlled substance box that had 25 vials inside of the box. LVN A was present and agreed that there were 25 vials of lorazepam in sealed bag for Resident #3. LVN A stated medications were counted every shift to make sure that the counts were correct. She stated she had not counted the medication in the refrigerator because she was not responsible for 200-300 medication cart which had the count sheets for Ativan (lorazepam) in the binder. During an interview on 01/22/2025 at 12:10 p.m., MA C stated she was responsible for the 200-300 hall medication cart. She observed the controlled substance count sheet and agreed that it stated 26 vials of lorazepam should be in the refrigerator for Resident #3. She stated she should have counted the refrigerator medications when she took control of the 200-300 medication cart at shift change. She stated she did not count the refrigerator medications this morning during shift change. She did not answer why she did not count the medications in the refrigerator when asked. During an interview on 01/23/2025 at 12:14 p.m., the DON stated medication aides and nurses were responsible for making sure controlled substance count sheets were accurate with medication on hand during shift change. He stated that both he and the ADON monitored the medication aides and nurses performed counts and had just counted the medication room fridge on 01/22/2025 before 4:00 p.m. and the count was correct. He stated he expected for nurses and medication aides to sign out medication on the controlled substance count sheets as they were given. He stated medication aides and nurses were to contact him if the count did not match what was written on the controlled substance count sheet and he would do an investigation to see why count sheets were off. He stated he would let corporate and state agency know of issue when his investigation could not find reason for why counts sheets were incorrect. He stated he would investigate why Ativan (lorazepam) did not match controlled count sheet. During a follow up interview on 01/23/2025 at 1:00 p.m., the DON stated his investigation led to the finding that LVN B had given lorazepam on 01/22/2025 around 5:00 p.m. He stated had LVN B signed the medication off of the controlled substance count sheet, the counts would match how much medication was on hand in the refrigerator. He stated the nurses and medication aides had been educated in the past about making sure count sheets were accurate and counted every shift change. He stated he felt more education was needed. During an interview on 01/23/2025 at 1:02 p.m., LVN B stated Resident #3 was having a seizure on 01/22/2025 around 5:00 p.m. and his hospice nurse was present in the facility. She stated she remembered the time because a new admission had arrived at the facility around the same time. She stated she had gotten medication vial from refrigerator in the medication room and had administered the Ativan (lorazepam) to Resident #3. She stated she did not sign it out on the controlled substance count sheet because she was distracted. She stated it was important to sign out medication use on controlled substance count sheet to keep account of the medication and prevent someone from taking it. During an observation on 01/23/2025 at 2:38 p.m., Resident #3 was in his room lying in bed that was in low position. He had side rails that were padded on his bed. His eyes were closed and no distress observed. His respirations were even and unlabored. Resident #3's call light was within reach of him. During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. She stated whoever was responsible for 200-300 medication cart should count the controlled substances in the refrigerator. She stated she had not been responsible for 200-300 medication cart on 1/22/2025 and was unsure why the controlled substances were not correct on the count sheet on 01/23/2025. During an interview on 01/24/2025 at 6:04 p.m., RN E stated she was responsible for 200-300 medication cart on the night of 01/22/2025. She stated she should have counted the controlled substances in the medication room refrigerator. She stated she had been education in the past to count the box for controlled substances in the refrigerator when she was responsible for the 200-300 medication cart. She did not give a reason why she did not count the controlled substances the night of 01/22/2025. She stated controlled substances were counted to prevent loss of medication from people taking medication out of the controlled substance box. During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for controlled medications to be counted every shift and for staff to follow facility's policy. He stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. The MD stated he does not review the narcotic count sheets during his resident review of how often medication was administered. He stated he obtains medication administration frequency from the DON and does not know where the DON obtains that information. During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the facility utilized controlled substance count sheets to correctly manage the controlled substances and dosages. She stated the controlled substance count sheets do help keep track of medication and reduce risk for misappropriation. She stated her expectation would be that the controlled substance count sheets be promptly updated when a medication dose had been given. She stated both her and the DON do weekly audits to make sure the controlled substances matched what was documented on the controlled substance count sheets. During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she rounded in the facility once a month. She stated she would do random spot checks of controlled substance count sheets to see if nurses and medication aides were signing medication in and out. She stated her expectation would be that the medication on hand match the controlled substance count sheet. She stated the negative effect of controlled substances not being accurate could be misappropriation of medications. She stated nurses and medication aides should document medication on controlled substance count sheet as soon as the medication was given. During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated staff laziness may have led to the failure of staff not counting the controlled substances in refrigerator because they had been educated to do so prior to 01/22/2025. He stated not counting controlled substance during shift change could lead to misappropriation of medications and if not found then licensure reporting to appropriate agency. During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for controlled substance count sheets to accurately reflect the amount of medication in storage. She stated controlled substance count sheets were done to help prevent medication misappropriation. She stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were controlled substances during shift change. Review of drugs.com accessed on 01/24/2025 at https://www.drugs.com/schedule-4-drugs.html revealed: Ativan (lorazepam) was listed under The following drugs are listed as Schedule 4 (IV) Drugs by the Controlled Substances Act (CSA) Review of the facility policy titled Controlled Substances dated July 2024 revealed: Dispensing and Reconciling Controlled Substances 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection / follow-up. 2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services .15. The consultant pharmacist or designee routinely monitors controlled substance storage records. 16. The director of nursing services maintains and disseminates to appropriate individuals a list of staff who have access to medication storage areas and controlled substance containers.

Based on observation, interview, and record review the facility failed to ensure separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for 1 of 1 medication rooms reviewed for medication labeling and storage. The facility failed to maintain controlled substance record count sheet with accurate amount of lorazepam (a controlled substance) stored in medication room refrigerator. These failures could place residents at risk of misappropriation of medications. Findings Included: During an observation on 01/23/2025 at 11:48 a.m., the medication room refrigerator had a locked box inside of the refrigerator that was not secured and could be removed easily from the refrigerator. Keys to the locked box, inside of the refrigerator, were stored on a hook that was secured to the left of the outside of the refrigerator. Anyone with access to the medication room had access to the locked box key. During an observation and interview on 01/24/2025 at 5:50 p.m., LVN D counted controlled substances in medication room refrigerator with MA C. LVN D removed keys from beside of the refrigerator and opened the locked box inside of the refrigerator to count the medications. During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for nurses and medication aides to follow facility policy when storing controlled substances. He stated the DON was responsible for monitoring that nurses and medication aides followed the policy. During an interview on 01/24/2025 at 10:30 a.m., the ADON stated the locked box in refrigerator, for controlled substances, should be secured to the refrigerator. She stated she did not know why the box had not been secured to the refrigerator. She stated the keys to the locked box in refrigerator for controlled substances should not be kept to the left outside of the refrigerator and should be stored on the nurse or medication aide keys that were responsible for the medication cart that kept the controlled substance count sheets in binder. She stated she did not know why keys had been stored next to the refrigerator but that storing the key that way could cause potential misuse of the controlled medications. She stated both her and the DON monitor that medication were stored appropriately. During a telephone interview on 01/24/2025 at 11:44 a.m., the pharmacy consultant stated she expected for staff not to store key to the locked box in the medication room next to the unlocked refrigerator. She stated the facility had moved the medication room recently from the back of the facility to the front and that may have led to controlled substances to not be stored appropriately. She stated the controlled substance box should be secured to the refrigerator and did not know why it was not. During a follow up interview on 01/24/2025 at 10:54 a.m., the DON stated the controlled substance box should be secured to the refrigerator and the keys to the box should not be stored outside of the refrigerator for all staff that had access to the medication room to have access to the controlled substances in the locked box. He stated recently the controlled substance box had been replaced due to the old one had rusted and he felt that led to the failure of new controlled substance box not being affixed. He stated staff laziness may have led to the failure of the key to the controlled substance box being stored next to the refrigerator in medication room. He stated not storing medication correctly could lead to misappropriation of medications During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for staff to go by facility policy when storing medications. She stated the ADON and the DON monitored that staff were storing medications appropriately. Review of the facility policy titled Controlled Substances dated July 2024 revealed: Storing Controlled Substances. 1. Controlled substances are separately locked in permanently affixed compartments, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. 2. All keys to controlled substance containers are on a single key ring that is different from any other keys. 3. The charge nurse on duty maintains the keys to controlled substance containers. The director of nursing services maintains a set of back-up keys for all medication storage areas including keys to controlled substance containers.

Based on interview, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 (Resident #3) of 6 residents reviewed for resident records. The facility failed to ensure Medication Administration Records were accurate in the electronic medical record for Resident #3. This failure could place residents at risk of having errors in care and treatment. The Findings included: Record review of Resident #3's electronic face sheet dated 01/23/2025 revealed he was a [AGE] year-old male admitted to the facility on [DATE] and most recently on 01/13/2025 with diagnoses to include: conversion disorder with seizures or convulsions (a mental health condition that causes seizures or convulsions) and anxiety. Record review of Resident #3's quarterly MDS dated [DATE] revealed: BIMS score of 03 which indicated severe cognitive impairment. Further review of the MDS Section I - Active Diagnoses revealed resident had seizure disorder or epilepsy and anxiety disorder. Record review of Resident #3's care plan dated 01/23/2025 revealed Resident #3 had seizures. Further review of care plan revealed interventions for seizures included to give medications as ordered, monitor/document effectiveness and side effects, use half side rails with seizure pads added to resident bed for safety, and to document seizure activity. Record review of Resident #3's electronic physician orders dated 01/21/2025 revealed one time order for Ativan (lorazepam) 2mg/ml inject 2mg IM (intramuscularly) one time only for anxiety. Further review revealed an electronic physician order dated 01/14/2025 lorazepam injection 1mg IM every 5 minutes prn anxiety. Record review of Resident #3's nursing progress notes which indicated that resident received 4 doses of Ativan (lorazepam) IM on 1/21/2025. Further review of nursing progress notes indicated Resident #3 received 1 dose of Ativan (lorazepam) IM on 1/22/2025 at 5:08 p.m. Record review of Resident #3's MAR dated January 2025 revealed no evidence that Ativan (lorazepam) had been administered on 1/22/2025. During an interview on 01/23/2025 at 1:02 p.m., LVN B stated she had administered lorazepam IM to Resident #3 on 01/22/2025. She stated she had written a progress note about resident on that date but must have forgotten to document medication administration on the MAR. She stated Resident #3's hospice nurse was present when lorazepam IM was administered, and medication was for an active seizure that Resident #3 had. She stated she felt being distracted prevented her from documenting medication administration in the MAR. She stated she knew to document medication administration in the resident's medical record and not performing could cause other nurses not to know she had administered the medication. During a telephone interview on 01/24/2025 at 8:41 a.m., the MD stated he expected for medication administration records to be correct for residents. He stated he expected for nursing staff to follow the facility's policy on medication administration and for the ADON and DON to monitor that nursing staff was following that policy. He stated he did not review MARs for his knowledge of the residents in the facility and would get information that he needed from the DON. During an interview on 01/24/2025 at 9:30 a.m., the ADMN stated the facility should follow the medication administration policy for clinical documentation of medications being administered. She stated the facility did not have a clinical documentation policy and used the medication administration policy. During an interview on 01/24/2025 at 10:30 a.m., the ADON stated she expected for nurses and medication aides to document medication administration on the MARs to help prevent medication errors. She stated documentation should be completed when medication was administered and no later than the end of nurses' and medication aide's shift. She stated the resident's clinical record should reflect what was going on with the residents including the medications that residents had taken to help prevent adverse effects. She stated both herself and the DON monitored that nurses and medication aides documented medications in the medical record. She stated emergent situation may have caused the nurse to forget to document the medication administration. During an interview on 01/24/2025 at 10:54 a.m., the DON stated he expected for the resident's MARs to reflect what medication had been given to those residents. He stated it was the responsibility of the nurse or medication aide to document medication administered on the MAR. He stated both he and the ADON monitored weekly that nurses and medication aides were documenting correctly by random chart reviews. He stated not documenting medications on the MAR would not affect what he reported to the MD because he used the controlled substance count sheets to see how frequently controlled substances were given. The DON stated it was easier to identify the time and frequency of medication administration on the controlled substance count sheets opposed to the MARs. He stated when Ativan (lorazepam) medication was documented on the MAR, it would trigger for the nurse to document the effectiveness of the medication. He stated not documenting Ativan (lorazepam) administration on the MAR could interfere with monitoring the effectiveness of medication. During a telephone interview on 01/24/2025 at 12:17 p.m., the pharmacy consultant stated she rounded in the facility once a month. She stated she did look at resident's MARs but did not monitor the MARs when in the building. She stated she relied on physician orders to see what medications were prescribed for her medication reviews. She stated she made recommendations based on physician orders. She stated she would expect for the MAR to reflect what medication had been given to residents. She stated not documenting on the MAR could interfere with other nurses and medication aides knowing what had been given to monitor the effectiveness of the medication. She stated not documented could also interfere with nurses to know to monitor for side effects including lethargy (difficult to be aroused / sleepy). During an interview on 01/24/2025 at 1:09 p.m., the ADMN stated she expected for nursing staff to follow policy when documenting medication administration. She stated the ADON and DON monitored that nursing staff followed the policy. She stated she expected for documentation to be completed by the end of the nurses' or medication aides' shift. She stated the MAR should reflect what had been given to the resident. She stated not documenting medication administration could cause adverse reaction to occur or could delay the responses to effectiveness of the medications. Review of facility policy titled Medication Administration dated 07/08/2024 revealed: 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions .22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; b. the dosage; c. the route of administration; d. the injection site (if applicable); e. any complaints or symptoms for which the drug was administered; f. any results achieved and when those results were observed; and g. the signature and title of the person administering the drug.

Based on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 Resident (Resident #34) of 4 residents reviewed for accident and hazards: The facility failed to ensure Resident #34's bed was on its lowest position while the resident was in his bed. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues as a result of accident hazards. Findings included: Record review of Resident #34's admission record dated 01/24/24 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #34's care plan dated 01/23/24 indicated in part: Focus: Resident is High risk for falls r/t dementia. GOAL: The resident will be free of falls through the review date. Interventions: Keep bed in low position with fall mat beside bed. Bed at lowest position and fall mat in place. Record review of Resident #34's MDS dated [DATE] indicated in part: BIMS = 00 indicating resident had severe impairment. Functional abilities and goals - Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair) = 01 indicating Dependent - Helper does all of the effort. Resident does none of the effort to complete the activity or, the assistance of 2 or more helpers is required for the resident to complete the activity. Record review of Resident #34's incident report dated 01/11/2024 indicated in part: Location: Resident's room. Nursing description: Heard resident calling for help. Nurse walked in room and found resident on the floor. Resident on the floor bed not in lowest position fall mat on the floor, resident in between bed and floor mat. Resident with right hip on floor, right arm behind his back, left leg and arm straight, With two assists, resident assisted back to bed. Denies pain in either shoulder. Full ROM with both shoulders. Full ROM to right hip. c/o low amount of pain during ROM. No pain to right hip when right hip joint is still. No pain to left leg. Full ROM to left leg. Dr. notified of fall and pain with right hip movement. Resident description: Resident unable to give description. Immediate action taken. Spoke with one CNAs and one TNA who put the resident to bed. Both stated bed would not go to lowest position. Nurse requested when equipment isn't working write it down in maintenance log. Bed put in maintenance log. LPN put bed in lowest position, did take longer than normal for bed to go to the floor. Record review of the facility self-report 476720 PIR dated 01/12/24 indicated in part: Resident #34 was found on the floor next to his bed and complained of right hip pain. X-ray was done and revealed a non-displaced right hip fracture. Review of hospital document date 01/11/24 indicated in part: Return to NH. Dx 1. Incomplete right inter-trochanter fracture non-surgical 2. AKA. This is a non-surgical fracture. Note: (An intertrochanteric fracture is a specific type of hip fracture, intertrochanteric means between the trochanters, which are bony protrusions on the femur or thighbone). Review of final radiology report document date 01/12/24 indicated in part: Impression subtle lucency through the right intertrochanteric region which may be secondary to a nondisplaced fracture. During an observation and interview on 01/23/24 at 12:24 PM Resident #34 was in the main dining room sitting up on his wheelchair awake and alert eating his lunch. Resident was asked if he recalled falling out of bed and he said he had never fallen out of bed before and had no complaints. During an interview and observation on 01/24/24 at 12:46 PM CNA A said she was working the floor on 01/11/2024 the day Resident #34 fell . CNA A said the bed was not fully down because the bed remote was not working correctly and she felt at fault because the resident had fallen and fractured his hip. The aide went to the resident's room and demonstrated at what height the bed was which was approximately 22 inches off the floor. CNA A said RN C performed the assessment and then they placed the resident back onto the bed and later the x-ray people came and took x-rays of the resident. During an interview on 01/24/24 at 03:00 PM RN C said on 01/11/24 she was at the nurses station and heard Resident #34 calling out for help. RN C said she walked into the room and noted the bed was not in its lowest position. RN C said the resident was on the floor on his right hip and was not on the mat, the resident was in between the bed and the mat on the floor. RN C said she assessed him and everything seemed okay at that time. RN C said CNA A said the bed would not go all the way down to the floor as it was not working properly. RN C said she asked the aide why she had not reported it to maintenance and the aide did not say anything and just started walking towards the maintenance log to book to document it. RN C said the bed worked just fine when she pressed the down button on the remote as the bed went all the way to the floor that same day. RN C said she called the doctor and family member to report the fall. RN C said it took a little while for doctor to get back and he ordered an x-ray which was done later in the day and it was positive non-displaced fracture. During an interview on 01/24/24 at 03:24 PM CNA A said Resident #34's bed was actually working that day, 01/11/24, and she just had not lower it all the way down. CNA A said she had gotten nervous and did not recall how the incident actually all occurred. During a telephone interview on 01/25/24 at 11:32 AM Resident #34's doctor said the resident's osteopenia (a condition in which bone mineral density is low) diagnosis could have contributed to the fracture even if the bed was in a low position. The doctor said he was aware of the fall and that corrective measures had been put into place. Record review of the maintenance log dated 01/11/24 indicated in part: Date 1/11. Room/Location Resident #34 bed in 14A. What needs to be repaired Resident #34's bed won't go in low position. Date\Time of repair Nothing wrong with bed works 2:30pm. During an interview on 01/25/24 at 12:46 PM the Maintenance Supervisor was asked about the maintenance log report where it indicated about Resident #34's bed no going to low position on 01/11/24. He said he had checked the bed and remote and that it was working fine when he checked it and did not need any repairs. During an interview on 01/25/24 at 03:12 PM the Administrator was made aware of how Resident #34's bed not being on lowest position due to staff not lowering it all the way down could have contributed to the resident sustaining a fracture. The Administrator said it was her expectations for staff to report any issue with beds not working properly right away to prevent falls. Record Review of the facility's policy titled, Fall prevention program dated 07/20/21 indicated in part: All residents will be assessed for the risk of falls at the time of admissions on a quarterly basis and upon significant change in condition thereafter. Based on the results of this assessments, specific interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. A fall can be defined as when a resident is found on the floor, a resident slide to the floor unassisted, a resident rolls off the bed/chair onto the floor including bedside mat. The following is a list of commonly used interventions that may be considered to minimize falls and injury - Resident room is maintained clutter free, bed maintained in low position with bedside mat.

Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure that non-potable water was properly labeled and stored in the kitchen. The facility failed to ensure that cleaning supplies were stored separately from food in the kitchen. These failures could affect residents who received meals prepared meals in the kitchen at risk for food borne illness and cross-contamination. The findings included: Observation on [DATE] beginning at 11:15 AM in the kitchen revealed: - 6 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of [DATE] - 8 boxes, each containing 3 1-gallon plastic jugs of water with expiration date of [DATE] (sign on top of two of the boxes stating non-potable water do not drink; these boxes were stored on a shelf with 10 boxes, each containing 3 1-gallon plastic jugs of water that were not expired, making it very difficult to distinguish between the expired and non-expired boxes) - 2, 50-pound boxes of potatoes stored on a shelf next to a gray plastic tub containing stained wash rags and a gray plastic tub containing mop heads In an interview on [DATE] at 11:35 AM the Dietary Manager stated that she was aware of the expired water that was being stored in the dry storage room. She stated it was kept there because the dietary staff used it to wash dishes when the water heater went out or the facility water had to be turned off for any reason. She stated that the reason the expired water and the non-expired water were stored together was a lack of storage space. Dietary Manager stated she had placed a sign on some of the water to make sure the staff was aware that it was not for drinking and was expired. When asked why all the expired boxes of water were not labeled with a sign and stored on a single shelf, she was unable to give an answer. She stated there was very little storage space in the kitchen and they (dietary staff) had to use whatever space they could to store everything (food, supplies). When asked if there was any external storage space, she stated that corporate had told her the facility would get a storage building but there had not been a timeline given for when. In an interview on [DATE] at 11:30 AM Cook B stated that the expired water should be stored in a different area than the food because it was not for drinking. She stated that the way the water storage was set up was not good and it was confusing. Cook B stated that anybody could walk into the kitchen and grab a jug of the expired water and not know because it was not clearly marked expired or not for resident use. She stated that the sign that stated do not drink looked like it was for only two boxes, not eight, and that was confusing because the expired water and the good water were stored together. Cook B stated there were times the jugs of water were used for the residents drinking water in addition to dishwashing, and she felt not having the boxes clearly marked and separated could be a problem. She stated that storage was a problem for the kitchen, and they needed more storage space. In an interview on [DATE] at 11:47 AM the Dietary Manager stated that the reason the wash rags and mop heads were stored on a shelf with food was due to lack of storage. She stated that the cleaning supplies were kept in the restroom in the kitchen but there was not enough storage space in there for the mop heads and rags. She stated that she believed by keeping the rags and mop heads in the plastic tubs they were separated enough from the food. She stated that the rags and mop heads were clean even though they were stained. The Dietary Manager acknowledged that storing the cleaning supplies with food items was a potential cross contamination issue and the rags and mop heads should be stored elsewhere. In an interview on [DATE] at 1:57 PM the Administrator stated that she had spoken with the Dietary Manager about the findings from the kitchen inspection on [DATE] and [DATE] and was aware of the issues. The Administrator stated the cleaning supplies should never be stored with food. She stated she was unaware of exactly how the water was stored but after it was explained to her, she agreed that having the expired water stored the way it was would be confusing and was not appropriate. She stated the facility did not have adequate storage space in the kitchen and that was the cause of the failure. She stated was in the process of getting the facility a 20-foot by 20-foot storage building to help with some of the storage issues the kitchen had. The Administrator stated the facility's parent corporation was supposed to do renovations in the kitchen to improve the storage but there had been no date set for them to start. Record review of facility policy titled Food Receiving and Storage dated [DATE] revealed, in part: Foods shall be received and stored in a manner that complies with safe food handling practices. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly.

Based on observation, interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment in 1 of 2 shower rooms, and 2 of 18 resident restrooms as evidenced by: - 1 of 2 shower rooms did not have a mirror. - Two resident restrooms did not have a mirror. This failure could place the residents who use these restrooms and shower room at risk for a diminished quality of life and a homelike environment. Findings include: Observation on 01/24/24 at 04:31 PM of two resident rooms, 20 and 61, revealed it did not have mirrors in the restroom. The other rooms did have a mirror. Observation on 01/24/24 at 04:40 PM of the shower room in the locked unit revealed it did not have a mirror . The other shower room does have a mirror. Interview with DON on 01/25/24 at 12:21 pm. the DON stated he was unaware of the missing mirrors in the resident's rooms and will have this fixed. The DON Sstated the facility is about to have major updates done and will have this rectified. Interview with the Maintenance Supervisor on 01/25/24 at 01:45 PM stated he was is aware of the missing mirrors in the resident's room but is not sure since when they had been missing. He stated the facility had tried to replace the mirrors at one point but the mirror that were bought were too big to fit the space. The Maintenance Supervisor was not aware of the shower room in the locked unit not having a mirror. Interview with resident who occupied room [ROOM NUMBER] on 01/25/24 at 02:35 PM stated she has not had a mirror in her bathroom since she was admitted to the facility on [DATE]. Resident stated she would like to have a mirror in her bathroom so she can put herself together in the morning. Record review of facilities policy titled Homelike Environment revised February 2021 indicated in part: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Front medication room) of 2 medication rooms inspected for medication storage. The medication room had expired vial of Tuberculin (TB) medication in the refrigerator. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect. The findings were: During an observation and interview on 01/23/24 at 02:28 PM revealed the medication room located by the front nurses station with RN D present. The door was locked so the nurse unlocked it. There was a small refrigerator in the medication room that contained an open vial of TB solution. The TB solution box had an open date of 08/01/2023 and the manufacturer's instructions on the box indicated Discard opened product after 30 days. RN D said she was not aware that the solution had been expired. During an interview on 01/23/24 at 02:36 PM the DON was shown the TB box and he said the solution had expired and he would dispose of it. The DON said if the expired solution was used it could lead to possible contamination on the person being tested . During an interview on 01/25/24 at 02:44 PM the Administrator said she was not sure regarding the TB storage instructions as her expertise was not in clinical. The Administrator said the TB vial should be disposed after 30 days if it indicated on it. She said it was all of nursing staff's job to check the medication room for expired medications and dispose of them. The Administrator said it was ultimately the ADON and the DON to monitor the medication rooms. The Administrator said it was not her clinical expertise but she would think an adverse reaction could occur if the used an expired TB solution. Record review of policy titled Medication labeling and storage dated 02/2023 indicated in part: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Medication labeling - The medication label includes at a minimum - expiration date when applicable. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to store all drugs in locked compartments for 1 of 1 medications storage compartment. The facility failed to ensure medication carts were locked when unattended for 2 (North hall cart and the Medicare hall cart) of 4 medication carts reviewed for drug storage. The discontinued controlled medications and biologicals kept in the DON's office were not kept behind 2 separate locks at all times. The medication carts for the North and Medicare halls were unlocked and unattended by staff. These failures could place the facility at risk of drug diversion and access to medications or accidental ingestion. Findings include: During an observation on 01/23/24 at beginning 12:16 PM the Medicare hall medication cart was seen unlocked and unattended for approximately 6 minutes. Inside the medication cart were several insulin pens, pill bottles and blister packets that contained several types of medication pills. There were some residents in the areas. During an interview on 01/23/24 at 12:22 PM the DON said the medication carts were supposed to be locked when unattended. The DON was shown the unlocked and unattended medication cart. The DON called RN D who was in the dining room and she came and locked the cart. During an interview on 01/23/24 at 02:34 PM RN D said she normally locked the medication cart when she stepped away from it. The RN said she locked the cart to prevent other people from having access to the cart. The RN said if the cart was left unlocked a resident could possibly get into it and ingest some of the medications. During an observation and interview at 01/24/24 at 03:38 PM the discontinued controlled medication cabinet was inspected with the ADON present. The ADON said the discontinued medication were kept in the DON's office restroom which had a hasp and a lock on it which was already unlocked. The ADON opened the restroom door and inside was a large cabinet that contained one lock which the ADON unlocked. The ADON said the second lock was the lock that was on the restroom door which was unlocked. The ADON said the lock on the restroom door was normally locked. The ADON was made aware that the DON's office had been observed by the surveyor on a couple of occasions and the office was unattended and the restroom lock was not locked therefore the discontinued medications not kept behind 2 locks at all times. Inside the discontinued medication cabinet there were several discontinued controlled medications such as liquid morphine, clonazepam and tramadol pills. During an observation and interview at 01/24/24 at 04:30 PM RN C entered a resident's room to administer some medication and left her medication cart unlocked. While in the resident's room, RN C said she normally locked the medication cart whenever she stepped away from the cart. After RN C returned to the cart, she noticed the cart was unlocked. RN C said the reason she locked her cart was to prevent from others getting into the cart and possibly ingesting some medications, sticking themselves with syringes and also there were several insulin pens in the cart. RN C said she thought she had locked the cart before she entered the room but must have forgotten. During an interview on 01/25/24 at 02:48 PM the Administrator said if the nurse was not at the medication cart, then it should be kept locked. The Administrator said the nurse that used the medication cart was responsible for making sure the cart was locked if they were not using it. The Administrator said if the cart was left unlocked a resident could get into the cart or even an employee. The Administrator said the failure possibly occurred because the nurse forgot to lock the cart when they stepped away. During an interview on 01/25/24 at 02:52 PM the Administrator said it was her expectation for the discontinued controlled medications to be stored behind 2 locks. The Administrator said it was the DON and ADON's responsibility to make sure the medications were kept locked. The Administrator said if the medications were not kept locked it could lead to anyone having access to the medications. The Administrator said the failure occurred because one of the 2 locks had malfunctioned and it had not been replaced. The Administrator said the lock had been now replaced. Record review of policy titled Medication labeling and storage dated 02/2023 indicated in part: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartment including but not limited to drawers, cabinets, carts containing medications and biologicals are locked when not in use and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. Controlled substance (Listed as scheduled II-V of the comprehensive drug abuse prevention and control act of 1976) and other drugs subject to abuse are separately locked in permanently affixed compartments, except when using single unit package during distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Record review of policy titled Security of medication cart dated 04/2007 indicated in part: The medication cart shall be secured during medication passes. The nurse must secure the medication cart during the medication pass to prevent unauthorized entry. Medication carts must be securely locked at all times when out of the nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. Record review of policy titled Controlled substances dated 11/2022 indicated in part: The facility complies with all laws, regulations and other requirements related to handling storage disposal and documentation of controlled medications (listed as schedule II-V of the comprehensive drug abuse prevention and control act of 1976). Storing controlled substances - controlled substances are separately locked in permanently affixed compartments except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #3 and #40) of 13 residents reviewed for infection control. The facility failed to ensure CNA A changed her gloves after they became contaminated while providing incontinent care for Resident #3 and Resident #40. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Resident #3 Record review of Resident #3's admission record dated 01/25/24 indicated she was admitted to the facility on [DATE] with diagnoses which included encephalopathy (brain damage), e. coli infection (bacterial infection), UTI (bladder infection), and heart failure (heart fails to pump blood adequately). She was [AGE] years of age. Record review of Resident #3's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =Always incontinent. Bowel Continence = Always incontinent. Record review of Resident #3's care plan dated 01/04/24 indicated in part: Problem: resident has bowel/ bladder incontinence r/t Activity Intolerance, Impaired Mobility, Loss of peritoneal/bowel tone. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Clean peri-area with each incontinence episode. Check and change every 2 hours as required for incontinence. Wash, rinse, and dry perineum. Change clothing PRN after incontinence episodes. Interventions: Monitor and document for signs and symptoms of Urinary tract infection: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Record review of #3's physician orders states, Apply peri-guard external ointment between gluteal folds topically every shift related to rash. Resident #40 Record review of Resident #40's admission record dated 01/25/24 indicated she was admitted to the facility on [DATE] with diagnoses which cerebral infarction (brain damage caused by obstructed blood flow), hemiplegia (paralysis to one side of body), dementia (impairment of memory and judgment), and dysphagia (difficulty swallowing). She was [AGE] years of age. Record review of Resident #40's MDS dated [DATE] indicated in part: Bladder and Bowel: Urinary Continence =Always incontinent. Bowel Continence = Always incontinent. Record review of Resident 's care plan dated 01/16/24 indicated in part: Problem has an ADL self-care performance deficit r/t Limited Mobility, Stroke. Goal: The resident will maintain current level of function in ADL's through the review date. Interventions: Monitor/document/report PRN s/sx of complications related to constipation: Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Excessive sweating, Abdomen: tenderness, guarding, rigidity, fecal compaction. During an observation on 01/24/24 at 10:15 AM CNA A washed her hands, closed the door, pulled the curtain, and donned clean gloves. CNA A pulled the residents pants down then pulled down the front of the brief and tucked it in. CNA A wiped Resident #40's front peri area with wet wipes times 4 and doffed (removed) her gloves. CNA A donned (applied) clean gloves and assisted the resident to roll to her left side and removed the brief. CNA A wiped the residents bottom with wet wipes times 4 and doffed gloves. CNA A donned clean gloves and placed a clean brief under the resident, rolled the resident to her back and secured the brief, doffed gloves and washed her hands. During an observation on 01/24/24 at 4:45PM CNA A entered the room, closed the door, and told resident #3 about changing the brief as she positioned the resident bed to lying position. CNA A donned clean gloves, pulled the front of the brief down and folded it in. CNA A wiped the front peri area with wet wipes times 5 but stated she was soiled and continued wiping until clean. CNA stated resident has diarrhea. CNA A assisted resident to roll to the right side and hold the bar. CNA A removed the soiled brief and doffed her soiled gloves. CNA A donned clean gloves. CNA A wiped residents bottom 8 times with wet wipes until clean then applied rash ointment. CNA A doffed soiled gloves and donned clean gloves, placed the clean brief under the resident, rolled resident to her back and secured the brief. Resident positioned for comfort by CNA A then doffed gloves and washed hands. CNA A failed to wash hands or use hand sanitizer between glove changes. During an interview on 01/24/24 at 5:00 PM CNA A was asked to describe the correct steps for incontinent care. CNA A stated that she knew that she was supposed to use hand sanitizer between glove changes but did not have any, so she didn't use any. CNA A stated that the failure could cause diarrhea to spread to other residents. During an interview on 01/25/24 at 1:20PM Lead CNA stated that she trains all new staff. Lead CNA stated that when a new CNA is hired, she shadows them for a few days. Lead CNA stated that she performs random audits about every 3 months. Lead CNA stated that the correct procedure is to wipe with 1 wet wipe and throw it away, wipe with the 2nd wet wipe and throw it away, then wipe with the 3rd wet wipe and throw it away. Then doff gloves and hand sanitize and don clean gloves. Turn the resident, wipe with 1 wet wipe and throw it away, wipe with 2nd wet wipe and throw away, to wipe with 3rd wet wipe and throw it away. Then doff gloves and hand sanitize, then don clean gloves. Place clean brief, secure the brief, and dress resident, make them comfortable. It is the expectation that staff washes hands or uses hand sanitizer between glove changes. During an interview on 01/25/24 at 11:42 AM the ADON stated that it is the facility expectation that staff uses hand sanitizer or washes hands between glove changes during incontinent care. The ADON stated that she does all training for nursing staff and lead CNA performs training for CNA staff. Record review of the facility's policy titled Personal protective equipment-gloves revised July 2009 indicated in part: Policy statement: Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. Wash your hands after removing gloves. Record review of the facility's competency check off titled Infection control Pericare-Incontinent Care and revised January 2023 indicated in part: Wash hand and apply gloves and remove brief. Wash hands and dry thoroughly. Apply gloves. a. Wet washcloth/cleaning wipe and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. c. Ask resident to turn on her side with top leg bent. d. Rinse wash cloth / new cleansing wipe and apply soap or skin cleansing agent. e. Wash rectal area thoroughly, wiping from the base of labia towards buttocks. f. Rinse and dry thoroughly. Wash hands, dry thoroughly, sanitize and apply gloves when going from dirty to clean. Apply thin layer of skin barrier and replace clean brief. Wash hands and dry thoroughly.

Based on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food sanitation and storage, in that: 1. The facility failed to ensure that foods in the dry goods storage are dated and labeled properly. 2. The facility failed to ensure items in the freezer were sealed properly. 3. The facility failed to maintain cleanliness to the dry good storage room floor. These failures could affect residents by placing them at risk of food borne illness. Findings include: Observation and interview on 07/17/2023 at 3:40 p.m., with the Dietary Manager (DM) revealed the in the dry storage area there was an unlabeled, undated loosely sealed bag of bread out of the original package sitting on a dry good shelf. The DM picked up the bag and said the bread should not have been left there because it was not properly sealed and dated. Observation of dry storage area revealed two dead roaches under the food shelf racks. The freezer revealed a large metal tray container with exposed mixed veggies that was not fully covered with aluminum foil; and a bag of fried okra dated 7/7/23 was not properly sealed in a quart size Ziplock bag. The DM said t all food items should have been properly sealed in the freezer to prevent freezer burn. Observation on 07/19/2023 at 10:35 a.m., revealed a dead roach under the dry storage shelf and a dead cricket. During an interview on 07/19/2023 at 11:40 a.m., the Administrator said she expected facility food services to follow policy when it comes to ensuring food items are labeled and stored to prevent any foodborne illness. The Administrator stated the building was older and there was a problem with pest when she took over on 4/1/2023. The Administrator said pest control was coming weekly at first and now are visiting bi-weekly or anytime an issue arises. The Administrator said kitchen staff are responsible for ensuring the kitchen and storage areas of the kitchen are clean including the floors. Review of facility policy Food Receiving and Storage dated October 2022, reads in part foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). All food stored in the refrigerator or freezer will be covered, labeled, and dated (use by date).

Based on interview and record review, the facility failed to ensure that the resident was free from neglect for 1 of 3 residents (Resident #1) reviewed for neglect. 1. The facility failed to implement new wound treatment orders and provide wound care to Resident #1's unstageable pressure ulcer to her right hip which had deteriorated to stage 4. Additionally, Resident #1 developed 3 other wounds in the following areas: a) Stage 3 right internal aspect upper thigh b) Unstageable left hip c) Unstageable right posterior aspect of lower thigh d) Unstageable left gluteal region. 2. The facility failed to ensure these multiple wounds on Resident #1 were identified, assessed, and treatment was provided to promote healing. 3. The facility failed to inform the physician of the Resident #1 pressure ulcers or obtained required orders to treat the resident's wounds. 4. The facility failed to document that Resident #1 had a pressure ulcer. An Immediate Jeopardy (IJ) was identified on 10/14/21. While the IJ was lowered on 10/15/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. The failure could affect residents by placing them at risk of abuse or neglect not being investigated and protective measures put in place to prevent further abuse/neglect Findings included: Resident #1 was still in the hospital at the time of this investigation because she was lethargic and refused to eat. On 10/14/21 at 9:15a.m, surveyor attempted to go and see Resident #2. Surveyor was denied access because Resident #1 was on Covid-19 protocol in the hospital. The admission observation report dated 09/11/21 reflected the following: Skin: Skin temperature: warm Skin moisture: dry Skin color: Jaundiced Petechiae present: no Skin turgor: NORMAL Alterations in Skin? NO. Review of Resident #1's physician orders revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment, undated revealed the resident was always continent of bowel/bladder and required limited assistance with most ADLs and transfer. The assessment reflected the resident was not at risk of developing pressure ulcer and had no pressure ulcers at the time of the assessment. The resident's BIMS score was 13 indicating intact cognition. Review of Resident #1's care plan dated 9/10/21 (when surveyor requested it) revealed the problem of pressure ulcer prevention was addressed with a goal to prevent/heal pressure sores and skin breakdown. Interventions included follow facility skin care protocol, preventative measures, report to charge nurse any redness or skin breakdown immediately and treat as ordered. The admission report revealed the facility did not know Resident #1 had pressure ulcers. Review of the facility wound management section used by the facility on the electronic record revealed it was blank. There was no information documented. Review of Resident #1's clinical records revealed there was no documented assessment of the wounds on 9/10/21 (admitted ). Review of Resident #1's current Braden Scale (predicts risk for pressure ulcer development) dated 10/01/21, 21 days after admission (admitted [DATE]) reflected a score of 16, indicating the resident was at a mild risk for the development of pressure ulcers. Review of Resident #1's nursing nurse's notes dated 09/11/21 (a day after Resident #1 was admitted ) did not indicate she had pressure ulcers. However, hospital transfer orders reflected an unstageable pressure ulcer on the right hip. The assessment did not reflect any description of the pressure ulcers to include color, measurement, or other characteristics. Review of the resident's clinical records revealed there was no documented assessment of the pressure ulcers on admission. In an interview with CNAA on 10/14/21 at 11:39a.m., she stated she provided care for Resident #1 on 10/09/21 and 10/10/21 as reflected in the facility's schedule. CNAA explained she was familiar and took care of Resident #1. She said the resident required limited assistance with most ADLs on admission. She had 1 wound on right hip on admission but developed others in the facility because she was picking on herself. CNAA explained Resident #1 cusses' aides out, was rude and not nice. She noted she refuses care sometimes. CNAA was asked who she told of Resident #1 wounds. She said everybody knew including the charge nurses and DON. During interview with CNAB on 10/14/21 at 2:15p.m, she said she took care of Resident #1 as reflected on the schedule dated 10/09/21and 10/10/21. She explained the resident almost always refuses shower because of pain. She said Resident #1 was moving around by self after admission but started declining. She was picking and scratching herself. She noted Resident #1 had multiple wounds with 2 major ones on the left leg and right hip. CNAB stated it was the facility protocol to report skin breakdown to the charge nurses. She said Resident #1 had the wounds for a long time and the nurses were aware of the multiple wounds. CNAB was asked if she documented skin condition after taking her a bath. She said she remembered the first time she took resident a bath and saw the wounds. She notified an agency nurse that was on duty. She cannot remember the name. They have a bath sheet that is mark done if the resident received shower and refused if they did not. Interview with CNAC on 10/15/21 at 11:39a.m revealed she took care of Resident #1 on 10/11/21 and 10/12/21 (day resident was transferred to the hospital). She explained Resident #1 required limited assistance when she was admitted . Resident #1 got worse scratching and picking at herself. She said the resident often refuses care including taking a shower because she was in pain most of the time. CNAC said she took the resident a bath on 10/12/21 (the day she went to the hospital. She noted resident multiple wounds with a big one on right hip. She could not exactly remember how many wounds. She notified the charge nurse of the different wounds. When asked which nurse, she said it was LVN D. CNAC said she did not document the Resident #1 condition. In an interview with LVND on 10/14/21 at 10:11a.m, she said she took care of Resident #1 on 10/11/21 and 10/12/21 (day she was transferred to the hospital). She was an agency nurse and did not work for the facility. She stated she was aware Resident #1 had multiple wounds. LVND said when she came on 10/12/21, the resident was not in good condition. She was jaundice (yellow in color), dry lips and could not get her to eat. Resident #1 was lethargic. She called the doctor and received an order to send Resident #1 to the hospital. LVND explained Resident #1 had multiple wounds which she dressed during the shifts. She was asked how she was able to provide Resident #1 wound care without physician orders or treatment notes? She said she received the information from the outgoing nurse. LVND was asked if she documented the treatment, she answered no. Review of Resident #1 clinical records did not show doctor's orders or wound treatment provided to Resident #1. During interview with LVNE on 10/15/21 at 11:08a.m, she was an agency nurse that took care of Resident #1 on 10/09/21. LVNE explained Resident #1 had multiple pressure ulcers which was in bad shape. She said it appears the resident has had the wound a long time. She provided wound care to Resident #1 one time. LVNE was asked how did she know what to use to provide wound care without physician orders or treatment notes? She said she received verbal report from RN F and what the facility was using to dress the wounds. She was asked how many wounds did the Resident #1 have? LVNE stated she did not know and failed to document her treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RNF on 10/15/21 at 1:44 p.m revealed she has been working for the facility for 5 years. Presently she works every other weekend. RNF said she was responsible and took care of Resident #1 on weekends. She explained Resident #1 had one pressure ulcers that she was aware until last week when she saw her, at which time Resident #1 had more wounds. When she asked CNAA, she said Resident #1 had always had the wounds. RNF proceeded to dress the wound. She was asked if she called the doctor when she discovered the new pressure ulcer. She said she did not. RHF stated she used facility standing wound treatment order. RNF was asked if she documented the multiple wounds and her treatment. She said she did not. RNF was asked to descript the facility protocol on admission of a resident. She explained on admission, the charge nurse looks at discharge information. The resident is assessed including detailed skin observations. The wound or pressure ulcers are documented. The charge nurse will call the doctor and received treatment instructions. He/she will follow the doctor's order. RNF acknowledged the facility protocol was not followed for Resident #1 care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview with DON on 10/15/21 at 10:42a.m she acknowledged the following on the care or lack thereof of Resident #1 1) She assessed the resident on admission 2) Stated the resident skin was assessed as normal 3) No documentation of Resident #1 weekly skin assessments 4) No physician orders for the pressure ulcer 5) No documentation of wound treatment provided to Resident #1 over 21 days after admission 6) Facility wound management section was blank for Resident #1 7) Staffs did not follow the facility policy in providing the necessary care and services to Resident #1 particularly pressure ulcer care 8) The physician was not aware of Resident #1's pressure ulcer until he was notified on 10/11/21 that Resident #1 pressure ulcer may be infected. He ordered an antibiotic treatment with [MEDICATION(S)] 9) She failed to train agency nurses on the facility policy on wound care and documentation 10) No documentation of first transfer to the hospital on 9/14/21 and return on 9/16/21 The DON explained Resident #1 did not let her look to complete assessment on admission day. She said she takes responsible for failure to document the resident assessment. The DON stated the facility was short of nurses and she had to do many tasks by herself. She was meant to train agency nurses but did not have time to do so. The DON said it was unfortunate that the agency nurses did not document as well. She was asked why there was no assessment after Resident #1 transfer to the hospital on 2 separate occasion. The DON said the facility just didn't. She stated, I dropped the ball. She noted there no physician orders to provide the necessary care and services to Resident #1. During interview with Physician Y on 10/14/21 at 2:25p.m, he said he was the primary for Resident #1. He explained he was not aware the resident had pressure ulcers. He knows Resident #1 had lots of itching. Physician Y said he was informed on 10/11/2021 that the resident pressure ulcers may be infected. He ordered an antibiotic treatment with [MEDICATION(S)]. The next day he gave order to transfer Resident #1 to the hospital due changes in her condition. Review of the facility abuse/neglect policy revised July 2017 reflected, All reports of resident abuse, neglect , exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will be also reported. Role of the Administrator: 1) If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual . 2) The Administrator will ensure that any further potential abuse, neglect, exploitation or mistreatment is prevented . Review of the facility policy on pressure ulcers/skin breakdown-clinical protocol revised April 2018 reflected the following: 1) The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2) In addition, the nurse shall describe and document/report the following: a) Full assessment of pressure sore including location, stage, length, width and depth, presence of exu-dates or necrotic tissue: b) Pain assessment c) Resident mobility status d) Current treatments, including support surfaces: and e) All active diagnoses 3) The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin condition. 4) The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5) The physician will help identify and define any complications related to pressure ulcers. Review of the facility policy on wound care revised October 2010 reflected, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1) Verify that there is a physician's order for this procedure. 2) Review the resident's care plan to assess for any special needs of the resident a) For example, the resident may have PRN orders for pain medication to be administered prior to wound care 3) Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc. with alcohol pleget before opening, as necessary. (Note: This may be performed at the treatment cart.). An Immediate Jeopardy (IJ) was identified, and the Administrator was informed, on 10/14/21 at 6:02 p.m. IJ template was provided to the Administrator at that time. The Facility's Plan of Removal was accepted on 10/15/21 at 12:25 a.m. and reflected the following: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on October 14, 2021 for neglecting to provide treatment and services to prevent the development and worsening of pressure ulcers. 1. Action: To ensure identification of pressure sores, center licensed nursing staff conducted and documented a head-to-toe skin inspection of all center residents. If a new skin alteration is noted during skin inspection, the attending physician will be notified to obtain treatment orders as indicated and a change of care plan will be initiated. Actual skin alternation and potential risk factors will be care planned to meet individual resident needs. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Licensed Nurses 2. Action: Nursing Administration to conduct education with licensed nursing staff regarding: 1) Notification of attending physician upon identification of resident change in condition to include skin alterations noted during admission/weekly skin inspections; and 2) Inspection and documentation of resident head-to-toe skin inspection upon admission and weekly thereafter. Beginning October 15, 2021, licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Regional Nursing Manager, Director of Nursing 3. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change to skin. Beginning October 15, 2021, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning October 14, 2021 and ending October 16, 2021. Responsible: Regional Nursing Manager, Director of Nursing 4. Nursing Administration began auditing the electronic medical record of each resident to ensure weekly skin checks are scheduled to be performed by a licensed nurse. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Regional Nursing Manager, Director of Nursing 5. Action: Beginning on October 15, 2021 and for the next 30 days, the Director of Nursing will utilize the Daily Clinical Meeting Process to validate charge nurse compliance with inspection, notification, and documentation of resident skin checks which are to be conducted upon admission and weekly thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Administrator, Director of Nursing Attachments- Daily Clinical Meeting Process To verify the facility implemented their plan of removal, the following observations, interviews and record review were conducted. Observations of 2 residents with pressure ulcers revealed they were correctly assessed for skin pressure ulcers/breakdown. Interviews conducted with 7 LVNs (LVND, LVN E, LVNG, LVNH, LVNK, LVNJ, LVNL) and 1 RN (RNF) across multiple shifts on 10/15/21 from 11:32 p.m. to 1:22 p.m. revealed the nurses verbalized comprehension of the in- service training. They stated they had been in-serviced on the facility's policy/procedure to include completing a full skin assessment on admission and weekly thereafter. The physician will be immediately notified of any skin alterations and obtain treatment orders. Weekly skin assessments were to be entered into the computer on admission and weekly skin assessments were now to be done by the charge nurses. The Director of nursing will use the clinical meeting process to validate charge nurse for compliance. Interviews conducted with 6 CNAs (CNAA, CNAB, CNAC, CNAM, CNAO, CNAP) across multiple shifts on 10/15/21 from 11:32a.m. to 1:32 p.m. revealed the CNAs verbalized comprehension of the in-service training. They stated they had received in-service training regarding monitoring skin every shift and entering observations in the resident's activity of daily living section. They stated they had been in-serviced on reporting any skin issues on the residents. The Administrator was notified on 10/15/21 at 11:26 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 10/15/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of Isolated because the facility was still monitoring their plan of removal.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of three residents reviewed for pressure ulcers. 1. The facility failed to implement new wound treatment orders and provide wound care to Resident #1's unstageable pressure ulcer to her right hip which had deteriorated to stage 4. Additionally, Resident #1 developed 3 other wounds in the following areas: a) Stage 3 right internal aspect upper thigh b) Unstageable left hip c) Unstageable right posterior aspect of lower thigh d) Unstageable left gluteal region. 2. The facility failed to ensure these multiple wounds on Resident #1 were identified, assessed, and treatment was provided to promote healing. 3. The facility failed to inform the physician of the Resident #1 pressure ulcers or obtained required orders to treat the resident's wounds. 4. The facility failed to document that Resident #1 had a pressure ulcer. An Immediate Jeopardy (IJ) was identified on 10/14/21. While the IJ was lowered on 10/15/21, the facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of a potentially life-threatening infection, including [CONDITION(S)] which could manifest into other health complications, pain, worsening pressure ulcers and a decreased quality of life. Findings included: Resident #1 was still in the hospital at the time of this investigation because she was lethargic and refused to eat. On 10/14/21 at 9:15a.m, surveyor attempted to go and see Resident #1. Surveyor was denied access because Resident #1 was Covid-19 protocol at the hospital. Review of Resident #1's admission observation report dated 09/11/21 reflected the following: Skin: Skin temperature: warm Skin moisture: dry Skin color: Jaundiced Petechiae (Small wound) present: no Skin turgor: NORMAL Alterations in Skin? NO. Review of Resident #1's physician orders dated 10/06/21revealed the resident was a [AGE] year old female admitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission MDS assessment undated received revealed the resident was always continent of bowel/bladder and required limited assistance with most ADLs and transfer. The assessment reflected the resident was not at risk of developing pressure ulcer and had no pressure ulcers at the time of the assessment. The resident's BIMS score was 13 indicating intact cognition. Review of Resident #1's care plan undated revealed the problem of pressure ulcer prevention was addressed with a goal to prevent/heal pressure sores and skin breakdown. Interventions included follow facility skin care protocol, preventative measures, report to charge nurse any redness or skin breakdown immediately and treat as ordered. The admission report revealed the facility did not document that Resident #1 had pressure ulcers. Review of the facility wound management section used by the facility on the electronic record revealed it was blank. There was no information documented. Review of Resident #1's clinical records revealed there was no documented assessment of the wounds on 9/10/21 (admitted ). Review of Resident #1's current Braden Scale (predicts risk for pressure ulcer development) dated 10/01/21, 21 days after admission (admitted [DATE]) reflected a score of 16, indicating the resident was at a mild risk for the development of pressure ulcers. Review of Resident #1's nursing nurse's notes dated 09/11/21 (a day after Resident #1 was admitted ) did not indicate she had pressure ulcers. However, hospital transfer orders dated 09/10/21 reflected an unstageable pressure ulcer on the right hip. The assessment did not reflect any description of the pressure ulcers to include color, measurement, or other characteristics. In an interview with CNAA on 10/14/21 at 11:39a.m., she stated she provided care for Resident #1 on 10/09/21 and 10/10/21 as reflected in the facility's schedule. CNAA explained she was familiar and took care of Resident #1. She said the resident required limited assistance with most ADLs on admission. She had 1 wound on right hip on admission but developed others in the facility because she was picking on herself. CNAA explained Resident #1 cusses' aides out, was rude and not nice. She noted she refuses care sometimes. CNAA was asked who she notified of Resident #1 wounds. She said everybody knew including the charge nurses and DON. During interview with CNAB on 10/14/21 at 2:15p.m, she stated she took care of Resident #1 as reflected on the schedule dated 10/09/21 and 10/10/21. She stated the resident almost always refuses showers because of pain. She said Resident #1 was moving around by self after admission but started declining. She was picking and scratching herself. She noted Resident #1 had multiple wounds with 2 major ones on the left leg and right hip. CNAB stated it was the facility protocol to report skin breakdown to the charge nurses. She said Resident #1 had the wounds for a long time and the nurses were aware of the multiple wounds. CNAB was asked if she documented skin condition after taking her a bath. She said she remembered the first time she assisted resident with a bath and saw the wounds. She notified an agency nurse that was on duty. She cannot remember the nurses name. They have a bath sheet that is marked done if the resident received shower and refused if they did not. Interview with CNAC on 10/15/21 at 11:39a.m she stated she took care of Resident #1 on 10/11/21 and 10/12/21 (day resident was transferred to the hospital). She explained Resident #1 required limited assistance when she was admitted . Resident #1 got worse scratching and picking at herself. She said the resident often refuses care including taking a shower because she was in pain most of the time. CNAC said she assisted Resident #1 with a bath on 10/12/21 (the day she went to the hospital). She noted resident had multiple wounds with a big one on right hip. She could not exactly remember how many wounds. She notified the charge nurse of the different wounds. When asked which nurse, she said it was LVN D. CNAC said she did not document Resident #1's condition. In an interview with LVND on 10/14/21 at 10:11a.m, she stated she took care of Resident #1 on 10/11/21 and 10/12/21 (day she was transferred to the hospital). She was an agency nurse and did not work for the facility. She stated she was aware Resident #1 had multiple wounds. LVND said when she came on 10/12/21, the resident was not in good condition. She was jaundice (yellow in color), dry lips and could not get her to eat. Resident #1 was lethargic. She called the doctor and received an order to send Resident #1 to the hospital. LVND explained Resident #1 had multiple wounds which she dressed during the shifts. She was asked how she was able to provide Resident #1 wound care without physician orders or treatment notes? She said she received the information from the outgoing nurse. LVND was asked if she documented the treatment, she answered no. Review of Resident #1 clinical records did not show doctor's orders or wound treatment provided to Resident #1. During interview with LVNE on 10/15/21 at 11:08a.m, she stated she was an agency nurse that took care of Resident #1 on 10/09/21. LVNE explained Resident #1 had multiple pressure ulcers which were in bad shape. She said it appeared the resident has had the wound, a long time. She provided wound care to Resident #1 one time. LVNE was asked how did she know what to use to provide wound care without physician orders or treatment notes? She said she received verbal report from RNF and what the facility was using to dress the wounds. She was asked how many wounds did the Resident #1 have? LVNE stated she did not know and failed to document her treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RNF on 10/15/21 at 1:44p.m revealed she has been working for the facility for 5 years. Presently she works every other weekend. RNF said she was responsible and took care of Resident #1 on weekends. She explained Resident #1 had one pressure ulcers that she was aware until last week when she saw her, at which time Resident #1 had more wounds When she asked CNAA, she said Resident #1 had always had the wounds. RNF proceeded to dress the wound. She was asked if she called the doctor when she discovered the new pressure ulcer. She said she did not. RHF stated she used facility standing wound treatment order. RNF was asked if she documented the multiple wounds and her treatment. She said she did not. RNF was asked to describe the facility protocol on admission of a resident. She explained on admission, the charge nurse looks at discharge information. The resident is assessed including detailed skin observations. The wound or pressure ulcers are documented. The charge nurse will call the doctor and received treatment instructions. He/she will follow the doctor's order. RNF acknowledged the facility protocol was not followed for Resident #1 care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of hospital record dated 10/14/21 revealed the pressure ulcers developed from 1 on admission to 4. During interview with DON on 10/15/21 at 10:42a.m she acknowledged the following on the care or lack thereof of Resident #1 1) She assessed the resident on admission 2) Stated the resident skin was assessed as normal 3) No documentation of Resident #1 weekly skin assessments 4) No physician orders for the pressure ulcer 5) No documentation of wound treatment provided to Resident #1 over 21 days after admission. 6) Facility wound management section was blank for Resident #1 7) Staffs did not follow the facility policy in providing the necessary care and services to Resident #1 particularly pressure ulcer care. 8) The physician was not aware of Resident #1's pressure ulcer until he was notified on 10/11/21 that Resident #1 pressure ulcer may be infected. He ordered an antibiotic treatment with [MEDICATION(S)]. 9) She failed to train agency nurses on the facility policy on wound care and documentation 10) No documentation of first transfer to the hospital on 9/14/21 and return on 9/16/21 The DON explained Resident #1 did not let her look to complete assessment on admission day. She said she takes responsible for failure to document the resident assessment. The DON stated the facility was short of nurses and she had to do many tasks by herself. She had meant to train agency nurses but did not have time to do so. The DON said it was unfortunate that the agency nurses did not document as well. She was asked why there was no assessment after Resident #1 transfer to the hospital on 2 separate occasion. The DON said the facility just didn't. She stated, I dropped the ball. She noted there no physician orders to provide the necessary care and services to Resident #1. During interview with Physician Y on 10/14/21 at 2:25p.m, he said he was the primary for Resident #1. He explained he was not aware the resident had pressure ulcers. He knows Resident #1 had lots of itching. Physician Y said he was informed on 10/11/21 that the resident pressure ulcers may be infected. He ordered an antibiotic treatment with [MEDICATION(S)] on 10/11/21. The next day on 10/12/21 he gave order to transfer Resident #1 to the hospital due being lethargic and refusing to eat. An Immediate Jeopardy (IJ) was identified on 10/14/21 at 6:02 p.m. The administrator was notified on 10/14/21 at 6:02pm of the IJ. The plan of removal was requested at that time and IJ template was provided to the Administrator. The Facility's Plan of Removal was accepted on 10/15/21 at 12:25 a.m. and reflected the following: Plan of Removal Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on October 14, 2021 for neglecting to provide treatment and services to prevent the development and worsening of pressure ulcers. 1. Action: To ensure identification of pressure sores, center licensed nursing staff conducted and documented a head-to-toe skin inspection of all center residents. If a new skin alteration is noted during skin inspection, the attending physician will be notified to obtain treatment orders as indicated and a change of care plan will be initiated. Actual skin alternation and potential risk factors will be care planned to meet individual resident needs. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Licensed Nurses 2. Action: Nursing Administration to conduct education with licensed nursing staff regarding: 1) Notification of attending physician upon identification of resident change in condition to include skin alterations noted during admission/weekly skin inspections; and 2) Inspection and documentation of resident head-to-toe skin inspection upon admission and weekly thereafter. Beginning October 15, 2021, licensed nurses (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Regional Nursing Manager, Director of Nursing 3. Action: Nursing Administration to conduct education with certified/temporary nursing assistants regarding notification of charge nurse upon identification of resident change to skin. Beginning October 15, 2021, certified/temporary nursing assistants (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Completion Timeline: Beginning October 14, 2021 and ending October 16, 2021. Responsible: Regional Nursing Manager, Director of Nursing 4. Nursing Administration began auditing the electronic medical record of each resident to ensure weekly skin checks are scheduled to be performed by a licensed nurse. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Regional Nursing Manager, Director of Nursing 5. Action: Beginning on October 15, 2021 and for the next 30 days, the Director of Nursing will utilize the Daily Clinical Meeting Process to validate charge nurse compliance with inspection, notification, and documentation of resident skin checks which are to be conducted upon admission and weekly thereafter. QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Completion Timeline: Beginning October 14, 2021 and ending October 15, 2021. Responsible: Administrator, Director of Nursing Attachments- Daily Clinical Meeting Process Review of the facility policy on pressure ulcers/skin breakdown-clinical protocol revised April 2018 reflected the following: 1) The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and history of pressure ulcer(s). 2) In addition, the nurse shall describe and document/report the following: a) Full assessment of pressure sore including location, stage, length, width and depth, presence of exu-dates or necrotic tissue: b) Pain assessment c) Resident mobility status d) Current treatments, including support surfaces: and e) All active diagnoses 3) The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin condition. 4) The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5) The physician will help identify and define any complications related to pressure ulcers. Review of the facility policy on wound care revised October 2010 reflected, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1) Verify that there is a physician's order for this procedure. 2) Review the resident's care plan to assess for any special needs of the resident a) For example, the resident may have PRN orders for pain medication to be administered prior to wound care 3) Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. Wipe nozzles, foil packets, bottle tops, etc. with alcohol pleget before opening, as necessary. (Note: This may be performed at the treatment cart.). To verify the facility implemented their plan of removal, the following observations, interviews and record review were conducted. Observations of 2 residents with pressure ulcers revealed they were correctly assessed for skin pressure ulcers/breakdown. Interviews conducted with 7 LVNs (LVND, LVN E, LVNG, LVNH, LVNK, LVNJ, LVNL) and 1 RN (RNF) across multiple shifts on 10/15/21 from 11:32 p.m. to 1:22 p.m. revealed the nurses verbalized comprehension of the in- service training. They stated they had been in-serviced on the facility's policy/procedure to include completing a full skin assessment on admission and weekly thereafter. The physician will be immediately notified of any skin alterations and obtain treatment orders. Weekly skin assessments were to be entered into the computer on admission and weekly skin assessments were now to be done by the charge nurses. The Director of nursing will use the clinical meeting process to validate charge nurse for compliance. Interviews conducted with 6 CNAs (CNAA, CNAB, CNAC, CNAM, CNAO, CNAP) across multiple shifts on 10/15/21 from 11:32a.m. to 1:32 p.m. revealed the CNAs verbalized comprehension of the in-service training. They stated they had received in-service training regarding monitoring skin every shift and entering observations in the resident's activity of daily living section. They stated they had been in-serviced on reporting any skin issues on the residents. The Administrator was notified on 10/15/21 at 11:26 p.m. that the Immediate Jeopardy was removed. While the IJ was removed on 10/15/21, the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy and a scope of Isolated because the facility was still monitoring their plan of removal.

Based on observations, interviews and record reviews, the facility failed to provide adequate supervision to prevent accidents for 5 of 5 residents (Resident #2, #4, #5, #6 and #7) reviewed for accidents. A. Resident #2 was not properly loaded into the van by Driver A who was using the lift; as a result of being improperly loaded, Resident #2 fell from her wheelchair landing on the van floor. Resident #2 sustained a C2 fracture in her neck related to the fall. B. Resident #4, #5, #6, and #7 were also improperly loaded into the van due to the facility's failing to ensure that an owner's manual was available that included instructions for safe loading and operation of the lift and that visible loading safety instructions inside the van were followed when loading residents. This facility failure resulted in harm to Resident #2 and could place an additional 30 residents that are loaded into the van by the lift at risk for falls and fatal injuries. The findings included: Resident #2 Record review of Resident #2's Physician order [REDACTED]., Mild Cognitive Impairment, Chronic Pain, and Essential (Primary) Hypertension. Review of her clinical record revealed she discharged on [DATE]. Record review of Resident #2's admission MDS 3.0, dated 12/27/2016, revealed she was unable to complete the Brief Interview for Mental Status Exam. Resident #2 was rarely/never understood. She needed two people physically assisting her with extensive assistance in order to transfer. For locomotion off the unit she needed one person physical assist an extensive assistance. She had impairment on both sides of her lower extremity. The mobility device that was checked was a wheelchair. Record review of Resident #2's care plan, created 1/25/17, indicated she was at risk for injury from tremors and involuntary movements as I have Parkinson's disease. She was at risk for falls, dated 1/25/17, due to: HTN (Hypertension}. Parkinson's disease and Muscle Weakness. She also had Cognitive Loss/Dementia, dated 1/25/17, which affected her decision making skills related to Alzheimer's disease. She needed total assistance with two staff members for transfers. Record review of Resident #2's care plan, date reviewed 3/7/17, under Problems/Needs revealed the following I have multiple problems that all affect my ability to walk. I have hx of and/or the potential to fall. It indicated she had fall in the van related to placing her feet down, falling forward while pushing resident in van, and the son was present. For approaches it said I need the nurses to: Assess me upon return sent to ER- FX to neck .History of FX to neck .XRAY results show no hardware in place .Did not return- family transferred. The care plan indicated a re-enactment was performed, and an investigation was done by the facility. Record review of Resident #2's incident report, dated 3/7/17, revealed an incident witnessed by Driver A at 10:00 a.m. The resident was being loaded via lift in van put legs under her w/c (wheelchair) when transport aide was pushing her w/c forward causing resd (resident) to fall forward into van resd c/o (complains of) neck pain transported to(Hospital B ER). The resident sustained [REDACTED]. The physician was notified, and the representative Family Member A was with Resident #2 at the time. RVP A and the Administrator signed the incident report on 3/17/17. On the incident investigation, it listed interventions in place to prevent incident: Equipment check and no issues noted. It indicated resident has osteoporosis. It stated the resident's cognitive status when the incident occurred was confused/disoriented and her judgment was impaired. On the incident report, dated 3/7/17, it revealed Resident family chose to transfer to another facility .Facility Adm (Administrator) called family to explain incident, son was present @ the time .No intentional harm from CNA. For the Clinical Assessment of Occurrence: 3/7/17 in reviewing x-ray findings there is Hx of injury to the neck AEB (as evidenced by) there is anterior plate et screw fixation C3-C4 without apparent hardware location. Re-inactment (re-enactment) with C.N.A. on occurrence- ruled out neglect AEB belt was on the resident @ the time of transfer, CNA transferred appropriately resident feet under the w/c which caused resident to fall forward. Record review of Resident #2's nursing note, dated 3/7/17, at 10:00 a.m. revealed the transport aide called the facility reported that resd had put feet under w/c when transport aide trying to load her into van et (and) fell forward this nurse instructed transport aide to call 911 et (and) get resd checked out d/t (due to) c/o neck pain. Record review of Resident #2's nursing note, dated 3/7/17, at 1:00 p.m. revealed that the nurse called Hospital B's ER (emergency room ) and Resident #2 was being transferred to Hospital A. Record review of Resident #2's Imaging Report from Hospital B, dated 3/7/17, revealed she had a nondisplaced type III odontoid fracture of the Cervical Spine. There is a nondisplaced type II odontoid fracture extending into the lateral masses of C2 bilaterally. There is an anterior plate and screw fixation device at the C3-4 level without apparent hardware location. There is degenerative disc disease at C6-7. Record review of Resident #2's clinical records retrieved from Hospital A, dated 3/20/17, revealed the following: after fall at standing level she was found to have a C2 fracture she was placed in collar . DATE OF ADMISSION: 3/7/17 The patient was trying to get from a wheelchair into a van and then her wheelchair was lifted .she fell forward into the van and she hit her head .She started to have excruciating pain right away .She was airlifted to our hospital for a higher level of care .The patient also injured her neck, right shoulder, right knee, and left shoulder. Past Surgical History: Back Surgery, carpal tunnel surgery, neck surgery, foot surgery, hernia repair, bilateral knee replacements, right tibia surgery after a fall . IMAGING STUDIES: Show apparent C2 type 3 dens fracture. Record review of Resident #2's Hospital A's Radiology Report, dated 3/8/17, revealed C2 fracture in collar .the fracture fragments of C2 are aligned .Anterior plate and screws transfix c3 and c4. C4, C5, and C6 are fused. According to the U.S. National Library of Medicine, the C2 is located on the spinal cord in the neck. The spinal cord is the main pathway of communication between the brain and the rest of the body. It is a long, fragile, tube like structure that extends downward from the base of the brain. It is the second vertebrae in the cervical spine, if damage occurs to this area it could potentially cause paralysis of some muscles used for breathing and all arm and leg muscles .Typically, fatal unless a ventilator is used. http://www.merckmanuals.com/home/brain-spinal-cord-and-nerve-disorders/spinal-cord-disorders/overview-of-spinal-cord-disorders (accessed on 4/03/17) Observation and interview on 3/24/17 at 9:35 a.m.-10:00 a.m. Driver A said that she was currently the Dietary Manager at the facility. She said she had been the van driver for the longest time at the facility. She said on 3/7/17 that Resident #2 fell inside the van on the carpet. She said that Resident #2 did have pegs or foot pedals, but that the resident would put her feet in the middle, and the pegs were more of a danger to have them on there. Driver A said she was worried about Resident #2 getting skin tears. She said Resident #2 has a bad habit of putting her feet back. She said that she was in the awning outside of the doctor's office, and she was loading her in the van forwards facing towards the van on the back lift. She said she pulled the wheelchair back, and the resident fell forward in the van. She said that Resident #2 had a skin tear on her knee, and a red mark on her face. She said the resident complained about her back hurting. She said she called 911. She said the resident's daughter called the facility. (Resident #2's son and daughter-in-law were with Driver A and Resident #2 at the time of the incident.) She said that 911 took her from the van to the hospital. She said that she and the son sat in the back of the van with the resident and talked with her waiting for the ambulance to arrive. She said Resident #2 was complaining of pain. Driver A said she has been driving the van for 7 years and has never had any issue transporting anyone. She said Resident #2 was already falling forward when she pulled the wheelchair back. The surveyor proceeded to go out to the van with Driver A, the Administrator and RNC A also came outside with the surveyor. The lift was located on the back of the van. Driver A explained that she was on the lift with Resident #2, and the son was standing to the right by the lift beside her on the ground. She said the daughter-in-law was on the other side of the lift. She demonstrated loading the resident forwards/inwards facing into the van in order to push her facing forward into the van. Driver A said that Resident #2 was already in the van when she tipped over inside the van. She said Resident #2 took her feet backwards, and she landed on the carpet of the van. RNC A and the Administrator observed this demonstration with the surveyor. Record review of Driver A's witness statement, dated 3/7/2017 at 2:19 p.m., revealed the following: I transported (Resident #2) to her Dr.'s (doctor's) appt. After the appt. (approx . (approximately) 10:00 a.m.), I pushed her out of the Dr.'s office .We got to the van, and her son was standing beside the van. She was put on the lift; the lift came up level with the van interior, both her son and I asked her to walk herself into the van. This would assist in getting her in the van. This meant she would move her feet in a walking motion while sitting in the wheelchair as she entered the van. I was going to push the chair into the van as she was walking; as I was pushing, her son said, Her Feet! At that point, her foot/feet were underneath the chair instead of in walking motion, and as I pushed the chair into the van, she went forward and fell on the floor. Her son got into the van, he was not able to assist due to back surgery. I did call 911 when it happened and I also called (ADON). She sent (maintenance) to help me. (Resident #2)'s son did ask me why we couldn't take her to the hospital since we were so close. I explained that since we did not know what her injuries were, we needed to wait for an ambulance because if I transported her, it may cause damage. She did complain about her right knee, forehead, and buttocks hurting. She complained about the right side of her neck hurting only after she had been put back into her wheelchair. We called (administrator) and call the ambulance again. The ambulance transported Resident #2 to the hospital. On the witness statement it was signed by Driver A, and included Clarification: walking- not standing, this is moving her feet in walking motion. It also indicated a reenactment was performed and witnessed by RVP A and the Administrator no facility inaction found. In an interview on 3/24/2017 at 8:22 a.m. and 8:40 a.m., the Administrator and ADON A said there had only been one issue with the facility van. They said an incident occurred with Resident #2, the she put her feet down on the ground and her legs started to go under her. Driver A was pushing her forward, and the family told her to stop. They said driver A did not see that her legs were under the wheelchair, and the resident fell forward in the van. They said Resident #2 fell to the floor board in the van. The Administrator said no one is the official van driver. He said they have drivers on the insurance, and they apply and their license has to be in good standing. He said there was no designated driver, whoever was on the insurance drives the van when needed. In an interview on 3/24/17 at 10:50 a.m. RVP A said that she closed the investigation of this incident herself. She said that they re-enacted it, and there was no defect on the lift. She said that she thought it just happened. She said she asked herself about the foot rests, but they could not get the wheelchair on the lift with the footrests. She said therapy also said Resident #2 did not utilize the footrests. She said there was nothing they could have done to prevent the incident. She said that she personally sat in the wheelchair and so did the Administrator and they could not get the footrests on there. She said she felt like they did not do anything wrong. She said that they made sure the resident was ok. She said she also had the belt on in her wheelchair, and she was secure in the chair. Observation on 3/29/17 at 8:56 a.m. and 9:05 a.m. revealed the van was a Ford Triton V8 model. The Surveyor was able to step inside the van, walk through the side by the space beside the seats and get in front of the lift. There was a sticker located on the outside of the lift visible when standing outside of the van at the bottom that said The Braun Corporation ADA since 1972 . When surveyor was inside the van multiple stickers were visible on the actual lift. There was a hole in the sticker located on the inside left lower corner of the lift that said the Model # was L Series 07 Serial 2507 cylinder 14CB, and Date 12/98. Inside the van when looking at the lift, on the right arm of the lift there was a sticker that covers approximately 1/3 of the arm in black and orange and the other half of the sticker was in green and white writing. The black and orange part of the sticker said Warning in black writing with an orange background. On a black background in white writing it revealed read manual before operating lift. Keep operator and bystanders clear of area which lift operates. Whenever a wheelchair passenger is on the platform, the: Passenger must face outward, .Wheelchair brakes must be locked, Roll stop must be up, Failure to follow these rules may result in serious bodily injury and/or property damage. Lift Operating Instructions were in white writing on a green background below on the sticker, and it revealed TO UNLOAD PASSENGER: 1. Load passenger onto platform facing outward and lock wheelchair brakes TO LOAD PASSENGER: 1. Load passenger facing outward and lock wheelchair brakes. ADON A and Surveyor looked through the van and no manual could be found. Record review of the Operator's Manual for: L200UARS Ultra Series 06 Commercial Wheelchair lifts The Braun Corporation, dated March 2002 and received from RNC A and ADON A on 3/28/17 at 10:35 a.m., revealed the following: WARNING: Read manual before operating lift. Failure to do so may result in serious bodily injury and/or property damage. Keep manual in lift storage pouch .Lift operation procedures are the same for all L200UARS Series lift models .The lift attendant should not ride on the platform with the passenger .Inboard facing of wheelchair lift passengers is not prohibited, but outboard facing passengers is recommended .Transit agency supervisors should train and educate lift attendants on the proper use and operation of the wheelchair lift if it is not possible for attendants to review the safety precautions and operation procedures with the wheelchair sales representative. This lift operator's manual must be stored in the lift-mounted manual storage pouch when not in use. In an interview on 3/28/2017 at 9:55 a.m. and 10:10 a.m. RNC A said the residents are always loaded forwards facing towards the van. She said the staff member is on the lift with them. She said Driver A can't leave the patient alone to go in and pull them into the van. She said we do not load them to pull them backwards. She said we do not have a checklist to drive the van. In an interview on 3/28/17 at 10:45 a.m. RNC A and ADON A said for training the van drivers, they read the policy, sign it and turn it in to corporate. They said the policy they are referring to was titled Securing a Wheelchair for Transportation. In an interview on 3/28/17 at 10:56 a.m. the Maintenance Director said that there was no warranty on the lift or van as they bought the van used. He said that he does not help with van transportation. In an interview on 3/28/17 at 11:05 a.m. Driver A said that either she or Driver B, her night cook, drive the van, and she said she believed another CNA also drove the van. She said I always stand on the lift with them. I don't want them to go over sideways. She said she always faces the residents forwards towards the van. She said her training was about seven years ago. She said the maintenance man at the time went over stuff with her. She said he showed her how to use the lift. She said there was not an in-service just him talking me through everything. When asked about a warranty, operator's or owner's manual she said that she has not looked over any of that related to the lift. She said she did not know who did the training for the other drivers. Surveyor showed her the manual given to her by the Administrator/RNC A, and she said she had never seen it. She said I was never told I could not stand up there, referring to standing on the lift with the resident. She said that not everyone uses the lift, and the residents that walk do not use the lift. She said she has done transports for well over 5 years. In an interview on 3/28/17 on 11:30 a.m. the Surveyor asked if ADON A or the Administrator had read through the Operator's manual that was provided to the surveyor by the facility. The Surveyor explained it said in the Operator's manual that there was to be no attendant on the lift. ADON A said she did not have anything to do with the van. They both indicated they had not read through the Operator's manual. The Administrator said that he was not signed up to use the van. He said that he had never operated the lift, and he did not know the Operator's manual said that the lift operator should not ride with the passenger. The surveyor then explained that it was recommended in the Operator's manual provided to the surveyor by the facility, that the resident face outwards away from the van. The Administrator said that he did not know how the resident could face outwards. The surveyor asked for a policy specific to the lift. In an interview on 3/28/17 at 11:30 a.m. and 11:45 am. the BOM said that only three people drive the van Driver A, Driver B, and Driver C. She said that she saw Driver A give instruction to Driver B on how to load, and instruction on the van. In an interview on 3/28/17 at 11:56 a.m. Driver C said that she had been working at the facility as a CNA for 3-4 years. She said she mainly works nights. She said that she had been driving the van for seven months. She said she does not drive the van that often. She said for her training Driver A instructed her on how to do everything. She said she was taught to ride up on the lift with the resident, put them in, and ride the lift down. She said she loads the residents facing towards the van (inwards). She said that she did not read a manual on the lift or a policy about the lift. She said there was no safety policy. She said there was no checklist. She said she took a resident out three weeks ago, but she did feel like she had enough training. In an interview on 3/28/17 at 12:25 p.m. and 12:30 p.m. the Administrator and RNC A said there was no specific policy regarding the lift. When asked about the Operator's manual provided to the surveyor, RNC A said I don't know that we've read it. The Administrator said it was nearly impossible not to ride the lift with the resident. They said the driver would have to raise them up, leave them there, and pull them through the front. They said safety overrides that, referring to the Operator's manual. The Surveyor asked if there was another manual or another policy. A policy was provided on Driver Orientation which included the safety director will be responsible for initial instructions consisting of defensive driving techniques and alcohol and controlled substance abuse training, etc .When asked about the Safety Director, the Administrator said that the Maintenance Director inspects the lift and van. When asked about the controlled substance abuse training, he said they screen for drug and alcohol upon hiring. He said he would check on items related to the policy. He said they are instructed on how to use the van by another van driver, or the previous ADON. He said he does not in-service the van drivers personally. In an interview on 3/28/17 at 1:00 p.m. the Administrator, RNC A, and ADON A said there was no other way they could load the resident. They said they cannot leave a patient up there, and pull them from the front. They said the person could tip back and fall out of the van. When the surveyor asked are you saying the lift should be done with two people, the Administrator said it's fine with one person. They said the picture in the Operator's manual shows a side loader not a back loader. Surveyor explained the Operator's manual was provided by them, and asked for an additional policy or manual. In an interview on 3/28/17 at 1:45 p.m. Family Member A said that on 3/7/2017, Resident #2 had just gotten out of the doctor's office. He said on Driver A was loading her up in the van. He said he was standing to the right side of the lift, and his wife was standing to the left side of the van. He said Driver A asked his wife to lift up Resident #2's legs. He said Driver A started to push her in the wheelchair into the van. He said that he asked her and told her to stop as Resident #2's feet were down. He said Driver A continued to push, and resident #2's feet got sucked up under the wheelchair. He said it threw Resident #2 forward onto the floor of the van. He said her head was in the floor of the back of the van. He said she got a knot on her head, and she had a broken neck from the incident. He said Driver A was behind Resident #2's wheelchair on the lift, and could not see her feet. He said Driver A should have stopped. He said Resident #2's feet were down. He said there needed to be pedals to keep her feet up. He said he was upset about the whole incident. He said that he had also recently had surgery on his back, and he jumped up into the van to get Resident#2's face out of the floor. He said he also hurt himself again. He said Driver A either did not hear him say stop or she just kept going. He said Resident #2 also dislocated her shoulder. He said this incident should have been handled differently. He said I don't want it to happen to anyone else. In an interview on 3/28/17 at 2:50 p.m. Driver B said he had been a van driver for three months. He said he had been trained by Driver A. He said he did not read a safety policy regarding the lift. He said he did not have defensive driving training, or alcohol substance abuse training. He said when he loads the residents he faces them forward toward the van (inwards). He said he could not find a manual in the van regarding the lift. He said he gets on the lift with them. He said he does check the weight limit on the lift. He said he had looked at the stickers that are on the actual lift in the van. He said he did read another policy, and then he signed a document giving the BOM permission to check his license. In an interview on 3/29/17 at 8:45 a.m. RVP A said that they do not have a policy that states that the loader can be on the lift. She said that she typed up the document Lift Operating Procedures from research that she had done regarding the lifts. She said that the accident did not happen because Driver A was on the lift. When asked if Driver A could see the resident's feet when she was on the lift, RVP A said that the surveyor would have to ask Driver A. She said if Resident #2 was loaded the other way she would not be able to turn the wheelchair around. She said one of her sources for the Lift Operating Procedures was the user driver's guidelines for the elderly or disabled. She said she was not sure the Operator's Manual given to the Surveyor was the correct manual. She said she was unsure where the Administrator got the manual. She said she would look to see if she could find it for their serial number that was located on the lift. In an interview on 3/29/17 at 9:13 a.m. when the Surveyor said there was a warning sticker on the lift that the passenger must face outwards, RNC A said that they must have missed the sticker. She said the previous Operator's/Owner's Manual given to the Surveyor was printed from the internet and found online. In an interview on 3/29/17 at 9:40 a.m. RNC A said that their lift was a Series 07, and the Operator's Manual provided to the Surveyor was 06. She said that they had given the Surveyor the wrong manual on the lift. In an interview on 3/29/17 at 10:30 a.m. RNC A said that she was able to get a hold of the company of the lift, and said that they were emailing her the owner's manual. In an interview on 3/29/17 at 11:10 a.m. with the Maintenance Director and Driver A, when the Surveyor asked about the van, the Maintenance Director said he had only been in his position one month, and Driver A had been there the longest. Driver A said that they have had the same van with the lift since she had started about 7 years ago. In an interview on 3/29/17 at 12:11 p.m. RVP A and RNC A said the manual sent by the company was a Series 07, but the model numbers did not match. RVP A said We do not have anything else to give you at this time. She said we will fix it. Resident #4 Record review of Resident #4's face sheet, dated 11/1/2016, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly MDS 3.0, dated 2/9/2017, revealed in he scored a five out of 15 on the BIMS indicating he was severely cognitively impaired. He needed one person physical assist and supervision for transfers. For locomotion off the unit he needed to set up help only and supervision. He had impairment on both sides of both his upper and lower extremities. The mobility device that was checked was a wheelchair. Record review of Resident #4's care plan, edited 2/2/2017, Category: ADL functional/Rehabilitation Potential . Impaired mobility uses wheelchair and walker Fall Risk. Observation and interview on 3/28/17 at 10:25 a.m. revealed Resident #4 sitting in his wheelchair in his room. When asked about the van, Resident #4 said they load him in the back facing towards the van on the lift. He said the person usually goes on the lift with him to load him in the van. In an interview on 3/28/17 at 1:00 p.m. ADON A said Resident #4 does use the lift, he was just not marked on the list of residents that use the lift. Resident #5 Record review of Resident #5's face sheet, dated 11/1/2016, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #5's quarterly MDS 3.0, dated 2/6/2017, revealed she scored a 15 out of 15 on the BIMS indicating she was cognitively intact. She needed one person physical assist and supervision to transfer. For locomotion off the unit she required set up help and supervision. The mobility devices that were checked on the MDS 3.0 included a walker and wheelchair. Record review of Resident #5's care plan, edited 11/3/2016, revealed she utilized an electric wheelchair to promote independence during locomotion about the facility. Her care plan, edited 11/3/2016, also indicated in the Category: Falls that she has multiple problems that affect her ability to walk. She has a history of falls, the potential to fall, and she was at risk for injury related to [DIAGNOSES REDACTED]. Observation and interview on 3/28/17 at 10:56 am. revealed Resident #5 resting in her room. Her electric scooter was in front of her. She said it's been a while since I have been on the van as my scooter does not work but they loaded me facing towards the van on the lift. She said the attendant/driver rode on the lift with me. Resident #6 Record review of Resident #6's face sheet, dated 11/1/16, revealed she was an [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's quarterly MDS 3.0, dated 2/23/17, revealed she scored a13 out of 15 on the BIMS indicating she was cognitively intact. She needed one person physical assist for transfers and supervision. For locomotion off unit, she needed one person physical assist with extensive assistance. She had impairment on both sides of both her upper and lower extremities. The mobility devices that were checked on the MDS 3.0 included a walker and wheelchair. Record review of Resident #6's care plan, edited 11/30/2016, revealed I use a walker for mobility when I walk with therapy. I also utilize a wheelchair. Observation and interview on 3/29/17 at 8:20 a.m. revealed Resident #6 sitting in a wheelchair in her room. She said there was a time that she had to go out to see the doctor. She said that the staff rode up on the lift with her standing behind her wheelchair. She said that she was loaded on the lift facing towards the van. She said the facility staff had a meeting with the residents about the lift yesterday, but she went to therapy instead of the meeting (3/28/17). Resident #7 Record Review of Resident #7's face sheet, dated 1/19/2017, revealed he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #7's quarterly MDS 3.0, dated 1/9/2017, revealed he scored a14 out of 15 on the BIMS indicating he was cognitively intact. He needed to person physical assist an extensive assistance to transfer. For locomotion off the unit he needed one person physical assist with supervision. He had impairment on both sides of both his upper and lower extremities. The mobility device that was checked was a wheelchair. Record review of Resident #7's care plan, edited 1/19/2017, revealed Category Falls: I have multiple problems that affect my ability to walk. I have HX of (and/or) the potential to fall and at risk for injury related to d/t parkinson's, adl assistance. In his care plan, edited 1/19/2017, revealed in Category: ADL Functional/Rehabilitation Potential he needed extensive assistance with ADLs. The mobility device that was checked was a wheelchair. Observation and interview on 3/29/17 at 10:10 a.m. revealed Resident #7 sitting in his recliner in his room listening to his television. He ha

Based on observations, interviews and record reviews, the facility failed to ensure residents were free from neglect for 3 of 5 residents (Resident #3, #4 and #5) reviewed for neglect. 1. Resident #3 developed a Stage II pressure ulcer 01/09/17 on her coccyx. Resident #3 developed 6 additional pressure ulcers while in the facility. The facility failed to assess or notify the physician of deterioration of her wounds resulting in Resident #3's pressure sores not being treated. 2. Resident #4 was readmitted to the facility with four Stage II pressure ulcers 09/16/16. Resident #4's pressure ulcers worsened to Stage IV and he developed three additional Stage IV pressure ulcers. The facility failed to notify the physician or coordinate with the hospice agency of the deterioration or wounds or the development of new sores. 3. Resident #5 was admitted to the facility without a pressure ulcer. Resident #5 had shearing to his buttock that deteriorated to a Stage IV pressure ulcer. The facility failed to notify the physician of the deterioration or the wound and provide a change in treatment as the wound deteriorated. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 02/08/17. While the IJ was lowered on 02/09/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These facility failures resulted in harm to Residents #3, 4 and 5 and could place the other two residents at risk for neglect which could lead to the development of new or worsening pressure ulcers which could lead [MEDICAL CONDITION], severe pain, hospitalization and even death. The findings include: 1. Review of Resident #3's closed clinical record revealed she was a [AGE] year old female admitted to the facility 06/19/15, readmitted [DATE] and discharged to the hospital 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] revealed no BIMS score or Mood assessment score, she was combative, resisted care, had short term and long term memory problems, inattention, disorganized thinking that was present and fluctuated, wandered daily, received antipsychotics, antianxiety, antidepressants and hypnotics 7 of the last 7 days, had unclear speech, sometimes understood and was understood, had delusions, used a wheelchair for mobility needed extensive assistance with ADL's, had no falls and no pressure ulcers and was occasionally incontinent of bowel and bladder. Review of Resident #3's Care Plan dated 12/06/16 revealed, .Pressure Ulcer-I am not as mobile as I used to be, my skin is fragile and may have problems: Skin tear, Bruising, Other ( .edited: 10/27/16 .Monitor me for s/s (signs and symptoms) of skin breakdown or bruising .Notify my Dr (doctor) of any skin breakdown or bruising . No update to the Care Plan was documented after her return 01/14/17. No other interventions to prevent skin breakdown were listed on the care plan. Review of Resident #3's Physician Order Report signed 01/03/17 revealed, .Head to toe skin assessment Q (every) week on Wed (Wednesday) on 6a-6p using the following codes 0= No New Area N= New Non-Pressure Area P=Pressure Area *See Nurses Notes* . Review of Resident #3's Physician's telephone order dated 01/09/17 revealed, .Cleanse Stage II ulcer to coccyx with NS or wound cleanser, apply hydrogel then cover with bordered gauze. Change daily & prn when soiled x 1 week and re-evaluate . Hydrated polymer (hydrogel) dressings, originally developed in the 1950s, contain 90% water in a gel base, which helps regulate fluid exchange from the wound surface. Hydrogel dressing are usually clear or translucent and vary in viscosity or thickness. (www.woundcareadvisor.com accessed 02/16/17) Review of Resident #3's E.D. Physician Documentation dated 01/12/17 at 6:17 a.m. revealed, .Stage II decubitus buttocks . Review of Resident #3's hospital E.D. Nurse Documentation dated 01/12/17 at 7:47 a.m. revealed, .Decubitus located on sacrum approximately 1.5x2.5cm has [DIAGNOSES REDACTED]tous edges . Review of Resident #3's facility (Re-) Admission Evaluation dated 01/14/17, untimed, revealed to have no dentures, daily oral care, a pressure ulcer to her coccyx (no measurements or staging), blisters to her right anterior ankle, left heel, right lateral heel, right heel (on a skin condition diagram of the areas) and a Foley catheter. The infection section was unmarked. The evaluation was completed by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 3:00 p.m. revealed, Res arrived via (name of ambulance company), daughter (name) notified @ this time. Arrived from (name of hospital) with DX: Pneumonia, Flu & UTI. N/O 1) [MEDICATION NAME] 75mg cap P.O. BID x 5 more doses. 2) [MEDICATION NAME] 750mg P.O. QD x 2 more doses start 01/15/17. 3) [MEDICATION NAME] 200mg P.O. QD x 13 more doses start 01/15/17. The note was written by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 4:00 p.m. revealed, Resident found to have an unstageable wound to the coccyx area measuring 2.8cm x 1.6 cm, no depth, eschar noted in the wound bed, no drainage, surrounding tissue red and blanchable, denies pain to area . The documentation was signed by RNF. Review of Resident #3's Progress Notes dated 01/14/17 at 4:20 p.m. revealed, Resident found to have blister L (left) outer heel. 1.7 cm x 1.7 cm, R (right) outer heel dark area 2.0 cm x 0.8 cm. R inner heel 1.1 cm x 0.9 cm .The documentation was signed by RN F. Review of Resident #3's Physician's telephone order dated 01/14/17 revealed, .Cleanse with NS or wound cleanser. Apply skin prep to L (left) heel BID until healed. DX: Blister L heel 1.7cm x1.7 cm . (There was no treatment written for the wound to the coccyx or the right ankle). Review of Resident #3's Braden Scale-for Predicting Pressure Sore Risk dated 01/14/17 revealed a score of 20. (A score of 12 or less represents a high risk of pressure ulcer development). Review of Resident #3's Clinically Unavoidable Pressure Ulcer Form dated 01/14/17 revealed, .Site: coccyx, Stage-Unstageable- date developed-01/14/17. Site: Rt (right) anterior ankle- Stage-III-date developed-01/14/17 The documentation was signed by LVN I. Review of Resident #3's Physician Orders did not reveal wound care orders for the right ankle or the coccyx written until 01/17/17, when a telephone order was written by LVN I for treatment of [REDACTED].Cleanse right anterior ankle with NS or wound cleanser. Apply TAO & cover with border foam dressing QD. 1.5x1.4 cm Stage III. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Unstageable 2.8x1.6 cm . The order was written by LVN M. In an interview on 02/08/17 at 10:20 a.m., LVN I said when asked what constituted an unavoidable pressure ulcer, she replied that if a resident had 2 or more pressure ulcers, they were considered unavoidable. LVN I said all licensed nurses were responsible for completing skin assessments as they arise. She said she did not write an order for [REDACTED]. Review of Resident #3's Telephone order dated 01/23/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day . Calcium alginate-Dressing with calcium and sodium fibers made from seaweed. Transforms into a moist gel consistency when it comes into contact with exudate or moisture. Absorbs up to 20 times its weight. Conforms to the shape of the wound. Fills in dead space: As it absorbs moisture and exudate, the gel fibers swell, making the dressing larger than when applied. Moist gel consistency will maintain moist healing environment and facilitate autolytic debridement (www.woundcareadvisor.com accessed 02/15/17 Review of Resident #3's Telephone order dated 01/29/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate, cover with transparent film dressing every other day . The order was written by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/20/17 revealed, Stage II .Right anterior ankle .0.3 x 0.2 . No drainage was documented and the skin was documented as intact and red/pink. The documentation was signed by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/25/17 and 01/29/17 revealed no staging of the right anterior ankle with measurements as 0.3 x 0.2, skin was red/pink. The documentation 01/25/17 was signed by LVN I. The documentation 01/29/17 did not have a signature. Review of Resident #3's Weekly Skin Documentation of her coccyx wound revealed, .01/20/17 US (unstageable)2 x 2 cm . Exudate was documented as serosanguinous, thin .Odor slight. Color/tissue type/percent/location-some necrotic, wound margins-red, surrounding tissue-pink . 01/25/17 US (unstageable) 3 x 2 cm. Exudate was documented as clear, thin, scant amount-odor slight .wound margins-red, color/tissue type/percent/location-red with small eschar, wound margins red, surrounding tissue-pink . 01/29/17 US (unstageable) 4 x 3 cm .Exudate was documented as serosanguinous, thin, moderate amount with strong, foul odor, color tissue type/percent/location-necrotic with red, wound margins red, surrounding tissue-pink . Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough or eschar are by definition unstageable. The base of the ulcer needs to be visible in order to properly stage the ulcer (though the ulcer will be at least a stage III, as slough and eschar do not form on stage I or II ulcers). (www.woundsource.com accessed 02/16/17) Review of Resident #3's Medication Sheet dated January, 2017 revealed wound care was provided as ordered (except from 1/15- 1/18). In an interview on 02/07/17 at 3:14 p.m., LVN C said Resident #3 received [MEDICATION NAME] in January 2017. She said Resident #3 got over the flu but did not improve much, having a decline in overall health lately. LVN C said Resident #3 used a wheelchair and ate independently prior to going to the hospital 01/30/17. She said Resident #3 had a shearing on her coccyx when she was admitted to the hospital 01/12/17, and when she returned (01/14/17) it was a little worse and continued to get worse before she went back to the hospital 01/30/17. She said Resident #3 had a pressure ulcer on her coccyx and left outer ankle, but she did not look at the wounds because the night shift changed the dressing. LVN C said Resident #3 came back from the hospital 01/14/17 with a Foley catheter that was left in. LVN C said when Resident #3 returned from the hospital 01/14/17, she was placed in isolation due to having the flu. She said on 01/30/17, Resident #3 had a low grade fever and did not look good, with an oxygen saturation in the 90% range, so she put oxygen via nasal cannula on her. LVN C said Resident #3 was not responding to verbalization, so she called Resident #3's daughter, who wanted the resident sent to the hospital. Review of Resident #3's History and Physical from the hospital dated 01/30/17 revealed, .Chief Complaint: The patient brought into the emergency room from the nursing home with complaints of low oxygen saturation and low blood pressure. History of present illness: The patient is a [AGE] year-old lady who was brought in from the nursing home with above-mentioned complaints. The patient is unable to give any meaningful history. Her blood pressure at the time of evaluation was 92/38 mmHg, and she was [MEDICAL CONDITION] at 110 per minute. The patient was recently sickened in the hospital [MEDICAL CONDITION] as well as influenza. Since then, she has been more or less bed-bound in the nursing home. Her daughter, who is the power of attorney, has given an order for [REDACTED]. Past Medical History: Quite complicated and significant for obsessive-compulsive disorder, depression, paranoia, muscle spasms, general decline, global cognitive impairment, [MEDICAL CONDITION], urinary incontinence, and recent immobilization due to generalized debility . In an interview on 02/08/17 at 8:21 a.m., RN H (a hospital RN) said she received Resident #3 on the telemetry unit from the emergency room around 6:00 p.m. 01/30/17. She said when she cleaned Resident #3 up she had 2 or 3 pressure ulcers on each foot and a pressure ulcer about a foot long on her bottom, with admitting [DIAGNOSES REDACTED].#3. RN H said she did an initial cleansing of Resident #3's wounds and called the physician who approved for the hospital's wound care consult. RN H said, It's (Resident #3's condition) not necessary. She said Resident #3's left leg may have been beginning to contract, or she may have been in a fetal position, because her left heel pushed into her right shin and her ankle bones were open yet scabbed over. Review of Resident #3's hospital nurse's notes dated 01/31/17 at 1:00 p.m. revealed, Called (name of facility) and spoke with a nurse named (LVN C) who stated she was the nurse who had taken care of (Resident #3's name). Inquired as to her baseline prior to her AMS. She stated that most of the time she was alert and oriented to person and place. Review of Resident #3's photos dated 01/31/17 (taken at the hospital by RN H) revealed her right ear had a small necrotic area on the lower portion. Resident #3's bottom had 2 large areas of necrotic skin with redness and slough surrounding them. The left upper buttock was approximately 6.0x3.3cm. Depth was not visible due to eschar. The right buttock was approximately 4.0x3.8cm. Depth was not visible due to eschar. There were 3 areas of open skin with slough on the left lateral buttock. An approximately 1.0 cm fluid-filled area was on the right upper buttock. A 1.7x2.5 cm area of eschar and slough was on Resident #3's right shin. An approximately 1.8 cm round eschar was on her left lateral ankle. An approximately 1.8cm round eschar area was on her right lateral ankle. The right heel was peeling with an open area approximately 1.3 cm. The left heel was brown color approximately 3cm round. Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from healthy skin. It's caused [MEDICAL CONDITION] also occurs in pressure wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty. (www.healthline.com accessed 02/15/17) Necrosis is the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, [MEDICAL CONDITION], or chemicals. Necrosis cannot be reversed. (www.medlineplus.com accessed 02/16/17) Review of Resident #3's photographed wounds in the hospital dated 02/02/17 revealed a Stage IV to her coccyx measured at 4.5x5.0 cm, unknown depth. A Stage III wound to the coccyx measured at 2.4x2.4 cm, unknown depth. Stage 3 Pressure Injury: Full-thickness skin loss-Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss-Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (www.npuap.org accessed 02/15/17) Review of Resident #3's hospital Nursing Wound Care Nurse Eval and assessment dated [DATE] revealed, .Etiology-pressure ulcer .location-coccyx, present on admission-yes, stage-thickness-full thickness, undermining?-yes, 12 o'clock to 2 o'clock. Wound bed-slough-eschar. 0% granulation, 1-25% slough, 51-76% eschar, peri wound-erythemic, edges-unattached, drainage-large amount sero-sanguinous . Primary dressing-[MEDICATION NAME] AG. Secondary dressing-[MEDICATION NAME] border-sacrum . Additional wounds? Yes. Location-right posterior lower leg, present on admission-yes, stage-thickness-unstageable, undermining-no, tunneling-no, wound bed-pink-red, slough-eschar. % 26-50-Granulation, 5 slough-26-50, % 0 eschar. Peri-wound-intact, edges-attached, drainage-small amount sero-sanguinous .Primary dressing-[MEDICATION NAME] AG, Secondary dressing-[MEDICATION NAME] border . [MEDICATION NAME] Ag with [MEDICATION NAME] ([MEDICATION NAME] Ag), silver impregnated antimicrobial dressing is a soft, sterile, non-woven pad or ribbon dressing composed of sodium [MEDICATION NAME] and 1.2% ionic silver which allows for a maximum of 12mg of silver for a 4 inch x 4 inch dressing. (www.drugs.com accessed 02/16/17) [MEDICATION NAME] is an absorbent, atraumatic dressing made from [MEDICATION NAME] foam. The outer surface of the foam is bonded to a vapour-permeable [MEDICATION NAME] membrane, which acts as a barrier to liquid and microorganisms. (www.dressings.org accessed 02/16/17) Observation at a local hospital on [DATE] at 10:15 a.m. revealed Resident #3 lying in a hospital bed. Her left coccyx wound was clean except for eschar along the left side. The shin and left lateral ankle wounds appeared to be healing with some slough observed. The heels were clean and dry. In an interview on 02/07/17 at 4:30 p.m., CNA E said she worked 6:00 a.m.-6:00 p.m., and Resident #3 had been up and down health wise lately. She said Resident #3 returned from the hospital 01/14/17 with a sore on her coccyx, ate less and was more dependent on staff for her ADL's. CNA E said Resident #3 had a blister on one knee and ankle right before she went back to the hospital 01/30/17. She added that Resident #3 would let staff turn and reposition her. She said she turned Resident #3 every 2 hours. In an interview on 02/07/17 at 4:15 p.m., CNA B said Resident #3 could perform some of her ADL's. She said at times, Resident #3 had pain and needed coaxing to reposition in bed. She said she saw Resident #3's pressure ulcer to her bottom right before the resident was sent to the hospital, and that it was a round sore that started as a shear. CNA B said on the day Resident #3 went to the hospital 01/30/17, she cleaned her up using wipes, put a brief on her and brushed her dentures. In an interview on 02/07/17 at 5:50 p.m., RN G said Resident #3 had some breakdown on her shin and ankle when she went to the hospital 01/30/17 but none on her bottom. In an interview on 02/07/17 at 5:53 p.m., the Administrator said Resident #3 had declined mentally recently and was not oriented. He said she went to the hospital in mid-January and came back with a pressure ulcer. He said upon her return, she was in isolation due to having the flu. He said her treatment plan and care remained the same even while in isolation. In an interview on 02/08/17 at 10:12 a.m., LVN I (facility staff) said Resident #3's pressure ulcer on her coccyx looked like a heart, having a little eschar with a moderate amount of serosanginous drainage. She said she worked the night shift 01/29/17 and saw Resident #3's coccyx wound, and it had a foul odor, but said she did not notify the physician. LVN I said she did not find daily documentation of Resident #3's wounds in her clinical record, and there was no documentation of Resident #3 having her coccyx wound dressing changed from 01/15/17-01/18/17. LVN I also said she did not find an order for [REDACTED]. She said she documented Resident #3's pressure ulcer and completed a form, Clinically Unavoidable Pressure Ulcer Form 01/14/17 for Resident #3 due to her decline on condition. LVN I said when a resident had 2 or more pressure ulcers, she documented them as clinically unavoidable. LVN I said dressing changes did not have specific times to be done. She said it depended on the resident and the workload as to when the dressing changes were scheduled. She said skin assessments were every licensed nurse's responsibility, even when a resident was in isolation. She said she normally worked Monday-Friday, but had worked the night shift 01/29/17 and changed Resident #3's dressing. She confirmed that she documented the wound to have a foul odor but did not contact the physician or document measurements/stage the wound. In an interview on 02/09/17 at 8:12 a.m., Physician L said he was Resident #3's Primary Care Physician. He said Resident #3 was emaciated and dehydrated when she was admitted to the hospital 01/30/17, including having dry mucous membranes. He said he had looked at Resident #3 and she had a large sacral wound that was Stage IV when she was admitted [DATE]. He said although Resident #3 had risk factors for malnutrition, the nursing facility should have a protocol for turning and repositioning residents, and that it would only take one shift of not being turned for a wound to deteriorate. He added that it depended on the commitment of the staff. Physician L said he would expect facility staff to notify him if a pressure ulcer was not improving or was deteriorating. He said he was not notified of the appearance of her wound. 2. Review of Resident #4's clinical record revealed he was a [AGE] year old male admitted to the facility 03/11/16 with [DIAGNOSES REDACTED]. Resident #4's Care Plan dated 09/22/16 regarding pressure ulcers revealed a pressure ulcer on his coccyx currently a Stage II, a pressure ulcer to his left upper ilium, right lower ischium, stage II pressure ulcer right medial ischium, right ischium, left buttock stage II, left ischium stage II, right buttock stage II (dated 07/11/16). Interventions for the pressure ulcers were, .my ulcer will heal 1 cm per month over the next 90 days .dietician to assess my diet for protein, calories, vitamins, and minerals at least quarterly .encourage me to eat 75-100% of my diet as ordered by my MD .keep me clean and dry .provide me with a pressure relieving mattress .provide me with treatments as ordered by my MD .report and drainage to my MD promptly .turn and reposition me when providing care and as my physical condition indicates .use good infection control when dealing with my ulcer . Review of Resident #4's Operative Report dated 10/27/16 revealed, .Preoperative Diagnosis: [REDACTED].Procedure Performed: Debridement of sacral and right ischial decubitus ulcers .The sacral ulcer had necrotic debris down to the sacrum. This was all sharply debrided including the subcutaneous tissue. This was debrided back to bleeding tissue. The resulting cavity is approximately 4 cm in diameter. Attention was turned to the right ischial tuberosity. There was a 4 to 5 cm diameter area of leathery dead skin. No surrounding [DIAGNOSES REDACTED]. This was excised with scalpel ___(blank space) go to the muscle. That muscle tissue was sharply debrided as well back to the bleeding tissue. Hemostasis was achieved. Both wounds were packed, and the patient was in the process of being extubated at the time of dictation . Review of resident #4's Quarterly MDS dated [DATE] revealed an unmeasured BIMS, mood of zero he resisted care 4-6 days, had short and long-term memory problems, needed extensive assistance with ADLs, had a pureed diet, was incontinent of bowel and had a Foley catheter. The MDS revealed almost constant pain, limited range of motion in his lower extremities and wore oxygen. The MDS revealed four stage II pressure ulcers present on admission, one stage III pressure ulcer present on admission measuring 2.5x6.0x0.3cm with slough, a pressure reducing device, nutrition/hydration intervention, non-surgical dressing, ointments/meds, antidepressant and diuretic given seven of the last seven days. No documentation of a Braden Scale for Resident #4 was provided upon request. Review of Resident #4's (undated) Physician's telephone order revealed, .Clean Stage IV to coccyx, (left upper) NS apply collagen then calcium alginate, island border. Clean Stage IV left buttock NS, apply collagen then calcium alginate, island border. Clean Stage IV outer buttock NS apply collagen then calcium alginate, island border. Clean Stage IV coccyx NS, apply collagen then calcium alginate, island border. Clean unstageable to upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right hip NS apply collagen then calcium alginate, island border. Clean Stage IV right lower buttock NS apply collagen then calcium alginate, island border . Each wound was to be cleaned and the dressing changed daily and prn. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed the right ischium wound measuring 2.0x3.0x2.0 cm and a coccyx wound measuring 12.0x8.0x7.0 cm. No exudate or wound bed appearance was documented. No staging was documented. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a right buttocks-distal proximate wound measuring 4.0x8.0x5.5 cm (unstaged). Exudate/consistency were documented as none. No margins were documented, surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 11/19/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Review of Resident #4's Weekly Skin Documentation dated 12/02/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Wound margins were documented as intact, surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a right buttock-distal proximate wound measuring 4.2x4.5x3.0 cm. Exudate was documented as red. Wound margins were documented as black, surrounding tissue was documented as red. Odor was checked. No wound margin was documented; surrounding tissue was documented as pink/red. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a left ischium et (and) coccyx wound that read, .ischium 2.0x3.0x2.0 cm .coccyx 12.0x8.0x7.0 cm. Exudate was documented as moderate. Odor was circled. No color/tissue type/percent/location was documented. No wound margins were documented; surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 (most recent documentation) revealed the left ischium at coccyx wound did not have a stage of the wound but measured 4.2x4.5x2.5cm. Review of Resident #4's Weekly Skin Documentation dated 11/18/16 revealed a coccyx wound measuring 6.0x3.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location was documented as excoriation. No wound margins or surrounding tissue was documented. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a coccyx wound measuring 4.2x4.5x2.5 cm. No other description of the wound was documented. Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a coccyx wound Stage III measuring 5.7x4.2x1.5 cm. Exudate was documented as green/yellow, thick consistency. Odor was marked yes. Color/tissue type/percent/location was documented as pink/red. Wound margins were pink/red, surrounding tissue was pink. Review of Resident #4's Weekly Skin Documentation dated 12/29/16 revealed a coccyx wound Stage IV measuring 18x13x3 cm. Exudate was documented as green, thick consistency. Odor was documented as yes. Color/tissue type/percent/location was Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a right lower hip Stage II measuring 1.8x0.8x>0.1 cm. Exudate/consistency/odor were documented as none. Color/tissue type/ percent/location was documented as pink/red granulation. Wound margins were documented as pink/red; surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 01/31/17 (most recent documentation) revealed a right lower hip wound Stage IV measuring 1.2x0.6x0.3 cm. Exudate was documented as yellow, thin consistency. Odor was documented as strong. Color/tissue type/percent/location was documented as granulation, pink/red/yellow. Wound margins were documented as pink, surrounding tissue was documented as pink. In an interview on 02/10/17 at 1:30 p.m., LVN I said Resident #4 had been in the hospital the following dates: 09/13/16-09/16/16, 10/02/16-10/03/16, 10/27/16-11/04/16 and 11/07/16-11/09/16. She said when Resident #4 returned to the facility 11/09/16, he was on hospice services. LVN I said if a pressure ulcer was not improving or if it was deteriorating, staff were to notify the physician for a change in treatment. LVN I said if a resident was receiving hospice services, the hospice agency would be notified for a change in treatment. In an interview on 02/07/17 at 5:32 p.m., RN F said she measured Resident #4's wounds 02/06/17 and provided a copy of them. She said she did weekly skin assessments in addition to the facility nurses skin assessments. Review of Resident #4's wound measurements taken by RN F ( a facility employee) 02/06/17 revealed the following: Left upper coccyx-6x5x1.5cm, left lower coccyx-3.5x2.5x0.5cm, left ischium-3x2x1.5cm, right upper coccyx-5.8x1x1.5, right outer coccyx-3x4x2.8cm, coccyx (middle)-8x3x3.5cm, right lower iscium-2.8x4x0.3cm, right ilium-0.8x1.2x0.2cm. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 10/07/16 revealed, .Coccyx Stage II . The documentation included the dressing was not intact, had no drainage and no odor. The documentation was written by LVN I. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 12/14/16, 12/15/16, 12/19/16 and 12/20/16 revealed, . Coccyx Stage IV . Documentation included the dressing was intact, dirty with drainage present that was green, thick and purulent and had an odor. The documentation was written by LVN C. Review of Resident #4's Daily Pressure Ulcer Documentation page 2 revealed a note dated 10/19/16 that read, .wound care completed to coccyx area, multiple Stage III areas noted with necrosis, sloughing, red/macerated, yellow/green drainage . The note was written by RN F. Review of Resident #4's Daily Pressure Ulcer Documentation page 2 dated 11/14/16 revealed, .wound care completed to coccyx area, multipl

Based on observations, interviews and record reviews, the facility failed to implement their written policies to prohibit neglect for 3 of 5 residents (Resident #3, #4 and #5) reviewed for neglect. 1. Resident #3 developed a Stage II pressure ulcer 01/09/17 on her coccyx. Resident #3 developed 6 additional pressure ulcers while in the facility. The facility failed to assess or notify the physician of deterioration of her wounds resulting in Resident #3's pressure sores not being treated. 2. Resident #4 was readmitted to the facility with four Stage II pressure ulcers 09/16/16. Resident #4's pressure ulcers worsened to Stage IV and he developed three additional Stage IV pressure ulcers. The facility failed to notify the physician or coordinate with the hospice agency of the deterioration or wounds or the development of new sores. 3. Resident #5 was admitted to the facility without a pressure ulcer. Resident #5 had shearing to his buttock that deteriorated to a Stage IV pressure ulcer. The facility failed to notify the physician of the deterioration or the wound and provide a change in treatment as the wound deteriorated. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 02/08/17. While the IJ was lowered on 02/09/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. These facility failures resulted in harm to Residents #3, #4 and #5 and could place the other two residents at risk for neglect which could lead to the development of new or worsening pressure ulcers which could lead [MEDICAL CONDITION], severe pain, hospitalization and even death. The findings include: Review of the facility's policy, Abuse Prevention Program, dated 01/15/15, revealed, Policy Statement-Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion .Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff form other agencies providing services to our residents, family members, legal guardians, sponsors, friends, visitors, or any other individuals . 1. Review of Resident #3's closed clinical record revealed she was a [AGE] year old female admitted to the facility 06/19/15, readmitted [DATE] and discharged to the hospital 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] revealed no BIMS score or Mood assessment score, she was combative, resisted care, had short term and long term memory problems, inattention, disorganized thinking that was present and fluctuated, wandered daily, received antipsychotics, antianxiety, antidepressants and hypnotics 7 of the last 7 days, had unclear speech, sometimes understood and was understood, had delusions, used a wheelchair for mobility needed extensive assistance with ADL's, had no falls and no pressure ulcers and was occasionally incontinent of bowel and bladder. Review of Resident #3's Care Plan dated 12/06/16 revealed, .Pressure Ulcer-I am not as mobile as I used to be, my skin is fragile and may have problems: Skin tear, Bruising, Other ( .edited: 10/27/16 .Monitor me for s/s (signs and symptoms) of skin breakdown or bruising .Notify my Dr (doctor) of any skin breakdown or bruising . No update to the Care Plan was documented after her return 01/14/17. No other interventions to prevent skin breakdown were listed on the care plan. Review of Resident #3's Physician Order Report signed 01/03/17 revealed, .Head to toe skin assessment Q (every) week on Wed (Wednesday) on 6a-6p using the following codes 0= No New Area N= New Non-Pressure Area P=Pressure Area *See Nurses Notes* . Review of Resident #3's Physician's telephone order dated 01/09/17 revealed, .Cleanse Stage II ulcer to coccyx with NS or wound cleanser, apply hydrogel then cover with bordered gauze. Change daily & prn when soiled x 1 week and re-evaluate . Hydrated polymer (hydrogel) dressings, originally developed in the 1950s, contain 90% water in a gel base, which helps regulate fluid exchange from the wound surface. Hydrogel dressing are usually clear or translucent and vary in viscosity or thickness. (www.woundcareadvisor.com accessed 02/16/17) Review of Resident #3's E.D. Physician Documentation dated 01/12/17 at 6:17 a.m. revealed, .Stage II decubitus buttocks . Review of Resident #3's hospital E.D. Nurse Documentation dated 01/12/17 at 7:47 a.m. revealed, .Decubitus located on sacrum approximately 1.5x2.5cm has [DIAGNOSES REDACTED]tous edges . Review of Resident #3's facility (Re-) Admission Evaluation dated 01/14/17, untimed, revealed to have no dentures, daily oral care, a pressure ulcer to her coccyx (no measurements or staging), blisters to her right anterior ankle, left heel, right lateral heel, right heel (on a skin condition diagram of the areas) and a Foley catheter. The infection section was unmarked. The evaluation was completed by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 3:00 p.m. revealed, Res arrived via (name of ambulance company), daughter (name) notified @ this time. Arrived from (name of hospital) with DX: Pneumonia, Flu & UTI. N/O 1) [MEDICATION NAME] 75mg cap P.O. BID x 5 more doses. 2) [MEDICATION NAME] 750mg P.O. QD x 2 more doses start 01/15/17. 3) [MEDICATION NAME] 200mg P.O. QD x 13 more doses start 01/15/17. The note was written by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 4:00 p.m. revealed, Resident found to have an unstageable wound to the coccyx area measuring 2.8cm x 1.6 cm, no depth, eschar noted in the wound bed, no drainage, surrounding tissue red and blanchable, denies pain to area . The documentation was signed by RNF. Review of Resident #3's Progress Notes dated 01/14/17 at 4:20 p.m. revealed, Resident found to have blister L (left) outer heel. 1.7 cm x 1.7 cm, R (right) outer heel dark area 2.0 cm x 0.8 cm. R inner heel 1.1 cm x 0.9 cm .The documentation was signed by RN F. Review of Resident #3's Physician's telephone order dated 01/14/17 revealed, .Cleanse with NS or wound cleanser. Apply skin prep to L (left) heel BID until healed. DX: Blister L heel 1.7cm x1.7 cm . (There was no treatment written for the wound to the coccyx or the right ankle). Review of Resident #3's Braden Scale-for Predicting Pressure Sore Risk dated 01/14/17 revealed a score of 20. (A score of 12 or less represents a high risk of pressure ulcer development). Review of Resident #3's Clinically Unavoidable Pressure Ulcer Form dated 01/14/17 revealed, .Site: coccyx, Stage-Unstageable- date developed-01/14/17. Site: Rt (right) anterior ankle- Stage-III-date developed-01/14/17 The documentation was signed by LVN I. Review of Resident #3's Physician Orders did not reveal wound care orders for the right ankle or the coccyx written until 01/17/17, when a telephone order was written by LVN I for treatment of [REDACTED].Cleanse right anterior ankle with NS or wound cleanser. Apply TAO & cover with border foam dressing QD. 1.5x1.4 cm Stage III. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Unstageable 2.8x1.6 cm . The order was written by LVN M. In an interview on 02/08/17 at 10:20 a.m., LVN I said when asked what constituted an unavoidable pressure ulcer, she replied that if a resident had 2 or more pressure ulcers, they were considered unavoidable. LVN I said all licensed nurses were responsible for completing skin assessments as they arise. She said she did not write an order for [REDACTED]. Review of Resident #3's Telephone order dated 01/23/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day . Calcium alginate-Dressing with calcium and sodium fibers made from seaweed. Transforms into a moist gel consistency when it comes into contact with exudate or moisture. Absorbs up to 20 times its weight. Conforms to the shape of the wound. Fills in dead space: As it absorbs moisture and exudate, the gel fibers swell, making the dressing larger than when applied. Moist gel consistency will maintain moist healing environment and facilitate autolytic debridement (www.woundcareadvisor.com accessed 02/15/17 Review of Resident #3's Telephone order dated 01/29/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate, cover with transparent film dressing every other day . The order was written by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/20/17 revealed, Stage II .Right anterior ankle .0.3 x 0.2 . No drainage was documented and the skin was documented as intact and red/pink. The documentation was signed by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/25/17 and 01/29/17 revealed no staging of the right anterior ankle with measurements as 0.3 x 0.2, skin was red/pink. The documentation 01/25/17 was signed by LVN I. The documentation 01/29/17 did not have a signature. Review of Resident #3's Weekly Skin Documentation of her coccyx wound revealed, .01/20/17 US (unstageable)2 x 2 cm . Exudate was documented as serosanguinous, thin .Odor slight. Color/tissue type/percent/location-some necrotic, wound margins-red, surrounding tissue-pink . 01/25/17 US (unstageable) 3 x 2 cm. Exudate was documented as clear, thin, scant amount-odor slight .wound margins-red, color/tissue type/percent/location-red with small eschar, wound margins red, surrounding tissue-pink . 01/29/17 US (unstageable) 4 x 3 cm .Exudate was documented as serosanguinous, thin, moderate amount with strong, foul odor, color tissue type/percent/location-necrotic with red, wound margins red, surrounding tissue-pink . Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough or eschar are by definition unstageable. The base of the ulcer needs to be visible in order to properly stage the ulcer (though the ulcer will be at least a stage III, as slough and eschar do not form on stage I or II ulcers). (www.woundsource.com accessed 02/16/17) Review of Resident #3's Medication Sheet dated January, 2017 revealed wound care was provided as ordered (except from 1/15- 1/18). In an interview on 02/07/17 at 3:14 p.m., LVN C said Resident #3 received [MEDICATION NAME] in January 2017. She said Resident #3 got over the flu but did not improve much, having a decline in overall health lately. LVN C said Resident #3 used a wheelchair and ate independently prior to going to the hospital 01/30/17. She said Resident #3 had a shearing on her coccyx when she was admitted to the hospital 01/12/17, and when she returned (01/14/17) it was a little worse and continued to get worse before she went back to the hospital 01/30/17. She said Resident #3 had a pressure ulcer on her coccyx and left outer ankle, but she did not look at the wounds because the night shift changed the dressing. LVN C said Resident #3 came back from the hospital 01/14/17 with a Foley catheter that was left in. LVN C said when Resident #3 returned from the hospital 01/14/17, she was placed in isolation due to having the flu. She said on 01/30/17, Resident #3 had a low grade fever and did not look good, with an oxygen saturation in the 90% range, so she put oxygen via nasal cannula on her. LVN C said Resident #3 was not responding to verbalization, so she called Resident #3's daughter, who wanted the resident sent to the hospital. Review of Resident #3's History and Physical from the hospital dated 01/30/17 revealed, .Chief Complaint: The patient brought into the emergency room from the nursing home with complaints of low oxygen saturation and low blood pressure. History of present illness: The patient is a [AGE] year-old lady who was brought in from the nursing home with above-mentioned complaints. The patient is unable to give any meaningful history. Her blood pressure at the time of evaluation was 92/38 mmHg, and she was [MEDICAL CONDITION] at 110 per minute. The patient was recently sickened in the hospital [MEDICAL CONDITION] as well as influenza. Since then, she has been more or less bed-bound in the nursing home. Her daughter, who is the power of attorney, has given an order for [REDACTED]. Past Medical History: Quite complicated and significant for obsessive-compulsive disorder, depression, paranoia, muscle spasms, general decline, global cognitive impairment, [MEDICAL CONDITION], urinary incontinence, and recent immobilization due to generalized debility . In an interview on 02/08/17 at 8:21 a.m., RN H (a hospital RN) said she received Resident #3 on the telemetry unit from the emergency room around 6:00 p.m. 01/30/17. She said when she cleaned Resident #3 up she had 2 or 3 pressure ulcers on each foot and a pressure ulcer about a foot long on her bottom, with admitting [DIAGNOSES REDACTED].#3. RN H said she did an initial cleansing of Resident #3's wounds and called the physician who approved for the hospital's wound care consult. RN H said, It's (Resident #3's condition) not necessary. She said Resident #3's left leg may have been beginning to contract, or she may have been in a fetal position, because her left heel pushed into her right shin and her ankle bones were open yet scabbed over. Review of Resident #3's hospital nurse's notes dated 01/31/17 at 1:00 p.m. revealed, Called (name of facility) and spoke with a nurse named (LVN C) who stated she was the nurse who had taken care of (Resident #3's name). Inquired as to her baseline prior to her AMS. She stated that most of the time she was alert and oriented to person and place. Review of Resident #3's photos dated 01/31/17 (taken at the hospital by RN H) revealed her right ear had a small necrotic area on the lower portion. Resident #3's bottom had 2 large areas of necrotic skin with redness and slough surrounding them. The left upper buttock was approximately 6.0x3.3cm. Depth was not visible due to eschar. The right buttock was approximately 4.0x3.8cm. Depth was not visible due to eschar. There were 3 areas of open skin with slough on the left lateral buttock. An approximately 1.0 cm fluid-filled area was on the right upper buttock. A 1.7x2.5 cm area of eschar and slough was on Resident #3's right shin. An approximately 1.8 cm round eschar was on her left lateral ankle. An approximately 1.8cm round eschar area was on her right lateral ankle. The right heel was peeling with an open area approximately 1.3 cm. The left heel was brown color approximately 3cm round. Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from healthy skin. It's caused [MEDICAL CONDITION] also occurs in pressure wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty. (www.healthline.com accessed 02/15/17) Necrosis is the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, [MEDICAL CONDITION], or chemicals. Necrosis cannot be reversed. (www.medlineplus.com accessed 02/16/17) Review of Resident #3's photographed wounds in the hospital dated 02/02/17 revealed a Stage IV to her coccyx measured at 4.5x5.0 cm, unknown depth. A Stage III wound to the coccyx measured at 2.4x2.4 cm, unknown depth. Stage 3 Pressure Injury: Full-thickness skin loss-Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss-Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (www.npuap.org accessed 02/15/17) Review of Resident #3's hospital Nursing Wound Care Nurse Eval and assessment dated [DATE] revealed, .Etiology-pressure ulcer .location-coccyx, present on admission-yes, stage-thickness-full thickness, undermining?-yes, 12 o'clock to 2 o'clock. Wound bed-slough-eschar. 0% granulation, 1-25% slough, 51-76% eschar, peri wound-erythemic, edges-unattached, drainage-large amount sero-sanguinous . Primary dressing-[MEDICATION NAME] AG. Secondary dressing-[MEDICATION NAME] border-sacrum . Additional wounds? Yes. Location-right posterior lower leg, present on admission-yes, stage-thickness-unstageable, undermining-no, tunneling-no, wound bed-pink-red, slough-eschar. % 26-50-Granulation, 5 slough-26-50, % 0 eschar. Peri-wound-intact, edges-attached, drainage-small amount sero-sanguinous .Primary dressing-[MEDICATION NAME] AG, Secondary dressing-[MEDICATION NAME] border . [MEDICATION NAME] Ag with [MEDICATION NAME] ([MEDICATION NAME] Ag), silver impregnated antimicrobial dressing is a soft, sterile, non-woven pad or ribbon dressing composed of sodium [MEDICATION NAME] and 1.2% ionic silver which allows for a maximum of 12mg of silver for a 4 inch x 4 inch dressing. (www.drugs.com accessed 02/16/17) [MEDICATION NAME] is an absorbent, atraumatic dressing made from [MEDICATION NAME] foam. The outer surface of the foam is bonded to a vapour-permeable [MEDICATION NAME] membrane, which acts as a barrier to liquid and microorganisms. (www.dressings.org accessed 02/16/17) Observation at a local hospital on [DATE] at 10:15 a.m. revealed Resident #3 lying in a hospital bed. Her left coccyx wound was clean except for eschar along the left side. The shin and left lateral ankle wounds appeared to be healing with some slough observed. The heels were clean and dry. In an interview on 02/07/17 at 4:30 p.m., CNA E said she worked 6:00 a.m.-6:00 p.m., and Resident #3 had been up and down health wise lately. She said Resident #3 returned from the hospital 01/14/17 with a sore on her coccyx, ate less and was more dependent on staff for her ADL's. CNA E said Resident #3 had a blister on one knee and ankle right before she went back to the hospital 01/30/17. She added that Resident #3 would let staff turn and reposition her. She said she turned Resident #3 every 2 hours. In an interview on 02/07/17 at 4:15 p.m., CNA B said Resident #3 could perform some of her ADL's. She said at times, Resident #3 had pain and needed coaxing to reposition in bed. She said she saw Resident #3's pressure ulcer to her bottom right before the resident was sent to the hospital, and that it was a round sore that started as a shear. CNA B said on the day Resident #3 went to the hospital 01/30/17, she cleaned her up using wipes, put a brief on her and brushed her dentures. In an interview on 02/07/17 at 5:50 p.m., RN G said Resident #3 had some breakdown on her shin and ankle when she went to the hospital 01/30/17 but none on her bottom. In an interview on 02/07/17 at 5:53 p.m., the Administrator said Resident #3 had declined mentally recently and was not oriented. He said she went to the hospital in mid-January and came back with a pressure ulcer. He said upon her return, she was in isolation due to having the flu. He said her treatment plan and care remained the same even while in isolation. In an interview on 02/08/17 at 10:12 a.m., LVN I (facility staff) said Resident #3's pressure ulcer on her coccyx looked like a heart, having a little eschar with a moderate amount of serosanginous drainage. She said she worked the night shift 01/29/17 and saw Resident #3's coccyx wound, and it had a foul odor, but said she did not notify the physician. LVN I said she did not find daily documentation of Resident #3's wounds in her clinical record, and there was no documentation of Resident #3 having her coccyx wound dressing changed from 01/15/17-01/18/17. LVN I also said she did not find an order for [REDACTED]. She said she documented Resident #3's pressure ulcer and completed a form, Clinically Unavoidable Pressure Ulcer Form 01/14/17 for Resident #3 due to her decline on condition. LVN I said when a resident had 2 or more pressure ulcers, she documented them as clinically unavoidable. LVN I said dressing changes did not have specific times to be done. She said it depended on the resident and the workload as to when the dressing changes were scheduled. She said skin assessments were every licensed nurse's responsibility, even when a resident was in isolation. She said she normally worked Monday-Friday, but had worked the night shift 01/29/17 and changed Resident #3's dressing. She confirmed that she documented the wound to have a foul odor but did not contact the physician or document measurements/stage the wound. In an interview on 02/09/17 at 8:12 a.m., Physician L said he was Resident #3's Primary Care Physician. He said Resident #3 was emaciated and dehydrated when she was admitted to the hospital 01/30/17, including having dry mucous membranes. He said he had looked at Resident #3 and she had a large sacral wound that was Stage IV when she was admitted [DATE]. He said although Resident #3 had risk factors for malnutrition, the nursing facility should have a protocol for turning and repositioning residents, and that it would only take one shift of not being turned for a wound to deteriorate. He added that it depended on the commitment of the staff. Physician L said he would expect facility staff to notify him if a pressure ulcer was not improving or was deteriorating. He said he was not notified of the appearance of her wound. 2. Review of Resident #4's clinical record revealed he was a [AGE] year old male admitted to the facility 03/11/16 with [DIAGNOSES REDACTED]. Resident #4's Care Plan dated 09/22/16 regarding pressure ulcers revealed a pressure ulcer on his coccyx currently a Stage II, a pressure ulcer to his left upper ilium, right lower ischium, stage II pressure ulcer right medial ischium, right ischium, left buttock stage II, left ischium stage II, right buttock stage II (dated 07/11/16). Interventions for the pressure ulcers were, .my ulcer will heal 1 cm per month over the next 90 days .dietician to assess my diet for protein, calories, vitamins, and minerals at least quarterly .encourage me to eat 75-100% of my diet as ordered by my MD .keep me clean and dry .provide me with a pressure relieving mattress .provide me with treatments as ordered by my MD .report and drainage to my MD promptly .turn and reposition me when providing care and as my physical condition indicates .use good infection control when dealing with my ulcer . Review of Resident #4's Operative Report dated 10/27/16 revealed, .Preoperative Diagnosis: [REDACTED].Procedure Performed: Debridement of sacral and right ischial decubitus ulcers .The sacral ulcer had necrotic debris down to the sacrum. This was all sharply debrided including the subcutaneous tissue. This was debrided back to bleeding tissue. The resulting cavity is approximately 4 cm in diameter. Attention was turned to the right ischial tuberosity. There was a 4 to 5 cm diameter area of leathery dead skin. No surrounding [DIAGNOSES REDACTED]. This was excised with scalpel ___(blank space) go to the muscle. That muscle tissue was sharply debrided as well back to the bleeding tissue. Hemostasis was achieved. Both wounds were packed, and the patient was in the process of being extubated at the time of dictation . Review of resident #4's Quarterly MDS dated [DATE] revealed an unmeasured BIMS, mood of zero he resisted care 4-6 days, had short and long-term memory problems, needed extensive assistance with ADLs, had a pureed diet, was incontinent of bowel and had a Foley catheter. The MDS revealed almost constant pain, limited range of motion in his lower extremities and wore oxygen. The MDS revealed four stage II pressure ulcers present on admission, one stage III pressure ulcer present on admission measuring 2.5x6.0x0.3cm with slough, a pressure reducing device, nutrition/hydration intervention, non-surgical dressing, ointments/meds, antidepressant and diuretic given seven of the last seven days. No documentation of a Braden Scale for Resident #4 was provided upon request. Review of Resident #4's (undated) Physician's telephone order revealed, .Clean Stage IV to coccyx, (left upper) NS apply collagen then calcium alginate, island border. Clean Stage IV left buttock NS, apply collagen then calcium alginate, island border. Clean Stage IV outer buttock NS apply collagen then calcium alginate, island border. Clean Stage IV coccyx NS, apply collagen then calcium alginate, island border. Clean unstageable to upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right hip NS apply collagen then calcium alginate, island border. Clean Stage IV right lower buttock NS apply collagen then calcium alginate, island border . Each wound was to be cleaned and the dressing changed daily and prn. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed the right ischium wound measuring 2.0x3.0x2.0 cm and a coccyx wound measuring 12.0x8.0x7.0 cm. No exudate or wound bed appearance was documented. No staging was documented. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a right buttocks-distal proximate wound measuring 4.0x8.0x5.5 cm (unstaged). Exudate/consistency were documented as none. No margins were documented, surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 11/19/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Review of Resident #4's Weekly Skin Documentation dated 12/02/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Wound margins were documented as intact, surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a right buttock-distal proximate wound measuring 4.2x4.5x3.0 cm. Exudate was documented as red. Wound margins were documented as black, surrounding tissue was documented as red. Odor was checked. No wound margin was documented; surrounding tissue was documented as pink/red. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a left ischium et (and) coccyx wound that read, .ischium 2.0x3.0x2.0 cm .coccyx 12.0x8.0x7.0 cm. Exudate was documented as moderate. Odor was circled. No color/tissue type/percent/location was documented. No wound margins were documented; surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 (most recent documentation) revealed the left ischium at coccyx wound did not have a stage of the wound but measured 4.2x4.5x2.5cm. Review of Resident #4's Weekly Skin Documentation dated 11/18/16 revealed a coccyx wound measuring 6.0x3.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location was documented as excoriation. No wound margins or surrounding tissue was documented. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a coccyx wound measuring 4.2x4.5x2.5 cm. No other description of the wound was documented. Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a coccyx wound Stage III measuring 5.7x4.2x1.5 cm. Exudate was documented as green/yellow, thick consistency. Odor was marked yes. Color/tissue type/percent/location was documented as pink/red. Wound margins were pink/red, surrounding tissue was pink. Review of Resident #4's Weekly Skin Documentation dated 12/29/16 revealed a coccyx wound Stage IV measuring 18x13x3 cm. Exudate was documented as green, thick consistency. Odor was documented as yes. Color/tissue type/percent/location was Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a right lower hip Stage II measuring 1.8x0.8x>0.1 cm. Exudate/consistency/odor were documented as none. Color/tissue type/ percent/location was documented as pink/red granulation. Wound margins were documented as pink/red; surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 01/31/17 (most recent documentation) revealed a right lower hip wound Stage IV measuring 1.2x0.6x0.3 cm. Exudate was documented as yellow, thin consistency. Odor was documented as strong. Color/tissue type/percent/location was documented as granulation, pink/red/yellow. Wound margins were documented as pink, surrounding tissue was documented as pink. In an interview on 02/10/17 at 1:30 p.m., LVN I said Resident #4 had been in the hospital the following dates: 09/13/16-09/16/16, 10/02/16-10/03/16, 10/27/16-11/04/16 and 11/07/16-11/09/16. She said when Resident #4 returned to the facility 11/09/16, he was on hospice services. LVN I said if a pressure ulcer was not improving or if it was deteriorating, staff were to notify the physician for a change in treatment. LVN I said if a resident was receiving hospice services, the hospice agency would be notified for a change in treatment. In an interview on 02/07/17 at 5:32 p.m., RN F said she measured Resident #4's wounds 02/06/17 and provided a copy of them. She said she did weekly skin assessments in addition to the facility nurses skin assessments. Review of Resident #4's wound measurements taken by RN F ( a facility employee) 02/06/17 revealed the following: Left upper coccyx-6x5x1.5cm, left lower coccyx-3.5x2.5x0.5cm, left ischium-3x2x1.5cm, right upper coccyx-5.8x1x1.5, right outer coccyx-3x4x2.8cm, coccyx (middle)-8x3x3.5cm, right lower iscium-2.8x4x0.3cm, right ilium-0.8x1.2x0.2cm. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 10/07/16 revealed, .Coccyx Stage II . The documentation included the dressing was not intact, had no drainage and no odor. The documentation was written by LVN I. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 12/14/16, 12/15/16, 12/19/16 and 12/20/16 revealed, . Coccyx Stage IV .

Based on observations, interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment, residents received care consistent with professional standards or practice to prevent pressure ulcers and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Resident #3, #4, and #5) reviewed for pressure ulcers. 1. Resident #3 developed a Stage II pressure ulcer 01/09/17 on her coccyx. Resident #3 developed 6 additional pressure ulcers while in the facility. The facility failed to assess or notify the physician of deterioration of her wounds resulting in Resident #3's pressure sores not being treated. 2. Resident #4 was readmitted to the facility with four Stage II pressure ulcers 09/16/16. Resident #4's pressure ulcers worsened to Stage IV and he developed three additional Stage IV pressure ulcers. The facility failed to notify the physician or coordinate with the hospice agency of the deterioration or wounds or the development of new sores. 3. Resident #5 was admitted to the facility without a pressure ulcer. Resident #5 had shearing to his buttock that deteriorated to a Stage IV pressure ulcer. The facility failed to notify the physician of the deterioration or the wound and provide a change in treatment as the wound deteriorated. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 02/08/17. While the IJ was lowered on 02/09/17, the facility remained out of compliance at a scope of pattern and severity level of actual harm that was not IJ because all measures for prevention and treatment of [REDACTED]. This deficient practice contributed to the development of new pressure ulcers and the worsening of existing pressure ulcers resulting in harm for Residents #3, #4 and #5, with the potential to place two other resident at risk for developing new or worsening pressure ulcers which could lead [MEDICAL CONDITION], severe pain, hospitalization and even death. The findings include: 1. Review of Resident #3's closed clinical record revealed she was a [AGE] year old female admitted to the facility 06/19/15, readmitted [DATE] and discharged to the hospital 01/30/17 with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS dated [DATE] revealed no BIMS score or Mood assessment score, she was combative, resisted care, had short term and long term memory problems, inattention, disorganized thinking that was present and fluctuated, wandered daily, received antipsychotics, antianxiety, antidepressants and hypnotics 7 of the last 7 days, had unclear speech, sometimes understood and was understood, had delusions, used a wheelchair for mobility needed extensive assistance with ADL's, had no falls and no pressure ulcers and was occasionally incontinent of bowel and bladder. Review of Resident #3's Care Plan dated 12/06/16 revealed, .Pressure Ulcer-I am not as mobile as I used to be, my skin is fragile and may have problems: Skin tear, Bruising, Other ( .edited: 10/27/16 .Monitor me for s/s (signs and symptoms) of skin breakdown or bruising .Notify my Dr (doctor) of any skin breakdown or bruising . No update to the Care Plan was documented after her return 01/14/17. No other interventions to prevent skin breakdown were listed on the care plan. Review of Resident #3's Physician Order Report signed 01/03/17 revealed, .Head to toe skin assessment Q (every) week on Wed (Wednesday) on 6a-6p using the following codes 0= No New Area N= New Non-Pressure Area P=Pressure Area *See Nurses Notes* . Review of Resident #3's Physician's telephone order dated 01/09/17 revealed, .Cleanse Stage II ulcer to coccyx with NS or wound cleanser, apply hydrogel then cover with bordered gauze. Change daily & prn when soiled x 1 week and re-evaluate . Hydrated polymer (hydrogel) dressings, originally developed in the 1950s, contain 90% water in a gel base, which helps regulate fluid exchange from the wound surface. Hydrogel dressing are usually clear or translucent and vary in viscosity or thickness. (www.woundcareadvisor.com accessed 02/16/17) Review of Resident #3's E.D. Physician Documentation dated 01/12/17 at 6:17 a.m. revealed, .Stage II decubitus buttocks . Review of Resident #3's hospital E.D. Nurse Documentation dated 01/12/17 at 7:47 a.m. revealed, .Decubitus located on sacrum approximately 1.5x2.5cm has [DIAGNOSES REDACTED]tous edges . Review of Resident #3's facility (Re-) Admission Evaluation dated 01/14/17, untimed, revealed to have no dentures, daily oral care, a pressure ulcer to her coccyx (no measurements or staging), blisters to her right anterior ankle, left heel, right lateral heel, right heel (on a skin condition diagram of the areas) and a Foley catheter. The infection section was unmarked. The evaluation was completed by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 3:00 p.m. revealed, Res arrived via (name of ambulance company), daughter (name) notified @ this time. Arrived from (name of hospital) with DX: Pneumonia, Flu & UTI. N/O 1) [MEDICATION NAME] 75mg cap P.O. BID x 5 more doses. 2) [MEDICATION NAME] 750mg P.O. QD x 2 more doses start 01/15/17. 3) [MEDICATION NAME] 200mg P.O. QD x 13 more doses start 01/15/17. The note was written by LVN M. Review of Resident #3's Progress Notes dated 01/14/17 at 4:00 p.m. revealed, Resident found to have an unstageable wound to the coccyx area measuring 2.8cm x 1.6 cm, no depth, eschar noted in the wound bed, no drainage, surrounding tissue red and blanchable, denies pain to area . The documentation was signed by RNF. Review of Resident #3's Progress Notes dated 01/14/17 at 4:20 p.m. revealed, Resident found to have blister L (left) outer heel. 1.7 cm x 1.7 cm, R (right) outer heel dark area 2.0 cm x 0.8 cm. R inner heel 1.1 cm x 0.9 cm .The documentation was signed by RN F. Review of Resident #3's Physician's telephone order dated 01/14/17 revealed, .Cleanse with NS or wound cleanser. Apply skin prep to L (left) heel BID until healed. DX: Blister L heel 1.7cm x1.7 cm . (There was no treatment written for the wound to the coccyx or the right ankle). Review of Resident #3's Braden Scale-for Predicting Pressure Sore Risk dated 01/14/17 revealed a score of 20. (A score of 12 or less represents a high risk of pressure ulcer development). Review of Resident #3's Clinically Unavoidable Pressure Ulcer Form dated 01/14/17 revealed, .Site: coccyx, Stage-Unstageable- date developed-01/14/17. Site: Rt (right) anterior ankle- Stage-III-date developed-01/14/17 The documentation was signed by LVN I. Review of Resident #3's Physician Orders did not reveal wound care orders for the right ankle or the coccyx written until 01/17/17, when a telephone order was written by LVN I for treatment of [REDACTED].Cleanse right anterior ankle with NS or wound cleanser. Apply TAO & cover with border foam dressing QD. 1.5x1.4 cm Stage III. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Unstageable 2.8x1.6 cm . The order was written by LVN M. In an interview on 02/08/17 at 10:20 a.m., LVN I said when asked what constituted an unavoidable pressure ulcer, she replied that if a resident had 2 or more pressure ulcers, they were considered unavoidable. LVN I said all licensed nurses were responsible for completing skin assessments as they arise. She said she did not write an order for [REDACTED]. Review of Resident #3's Telephone order dated 01/23/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply calcium alginate & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day . Calcium alginate-Dressing with calcium and sodium fibers made from seaweed. Transforms into a moist gel consistency when it comes into contact with exudate or moisture. Absorbs up to 20 times its weight. Conforms to the shape of the wound. Fills in dead space: As it absorbs moisture and exudate, the gel fibers swell, making the dressing larger than when applied. Moist gel consistency will maintain moist healing environment and facilitate autolytic debridement (www.woundcareadvisor.com accessed 02/15/17 Review of Resident #3's Telephone order dated 01/29/17 revealed, .DC cleanse coccyx with NS or wound cleanser. Apply hydrogel & cover with border foam dressing every other day. Cleanse coccyx with NS or wound cleanser. Apply calcium alginate, cover with transparent film dressing every other day . The order was written by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/20/17 revealed, Stage II .Right anterior ankle .0.3 x 0.2 . No drainage was documented and the skin was documented as intact and red/pink. The documentation was signed by LVN I. Review of Resident #3's Weekly Skin Documentation dated 01/25/17 and 01/29/17 revealed no staging of the right anterior ankle with measurements as 0.3 x 0.2, skin was red/pink. The documentation 01/25/17 was signed by LVN I. The documentation 01/29/17 did not have a signature. Review of Resident #3's Weekly Skin Documentation of her coccyx wound revealed, .01/20/17 US (unstageable)2 x 2 cm . Exudate was documented as serosanguinous, thin .Odor slight. Color/tissue type/percent/location-some necrotic, wound margins-red, surrounding tissue-pink . 01/25/17 US (unstageable) 3 x 2 cm. Exudate was documented as clear, thin, scant amount-odor slight .wound margins-red, color/tissue type/percent/location-red with small eschar, wound margins red, surrounding tissue-pink . 01/29/17 US (unstageable) 4 x 3 cm .Exudate was documented as serosanguinous, thin, moderate amount with strong, foul odor, color tissue type/percent/location-necrotic with red, wound margins red, surrounding tissue-pink . Pressure ulcers are localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Ulcers covered with slough or eschar are by definition unstageable. The base of the ulcer needs to be visible in order to properly stage the ulcer (though the ulcer will be at least a stage III, as slough and eschar do not form on stage I or II ulcers). (www.woundsource.com accessed 02/16/17) Review of Resident #3's Medication Sheet dated January, 2017 revealed wound care was provided as ordered (except from 1/15- 1/18). In an interview on 02/07/17 at 3:14 p.m., LVN C said Resident #3 received [MEDICATION NAME] in January 2017. She said Resident #3 got over the flu but did not improve much, having a decline in overall health lately. LVN C said Resident #3 used a wheelchair and ate independently prior to going to the hospital 01/30/17. She said Resident #3 had a shearing on her coccyx when she was admitted to the hospital 01/12/17, and when she returned (01/14/17) it was a little worse and continued to get worse before she went back to the hospital 01/30/17. She said Resident #3 had a pressure ulcer on her coccyx and left outer ankle, but she did not look at the wounds because the night shift changed the dressing. LVN C said Resident #3 came back from the hospital 01/14/17 with a Foley catheter that was left in. LVN C said when Resident #3 returned from the hospital 01/14/17, she was placed in isolation due to having the flu. She said on 01/30/17, Resident #3 had a low grade fever and did not look good, with an oxygen saturation in the 90% range, so she put oxygen via nasal cannula on her. LVN C said Resident #3 was not responding to verbalization, so she called Resident #3's daughter, who wanted the resident sent to the hospital. Review of Resident #3's History and Physical from the hospital dated 01/30/17 revealed, .Chief Complaint: The patient brought into the emergency room from the nursing home with complaints of low oxygen saturation and low blood pressure. History of present illness: The patient is a [AGE] year-old lady who was brought in from the nursing home with above-mentioned complaints. The patient is unable to give any meaningful history. Her blood pressure at the time of evaluation was 92/38 mmHg, and she was [MEDICAL CONDITION] at 110 per minute. The patient was recently sickened in the hospital [MEDICAL CONDITION] as well as influenza. Since then, she has been more or less bed-bound in the nursing home. Her daughter, who is the power of attorney, has given an order for [REDACTED]. Past Medical History: Quite complicated and significant for obsessive-compulsive disorder, depression, paranoia, muscle spasms, general decline, global cognitive impairment, [MEDICAL CONDITION], urinary incontinence, and recent immobilization due to generalized debility . In an interview on 02/08/17 at 8:21 a.m., RN H (a hospital RN) said she received Resident #3 on the telemetry unit from the emergency room around 6:00 p.m. 01/30/17. She said when she cleaned Resident #3 up she had 2 or 3 pressure ulcers on each foot and a pressure ulcer about a foot long on her bottom, with admitting [DIAGNOSES REDACTED].#3. RN H said she did an initial cleansing of Resident #3's wounds and called the physician who approved for the hospital's wound care consult. RN H said, It's (Resident #3's condition) not necessary. She said Resident #3's left leg may have been beginning to contract, or she may have been in a fetal position, because her left heel pushed into her right shin and her ankle bones were open yet scabbed over. Review of Resident #3's hospital nurse's notes dated 01/31/17 at 1:00 p.m. revealed, Called (name of facility) and spoke with a nurse named (LVN C) who stated she was the nurse who had taken care of (Resident #3's name). Inquired as to her baseline prior to her AMS. She stated that most of the time she was alert and oriented to person and place. Review of Resident #3's photos dated 01/31/17 (taken at the hospital by RN H) revealed her right ear had a small necrotic area on the lower portion. Resident #3's bottom had 2 large areas of necrotic skin with redness and slough surrounding them. The left upper buttock was approximately 6.0x3.3cm. Depth was not visible due to eschar. The right buttock was approximately 4.0x3.8cm. Depth was not visible due to eschar. There were 3 areas of open skin with slough on the left lateral buttock. An approximately 1.0 cm fluid-filled area was on the right upper buttock. A 1.7x2.5 cm area of eschar and slough was on Resident #3's right shin. An approximately 1.8 cm round eschar was on her left lateral ankle. An approximately 1.8cm round eschar area was on her right lateral ankle. The right heel was peeling with an open area approximately 1.3 cm. The left heel was brown color approximately 3cm round. Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from healthy skin. It's caused [MEDICAL CONDITION] also occurs in pressure wounds (bedsores). Eschar is typically tan, brown, or black, and may be crusty. (www.healthline.com accessed 02/15/17) Necrosis is the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, [MEDICAL CONDITION], or chemicals. Necrosis cannot be reversed. (www.medlineplus.com accessed 02/16/17) Review of Resident #3's photographed wounds in the hospital dated 02/02/17 revealed a Stage IV to her coccyx measured at 4.5x5.0 cm, unknown depth. A Stage III wound to the coccyx measured at 2.4x2.4 cm, unknown depth. Stage 3 Pressure Injury: Full-thickness skin loss-Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss-Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (www.npuap.org accessed 02/15/17) Review of Resident #3's hospital Nursing Wound Care Nurse Eval and assessment dated [DATE] revealed, .Etiology-pressure ulcer .location-coccyx, present on admission-yes, stage-thickness-full thickness, undermining?-yes, 12 o'clock to 2 o'clock. Wound bed-slough-eschar. 0% granulation, 1-25% slough, 51-76% eschar, peri wound-erythemic, edges-unattached, drainage-large amount sero-sanguinous . Primary dressing-[MEDICATION NAME] AG. Secondary dressing-[MEDICATION NAME] border-sacrum . Additional wounds? Yes. Location-right posterior lower leg, present on admission-yes, stage-thickness-unstageable, undermining-no, tunneling-no, wound bed-pink-red, slough-eschar. % 26-50-Granulation, 5 slough-26-50, % 0 eschar. Peri-wound-intact, edges-attached, drainage-small amount sero-sanguinous .Primary dressing-[MEDICATION NAME] AG, Secondary dressing-[MEDICATION NAME] border . [MEDICATION NAME] Ag with [MEDICATION NAME] ([MEDICATION NAME] Ag), silver impregnated antimicrobial dressing is a soft, sterile, non-woven pad or ribbon dressing composed of sodium [MEDICATION NAME] and 1.2% ionic silver which allows for a maximum of 12mg of silver for a 4 inch x 4 inch dressing. (www.drugs.com accessed 02/16/17) [MEDICATION NAME] is an absorbent, atraumatic dressing made from [MEDICATION NAME] foam. The outer surface of the foam is bonded to a vapour-permeable [MEDICATION NAME] membrane, which acts as a barrier to liquid and microorganisms. (www.dressings.org accessed 02/16/17) Observation at a local hospital on [DATE] at 10:15 a.m. revealed Resident #3 lying in a hospital bed. Her left coccyx wound was clean except for eschar along the left side. The shin and left lateral ankle wounds appeared to be healing with some slough observed. The heels were clean and dry. In an interview on 02/07/17 at 4:30 p.m., CNA E said she worked 6:00 a.m.-6:00 p.m., and Resident #3 had been up and down health wise lately. She said Resident #3 returned from the hospital 01/14/17 with a sore on her coccyx, ate less and was more dependent on staff for her ADL's. CNA E said Resident #3 had a blister on one knee and ankle right before she went back to the hospital 01/30/17. She added that Resident #3 would let staff turn and reposition her. She said she turned Resident #3 every 2 hours. In an interview on 02/07/17 at 4:15 p.m., CNA B said Resident #3 could perform some of her ADL's. She said at times, Resident #3 had pain and needed coaxing to reposition in bed. She said she saw Resident #3's pressure ulcer to her bottom right before the resident was sent to the hospital, and that it was a round sore that started as a shear. CNA B said on the day Resident #3 went to the hospital 01/30/17, she cleaned her up using wipes, put a brief on her and brushed her dentures. In an interview on 02/07/17 at 5:50 p.m., RN G said Resident #3 had some breakdown on her shin and ankle when she went to the hospital 01/30/17 but none on her bottom. In an interview on 02/07/17 at 5:53 p.m., the Administrator said Resident #3 had declined mentally recently and was not oriented. He said she went to the hospital in mid-January and came back with a pressure ulcer. He said upon her return, she was in isolation due to having the flu. He said her treatment plan and care remained the same even while in isolation. In an interview on 02/08/17 at 10:12 a.m., LVN I (facility staff) said Resident #3's pressure ulcer on her coccyx looked like a heart, having a little eschar with a moderate amount of serosanginous drainage. She said she worked the night shift 01/29/17 and saw Resident #3's coccyx wound, and it had a foul odor, but said she did not notify the physician. LVN I said she did not find daily documentation of Resident #3's wounds in her clinical record, and there was no documentation of Resident #3 having her coccyx wound dressing changed from 01/15/17-01/18/17. LVN I also said she did not find an order for [REDACTED]. She said she documented Resident #3's pressure ulcer and completed a form, Clinically Unavoidable Pressure Ulcer Form 01/14/17 for Resident #3 due to her decline on condition. LVN I said when a resident had 2 or more pressure ulcers, she documented them as clinically unavoidable. LVN I said dressing changes did not have specific times to be done. She said it depended on the resident and the workload as to when the dressing changes were scheduled. She said skin assessments were every licensed nurse's responsibility, even when a resident was in isolation. She said she normally worked Monday-Friday, but had worked the night shift 01/29/17 and changed Resident #3's dressing. She confirmed that she documented the wound to have a foul odor but did not contact the physician or document measurements/stage the wound. In an interview on 02/09/17 at 8:12 a.m., Physician L said he was Resident #3's Primary Care Physician. He said Resident #3 was emaciated and dehydrated when she was admitted to the hospital 01/30/17, including having dry mucous membranes. He said he had looked at Resident #3 and she had a large sacral wound that was Stage IV when she was admitted [DATE]. He said although Resident #3 had risk factors for malnutrition, the nursing facility should have a protocol for turning and repositioning residents, and that it would only take one shift of not being turned for a wound to deteriorate. He added that it depended on the commitment of the staff. Physician L said he would expect facility staff to notify him if a pressure ulcer was not improving or was deteriorating. He said he was not notified of the appearance of her wound. 2. Review of Resident #4's clinical record revealed he was a [AGE] year old male admitted to the facility 03/11/16 with [DIAGNOSES REDACTED]. Resident #4's Care Plan dated 09/22/16 regarding pressure ulcers revealed a pressure ulcer on his coccyx currently a Stage II, a pressure ulcer to his left upper ilium, right lower ischium, stage II pressure ulcer right medial ischium, right ischium, left buttock stage II, left ischium stage II, right buttock stage II (dated 07/11/16). Interventions for the pressure ulcers were, .my ulcer will heal 1 cm per month over the next 90 days .dietician to assess my diet for protein, calories, vitamins, and minerals at least quarterly .encourage me to eat 75-100% of my diet as ordered by my MD .keep me clean and dry .provide me with a pressure relieving mattress .provide me with treatments as ordered by my MD .report and drainage to my MD promptly .turn and reposition me when providing care and as my physical condition indicates .use good infection control when dealing with my ulcer . Review of Resident #4's Operative Report dated 10/27/16 revealed, .Preoperative Diagnosis: [REDACTED].Procedure Performed: Debridement of sacral and right ischial decubitus ulcers .The sacral ulcer had necrotic debris down to the sacrum. This was all sharply debrided including the subcutaneous tissue. This was debrided back to bleeding tissue. The resulting cavity is approximately 4 cm in diameter. Attention was turned to the right ischial tuberosity. There was a 4 to 5 cm diameter area of leathery dead skin. No surrounding [DIAGNOSES REDACTED]. This was excised with scalpel ___(blank space) go to the muscle. That muscle tissue was sharply debrided as well back to the bleeding tissue. Hemostasis was achieved. Both wounds were packed, and the patient was in the process of being extubated at the time of dictation . Review of resident #4's Quarterly MDS dated [DATE] revealed an unmeasured BIMS, mood of zero he resisted care 4-6 days, had short and long-term memory problems, needed extensive assistance with ADLs, had a pureed diet, was incontinent of bowel and had a Foley catheter. The MDS revealed almost constant pain, limited range of motion in his lower extremities and wore oxygen. The MDS revealed four stage II pressure ulcers present on admission, one stage III pressure ulcer present on admission measuring 2.5x6.0x0.3cm with slough, a pressure reducing device, nutrition/hydration intervention, non-surgical dressing, ointments/meds, antidepressant and diuretic given seven of the last seven days. No documentation of a Braden Scale for Resident #4 was provided upon request. Review of Resident #4's (undated) Physician's telephone order revealed, .Clean Stage IV to coccyx, (left upper) NS apply collagen then calcium alginate, island border. Clean Stage IV left buttock NS, apply collagen then calcium alginate, island border. Clean Stage IV outer buttock NS apply collagen then calcium alginate, island border. Clean Stage IV coccyx NS, apply collagen then calcium alginate, island border. Clean unstageable to upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right upper coccyx NS, apply collagen then calcium alginate, island border. Clean Stage IV right hip NS apply collagen then calcium alginate, island border. Clean Stage IV right lower buttock NS apply collagen then calcium alginate, island border . Each wound was to be cleaned and the dressing changed daily and prn. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed the right ischium wound measuring 2.0x3.0x2.0 cm and a coccyx wound measuring 12.0x8.0x7.0 cm. No exudate or wound bed appearance was documented. No staging was documented. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a right buttocks-distal proximate wound measuring 4.0x8.0x5.5 cm (unstaged). Exudate/consistency were documented as none. No margins were documented, surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 11/19/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Review of Resident #4's Weekly Skin Documentation dated 12/02/16 revealed a right buttocks-distal proximate wound measuring 5.5x5.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location were documented as excoriation. Wound margins were documented as intact, surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a right buttock-distal proximate wound measuring 4.2x4.5x3.0 cm. Exudate was documented as red. Wound margins were documented as black, surrounding tissue was documented as red. Odor was checked. No wound margin was documented; surrounding tissue was documented as pink/red. Review of Resident #4's Weekly Skin Documentation dated 11/09/16 revealed a left ischium et (and) coccyx wound that read, .ischium 2.0x3.0x2.0 cm .coccyx 12.0x8.0x7.0 cm. Exudate was documented as moderate. Odor was circled. No color/tissue type/percent/location was documented. No wound margins were documented; surrounding tissue was documented as intact. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 (most recent documentation) revealed the left ischium at coccyx wound did not have a stage of the wound but measured 4.2x4.5x2.5cm. Review of Resident #4's Weekly Skin Documentation dated 11/18/16 revealed a coccyx wound measuring 6.0x3.0 cm. Exudate was documented as yellow. Color/tissue type/percent/location was documented as excoriation. No wound margins or surrounding tissue was documented. Review of Resident #4's Weekly Skin Documentation dated 12/16/16 revealed a coccyx wound measuring 4.2x4.5x2.5 cm. No other description of the wound was documented. Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a coccyx wound Stage III measuring 5.7x4.2x1.5 cm. Exudate was documented as green/yellow, thick consistency. Odor was marked yes. Color/tissue type/percent/location was documented as pink/red. Wound margins were pink/red, surrounding tissue was pink. Review of Resident #4's Weekly Skin Documentation dated 12/29/16 revealed a coccyx wound Stage IV measuring 18x13x3 cm. Exudate was documented as green, thick consistency. Odor was documented as yes. Color/tissue type/percent/location was Review of Resident #4's Weekly Skin Documentation dated 12/20/16 revealed a right lower hip Stage II measuring 1.8x0.8x>0.1 cm. Exudate/consistency/odor were documented as none. Color/tissue type/ percent/location was documented as pink/red granulation. Wound margins were documented as pink/red; surrounding tissue was documented as pink. Review of Resident #4's Weekly Skin Documentation dated 01/31/17 (most recent documentation) revealed a right lower hip wound Stage IV measuring 1.2x0.6x0.3 cm. Exudate was documented as yellow, thin consistency. Odor was documented as strong. Color/tissue type/percent/location was documented as granulation, pink/red/yellow. Wound margins were documented as pink, surrounding tissue was documented as pink. In an interview on 02/10/17 at 1:30 p.m., LVN I said Resident #4 had been in the hospital the following dates: 09/13/16-09/16/16, 10/02/16-10/03/16, 10/27/16-11/04/16 and 11/07/16-11/09/16. She said when Resident #4 returned to the facility 11/09/16, he was on hospice services. LVN I said if a pressure ulcer was not improving or if it was deteriorating, staff were to notify the physician for a change in treatment. LVN I said if a resident was receiving hospice services, the hospice agency would be notified for a change in treatment. In an interview on 02/07/17 at 5:32 p.m., RN F said she measured Resident #4's wounds 02/06/17 and provided a copy of them. She said she did weekly skin assessments in addition to the facility nurses skin assessments. Review of Resident #4's wound measurements taken by RN F ( a facility employee) 02/06/17 revealed the following: Left upper coccyx-6x5x1.5cm, left lower coccyx-3.5x2.5x0.5cm, left ischium-3x2x1.5cm, right upper coccyx-5.8x1x1.5, right outer coccyx-3x4x2.8cm, coccyx (middle)-8x3x3.5cm, right lower iscium-2.8x4x0.3cm, right ilium-0.8x1.2x0.2cm. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 10/07/16 revealed, .Coccyx Stage II . The documentation included the dressing was not intact, had no drainage and no odor. The documentation was written by LVN I. Review of Resident #4's Daily Pressure Ulcer Documentation page 1 dated 12/14/16, 12/15/16, 12/19/16 and 12/20/16 revealed, . Coccyx Stage IV . Documentation included the dressing was intact, dirty with drainage present that was green, thick and purulent and had an odor. The documentation was written by LVN C. Review of Resident #4's Daily Pressure Ulcer Documentation page 2 revealed a note dated 10/19/16 that read, .wound care compl

Based on interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of 5 residents (Resident # 1) reviewed for accidents and supervision. The facility failed to : 1) ensure Resident # 1 (who had a known history of falls with a previous hip fracture) after the resident transferred to the secure unit. Facility staff failed to ensure Resident # 1 had a pressure alarm on her bed and a fall mat beside her bed. Resident #1 fell [DATE] and was hospitalized due to sustaining a fractured hip. These failures resulted in harm to Resident #1 and could place the other 5 residents in the facility that had fall mats and 6 residents with pressure alarms at risk for falls and injuries. Findings include: Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Physician order [REDACTED]. Review of Resident #1's Admission MDS dated [DATE] revealed her decision-making was severely impaired, she had inattention and disorganized thinking; altered level of consciousness and psychomotor retardation, needed extensive assistance with all ADL's and was incontinent of bowel and bladder. Review of Resident #1's Care Plan dated 02/17/16 revealed, .Problem: Falls. Resident has a potential for falls and is a risk for increased falls as evidenced by: recent falls that resulted in a fractured hip prior to admission. Pressure alarm as ordered . Review of Resident #1's Care Plan dated 02/27/16 revealed, .Problem: .I am at risk for pain related to a prior fractured (hip) due to aftercare of hip fracture .Approach: .pressure alarm while in high back w/c .pressure pad alarm while in bed and up in w/c, floor mat at bedside . Review of Resident #1's Care Plan dated 03/01/16 revealed, .Problem; .I am at risk for episodes of anxiety and receive anti-anxiety medication as needed. I am at risk for falls . Review of Resident #1's Care Plan dated 03/16/16 revealed, .Problem .I receive anti-depressant medication, which puts me at risk for falls and adverse reactions . In an interview on 4/19/2016 at 9:55 am the interim administrator said that Resident #1 was currently in the hospital due to a broken hip. Review of the facility's Incident/Accident Report dated 04/14/16 at 4:38 p.m. revealed, .Equipment involved .wheelchair, beds, floor .Heard a yell from room 49. Walked into room with aides and found Res between her wheelchair and her roommates bed. S/S of fracture noted to L (left) leg . Review Resident #1's Nurse's Notes dated 04/14/16 at 4:38 p.m. revealed, .Found res (resident) between her w/c and her roommate's bed .attempting to transfer from bed to w/c . Review of the facility's Interview Worksheet dated 04/14/16 revealed CNA A's statement regarding Resident #1 read, .I heard a yell went quickly to see who it was and what happened and resident was on the floor . In an interview on 04/19/16 at 11:40 a.m., CNA A said she was working on the day of the incident (04/14/16) and heard a scream and went to room Resident #1's room and saw Resident #1 on the floor. CNA A said she waited for the nurse to assess the resident, and Resident #1 pulled up her pant leg and there was a knot at the top of her leg. CNA A said Resident #1's seat belt alarm was in her wheelchair, but that Resident #1 had been in bed prior to her fall. CNA A said Resident #1 only had one alarm that was used in both her wheelchair and bed. In an interview on 04/19/2016 at 12:05 pm, Physician A confirmed that Resident #1 had sustained a broken hip. In an interview on 04/19/16 at 3:00 p.m., LVN A said the CNAs were responsible for making sure the pressure alarms were transferred from bed to chair or vice versa when a resident transferred. LVN A said nursing staff were now responsible for checking and documenting that pressure alarms were on and functioning every two hours since Resident #1 fell and broke her hip. Record review on 04/19/2016 at 3:00 p.m. with LVN A of the tab alarm/fall mat log revealed that the documentation on the log was complete. In an interview on 04/19/16 at 3:10 p.m., RN A said she was told by LVN B that Resident #1's fall mat was left in the room across the hall. She said Resident #1's pressure alarm was left in her wheelchair when she was put in bed. RN A said the facility was 'honest' and reported their failure. In an interview on 04/19/16 at 3:15 a.m., LVN B said Resident #1 was moved to the secure unit the evening of 04/13/16 by facility staff and placed in a room. She said the next day, Resident #1 was moved across the hall, but staff that moved her did not move her fall mat at that time. LVN B said whoever transfers a resident with a pressure alarm was responsible for ensuring the pressure alarm went with the resident as part of the transfer, but that Resident #1's pressure alarm was found in her wheelchair after she fell getting out of her bed. LVN B said the pressure alarm was initiated at the request of therapy because Resident #1 was impulsive and would get up without calling for assistance. In an interview on 04/19/16 at 5:30 p.m., LVN C said she was on duty when Resident #1 fell . LVN C said on 04/14/16, Resident #1 had worked with therapy, and that the therapist put Resident #1 back to bed about 20 minutes before she was found on the floor. She said the pressure alarm was found in Resident #1's wheelchair, and that her fall mat was found in the room across the hall. In an interview on 04/19/16 at 3:20 p.m., LVN B said the facility did not have policies on pressure alarms or fall mats. LVN B said these items were used as nursing interventions. Review of a list provided by the facility 04/19/16 revealed 6 residents with orders for fall mats and 7 residents with orders for pressure alarms, including Resident #1, who had orders for both items.

Based on observation, interview and record review, the facility failed to ensure 1 of 10 residents (Resident #1) reviewed for Abuse had the right to be free from verbal and mental abuse. Resident #1 was verbally and mentally abused by the Administrator, and was not protected by the facility during the investigation of abuse. Resident #1 was taken out of the facility by VPCS A and RNC A to meet with the alleged perpetrator (the Administrator) during the investigation of abuse. Resident #1 was coerced into allowing the Administrator to return to the facility, and into withdrawing his complaint to D.A.D.S. (Department of Aging and Disability Services). Resident #1 became suicidal, expressed fear she screamed at me like a monster, and he experienced nightmares. Resident #1 experienced psychological harm and was hospitalized due to continued fear. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/29/15. While the IJ was removed effective 9/30/15, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #1 experienced psychological harm and was hospitalized due to continued fear. This failure had the potential to affect all 68 residents by putting them at risk for verbal and mental abuse, psychological distress, and fear of retaliation. Findings Included: Record review of Resident #1's Admission Record dated 9/28/15 revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. He was discharged to Psychiatric Hospital A on 9/26/15 at 4:30 p.m. He was admitted with the following Diagnoses: [REDACTED]. Record review of Resident #1's Admission MDS 3.0 (Minimum Data Set) dated 9/5/15 revealed he did not have any conditions related to ID/DD (Intellectual Disability/ Developmental Disability) status. In Section B: Hearing, Speech, and Vision he had clear speech, was able to make himself understood, and has a clear comprehension of the ability to understand others. In Section C: Cognitive Status, he scored a 10 of 15 on the BIMS (Brief Interview for Mental Status) indicating he was moderately cognitively impaired. In Section H: Bladder and Bowel, Resident #1 was always continent of bowel and bladder. Record review of Resident #1's care plan dated 9/28/15 revealed the following: Category: Cognitive Loss/Dementia .Approach .Allow me time to voice my concerns .Observe me for signs and symptoms of frustration and anxiety; change activity if observed. If I am having an episode of anxiety or agitation, gently calm and refocus my attention .Please use eye contact and use words such as Do and Let's. Try not to use words such as Don't. I am a smoker .Approach Start Date 8/31/2015 .inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. I exhibit signs and symptoms of depression. I receive anti-depressant medication Approach .attempt to determine the cause of my upset and resolve if possible. Record review of Resident #1's Attachment 'K' Smoking, signed by Resident #1 on 8/31/15, revealed the following: .we must also respect the rights of those residents and employees who choose to smoke. It is not our intent to establish a smoking policy based on moral judgments, or to deny one group of residents or employees rights over another .Certain smoking restrictions apply to our residents and visitors. The facility will supervise all resident smoking for the safety of all residents and employees .All resident smoking paraphernalia must be checked in with the nurse. The policy did not specifically address supervised smoking when a resident is out on therapeutic pass. Record review of Resident #1's Durable Power of Attorney dated 9/10/15 revealed Resident #1 designates his sister as his Durable Power of Attorney for Healthcare if he is unable to make the decision himself. Record review of Resident #1's Social Services note dated 9/09/15 at 3:00 p.m. revealed the following: Resident alert. He states he was living on his own in an apt. but decided to move to the facility because he is not able to care for himself. He states he has numbness in his hands, legs, feet .Resident wears glasses. He states he has no problem with his hearing. He communicates well. He states he went to 10th grade and was always in Special Ed. Classes. He reports he received MHMR (Mental Health Mental [MEDICAL CONDITION]) services while living in community .Resident states he doesn't think he will need MHMR services in facility. Record review of Resident #1's Social Services note dated 9/16/15 at 9:31 a.m. revealed the following: He (Resident #1) bought cigarettes at corner store then proceeded to smoke in front of restaurant next door to facility. Restaurant has outdoor tables. Resident states he was approached by Administrator as she was driving to the facility and asked to put out cigarette and return to the facility. Staff reports he became angry and wanted to call STATE .He stated to SW that at one point when discussing smoking privileges, which are different than facility's rules on smoking, Administrator stated then maybe you don't belong here. SW did ask Administrator if she did make that statement to resident. Admin. reports she did not. Record review of Resident #1's Social Services note dated 9/17/15 at 10:13 a.m. revealed the following: Ombudsman returned call. SW explained the situation with resident. Ombudsman did state that resident (he is responsible for self) while signed out of facility, should be able to smoke anywhere he wants. Ombudsman also stated to SW that resident had also contacted her office and it sounded as if there was more involved than just the smoking question. SW did find out that resident was very upset about the manner in which he had been approached/spoken to about his smoking. He believed Administrator had been rude to him. He did contact the Compliance line .Thursday, late afternoon Resident came to SW's office and asked if SW knew where ADON was. Resident stated that ADON had told him Administrator had left the building but her office door was open and he knew she was back in the building. Resident was crying and upset .Resident was crying and asked if Administrator was in the building. ADON stated to him that Administrator was not in building but RNC A was in the building and using Administrator's office .Administrator was not in building. Record review of Resident #1's Social Services note dated 9/22/15 revealed the following: SW completing GDS (Geriatric Depression Scale), BIMS (Brief Interview for Mental Status), and Mini Mental Exam in Marketing office, when RNC A walked into office and asked resident that since he wanted to retract his complaint (pertaining to Administrator) to DADS, would he like to go ahead and call, RNC A had her cell phone and number already dialed and ready for resident to call. 1st number dialed was not correct number; she left marketing office, obtained correct number and came back with cell phone so that resident could contact DADS and retract complaint. While RNC A was gone, SW did ask resident if that is what he wanted to do. He hesitated and SW explained to him that he needed to do whatever he truly wanted to do. He stated that yes he had told them that he would call and retract statement. After call he gave nurse her phone back and said well that didn't go well. Nurse asked why and he stated that he was told that they could not drop complaint and they would have to investigate it . Additional Info: .SW asked resident how he felt about what had just occurred. He stated, I feel as if I am being pushed into something I don't want to do. Once again, SW stated to him that he needed to do what he wanted to do not what somebody else wanted him to do. He asked SW what he should tell State; SW responded with tell them the truth. Record review of Resident #1's Nurses Notes revealed the following: 9/12/15 1:00 p.m. alert & (and) oriented, cont of B+B (Bowel and Bladder) .able to make needs known. 9/16/15 8:40 a.m. signed by LVN A Res'd (Resident #1) signed out at 8:00 a.m. Admin .on way to work et (and) seen res'd at restaurant smoking. She asked res'd to come back to facility. Administrator spoke with this nurse et stated resds cannot smoke even if they sign out. Res'd came back to facility at 8:25 a.m. This nurse asked res'd where he got cigarettes et he stated from the nurse that let me sign out. This nurse informed res'd when he signs out, he is unable to smoke per the Administrator. Res'd began yelling I'll go tell that [***] its my right. I can sign out et smoke if I want to. Its none of her business what I do if I sign out. Res'd directed to admins office. Res'd cont (continued) to yell, that ' s my right to smoke if I sign out The Administrator stated if you are a supervised smoker here, you are a supervised smoker when you are signed out. If something happens to you signed out smoking I am still responsible for you, Res'd stated its my right et I will call state. The Administrator stated go ahead et call them et they will tell you the same thing.The Administrator stated You won't talk to me like that et with that tone. Res'd stated I'm telling you its my right to smoke if I'm signed out. The Administrator stated well maybe this is not the place for you. 9/26/15 10:00 a.m signed by LVN A Resds (Resident's) friend here upset d/t (due to) res'd telling her he told nurse night before last he tried to kill himself in shower .Res'd states I didn't try, I told the nurse I wanted to et the nurse stated You don't need to talk like that or they will put you some place according to res'd. This nurse called DON. Res'd placed on Q15 min check's for suicidal ideation. 9/26/15 10:30 a.m. signed by LVN A on call MD paged et notified of suicidal thoughts .MHMR here to eval. 9/26/15 12:45 p.m. signed by the DON The MHMR representative states pt is unsafe at facility d/t (due to) environmental stressors et that he needed moved immediately. Record review of Resident #1's physician telephone order dated 9/26/15 at 4:00 p.m. revealed Psychiatric Hospital A to eval et (and) treat. Record review of Resident #1's Release of Responsibility for Leave of Absence,' in the sign-out book at the nurse's station, revealed Resident #1 signed himself out on 9/16/15 at 8:00 a.m. and signed himself back in at 8:25 a.m. The Release of Responsibility for Leave of Absence also included a statement I, the undersigned, hereby accept responsibility Resident #1 while away from (Nursing Facility) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away. I understand that a bed will be reserved for the above-named resident/patient when he returns on or before the appointed date and time. Record review of documents from Psychiatric Hospital A dated 9/26/15: Adult Integrated Assessment: Suicidal: Indicator (s): Plan to Hang Self Intake Assessment: Legal Guardian: Self Adult Presenting problem: XXX[AGE] year old male reported to his nurse at nursing home he would hang himself at the shower .Pt. is having conflict with an Administrator Special Needs: Learning Disability, Bathing Assistance, Cognitive Impairment Suicide Risk Assessment: the lady at the nursing home made me depressed. I don't know, I was just trying to get out of the situation. Physician's Preadmission Examination Orders and Preliminary Plan of Care Diagnoses: [REDACTED]. Psychiatric Evaluation: 39 y/o (year old) mentally delayed man who presents to hospital with depression .Depression precipitated by decrease autonomy at nursing home .cites frequent disagreements with nursing home administrator .and her deprecating statements you don't need to be here. Currently lives in nursing home d/t (due to) mental learning disability. Mental capacity of 13 y/o per history .11 grade education .support system consists of Sister and nursing home staff . with a reviewing physician signature signed 9/28/15. 9/28/15 Physician Daily Progress Note pt speaks of situation that led to his admission 'I was just frustrated' - states did not plan or intend to hurt himself. Observations on 9/27/15 at 11:37 a.m. and on 9/28/15 at 1:30 p.m. revealed Resident #1 was not in the facility. Observation and Interview on 9/29/15 at 9:25 a.m. revealed Resident #1 in a small conference room at Psychiatric Hospital A. He was alert and oriented, in blue paper scrubs, appearing ungroomed and disheveled. He was in a wheelchair for mobility. Resident #1 said that he was his own responsible party. He said he signed out of the facility (9/16/15) to go down to the convenience store. He said he spoke with a nurse who gave him his cigarettes and lighter. Resident #1 said he stopped at a Mexican food restaurant across from the park to smoke a cigarette. He said that the Administrator pulled up and yelled at him saying he could not be out smoking and he had 5 seconds to get back to the facility. Resident #1 said when he got back to the facility LVN A said that she got in trouble due to him signing himself out with his cigarettes. He said they went to the Administrator's office and the Administrator was very angry. Resident #1 said the Administrator said he could not sign out with his cigarettes unless he was accompanied by someone else. He said the Administrator screamed I don't think you belong here. He said it made him feel very upset. Resident #1 said he could not eat lunch because he was very upset. He said he had nightmares about the way the Administrator had talked to him, and he was really hurt and afraid. (During the interview process Resident #1 became tearful while discussing the treatment by the Administrator.) Resident #1 said the Ombudsman came to see him and Corporate told Administrator she had to leave the building. Resident #1 said Corporate RNC A asked him if he wanted to go with her to a local fast-food restaurant and get something to drink (9/22/15). He said before he could go he had to put a diaper on .they put it on over his underwear. Resident #1 said RNC A did not want him to have an accident in her new car. He said it made him feel bad and very much embarrassed. (He was tearful while discussing his embarrassment of being asked to put a brief on to ride in RNC A's vehicle.) Resident #1 said they drove down the road and RNC A said I have to be honest, we are meeting VPCS A and the Administrator there. Resident #1 said he told RNC A No, I want to go home. Resident #1 said he was afraid the Administrator was going to hurt him. He said RNC A stopped at another local fast-food restaurant to get them drinks and texted someone. Resident #1 said by the time they arrived back at the facility VPCS A was there. He said VPCS A said the Administrator is crying and upset about how she treated you .she has not eaten in days. Resident #1 said he felt sad and VPCS A said he should talk to the Administrator. He said VPCS A convinced him because he felt sorry for the Administrator. He said he agreed to go to a local burger place with VPCS A and RNC A and meet with the Administrator. Resident #1 said he got a bacon cheeseburger with fries. He said he asked the Administrator if she wanted anything and she said no, I haven't eaten in 4 days. He said RNC A, VPCS A, and the Administrator were talking to each other not to him. Resident #1 said the Administrator said she was sorry and it wouldn't happen again. He said he could tell they were all friends; they were all talking amongst themselves and not to him. Resident #1 said he felt scared and didn't want anyone starving because of him. Resident #1 said he felt ashamed. He said they asked him if the Administrator could come back to the nursing home in front of the Administrator, and he told them I guess so. (Resident #1 became tearful again while discussing how he felt during his encounter with RNC A, VPCS A, and the Administrator at a local burger place.) He said later RNC A came in when he was with Social Worker A and asked if he was ready to call D.A.D.S. and drop the complaint. He said RNC A pulled out her phone and said here let me dial D.A.D.S. for you. Resident #1 said RNC A dialed the number, and he tried to drop the complaint. He said D.A.D.S. would not let him drop the complaint, and that was the last time he saw RNC A. He said this was not the first incident with the Administrator. Resident #1 said she speaks to me like a dog with fleas. Resident #1 said the Administrator got mad at him, due to Resident #1 having diarrhea on himself in bed after drinking Milk of Magnesia (9/11/15). He said he went on himself again and a CNA told him that they would get him cleaned up in a bit. Resident #1 said he had already taken Trazadone and fell asleep. He said he slept in it all night long. He said his privates were burning. He said he wanted a shower. He said the staff told him no not until breakfast. Resident #1 said then everyone was in a meeting and he was burning and hurting. He said he did not get it changed until 10:30 a.m. and they had to wet him with the shower head because it was dried onto his skin. He said his sister went to the Administrator about this and the Administrator said he whines about every little thing. He said he is still scared of the Administrator, and he does not want to be around the Administrator by himself ever. He said he talked to MHMR .to other people .some liked her some disliked her. Resident #1 said he felt pulled in the middle .he felt like he wanted to kill himself, due to being pulled in the middle. He said when he felt like this (9/26/15) he told his friend who told LVN A, and MHMR got there. He said he told her everything. Resident #1 said he felt ganged up on by VPCS A, RNC A, and the Administrator. He said he wanted to discharge today, and wants to go home (the facility), but he is still hurt and scared of the Administrator. Resident #1 said he feels the whole thing was a set up to get the Administrator back. He said he felt scared to say he didn't want the Administrator back in front of the Administrator, RNC A, and VPCS A. He said he felt there was no one on his side .only the Administrator's side. He said he was unsure if the Administrator would physically harm him, but she screamed at him like a monster. He said first she was nice, then turned into a monster. Resident #1 said it was not fair to have to move somewhere else due to the Administrator being there. Resident #1 said he has friends and family there. He does not want to leave and go to another place a lot of people treat him good. He said the Administrator made up a lie, and said she was worried he was going to catch the school on fire when he was smoking at the Mexican restaurant, but the Mexican restaurant is nowhere near the school about three blocks from the school. In an interview on 9/28/15 at 2:15 p.m., LVN A said that she was there when the incident occurred on 9/16/15 in the Administrator's office; she said that she was in the room with the Administrator, LVN B, and Resident #1. She said she had been working at the facility for three years. She said that the Administrator came into work and said Resident #1 is next door smoking at the Mexican restaurant, and that she told him to come back to the facility. LVN A said Resident #1 came back to the facility saying that's my right regarding smoking at the Mexican restaurant. LVN A said that she went in to the Administrator's office with the LVN B and Resident #1. LVN A said Resident #1 continued to say that's my right, but the Administrator would not listen to him. LVN A said the Administrator got mad and lost her temper. LVN A said the Administrator said to Resident #1 you don't belong here. LVN A said the Administrator had her finger pointed in his face .she was real loud and ugly. LVN A said it was abusive, referring to the Administrator's behavior towards Resident #1, and the Administrator threatened the resident. LVN A said she was retaliated against for reporting the abuse of Resident #1 by the Regional Nurse Consultant (RNC A) and the Vice President of Clinical Operations (VPCO). LVN A said on Tuesday, 9/22/15, RNC A told her to go put a brief on Resident #1, because she was taking him in her personal vehicle to go get a coke. LVN A said I asked her why he's (Resident #1) not incontinent. LVN A said RNC A said to her I do not want him (Resident #1) to have diarrhea in my brand new car. LVN A said she went to Resident #1 and helped him put on a brief, but I did not want to do it. She said that she helped put the brief on Resident #1, because they had been interrogating her. She said I thought that was wrong .it's wrong, referring to the situation with the Administrator and the incident with RNC A. LVN A said that Resident #1 told her later that day after he went and got a coke that RNC A wanted him to meet the Administrator there and that he told RNC A no. LVN A said later that same day, VPCS A said to LVN A that she wanted to see if Resident #1 wanted a burger and put Resident #1in her car. LVN A said she was working on Saturday 9/26/15 when Resident #1's friend came in to the facility and told her that Resident #1 had told her that he wanted to kill himself. LVN A said she asked Resident #1 if he was suicidal, and Resident #1 said No but I wish I would die. LVN A said she immediately called the DON. She said that she felt like it was unsafe for Resident #1 to be in the facility with the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN A on 9/30/15 confirmed the details in the interview with LVN A. In an interview on 9/28/15 at 3:07 p.m. LVN B said that she had been working at the facility since 2011. She said that the Administrator has been working at the building for 6 weeks. She said on 9/16/15 she got paged to the Administrator's office, and said that the Administrator told her that she saw Resident #1 smoking at the Mexican restaurant on her way to work. LVN B said the Administrator told her Resident #1 did not have his glasses on, and he said to the Administrator who are you? LVN B said the Administrator told her she said to Resident #1 that he cannot smoke unsupervised even if it is off property. LVN B said Resident #1 returned to the facility, and he said I have rights I can sign myself out. LVN A was in hall and they came into the Administrator's office. LVN B said that the Administrator said yes, you have rights but you can't smoke unsupervised. LVN B said that Resident #1 said I thought I was responsible for myself once I signed out. LVN B said that Resident #1 was frustrated, but lowered his voice when the Administrator asked him to lower his voice. LVN B said Resident #1 kept saying that he has rights. She said the Administrator raised her voice, and her tone was angry. LVN B said the Administrator pointed her finger in his face. She said she said to Resident #1 maybe this is not the place for you, in a threatening manner. LVN B said I felt like she was being verbally abusive. LVN B said I would never talk to them like that. She said my mind was shocked about her behavior. She said Resident #1 asked her to call his sister and the Ombudsman. She said that was it that day, and that night Resident #1 asked for the corporate compliance line. LVN B said the next day (9/17/15) that Resident #1 came to her and said it made me feel like I was mentally abused, referring to the Administrator's behavior. LVN B said until Resident #1 said it to her, she realized that it was abuse, and she was still in shock from the incident. LVN B said she immediately reported in to the DON, and that someone from corporate was going to handle it. The Administrator was told to leave. She said RNC A came down that Thursday (9/17/15), and Monday (9/21/15) VPCS A and RNC A were asking the staff questions. She said Tuesday (9/22/15) RNC A took Resident #1 to her a drink; she said Resident #1 was asked to put on a brief so he did not mess in the car. She said VPCS A and RNC A took him to lunch in a personal vehicle. LVN B said later that day Resident #1 told her that they took him to meet the Administrator. LVN B said she asked Resident #1 what changed your mind, and he said to her that they kept asking him to meet with her, and they asked him in front of the Administrator if she could come back. LVN B said Resident #1 told her that he said yes, because she (the Administrator) was sitting right there .she scares me. LVN B said Resident #1 told her he felt bribed. She said that he told her when she took him to Psychiatric Hospital A that he said he wanted to come back to the facility, but he was scared of the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN B on 9/28/15 confirmed the details in the interview with LVN B and revealed the following: I was asked to read the nn's (nurse's notes) I read them I was in ADM office. After I read the nn's the Administrator stated I didn't say that about him I never said maybe this isn ' t the place for you then I stated yes you did the Administrator stated I don't remember saying that I must have been that mad I don't remember it.Later that afternoon RNC A came to investigate she asked me if I felt like DON was feeding Resident #1 information to get rid of the Administrator. I stated no the DON wasn't around when everything happened .RNC A asked me if I was comfortable saying if it was abusive or not. I stated well it's never easy to say someone is abusive, but yes it was she crossed the line when she made him feel like he wasn ' t wanted here. She also crossed the line shaking her finger at him. I was not interviewed again until the following Monday 9/21/15 I was interviewed by VPCS A. She asked me if I could define mental abuse I stated it's when someone feels degraded, to feel bad about themselves, belittled, humiliated. She stated OK she asked me if I feel like the Administrator should be fired I stated I don't know that ' s not up to me. She then asked me ok if it were one of your CNA's would you want them to continue to work here. I stated no, not if they couldn't control themselves. If you do it once whats to stop you from doing it again. VPCS A then asked me if Resident #1 had any psych DX I stated no, not that I'm aware of she then asked me Is he a trouble maker? I stated no, he is very timid et meek.VPCS A asked me if I felt it was abusive why didn't I report it Wednesday .I stated I really couldn't understand what happened I couldn't process it .She stated ok so at first you weren't sure if it was abusive .I said I really didn't know what to think when Resident #1 came in my office Thursday morning and I heard him saying the words it clicked oh my gosh it is abusive this was before he stated he felt mentally abused. She asked me if I felt comfortable reporting Abuse to Corporate I stated No, I feel like I will be retaliated against. VPCS A stated no you weren't you can trust us. The rest of the Witness Statement corresponds with the Interview with LVN B. In an interview on 9/27/15 at 8:40 a.m., the MHMR representative said that Resident #1 is currently at Psychiatric Hospital A. She said she went to the facility on [DATE] to assess the resident as she was called that he was suicidal. She said Resident #1 is very smart. She said that she had worked with Resident #1 for 9 years, and this behavior was unusual for him, and I believe him. She said Resident #1 said that the Administrator had threatened him, and yelled at him saying maybe you don't belong here. The MHMR representative said when she saw Resident #1 on Saturday, 9/26/15, he was so light-headed .all he wanted to do was get away from them, referring to the Administrator, RNC A, and VPCS A. She said that the staff told her that the Administrator was put on leave, but the Administrator arranged to have 2 people RNC A and VPCS A entice Resident #1 to go with them to meet with them, previously that week. The MHMR representative said they made Resident #1 put diapers over his pants to not soil RNC A's car, under the premise to get a coke. The MHMR representative said Resident #1 told her that RNC A said while he was in the car, that the Administrator was waiting for them at the local fast-food restaurant. The MHMR representative said Resident #1 told RNC A he did not want to see go. She said then later that same day VPCS A and RNC A take him to a local burger place to meet with the Administrator. The MHMR representative said that Resident #1 does not have any teeth, is diabetic .and they buy him a cheeseburger. The MHMR representative said Resident #1 said that the Administrator starting telling him she has been feeling sick and starts apologizing to Resident #1. The MHMR representative said Resident #1 told her he felt trapped with 3 women pressuring him. She said the situation with the Administrator lead him to his suicidal situation. She said Resident #1 said that the Administrator came back prior to the D.A.D.S. investigation on Thursday, 9/24/15. She said Resident #1 told her she came up behind him tapped him on the shoulder and rubbed his shoulders. The MHMR representative said Resident #1 told her I'm scared of her. The MHMR representative said Resident #1 had told his friend Helen that he wanted to kill himself and hang himself in the shower. The MHMR representative said that the DON called the Crisis line, and she went to assess him. She said that she got him into the psychiatric hospital and told the staff I'm not leaving here until he is out of this facility. The MHMR representative said I stayed until I saw Resident #1 on the van .I verified his arrival. In an interview on 9/27/15 at 11:37 a.m. RN A said that she was the weekend RN. She said that she felt like a resident (Resident #1) was .coerced by RNC A and VPCS A. She said RNC A and VPCS A took him out to eat, and made one of the nurses put a diaper on him for him to sit in her car. RN A said LVN A was the one that put the brief on him for RNC A. She said Resident #1 is afraid of the Administrator. The Administrator was suspended. She said that she was yelled at by his friends .he (Resident #1) was trying to tie his sheets and hang himself on Saturday (9/26/15). RN A said Resident #1 was taken away from the facility, and then told to cancel his complaint. In an interview on 9/27/15 at 12:01 p.m. the DON said she had been working at the facility for almost a year. She said that she was staying at the facility for Resident #1. She said the Administrator raised her voice, and shook her finger at Resident #1 over the smoking rules on the morning of (9/16/15). The DON said the Administrator said to Resident #1 maybe you don't belong here. She said she was not in the room when this occurred, but LVN A, LVN B, Resident #1, and the Administrator were all in the room together. She said initially they referring to LVN A and LVN B did not think it was abuse, but said they were in shock, and it was not appropriate, referring the Administrator's behavior towards Resident #1. She said the next day they realized it was verbal abuse, and LVN B came to her (9/17/15). The DON said she texted Corporate the accusation of Abuse and started interviewing Resident #1. She said that the Administrator was suspended, and RNC A came down to the facility. She said RNC A took Resident #1 out to get a coke on 9/22/15. The DON said RNA A and VPCS A said they were taking him out for lunch to a local burger place (9/22/15). The DON said Resident #1 was afraid of the Administrator. The DON said that

Based on interview and record review the facility failed to ensure allegations of verbal and mental abuse were thoroughly investigated and to prevent further potential abuse while the investigation was in progress for 1 of 10 residents (Resident #1) reviewed for Abuse as evidenced by: Resident #1 was verbally and mentally abused by the Administrator, and was not protected by the facility during the investigation of abuse. Resident #1 was taken out of the facility by VPCS A and RNC A to meet with the alleged perpetrator (the Administrator) during the investigation of abuse. Resident #1 was coerced into allowing the Administrator to return to the facility, and into withdrawing his complaint to D.A.D.S. (Department of Aging and Disability Services). Resident #1 became suicidal, expressed fear she screamed at me like a monster, and he experienced nightmares. Resident #1 experienced psychological harm and was hospitalized due to continued fear. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/29/15. While the IJ was removed effective 9/30/15, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #1 experienced psychological harm and was hospitalized due to continued fear. This failure had the potential to affect all 68 residents by putting them at risk for verbal and mental abuse, psychological distress, and fear of retaliation. Findings Included: Record review of Resident #1's Admission Record dated 9/28/15 revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. He was discharged to Psychiatric Hospital A on 9/26/15 at 4:30 p.m. He was admitted with the following Diagnoses: [REDACTED]. Record review of Resident #1's Admission MDS 3.0 (Minimum Data Set) dated 9/5/15 revealed he did not have any conditions related to ID/DD (Intellectual Disability/ Developmental Disability) status. In Section B: Hearing, Speech, and Vision he had clear speech, was able to make himself understood, and has a clear comprehension of the ability to understand others. In Section C: Cognitive Status, he scored a 10 of 15 on the BIMS (Brief Interview for Mental Status) indicating he was moderately cognitively impaired. In Section H: Bladder and Bowel, Resident #1 was always continent of bowel and bladder. Record review of Resident #1's care plan dated 9/28/15 revealed the following: Category: Cognitive Loss/Dementia .Approach .Allow me time to voice my concerns .Observe me for signs and symptoms of frustration and anxiety; change activity if observed. If I am having an episode of anxiety or agitation, gently calm and refocus my attention .Please use eye contact and use words such as Do and Let's. Try not to use words such as Don't. I am a smoker .Approach Start Date 8/31/2015 .inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. I exhibit signs and symptoms of depression. I receive anti-depressant medication Approach .attempt to determine the cause of my upset and resolve if possible. Record review of Resident #1's Attachment 'K' Smoking, signed by Resident #1 on 8/31/15, revealed the following: .we must also respect the rights of those residents and employees who choose to smoke. It is not our intent to establish a smoking policy based on moral judgments, or to deny one group of residents or employees rights over another .Certain smoking restrictions apply to our residents and visitors. The facility will supervise all resident smoking for the safety of all residents and employees .All resident smoking paraphernalia must be checked in with the nurse. The policy did not specifically address supervised smoking when a resident is out on therapeutic pass. Record review of Resident #1's Durable Power of Attorney dated 9/10/15 revealed Resident #1 designates his sister as his Durable Power of Attorney for Healthcare if he is unable to make the decision himself. Record review of Resident #1's Social Services note dated 9/09/15 at 3:00 p.m. revealed the following: Resident alert. He states he was living on his own in an apt. but decided to move to the facility because he is not able to care for himself. He states he has numbness in his hands, legs, feet .Resident wears glasses. He states he has no problem with his hearing. He communicates well. He states he went to 10th grade and was always in Special Ed. Classes. He reports he received MHMR (Mental Health Mental [MEDICAL CONDITION]) services while living in community .Resident states he doesn't think he will need MHMR services in facility. Record review of Resident #1's Social Services note dated 9/16/15 at 9:31 a.m. revealed the following: He (Resident #1) bought cigarettes at corner store then proceeded to smoke in front of restaurant next door to facility. Restaurant has outdoor tables. Resident states he was approached by Administrator as she was driving to the facility and asked to put out cigarette and return to the facility. Staff reports he became angry and wanted to call STATE .He stated to SW that at one point when discussing smoking privileges, which are different than facility's rules on smoking, Administrator stated then maybe you don't belong here. SW did ask Administrator if she did make that statement to resident. Admin. reports she did not. Record review of Resident #1's Social Services note dated 9/17/15 at 10:13 a.m. revealed the following: Ombudsman returned call. SW explained the situation with resident. Ombudsman did state that resident (he is responsible for self) while signed out of facility, should be able to smoke anywhere he wants. Ombudsman also stated to SW that resident had also contacted her office and it sounded as if there was more involved than just the smoking question. SW did find out that resident was very upset about the manner in which he had been approached/spoken to about his smoking. He believed Administrator had been rude to him. He did contact the Compliance line .Thursday, late afternoon Resident came to SW's office and asked if SW knew where ADON was. Resident stated that ADON had told him Administrator had left the building but her office door was open and he knew she was back in the building. Resident was crying and upset .Resident was crying and asked if Administrator was in the building. ADON stated to him that Administrator was not in building but RNC A was in the building and using Administrator's office .Administrator was not in building. Record review of Resident #1's Social Services note dated 9/22/15 revealed the following: SW completing GDS (Geriatric Depression Scale), BIMS (Brief Interview for Mental Status), and Mini Mental Exam in Marketing office, when RNC A walked into office and asked resident that since he wanted to retract his complaint (pertaining to Administrator) to DADS, would he like to go ahead and call, RNC A had her cell phone and number already dialed and ready for resident to call. 1st number dialed was not correct number; she left marketing office, obtained correct number and came back with cell phone so that resident could contact DADS and retract complaint. While RNC A was gone, SW did ask resident if that is what he wanted to do. He hesitated and SW explained to him that he needed to do whatever he truly wanted to do. He stated that yes he had told them that he would call and retract statement. After call he gave nurse her phone back and said well that didn't go well. Nurse asked why and he stated that he was told that they could not drop complaint and they would have to investigate it . Additional Info: .SW asked resident how he felt about what had just occurred. He stated, I feel as if I am being pushed into something I don't want to do. Once again, SW stated to him that he needed to do what he wanted to do not what somebody else wanted him to do. He asked SW what he should tell State; SW responded with tell them the truth. Record review of Resident #1's Nurses Notes revealed the following: 9/12/15 1:00 p.m. alert & (and) oriented, cont of B+B (Bowel and Bladder) .able to make needs known. 9/16/15 8:40 a.m. signed by LVN A Res'd (Resident #1) signed out at 8:00 a.m. Admin .on way to work et (and) seen res'd at restaurant smoking. She asked res'd to come back to facility. Administrator spoke with this nurse et stated resds cannot smoke even if they sign out. Res'd came back to facility at 8:25 a.m. This nurse asked res'd where he got cigarettes et he stated from the nurse that let me sign out. This nurse informed res'd when he signs out, he is unable to smoke per the Administrator. Res'd began yelling I'll go tell that [***] its my right. I can sign out et smoke if I want to. Its none of her business what I do if I sign out. Res'd directed to admins office. Res'd cont (continued) to yell, that ' s my right to smoke if I sign out The Administrator stated if you are a supervised smoker here, you are a supervised smoker when you are signed out. If something happens to you signed out smoking I am still responsible for you, Res'd stated its my right et I will call state. The Administrator stated go ahead et call them et they will tell you the same thing.The Administrator stated You won't talk to me like that et with that tone. Res'd stated I'm telling you its my right to smoke if I'm signed out. The Administrator stated well maybe this is not the place for you. 9/26/15 10:00 a.m signed by LVN A Resds (Resident's) friend here upset d/t (due to) res'd telling her he told nurse night before last he tried to kill himself in shower .Res'd states I didn't try, I told the nurse I wanted to et the nurse stated You don't need to talk like that or they will put you some place according to res'd. This nurse called DON. Res'd placed on Q15 min check's for suicidal ideation. 9/26/15 10:30 a.m. signed by LVN A on call MD paged et notified of suicidal thoughts .MHMR here to eval. 9/26/15 12:45 p.m. signed by the DON The MHMR representative states pt is unsafe at facility d/t (due to) environmental stressors et that he needed moved immediately. Record review of Resident #1's physician telephone order dated 9/26/15 at 4:00 p.m. revealed Psychiatric Hospital A to eval et (and) treat. Record review of Resident #1's Release of Responsibility for Leave of Absence,' in the sign-out book at the nurse's station, revealed Resident #1 signed himself out on 9/16/15 at 8:00 a.m. and signed himself back in at 8:25 a.m. The Release of Responsibility for Leave of Absence also included a statement I, the undersigned, hereby accept responsibility Resident #1 while away from (Nursing Facility) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away. I understand that a bed will be reserved for the above-named resident/patient when he returns on or before the appointed date and time. Record review of documents from Psychiatric Hospital A dated 9/26/15: Adult Integrated Assessment: Suicidal: Indicator (s): Plan to Hang Self Intake Assessment: Legal Guardian: Self Adult Presenting problem: XXX[AGE] year old male reported to his nurse at nursing home he would hang himself at the shower .Pt. is having conflict with an Administrator Special Needs: Learning Disability, Bathing Assistance, Cognitive Impairment Suicide Risk Assessment: the lady at the nursing home made me depressed. I don't know, I was just trying to get out of the situation. Physician's Preadmission Examination Orders and Preliminary Plan of Care Diagnoses: [REDACTED]. Psychiatric Evaluation: 39 y/o (year old) mentally delayed man who presents to hospital with depression .Depression precipitated by decrease autonomy at nursing home .cites frequent disagreements with nursing home administrator .and her deprecating statements you don't need to be here. Currently lives in nursing home d/t (due to) mental learning disability. Mental capacity of 13 y/o per history .11 grade education .support system consists of Sister and nursing home staff . with a reviewing physician signature signed 9/28/15. 9/28/15 Physician Daily Progress Note pt speaks of situation that led to his admission 'I was just frustrated' - states did not plan or intend to hurt himself. Observations on 9/27/15 at 11:37 a.m. and on 9/28/15 at 1:30 p.m. revealed Resident #1 was not in the facility. Observation and Interview on 9/29/15 at 9:25 a.m. revealed Resident #1 in a small conference room at Psychiatric Hospital A. He was alert and oriented, in blue paper scrubs, appearing ungroomed and disheveled. He was in a wheelchair for mobility. Resident #1 said that he was his own responsible party. He said he signed out of the facility (9/16/15) to go down to the convenience store. He said he spoke with a nurse who gave him his cigarettes and lighter. Resident #1 said he stopped at a Mexican food restaurant across from the park to smoke a cigarette. He said that the Administrator pulled up and yelled at him saying he could not be out smoking and he had 5 seconds to get back to the facility. Resident #1 said when he got back to the facility LVN A said that she got in trouble due to him signing himself out with his cigarettes. He said they went to the Administrator's office and the Administrator was very angry. Resident #1 said the Administrator said he could not sign out with his cigarettes unless he was accompanied by someone else. He said the Administrator screamed I don't think you belong here. He said it made him feel very upset. Resident #1 said he could not eat lunch because he was very upset. He said he had nightmares about the way the Administrator had talked to him, and he was really hurt and afraid. (During the interview process Resident #1 became tearful while discussing the treatment by the Administrator.) Resident #1 said the Ombudsman came to see him and Corporate told Administrator she had to leave the building. Resident #1 said Corporate RNC A asked him if he wanted to go with her to a local fast-food restaurant and get something to drink (9/22/15). He said before he could go he had to put a diaper on .they put it on over his underwear. Resident #1 said RNC A did not want him to have an accident in her new car. He said it made him feel bad and very much embarrassed. (He was tearful while discussing his embarrassment of being asked to put a brief on to ride in RNC A's vehicle.) Resident #1 said they drove down the road and RNC A said I have to be honest, we are meeting VPCS A and the Administrator there. Resident #1 said he told RNC A No, I want to go home. Resident #1 said he was afraid the Administrator was going to hurt him. He said RNC A stopped at another local fast-food restaurant to get them drinks and texted someone. Resident #1 said by the time they arrived back at the facility VPCS A was there. He said VPCS A said the Administrator is crying and upset about how she treated you .she has not eaten in days. Resident #1 said he felt sad and VPCS A said he should talk to the Administrator. He said VPCS A convinced him because he felt sorry for the Administrator. He said he agreed to go to a local burger place with VPCS A and RNC A and meet with the Administrator. Resident #1 said he got a bacon cheeseburger with fries. He said he asked the Administrator if she wanted anything and she said no, I haven't eaten in 4 days. He said RNC A, VPCS A, and the Administrator were talking to each other not to him. Resident #1 said the Administrator said she was sorry and it wouldn't happen again. He said he could tell they were all friends; they were all talking amongst themselves and not to him. Resident #1 said he felt scared and didn't want anyone starving because of him. Resident #1 said he felt ashamed. He said they asked him if the Administrator could come back to the nursing home in front of the Administrator, and he told them I guess so. (Resident #1 became tearful again while discussing how he felt during his encounter with RNC A, VPCS A, and the Administrator at a local burger place.) He said later RNC A came in when he was with Social Worker A and asked if he was ready to call D.A.D.S. and drop the complaint. He said RNC A pulled out her phone and said here let me dial D.A.D.S. for you. Resident #1 said RNC A dialed the number, and he tried to drop the complaint. He said D.A.D.S. would not let him drop the complaint, and that was the last time he saw RNC A. He said this was not the first incident with the Administrator. Resident #1 said she speaks to me like a dog with fleas. Resident #1 said the Administrator got mad at him, due to Resident #1 having diarrhea on himself in bed after drinking Milk of Magnesia (9/11/15). He said he went on himself again and a CNA told him that they would get him cleaned up in a bit. Resident #1 said he had already taken Trazadone and fell asleep. He said he slept in it all night long. He said his privates were burning. He said he wanted a shower. He said the staff told him no not until breakfast. Resident #1 said then everyone was in a meeting and he was burning and hurting. He said he did not get it changed until 10:30 a.m. and they had to wet him with the shower head because it was dried onto his skin. He said his sister went to the Administrator about this and the Administrator said he whines about every little thing. He said he is still scared of the Administrator, and he does not want to be around the Administrator by himself ever. He said he talked to MHMR .to other people .some liked her some disliked her. Resident #1 said he felt pulled in the middle .he felt like he wanted to kill himself, due to being pulled in the middle. He said when he felt like this (9/26/15) he told his friend who told LVN A, and MHMR got there. He said he told her everything. Resident #1 said he felt ganged up on by VPCS A, RNC A, and the Administrator. He said he wanted to discharge today, and wants to go home (the facility), but he is still hurt and scared of the Administrator. Resident #1 said he feels the whole thing was a set up to get the Administrator back. He said he felt scared to say he didn't want the Administrator back in front of the Administrator, RNC A, and VPCS A. He said he felt there was no one on his side .only the Administrator's side. He said he was unsure if the Administrator would physically harm him, but she screamed at him like a monster. He said first she was nice, then turned into a monster. Resident #1 said it was not fair to have to move somewhere else due to the Administrator being there. Resident #1 said he has friends and family there. He does not want to leave and go to another place a lot of people treat him good. He said the Administrator made up a lie, and said she was worried he was going to catch the school on fire when he was smoking at the Mexican restaurant, but the Mexican restaurant is nowhere near the school about three blocks from the school. In an interview on 9/28/15 at 2:15 p.m., LVN A said that she was there when the incident occurred on 9/16/15 in the Administrator's office; she said that she was in the room with the Administrator, LVN B, and Resident #1. She said she had been working at the facility for three years. She said that the Administrator came into work and said Resident #1 is next door smoking at the Mexican restaurant, and that she told him to come back to the facility. LVN A said Resident #1 came back to the facility saying that's my right regarding smoking at the Mexican restaurant. LVN A said that she went in to the Administrator's office with the LVN B and Resident #1. LVN A said Resident #1 continued to say that's my right, but the Administrator would not listen to him. LVN A said the Administrator got mad and lost her temper. LVN A said the Administrator said to Resident #1 you don't belong here. LVN A said the Administrator had her finger pointed in his face .she was real loud and ugly. LVN A said it was abusive, referring to the Administrator's behavior towards Resident #1, and the Administrator threatened the resident. LVN A said she was retaliated against for reporting the abuse of Resident #1 by the Regional Nurse Consultant (RNC A) and the Vice President of Clinical Operations (VPCO). LVN A said on Tuesday, 9/22/15, RNC A told her to go put a brief on Resident #1, because she was taking him in her personal vehicle to go get a coke. LVN A said I asked her why he's (Resident #1) not incontinent. LVN A said RNC A said to her I do not want him (Resident #1) to have diarrhea in my brand new car. LVN A said she went to Resident #1 and helped him put on a brief, but I did not want to do it. She said that she helped put the brief on Resident #1, because they had been interrogating her. She said I thought that was wrong .it's wrong, referring to the situation with the Administrator and the incident with RNC A. LVN A said that Resident #1 told her later that day after he went and got a coke that RNC A wanted him to meet the Administrator there and that he told RNC A no. LVN A said later that same day, VPCS A said to LVN A that she wanted to see if Resident #1 wanted a burger and put Resident #1in her car. LVN A said she was working on Saturday 9/26/15 when Resident #1's friend came in to the facility and told her that Resident #1 had told her that he wanted to kill himself. LVN A said she asked Resident #1 if he was suicidal, and Resident #1 said No but I wish I would die. LVN A said she immediately called the DON. She said that she felt like it was unsafe for Resident #1 to be in the facility with the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN A on 9/30/15 confirmed the details in the interview with LVN A. In an interview on 9/28/15 at 3:07 p.m. LVN B said that she had been working at the facility since 2011. She said that the Administrator has been working at the building for 6 weeks. She said on 9/16/15 she got paged to the Administrator's office, and said that the Administrator told her that she saw Resident #1 smoking at the Mexican restaurant on her way to work. LVN B said the Administrator told her Resident #1 did not have his glasses on, and he said to the Administrator who are you? LVN B said the Administrator told her she said to Resident #1 that he cannot smoke unsupervised even if it is off property. LVN B said Resident #1 returned to the facility, and he said I have rights I can sign myself out. LVN A was in hall and they came into the Administrator's office. LVN B said that the Administrator said yes, you have rights but you can't smoke unsupervised. LVN B said that Resident #1 said I thought I was responsible for myself once I signed out. LVN B said that Resident #1 was frustrated, but lowered his voice when the Administrator asked him to lower his voice. LVN B said Resident #1 kept saying that he has rights. She said the Administrator raised her voice, and her tone was angry. LVN B said the Administrator pointed her finger in his face. She said she said to Resident #1 maybe this is not the place for you, in a threatening manner. LVN B said I felt like she was being verbally abusive. LVN B said I would never talk to them like that. She said my mind was shocked about her behavior. She said Resident #1 asked her to call his sister and the Ombudsman. She said that was it that day, and that night Resident #1 asked for the corporate compliance line. LVN B said the next day (9/17/15) that Resident #1 came to her and said it made me feel like I was mentally abused, referring to the Administrator's behavior. LVN B said until Resident #1 said it to her, she realized that it was abuse, and she was still in shock from the incident. LVN B said she immediately reported in to the DON, and that someone from corporate was going to handle it. The Administrator was told to leave. She said RNC A came down that Thursday (9/17/15), and Monday (9/21/15) VPCS A and RNC A were asking the staff questions. She said Tuesday (9/22/15) RNC A took Resident #1 to her a drink; she said Resident #1 was asked to put on a brief so he did not mess in the car. She said VPCS A and RNC A took him to lunch in a personal vehicle. LVN B said later that day Resident #1 told her that they took him to meet the Administrator. LVN B said she asked Resident #1 what changed your mind, and he said to her that they kept asking him to meet with her, and they asked him in front of the Administrator if she could come back. LVN B said Resident #1 told her that he said yes, because she (the Administrator) was sitting right there .she scares me. LVN B said Resident #1 told her he felt bribed. She said that he told her when she took him to Psychiatric Hospital A that he said he wanted to come back to the facility, but he was scared of the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN B on 9/28/15 confirmed the details in the interview with LVN B and revealed the following: I was asked to read the nn's (nurse's notes) I read them I was in ADM office. After I read the nn's the Administrator stated I didn't say that about him I never said maybe this isn ' t the place for you then I stated yes you did the Administrator stated I don't remember saying that I must have been that mad I don't remember it.Later that afternoon RNC A came to investigate she asked me if I felt like DON was feeding Resident #1 information to get rid of the Administrator. I stated no the DON wasn't around when everything happened .RNC A asked me if I was comfortable saying if it was abusive or not. I stated well it's never easy to say someone is abusive, but yes it was she crossed the line when she made him feel like he wasn ' t wanted here. She also crossed the line shaking her finger at him. I was not interviewed again until the following Monday 9/21/15 I was interviewed by VPCS A. She asked me if I could define mental abuse I stated it's when someone feels degraded, to feel bad about themselves, belittled, humiliated. She stated OK she asked me if I feel like the Administrator should be fired I stated I don't know that ' s not up to me. She then asked me ok if it were one of your CNA's would you want them to continue to work here. I stated no, not if they couldn't control themselves. If you do it once whats to stop you from doing it again. VPCS A then asked me if Resident #1 had any psych DX I stated no, not that I'm aware of she then asked me Is he a trouble maker? I stated no, he is very timid et meek.VPCS A asked me if I felt it was abusive why didn't I report it Wednesday .I stated I really couldn't understand what happened I couldn't process it .She stated ok so at first you weren't sure if it was abusive .I said I really didn't know what to think when Resident #1 came in my office Thursday morning and I heard him saying the words it clicked oh my gosh it is abusive this was before he stated he felt mentally abused. She asked me if I felt comfortable reporting Abuse to Corporate I stated No, I feel like I will be retaliated against. VPCS A stated no you weren't you can trust us. The rest of the Witness Statement corresponds with the Interview with LVN B. In an interview on 9/27/15 at 8:40 a.m., the MHMR representative said that Resident #1 is currently at Psychiatric Hospital A. She said she went to the facility on [DATE] to assess the resident as she was called that he was suicidal. She said Resident #1 is very smart. She said that she had worked with Resident #1 for 9 years, and this behavior was unusual for him, and I believe him. She said Resident #1 said that the Administrator had threatened him, and yelled at him saying maybe you don't belong here. The MHMR representative said when she saw Resident #1 on Saturday, 9/26/15, he was so light-headed .all he wanted to do was get away from them, referring to the Administrator, RNC A, and VPCS A. She said that the staff told her that the Administrator was put on leave, but the Administrator arranged to have 2 people RNC A and VPCS A entice Resident #1 to go with them to meet with them, previously that week. The MHMR representative said they made Resident #1 put diapers over his pants to not soil RNC A's car, under the premise to get a coke. The MHMR representative said Resident #1 told her that RNC A said while he was in the car, that the Administrator was waiting for them at the local fast-food restaurant. The MHMR representative said Resident #1 told RNC A he did not want to see go. She said then later that same day VPCS A and RNC A take him to a local burger place to meet with the Administrator. The MHMR representative said that Resident #1 does not have any teeth, is diabetic .and they buy him a cheeseburger. The MHMR representative said Resident #1 said that the Administrator starting telling him she has been feeling sick and starts apologizing to Resident #1. The MHMR representative said Resident #1 told her he felt trapped with 3 women pressuring him. She said the situation with the Administrator lead him to his suicidal situation. She said Resident #1 said that the Administrator came back prior to the D.A.D.S. investigation on Thursday, 9/24/15. She said Resident #1 told her she came up behind him tapped him on the shoulder and rubbed his shoulders. The MHMR representative said Resident #1 told her I'm scared of her. The MHMR representative said Resident #1 had told his friend Helen that he wanted to kill himself and hang himself in the shower. The MHMR representative said that the DON called the Crisis line, and she went to assess him. She said that she got him into the psychiatric hospital and told the staff I'm not leaving here until he is out of this facility. The MHMR representative said I stayed until I saw Resident #1 on the van .I verified his arrival. In an interview on 9/27/15 at 11:37 a.m. RN A said that she was the weekend RN. She said that she felt like a resident (Resident #1) was .coerced by RNC A and VPCS A. She said RNC A and VPCS A took him out to eat, and made one of the nurses put a diaper on him for him to sit in her car. RN A said LVN A was the one that put the brief on him for RNC A. She said Resident #1 is afraid of the Administrator. The Administrator was suspended. She said that she was yelled at by his friends .he (Resident #1) was trying to tie his sheets and hang himself on Saturday (9/26/15). RN A said Resident #1 was taken away from the facility, and then told to cancel his complaint. In an interview on 9/27/15 at 12:01 p.m. the DON said she had been working at the facility for almost a year. She said that she was staying at the facility for Resident #1. She said the Administrator raised her voice, and shook her finger at Resident #1 over the smoking rules on the morning of (9/16/15). The DON said the Administrator said to Resident #1 maybe you don't belong here. She said she was not in the room when this occurred, but LVN A, LVN B, Resident #1, and the Administrator were all in the room together. She said initially they referring to LVN A and LVN B did not think it was abuse, but said they were in shock, and it was not appropriate, referring the Administrator's behavior towards Resident #1. She said the next day they realized it was verbal abuse, and LVN B came to her (9/17/15). The DON said she texted Corporate the accusation of Abuse and started interviewing Resident #1. She said that the Administrator was suspended, and RNC A came down to the facility. She said RNC A took Resident #1 out to get a coke on 9/22/15. The DON said RNA A and VPCS A said they were taking him out for lunch to a

Based on interviews and record review the facility failed to develop and implement written policies and procedures that prohibit abuse of residents for 1 of 10 residents (Resident #1) reviewed for abuse. Resident #1 was verbally and mentally abused by the Administrator, and was not protected by the facility during the investigation of abuse. Resident #1 was taken out of the facility by VPCS A and RNC A to meet with the alleged perpetrator (the Administrator) during the investigation of abuse. Resident #1 was coerced into allowing the Administrator to return to the facility, and into withdrawing his complaint to D.A.D.S. (Department of Aging and Disability Services). Resident #1 became suicidal, expressed fear she screamed at me like a monster, and he experienced nightmares. Resident #1 experienced psychological harm and was hospitalized due to continued fear. These failures resulted in identification of an IJ (Immediate Jeopardy) on 9/29/15. While the IJ was removed effective 9/30/15, the facility remained out of compliance at a severity level of actual harm and a scope of a pattern; due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Resident #1 experienced psychological harm and was hospitalized due to continued fear. This failure had the potential to affect all 68 residents by putting them at risk for verbal and mental abuse, psychological distress, and fear of retaliation. Findings Included: Record review of the facility policy titled, Abuse Prevention Program, dated 1/15/15 and received from the Administrator on 9/29/15, revealed the following: Our residents have the right to be free from abuse . 1. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, facility staff . 2. We will not knowingly employ or expose our residents to any individual who has been convicted of abusing, neglecting, or mistreating individuals . Abuse Investigation Protocol 9. Employees of this facility who have been accused of resident abuse will be suspended until the investigation has been completed . 11. The administrator will inform the resident and his/her representative (sponsor) of the progress of the investigation . 18. Inquiries concerning abuse reporting and investigation should be referred to the administrator or to his/her designee . Investigating Allegations of Verbal or Mental Abuse 1. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, telling the resident that he/she will be separated from other residents, etc. 2. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment of deprivation . 3. When conducting an investigation of verbal or mental abuse, implement the following protocol: a. Determine if the resident/family perceived the abuse to be disparaging, threatening, disparaging, or derogatory; b. Determine the resident's/family's response to the abusive act (e.g., Was the resident/family upset, humiliated, frightened, etc.); and c. Determine if the intent of the abusive act was willful . Reporting Abuse to Facility Management 16. A person shall not knowingly - a. attempt, with or without threats or promises of benefit, to induce another to fail to report an incident mistreatment or other offence. Protecting of Residents During Abuse Investigations Our facility will protect residents from harm during investigations of abuse allegations . a. Employees accused of participating in the alleged abuse will be immediately suspended pending the outcome of the investigation. b. If the alleged abuse involves a resident's family member or visitor, such person (s) will not be permitted to have unsupervised visits with the resident . Recognizing Signs and Symptoms of Abuse/Neglect . c. Signs/Symptoms of psychological abuse/neglect: . · Paranoia; · Depression; · Confusion; · Disorientation; · Withdrawal; . · Low self esteem or self worth; · Anger; · Suicial. Record review of Resident #1's Admission Record dated 9/28/15 revealed he was a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE]. He was discharged to Psychiatric Hospital A on 9/26/15 at 4:30 p.m. He was admitted with the following Diagnoses: [REDACTED]. Record review of Resident #1's Admission MDS 3.0 (Minimum Data Set) dated 9/5/15 revealed he did not have any conditions related to ID/DD (Intellectual Disability/ Developmental Disability) status. In Section B: Hearing, Speech, and Vision he had clear speech, was able to make himself understood, and has a clear comprehension of the ability to understand others. In Section C: Cognitive Status, he scored a 10 of 15 on the BIMS (Brief Interview for Mental Status) indicating he was moderately cognitively impaired. In Section H: Bladder and Bowel, Resident #1 was always continent of bowel and bladder. Record review of Resident #1's care plan dated 9/28/15 revealed the following: Category: Cognitive Loss/Dementia .Approach .Allow me time to voice my concerns .Observe me for signs and symptoms of frustration and anxiety; change activity if observed. If I am having an episode of anxiety or agitation, gently calm and refocus my attention .Please use eye contact and use words such as Do and Let's. Try not to use words such as Don't. I am a smoker .Approach Start Date 8/31/2015 .inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. I exhibit signs and symptoms of depression. I receive anti-depressant medication Approach .attempt to determine the cause of my upset and resolve if possible. Record review of Resident #1's Attachment 'K' Smoking, signed by Resident #1 on 8/31/15, revealed the following: .we must also respect the rights of those residents and employees who choose to smoke. It is not our intent to establish a smoking policy based on moral judgments, or to deny one group of residents or employees rights over another .Certain smoking restrictions apply to our residents and visitors. The facility will supervise all resident smoking for the safety of all residents and employees .All resident smoking paraphernalia must be checked in with the nurse. The policy did not specifically address supervised smoking when a resident is out on therapeutic pass. Record review of Resident #1's Durable Power of Attorney dated 9/10/15 revealed Resident #1 designates his sister as his Durable Power of Attorney for Healthcare if he is unable to make the decision himself. Record review of Resident #1's Social Services note dated 9/09/15 at 3:00 p.m. revealed the following: Resident alert. He states he was living on his own in an apt. but decided to move to the facility because he is not able to care for himself. He states he has numbness in his hands, legs, feet .Resident wears glasses. He states he has no problem with his hearing. He communicates well. He states he went to 10th grade and was always in Special Ed. Classes. He reports he received MHMR (Mental Health Mental [MEDICAL CONDITION]) services while living in community .Resident states he doesn't think he will need MHMR services in facility. Record review of Resident #1's Social Services note dated 9/16/15 at 9:31 a.m. revealed the following: He (Resident #1) bought cigarettes at corner store then proceeded to smoke in front of restaurant next door to facility. Restaurant has outdoor tables. Resident states he was approached by Administrator as she was driving to the facility and asked to put out cigarette and return to the facility. Staff reports he became angry and wanted to call STATE .He stated to SW that at one point when discussing smoking privileges, which are different than facility's rules on smoking, Administrator stated then maybe you don't belong here. SW did ask Administrator if she did make that statement to resident. Admin. reports she did not. Record review of Resident #1's Social Services note dated 9/17/15 at 10:13 a.m. revealed the following: Ombudsman returned call. SW explained the situation with resident. Ombudsman did state that resident (he is responsible for self) while signed out of facility, should be able to smoke anywhere he wants. Ombudsman also stated to SW that resident had also contacted her office and it sounded as if there was more involved than just the smoking question. SW did find out that resident was very upset about the manner in which he had been approached/spoken to about his smoking. He believed Administrator had been rude to him. He did contact the Compliance line .Thursday, late afternoon Resident came to SW's office and asked if SW knew where ADON was. Resident stated that ADON had told him Administrator had left the building but her office door was open and he knew she was back in the building. Resident was crying and upset .Resident was crying and asked if Administrator was in the building. ADON stated to him that Administrator was not in building but RNC A was in the building and using Administrator's office .Administrator was not in building. Record review of Resident #1's Social Services note dated 9/22/15 revealed the following: SW completing GDS (Geriatric Depression Scale), BIMS (Brief Interview for Mental Status), and Mini Mental Exam in Marketing office, when RNC A walked into office and asked resident that since he wanted to retract his complaint (pertaining to Administrator) to DADS, would he like to go ahead and call, RNC A had her cell phone and number already dialed and ready for resident to call. 1st number dialed was not correct number; she left marketing office, obtained correct number and came back with cell phone so that resident could contact DADS and retract complaint. While RNC A was gone, SW did ask resident if that is what he wanted to do. He hesitated and SW explained to him that he needed to do whatever he truly wanted to do. He stated that yes he had told them that he would call and retract statement. After call he gave nurse her phone back and said well that didn't go well. Nurse asked why and he stated that he was told that they could not drop complaint and they would have to investigate it . Additional Info: .SW asked resident how he felt about what had just occurred. He stated, I feel as if I am being pushed into something I don't want to do. Once again, SW stated to him that he needed to do what he wanted to do not what somebody else wanted him to do. He asked SW what he should tell State; SW responded with tell them the truth. Record review of Resident #1's Nurses Notes revealed the following: 9/12/15 1:00 p.m. alert & (and) oriented, cont of B+B (Bowel and Bladder) .able to make needs known. 9/16/15 8:40 a.m. signed by LVN A Res'd (Resident #1) signed out at 8:00 a.m. Admin .on way to work et (and) seen res'd at restaurant smoking. She asked res'd to come back to facility. Administrator spoke with this nurse et stated resds cannot smoke even if they sign out. Res'd came back to facility at 8:25 a.m. This nurse asked res'd where he got cigarettes et he stated from the nurse that let me sign out. This nurse informed res'd when he signs out, he is unable to smoke per the Administrator. Res'd began yelling I'll go tell that [***] its my right. I can sign out et smoke if I want to. Its none of her business what I do if I sign out. Res'd directed to admins office. Res'd cont (continued) to yell, that ' s my right to smoke if I sign out The Administrator stated if you are a supervised smoker here, you are a supervised smoker when you are signed out. If something happens to you signed out smoking I am still responsible for you, Res'd stated its my right et I will call state. The Administrator stated go ahead et call them et they will tell you the same thing.The Administrator stated You won't talk to me like that et with that tone. Res'd stated I'm telling you its my right to smoke if I'm signed out. The Administrator stated well maybe this is not the place for you. 9/26/15 10:00 a.m signed by LVN A Resds (Resident's) friend here upset d/t (due to) res'd telling her he told nurse night before last he tried to kill himself in shower .Res'd states I didn't try, I told the nurse I wanted to et the nurse stated You don't need to talk like that or they will put you some place according to res'd. This nurse called DON. Res'd placed on Q15 min check's for suicidal ideation. 9/26/15 10:30 a.m. signed by LVN A on call MD paged et notified of suicidal thoughts .MHMR here to eval. 9/26/15 12:45 p.m. signed by the DON The MHMR representative states pt is unsafe at facility d/t (due to) environmental stressors et that he needed moved immediately. Record review of Resident #1's physician telephone order dated 9/26/15 at 4:00 p.m. revealed Psychiatric Hospital A to eval et (and) treat. Record review of Resident #1's Release of Responsibility for Leave of Absence,' in the sign-out book at the nurse's station, revealed Resident #1 signed himself out on 9/16/15 at 8:00 a.m. and signed himself back in at 8:25 a.m. The Release of Responsibility for Leave of Absence also included a statement I, the undersigned, hereby accept responsibility Resident #1 while away from (Nursing Facility) and absolve the management of said facility, its personnel and the attending physician of responsibility for any deterioration in condition, or accident that may happen while the resident/patient is away. I understand that a bed will be reserved for the above-named resident/patient when he returns on or before the appointed date and time. Record review of documents from Psychiatric Hospital A dated 9/26/15: Adult Integrated Assessment: Suicidal: Indicator (s): Plan to Hang Self Intake Assessment: Legal Guardian: Self Adult Presenting problem: XXX[AGE] year old male reported to his nurse at nursing home he would hang himself at the shower .Pt. is having conflict with an Administrator Special Needs: Learning Disability, Bathing Assistance, Cognitive Impairment Suicide Risk Assessment: the lady at the nursing home made me depressed. I don't know, I was just trying to get out of the situation. Physician's Preadmission Examination Orders and Preliminary Plan of Care Diagnoses: [REDACTED]. Psychiatric Evaluation: 39 y/o (year old) mentally delayed man who presents to hospital with depression .Depression precipitated by decrease autonomy at nursing home .cites frequent disagreements with nursing home administrator .and her deprecating statements you don't need to be here. Currently lives in nursing home d/t (due to) mental learning disability. Mental capacity of 13 y/o per history .11 grade education .support system consists of Sister and nursing home staff . with a reviewing physician signature signed 9/28/15. 9/28/15 Physician Daily Progress Note pt speaks of situation that led to his admission 'I was just frustrated' - states did not plan or intend to hurt himself. Observations on 9/27/15 at 11:37 a.m. and on 9/28/15 at 1:30 p.m. revealed Resident #1 was not in the facility. Observation and Interview on 9/29/15 at 9:25 a.m. revealed Resident #1 in a small conference room at Psychiatric Hospital A. He was alert and oriented, in blue paper scrubs, appearing ungroomed and disheveled. He was in a wheelchair for mobility. Resident #1 said that he was his own responsible party. He said he signed out of the facility (9/16/15) to go down to the convenience store. He said he spoke with a nurse who gave him his cigarettes and lighter. Resident #1 said he stopped at a Mexican food restaurant across from the park to smoke a cigarette. He said that the Administrator pulled up and yelled at him saying he could not be out smoking and he had 5 seconds to get back to the facility. Resident #1 said when he got back to the facility LVN A said that she got in trouble due to him signing himself out with his cigarettes. He said they went to the Administrator's office and the Administrator was very angry. Resident #1 said the Administrator said he could not sign out with his cigarettes unless he was accompanied by someone else. He said the Administrator screamed I don't think you belong here. He said it made him feel very upset. Resident #1 said he could not eat lunch because he was very upset. He said he had nightmares about the way the Administrator had talked to him, and he was really hurt and afraid. (During the interview process Resident #1 became tearful while discussing the treatment by the Administrator.) Resident #1 said the Ombudsman came to see him and Corporate told Administrator she had to leave the building. Resident #1 said Corporate RNC A asked him if he wanted to go with her to a local fast-food restaurant and get something to drink (9/22/15). He said before he could go he had to put a diaper on .they put it on over his underwear. Resident #1 said RNC A did not want him to have an accident in her new car. He said it made him feel bad and very much embarrassed. (He was tearful while discussing his embarrassment of being asked to put a brief on to ride in RNC A's vehicle.) Resident #1 said they drove down the road and RNC A said I have to be honest, we are meeting VPCS A and the Administrator there. Resident #1 said he told RNC A No, I want to go home. Resident #1 said he was afraid the Administrator was going to hurt him. He said RNC A stopped at another local fast-food restaurant to get them drinks and texted someone. Resident #1 said by the time they arrived back at the facility VPCS A was there. He said VPCS A said the Administrator is crying and upset about how she treated you .she has not eaten in days. Resident #1 said he felt sad and VPCS A said he should talk to the Administrator. He said VPCS A convinced him because he felt sorry for the Administrator. He said he agreed to go to a local burger place with VPCS A and RNC A and meet with the Administrator. Resident #1 said he got a bacon cheeseburger with fries. He said he asked the Administrator if she wanted anything and she said no, I haven't eaten in 4 days. He said RNC A, VPCS A, and the Administrator were talking to each other not to him. Resident #1 said the Administrator said she was sorry and it wouldn't happen again. He said he could tell they were all friends; they were all talking amongst themselves and not to him. Resident #1 said he felt scared and didn't want anyone starving because of him. Resident #1 said he felt ashamed. He said they asked him if the Administrator could come back to the nursing home in front of the Administrator, and he told them I guess so. (Resident #1 became tearful again while discussing how he felt during his encounter with RNC A, VPCS A, and the Administrator at a local burger place.) He said later RNC A came in when he was with Social Worker A and asked if he was ready to call D.A.D.S. and drop the complaint. He said RNC A pulled out her phone and said here let me dial D.A.D.S. for you. Resident #1 said RNC A dialed the number, and he tried to drop the complaint. He said D.A.D.S. would not let him drop the complaint, and that was the last time he saw RNC A. He said this was not the first incident with the Administrator. Resident #1 said she speaks to me like a dog with fleas. Resident #1 said the Administrator got mad at him, due to Resident #1 having diarrhea on himself in bed after drinking Milk of Magnesia (9/11/15). He said he went on himself again and a CNA told him that they would get him cleaned up in a bit. Resident #1 said he had already taken Trazadone and fell asleep. He said he slept in it all night long. He said his privates were burning. He said he wanted a shower. He said the staff told him no not until breakfast. Resident #1 said then everyone was in a meeting and he was burning and hurting. He said he did not get it changed until 10:30 a.m. and they had to wet him with the shower head because it was dried onto his skin. He said his sister went to the Administrator about this and the Administrator said he whines about every little thing. He said he is still scared of the Administrator, and he does not want to be around the Administrator by himself ever. He said he talked to MHMR .to other people .some liked her some disliked her. Resident #1 said he felt pulled in the middle .he felt like he wanted to kill himself, due to being pulled in the middle. He said when he felt like this (9/26/15) he told his friend who told LVN A, and MHMR got there. He said he told her everything. Resident #1 said he felt ganged up on by VPCS A, RNC A, and the Administrator. He said he wanted to discharge today, and wants to go home (the facility), but he is still hurt and scared of the Administrator. Resident #1 said he feels the whole thing was a set up to get the Administrator back. He said he felt scared to say he didn't want the Administrator back in front of the Administrator, RNC A, and VPCS A. He said he felt there was no one on his side .only the Administrator's side. He said he was unsure if the Administrator would physically harm him, but she screamed at him like a monster. He said first she was nice, then turned into a monster. Resident #1 said it was not fair to have to move somewhere else due to the Administrator being there. Resident #1 said he has friends and family there. He does not want to leave and go to another place a lot of people treat him good. He said the Administrator made up a lie, and said she was worried he was going to catch the school on fire when he was smoking at the Mexican restaurant, but the Mexican restaurant is nowhere near the school about three blocks from the school. In an interview on 9/28/15 at 2:15 p.m., LVN A said that she was there when the incident occurred on 9/16/15 in the Administrator's office; she said that she was in the room with the Administrator, LVN B, and Resident #1. She said she had been working at the facility for three years. She said that the Administrator came into work and said Resident #1 is next door smoking at the Mexican restaurant, and that she told him to come back to the facility. LVN A said Resident #1 came back to the facility saying that's my right regarding smoking at the Mexican restaurant. LVN A said that she went in to the Administrator's office with the LVN B and Resident #1. LVN A said Resident #1 continued to say that's my right, but the Administrator would not listen to him. LVN A said the Administrator got mad and lost her temper. LVN A said the Administrator said to Resident #1 you don't belong here. LVN A said the Administrator had her finger pointed in his face .she was real loud and ugly. LVN A said it was abusive, referring to the Administrator's behavior towards Resident #1, and the Administrator threatened the resident. LVN A said she was retaliated against for reporting the abuse of Resident #1 by the Regional Nurse Consultant (RNC A) and the Vice President of Clinical Operations (VPCO). LVN A said on Tuesday, 9/22/15, RNC A told her to go put a brief on Resident #1, because she was taking him in her personal vehicle to go get a coke. LVN A said I asked her why he's (Resident #1) not incontinent. LVN A said RNC A said to her I do not want him (Resident #1) to have diarrhea in my brand new car. LVN A said she went to Resident #1 and helped him put on a brief, but I did not want to do it. She said that she helped put the brief on Resident #1, because they had been interrogating her. She said I thought that was wrong .it's wrong, referring to the situation with the Administrator and the incident with RNC A. LVN A said that Resident #1 told her later that day after he went and got a coke that RNC A wanted him to meet the Administrator there and that he told RNC A no. LVN A said later that same day, VPCS A said to LVN A that she wanted to see if Resident #1 wanted a burger and put Resident #1in her car. LVN A said she was working on Saturday 9/26/15 when Resident #1's friend came in to the facility and told her that Resident #1 had told her that he wanted to kill himself. LVN A said she asked Resident #1 if he was suicidal, and Resident #1 said No but I wish I would die. LVN A said she immediately called the DON. She said that she felt like it was unsafe for Resident #1 to be in the facility with the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN A on 9/30/15 confirmed the details in the interview with LVN A. In an interview on 9/28/15 at 3:07 p.m. LVN B said that she had been working at the facility since 2011. She said that the Administrator has been working at the building for 6 weeks. She said on 9/16/15 she got paged to the Administrator's office, and said that the Administrator told her that she saw Resident #1 smoking at the Mexican restaurant on her way to work. LVN B said the Administrator told her Resident #1 did not have his glasses on, and he said to the Administrator who are you? LVN B said the Administrator told her she said to Resident #1 that he cannot smoke unsupervised even if it is off property. LVN B said Resident #1 returned to the facility, and he said I have rights I can sign myself out. LVN A was in hall and they came into the Administrator's office. LVN B said that the Administrator said yes, you have rights but you can't smoke unsupervised. LVN B said that Resident #1 said I thought I was responsible for myself once I signed out. LVN B said that Resident #1 was frustrated, but lowered his voice when the Administrator asked him to lower his voice. LVN B said Resident #1 kept saying that he has rights. She said the Administrator raised her voice, and her tone was angry. LVN B said the Administrator pointed her finger in his face. She said she said to Resident #1 maybe this is not the place for you, in a threatening manner. LVN B said I felt like she was being verbally abusive. LVN B said I would never talk to them like that. She said my mind was shocked about her behavior. She said Resident #1 asked her to call his sister and the Ombudsman. She said that was it that day, and that night Resident #1 asked for the corporate compliance line. LVN B said the next day (9/17/15) that Resident #1 came to her and said it made me feel like I was mentally abused, referring to the Administrator's behavior. LVN B said until Resident #1 said it to her, she realized that it was abuse, and she was still in shock from the incident. LVN B said she immediately reported in to the DON, and that someone from corporate was going to handle it. The Administrator was told to leave. She said RNC A came down that Thursday (9/17/15), and Monday (9/21/15) VPCS A and RNC A were asking the staff questions. She said Tuesday (9/22/15) RNC A took Resident #1 to her a drink; she said Resident #1 was asked to put on a brief so he did not mess in the car. She said VPCS A and RNC A took him to lunch in a personal vehicle. LVN B said later that day Resident #1 told her that they took him to meet the Administrator. LVN B said she asked Resident #1 what changed your mind, and he said to her that they kept asking him to meet with her, and they asked him in front of the Administrator if she could come back. LVN B said Resident #1 told her that he said yes, because she (the Administrator) was sitting right there .she scares me. LVN B said Resident #1 told her he felt bribed. She said that he told her when she took him to Psychiatric Hospital A that he said he wanted to come back to the facility, but he was scared of the Administrator. Record Review of a D.A.D.S. Witness Statement written and signed by LVN B on 9/28/15 confirmed the details in the interview with LVN B and revealed the following: I was asked to read the nn's (nurse's notes) I read them I was in ADM office. After I read the nn's the Administrator stated I didn't say that about him I never said maybe this isn ' t the place for you then I stated yes you did the Administrator stated I don't remember saying that I must have been that mad I don't remember it.Later that afternoon RNC A came to investigate she asked me if I felt like DON was feeding Resident #1 information to get rid of the Administrator. I stated no the DON wasn't around when everything happened .RNC A asked me if I was comfortable saying if it was abusive or not. I stated well it's never easy to say someone is abusive, but yes it was she crossed the line when she made him feel like he wasn ' t wanted here. She also crossed the line shaking her finger at him. I was not interviewed again until the following Monday 9/21/15 I was interviewed by VPCS A. She asked me if I could define mental abuse I stated it's when someone feels degraded, to feel bad about themselves, belittled, humiliated. She stated OK she asked me if I feel like the Administrator should be fired I stated I don't know that ' s not up to me. She then asked me ok if it were one of your CNA's would you want them to continue to work here. I stated no, not if they couldn't control themselves. If you do it once whats to stop you from doing it again. VPCS A then asked me if Resident #1 had any psych DX I stated no, not that I'm aware of she then asked me Is he a trouble maker? I stated no, he is very timid et meek.VPCS A asked me if I felt it was abusive why didn't I report it Wednesday .I stated I really couldn't understand what happened I couldn't process it .She stated ok so at first you weren't sure if it was abusive .I said I really didn't know what to think when Resident #1 came in my office Thursday morning and I heard him saying the words it clicked oh my gosh it is abusive this was before he stated he felt mentally abused. She asked me if I felt comfortable reporting Abuse to Corporate I stated No, I feel like I will be retaliated against. VPCS A stated no you weren't you can trust us. The rest of the Witness Statement corresponds with the Interview with LVN B. In an interview on 9/27/15 at 8:40 a.m., the MHMR representative said that Resident #1 is currently at Psychiatric Hospital A. She said she went to the facility on [DATE] to assess the resident as she was called that he was suicidal. She said Resident #1 is very smart. She said that she had worked with Resident #1 for 9 years, and this behavior was unusual for him, and I believe him. She said Resident #1 said that the Administrator had threatened him, and yelled at him saying maybe you don't belong here. The MHMR representative said when she saw Resident #1 on Saturday, 9/26/15, he was so light-headed .all he wanted to do was get away from them, referring to the Administrator, RNC A, and VPCS A. She said that the staff told her that the Administrator was put on leave, but the Administrator arranged to have 2 people RNC A and VPCS A entice Resident #1 to go with them to meet with them, previously that week. The MHMR representative said they made Resident #1 put diapers over his pants to not soil RNC A's car, under the premise to get a coke. The MHMR representative said Resident #1 told her that RNC A said while he was in the car, that the Administrator was waiting for them at the local fast-food restaurant. The MHMR representative said Resident #1 told RNC A he did not want to see go. She said then later that same day VPCS A and RNC A take him to a local burger place to meet with the Administrator. The MHMR representative said that Resident #1 does not have any teeth, is diabetic .and they buy him a cheeseburger. The MHMR representa

Based on observation, interview and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent a fall for 1 of 4 residents (Resident # 2) who were reviewed for accidents and supervision. The facility failed to ensure that Resident #2 ' s bed alarm was placed on the bed. Resident #2 suffered a fall on 8/20/15 resulting in a fractured left hip. This facility failure resulted in actual harm to Resident #2 and could affect any of the other 11 residents identified by the facility as having bed alarms by placing them at risk for falls, injuries or fractures. Findings included: Review of Resident #2's physician ' s orders dated 7/9/15-9/9/15 revealed he was a [AGE] year old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. These orders contained an order for [REDACTED]. Review of Resident #2's Quarterly MDS 3.0 (Minimum Data Set), dated 6/10/15, revealed in Section C- Cognitive Patterns BIMS (Brief Interview for Mental Status) was answered no indicating that he is rarely or never understood. He required extensive to total assistance of one to two persons for Activities of Daily Living. The resident required the use of a wheelchair. He had frequent incontinence of bowel and bladder. Review of Resident #2's Fall Risk assessment dated [DATE] identified the resident as a high risk for falls with a score of 22. The criteria for identification of high risk for falls indicated a total score of 10 or greater. Review of Resident #2 ' s nurse ' s notes written by LVN A on 8/20/15 revealed the following: Late Entry 1740 (5:40 p.m.) At 0455 this am this nurse heard pt (patient) call out Hey Man from his room. Upon entering room pt was found on fall mat in front of Bed A lying on (L) side. Sheet was placed behind resident pt was assessed for injury skin tear noted to (L) wrist and (L) shoulder with bruising noted around (L) shoulder. Pt c/o pain to (L) hip area. Pillow placed between pt knees pt rolled onto sheet and transferred to bed via sling method. V/S WNL. Skin tear cleaned with NS. Skin reaproximated on wrist. Fax sent to PCP A for notification. DON called. Hip X Ray ordered. Pt in bed with eyes closed easily arousable cont to verbalize pain to (L) hip area upon questioning. Neuro checks initiated and remained WNL. (There was no documentation as to whether the resident ' s bed alarm was in place) Review of Resident #2 ' s nurse ' s notes written by LVN B on 8/20/15 revealed the following: 0810 (Local mobile X ray) here to X ray L hip 0945 Recd report from (local mobile x ray company) showing (L) femoral neck acute displaced intertrochanteric fracture. Faxed PCP A ' s office, RCP. Called with report et said faxing report now. Will review et call back. 0950 PCP A ' s office called Transport to (local hospital) 0955 Called local ambulance for transport 1012 Res (Resident) departed facility for (local hospital) 1015 Called daughter. No answer. Left message. 1230 (Local hospital) called. Surgery scheduled Fri AM. Fax copy of DNR and POA to ER. Faxed copy of DNR. Unable to locate POA at this time. 1245 Notified daughter (local hospital) needs copy of POA. She will be in town tomorrow. Review of Resident #2 ' s X-ray report dated 8/20/15 at 8:39 am revealed: History: Pain. Possible fall Portable Left Hip: Findings: There is a left femoral neck intertrochanteric fracture. The fracture is a four-part displaced intertrochanteric fracture with varus angulation and displacement laterally and superiorly and avulsion of the trochanters. There is osteoporosis. There is moderate degenerative joint disease. The joint shows no dislocation. Impression: Left Femoral Neck Acute Displaced Intertrochanteric Fracture. Source: Femoral neck fractures occur in the narrowed section of the upper femur that lies between the rounded femoral head and bony projections called trochanters. Intertrochanteric fractures occur more laterally than femoral neck fractures, in the area between the greater and lesser trochanters. The trochanters are bony projections where major hip muscles attach. Intertrochanteric hip fractures occur outside of the joint capsule. http://www.ncbi.nlm.nih.gov/books/NBK / Review of the facility incident log on 8/20/15 revealed that Resident #2 got up from bed to go to the bathroom and slipped and fell . The contributing factor indicated that the pressure alarm was not in place. The intervention to prevent reoccurrence was education to staff to make sure alarms are in place. Review of the facility incident investigation report regarding Resident #2 ' s fall that occurred on 8/20/15 was completed by the Director of Nurses and dated 8/21/15. The report revealed that Resident #2 ' s cognitive status at the time that the incident occurred was documented as impaired judgement, confused and disoriented. The interventions in place to prevent the incident were listed as pressure alarm, low bed with fall mat and helmet. The interventions needed to prevent recurrence were marked as counsel staff to always place pressure alarms on patient with orders for them and check with nurse prior to start of shift. In an interview on 9/2/15 at 2:05 p.m., the DON said CNA A was a new staff member and she did not put the bed alarm in place for Resident #2. The DON said CNA A had been in-serviced on the bed alarms before Resident #2 ' s fall on 8/20/15 and she was suspended for not following policy and procedure. The DON said that CNA A had returned to work on 8/24/15. In an interview on 9/2/15 at 2:15 p.m., the Regional Nurse Consultant said that the nurse checks the alarms every shift and documents on the treatment record. Review of the interview worksheet signed by CNA A on 8/20/15 revealed: Knowledge about possible cause of the incident was checked yes. Describe: Bed alarm was not in place. It was in the w/c next to the bed. Knowledge of an injury was checked no. Describe: c/o hip pain, shoulder, wrist pain. In an interview on 9/2/15 at 3:00 p.m., CNA A said that she had accepted the responsibility for not placing the bed alarm underneath Resident #2. She said that she had failed to move it from the wheelchair to the bed when she put Resident #2 into bed. Review of the interview worksheet signed by LVN A on 8/26/15 revealed: Knowledge about possible cause of the incident was checked yes. Describe: Bed alarm was not in place. Resident confused frequently up and down. Decreased mobility and inability to redirect. Unaware of limitations. Knowledge of an injury was checked yes. Describe: Skin tear (L) fa, c/o shoulder pain, ST (L) shoulder, c/o hip pain. LVN A was no longer employed by the facility and was not able to be contacted. Review of the facility policy titled Nursing Guidelines Use Physical Restraints, Personal Alarm Use, Side Rail Use dated 4/19/14 revealed: Visualization of the alarms is performed every shift and documented on either the MAR or TAR. Functionality of the devices is validated weekly and as required. (This is validated by activation of the alarm to ensure battery is working). Evidence of the battery validation can also be documented on the MAR/TAR. The list of 12 residents that use bed alarms as prevention for falls was provided by the Director of Nurses on 9/3/15 at 11:00 a.m.

Based on observation, interview, and record review the facility failed to ensure three (Residents #1, #2, and #3) of six residents were able to exercise their rights as a resident of the facility and as a citizen or resident of the United States, and to be free of interference, coercion, discrimination, and reprisal from the facility in exercising their rights. A. Physician A (who is also the medical director for the facility) declared Resident #1 " not mentally capacitated for medical, personal or financial decisions due to psychotic mental illness " without a court order or a second physician ' s opinion. Resident #1 was placed on the secure unit and was told by facility he could not leave the facility when he requested to do so. B. Physician A declared Resident #2 " not mentally capacitated for medical, personal or financial decisions d/t (due to) psychotic mental illness " without a court order or a second physician ' s opinion. Physician A ordered that Resident #2 be placed on the secure unit for behaviors until Resident #2 calmed down, and to be moved to the secure unit permanently if she had to be taken to the unit at least once a day for three days C. Physician A declared Resident #3 " not mentally capacitated for medical, financial, or personal decisions due to psychotic mental illness " without a court order or a second physician ' s opinion. Physician A ordered that Resident #3 be moved to the secure unit immediately if she made any homicidal statements or display hypersexual, assaultive, or exit seeking behavior. This failure could place the 52 residents with Physician A as their primary care physician at risk of a violation of the residents ' rights by declaring them incapacitated without the required legal proceedings or secondary opinion, not providing the least restrictive environment, and using threats of a restrictive environment to control behaviors. Finding included: Record review of Resident #1 ' s Resident Admission Record, undated, revealed he was a [AGE] year old male admitted to the facility on [DATE] and was discharged on [DATE]. The Admission Record identified Resident #1 ' s [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Multiple Data Set (MDS) assessment, dated 07/24/14, revealed Resident #1 ' s Brief Interview of Mental Status (BIMS) score was 15 out of 15, indicating Resident #15 is cognitively intact. The MDS indicated Resident #1 was displaying disorganized thinking at the time of the assessment, but no inattention, altered level of consciousness, or psychomotor [MEDICAL CONDITION]. The MDS indicated Resident #1 ' s Resident Mood Interview score was 15 out of 27 indicating Resident #1 was experiencing moderately severe depression. The MDS indicated Resident #1 was experiencing delusions but no hallucinations. The MDS also indicated Resident #1 was displaying verbal behavioral symptoms directed toward others and other behaviors not directed at others. The MDS indicated Resident #1 ' s behaviors were interfering with his care, but did not put him or others at significant risk for physical illness or injury or disrupt others care or living environment. The MDS indicated Resident #1 displayed wandering behaviors 1 to 3 days, but not daily, and did not place the resident at risk of getting to a potentially dangerous place. The MDS indicated Resident #1 was independent in his mobility, transfers, locomotion, dressing, eating, and toileting. The MDS indicated Resident #1 required set up assistance of staff with dressing, eating, and toileting. The MDS indicated Resident #1 ' s [DIAGNOSES REDACTED]. Record review of Resident #1 ' s care plan, undated, revealed multiple problems identified in the category of Behavioral Symptoms. The care plan identified the following problem, goals, and approaches: Problem: I have behavior symptoms. As evidenced by my wandering related to exit seeking and delusions. I reside in a Secure Unit. I am at risk for fall and injury due to my unawareness of safety (start date 07/31/14). Goals: My dignity will be maintained and I will wander about the Secure Unit without occurrence of Significant Injury over the next 90 days. Approach: Keep my room free of clutter and possible hazards. Wear wanderguard at all times until nursing staff removes (start date 08/25/14, edited 09/02/14); assist me in reorientation to room and secure unit with verbal cues (start date 07/31/14); encourage activities of my preference and attempt to keep me occupied (start date 07/31/14); explain all procedures using terms that I can understand (start date 07/31/14); I need to be reassessed regularly for my ability to reside off of the Secure Unit (start date 07/31/14). Problem: I have diagnosed with [REDACTED]. Approach: Administer medication per MD ' s (medical doctor) orders; Keep MD informed of resident condition (edited 07/31/14). Problem: Decisional conflict R/T (related to) delusions and not mentally capacitated for medical, personal, or financial decision due to psychotic mental illness (start date 07/31/14). Goal: Resident will make an informed choice. Approach: Assist resident in clarifying values (start date 07/31/14); determine if decision made by the resident endangers the resident or other. Intervene if necessary (start date 07/31/14); Explain the benefits, options, and consequences of decisions/Have social worker to do assessments per MD ' s orders/Keep MD informed of condition (start date 07/31/14). Problem: Mentally unable to make decisions for self, mentally, personally, and financially. Social worker to get a surrogate decision maker (start date 07/31/14). Goal: SW (social worker) will obtain a decision maker for the resident without any difficulty R/T the resident being mentally unable to make decisions for self. Approach: SW to find a surrogate decision maker either family a guardian appointed by the courts (start date 07/31/14). Problem: I call the bank, electric company etcetera to try and get electric turned on at my house and to get money from my account. I have no short term memory and I do not remember that I will not return (start date 08/04/14). Goal: I will not engage in getting my electric turned on or have funds sent to me. My family is in charge of all my business affairs. Approach: Family wishes that staff defer call to them and that resident is not able to call business about getting electric or gas turned back on at his home or have funds sent to him that he no longer has a banking account. Keep MD informed of resident condition and if he continually tries to make calls to business. Resident is not mentally able to handle business or medical affairs (start date 08/04/14). Problem: Resident to reside in the Secure Unit R/T Elopement risk (start date 09/26/14). Goal: Dignity will be maintained and resident will wander about unit without occurrence of any injury or extreme behaviors. Approach: Monitor every hour and prn to assure residents safety. Activity Director to monitor/discuss activity preference. Explain all procedures, using terms/gestures resident can understand-repeat PRN. Call by name when giving care, involve in care as much as possible. Keep environment free of possible hazards. Keep MD and family informed of any changes in conditions and medications (start date 09/26/14). Problem: Resident calls from his personal cell phone the ombudsman to report false allegations and complaints about staff and calls psychiatric hospital to self-admit himself uses this as a stepping stone to escape to his community and also request to be sent to local ER as a way to leave and go back in community or another facility (start date 10/03/14). Goal: I will not call psychiatric hospitals in an attempt to leave and I will not call ombudsman and report false allegations regarding staff. Approach: Redirect resident, Refer to SW, Notify MD if behaviors escalates towards danger to self or others (start date 10/03/14). Record review of Resident #1 ' s clinical record revealed the following physician ' s telephone orders: 07/19/14 " Not mentally capacitated for medical, personal of financial decisions due to psychotic mental illness " signed by Physician A on 07/19/14 08/25/14 " . . . May move to front hall w/ (with) Wander Guard x (for) 1 week & then may remove at nurse discretion " 09/17/14 " Try to set a time for a pre-DC (discharge) meeting (with) me, Res (resident), NH (nursing home) staff and SW and family if possible tomorrow before he leaves. Notify me " signed by Physician A on 09/18/14 09/24/14 " 1. Discharge when all arrangements for travel and lodging are complete 2. Assist Res (resident) in finding pathway to becoming an Adult Foster Care provider " signed by Physician A on 09/24/14 Record review of Resident #1 ' s clinical record revealed the following physician ' s progress notes: 08/01/14 " MDD (major [MEDICAL CONDITION]) with psychotic features " signed by Physician A 08/25/14 " . . . he denies delusions, fears & has correct logic Is wanting to move to the front and get some help using computer. He states he would be good up there . . .alert, calm voice. Pleasant but frustrated by poor pain control . . . No [MEDICAL CONDITION], delusions, anxiety or exit seeking behavior . . . " 09/18/14 " . . . trying to get his electricity on at home by phone at my visit. Intents to leave tomorrow. Says sisters stealing from his father . . . didn ' t show delusions . . . doesn ' t want family involved in DC plan. Came to us very much mentally incapacitated but better now-not sure if enough to go home. Told him we need pre-DC mtng (meeting) & discussed some (with) SW and Admin (administrator) " . 09/24/14 " . . . ready to leave. Wants sisters to transport but doesn ' t want them to be involved in aftercare planning . . . says he ' ll be compliant (with) meds. Denis paranoid delusions . . . wants to take another Res to live (with) him . . . this Res willing to wait for DC to see if OR (other resident) can pass self meds test & if I ' ll consider his discharge then. Also willing to look into becoming an Adult Foster Care provider for OR . . . not depressed or psychotic now. Some obstinance & anger toward sisters may or may not be residual paranoia but I doubt it is . . . Able to think in abstract. Judgment fairly intact today . . . Begin DC planning and both he & OR could leave AMA (against medical advice) but if they want my " blessing " then coop (cooperate) (with) my MD orders this date . . . " Signed by Physician A 10/03/14 " . . . promises no trouble if I move him back to front hall, hates the chaos on the unit. Want to go to (local psychiatric hospital) & stay 3 days then return to (other city) NH there won ' t take him back . . . reviewed original admit, subsequent transfer to front ward, Return to unit dt psychotic delusions leading to call by Res to police & current behavior. He is not mentally capacitated . . . [MEDICAL CONDITION] & was a danger to self & others . . . paranoid ideation but is not currently a danger. He is not mentally capacitated to make own decisions including placement but our attempts to get him a guardian are still no productive & I don ' t feel I can hold him against his will. He may go to (psychiatric hospital) if they will accept & if not, I will move him to the front ward (with) wander guard with plans to transfer after the wkend (weekend) or for him to make new plans . . . " signed by Physician A Record review of Resident#1 ' s clinical record revealed the following nurses ' notes: " 07/22/14 13:25 (1:25 PM) Resd (resident) has requested mulit (multiple) times to use the phone called sister . . . stated to sister " I have to get on a bus and get out of here I might Die on the bus but I have to go " Resd requested to call his local water dept (department) . . . called bank . . . " No entries in the nurses ' notes between 08/03/14 and 08/20/14. No entries in the nurses ' notes between 08/27/14 and 09/15/14. " 09/27/14 06:15 (AM) Res asks to talk to Fac (facility) Admin. Attempted to call since its her day off. Fac Admin 0 (zero/no) answer. Res is mentally incompetent but attempted to call facility admin as requested " 09/27/14 08:30 (AM) Res requested to " leave facility and sign AMA " . Reported to ADON. Notified MD of request. MD stated " He can ' t. He ' s not competent. Explain this is new start to be in compliance and work his way back to the community. " This nurse reported res hasn ' t been taking night time meds. MD stated has the right to refuse anti-psychotics but document " In an interview on 10/15/14 at 2:55 PM, Physician A stated that Resident #1 was mentally incompetent because of psychiatric issues. Physician A (stated that there is a problem in this state because the state won ' t take guardianship if a person has psychiatric issues. Physician A stated that if he judges a resident to be a danger to himself or other he would stand his ground on declaring them incapacitated. Physician A stated that he was prepared to go to court regarding Resident #1. Physician A stated refusing to let a resident leave the facility is really false imprisonment, but he makes his decisions based on what is best for the resident and the public. Physician A stated he believed Resident #1 to be a danger to himself and others, and if Resident #1 went out and harmed someone it would be his (Physician A) responsibility. Physician A stated that it would be like in an emergency room when they wouldn ' t let someone leave who was drunk and had been hit on the head. Physician A stated in that situation the person wouldn ' t be allowed to leave without medical treatment and they would have to be committed to provide the person with treatment. Physician A stated that if the surveyor felt we had to we could cite him, but he would ask that there not be a fine because he did what was right. Physician A stated he did not present an alternative reason for staying to Resident #1 because he was not going to try to reason with someone who is mentally ill. In an interview on 10/15/14 at 5:20 PM, the ADON stated she was at the facility on 09/27/14 when Resident #1 stated he wanted to leave AMA. The ADON stated she instructed the nurse on duty to contact Physician A. The ADON stated she is not sure what the nurse on duty told Resident #1 about what Physician A said in regarding to Resident #1 leaving. The ADON stated that she was able to talk Resident #1 in to staying until Monday. The ADON stated that on the Monday (09/29/14) following the incident she tried to get the ADMN and Physician A to let Resident #1 leave. The ADON stated she did not know why Resident #1 couldn ' t just leave. In an interview on 10/15/14 at 6:10 PM, LVN A stated she was the charge nurse on the secure unit on the 6:00 PM to 6:00 AM shift. LVN A confirmed she was familiar with Resident #1 from his stay at the facility. LVN A stated that Resident #1 was put on the secure unit as soon as he admitted to the facility due to him being an elopement risk. LVN A stated when this decreased he was moved to the front hall, but then began refusing his meds and called 911. LVN A stated she is not certain, but she believes law enforcement found a screwdriver under his bed when they arrived so he was moved to the secure unit again. In an interview on 10/16/14 at 1:30 PM, the Social Worker (SWRK) stated Resident #1 came to the facility very delusional and was placed on the secure unit due to being an elopement risk. The SWRK stated Physician A thought Resident #1 was incompetent so she sought guardianship through a local organization. The SWRK stated she applied for the local organization to take guardianship, but then Resident #1 ' s family member said he would take guardianship so the local organization did not pursue it any further. The SWRK stated Resident #1 was evaluated by a psychiatric facility prior to coming to the facility, but she did not recall any medical records from that facility that deemed Resident #1 incapacitated or incompetent. The SWRK stated she recalled one time when Resident #1 asked to leave AMA, and she told him he could leave, but she would have to notify Adult Protect Services (APS). The SWRK stated she was not at the facility when Resident #1 asked to leave AMA and Physician A refused. The SWRK stated another reason guardianship was not pursued was Resident #1 ' s medications was working and he was able to move off the secure unit, but then he stopped taking his medication and became delusional again. The SWRK stated upon admission Resident #1 signed all his releases for his [MEDICAL CONDITION] medications, indicating he was competent enough to sign a release for medication when admitted . The SWRK stated when Physician A writes an order about a resident being incapacitated then she starts workings on a way to obtain a guardian for the resident. In an interview on 10/17/14 at 2:27 PM, LVN B stated she did remember Resident #1 and did not know why he was ever placed on the secure unit. LVN B stated that she requested Resident #1 be moved off the secure unit because he was not displaying any behaviors. Resident #2 Record review of Resident #2 ' s face sheet, dated 10/17/14, revealed she was a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2 ' s Multiple Data Set (MDS) assessment, dated 09/16/14, revealed a Brief Mental Status Interview score of 14 out of 15, indicating she is cognitively intact. The MDS indicated that Resident #2 had inattention and disorganized thinking at times. The MDS revealed that Resident #2 had delusions, rejects care, and is verbally abusive. The MDS indicated that Resident #2 required the assistance of one person for bed mobility, transfers, mobility, dressing, toilet use, and personal hygiene. The MDS indicated that Resident #2 is occasionally incontinent of bladder and continent of bowel. The MDS indicated that Resident #2 received Depression medication every day for the past seven days. The MDS identified Resident #2 ' s [DIAGNOSES REDACTED]. Observation on 10/16/14 at 3:00 PM revealed Resident #2 speaking with the Administrator. Resident #2 appeared visibly upset and was overheard stating to the Administrator that she was leaving. The Administrator stated to Resident #2 that she is leaving on 10/31/14. Resident #2 said the facility is hurting her by overdosing her with medications. Resident #2 said several times that she did not want to be moved to the back hall. Resident #2 appeared to have a distressed facial expression, guarded body language, and spoke with a worried, high pitched voiced, conveying apprehension about the possibility of moving to the " back hall " . Interview on 10/17/14 at 2:25 PM revealed Resident #2 appeared apprehensive when the " back hall " was mentioned. Resident #2 pulled back physically from the surveyor and asked the surveyor several times why she had to go to the " back " . Resident #2 continued to present physical signs of distress and apprehension until she was reassured by the surveyor that the surveyor was just asking her about the back hall and not telling her she was moving there. Resident #2 said she did not want to be moved to the back hall because men come in her room and the other residents come in to her room and take things. Record review of Resident #2 ' s Progress Notes, dated 09/09/14, indicated Resident #2 " is not mentally capacitated for medical, financial, or personal decisions dt (due to) psychotic mental illness complicated by Axis II Personality Disorder. Res (resident) has difficulty in thinking in the abstract and lacks good judgment esp (especially) when the decision at hand interfaces (with) her delusional system that everyone is trying to harm her or dislikes her. Agree (with) need for Guardianship. This is likely permanent though it is possible she could regain capacity if [MEDICAL CONDITION] were controlled. The incapacity is TOTAL. " The American Psychiatric Association (APA) defines an axis as a " domain of information that may help the clinician plan treatment and predict outcome " . There are five axes identified by the APA, and Axis II is " for reporting Personality Disorders and Mental [MEDICAL CONDITION]. It May also be used for noting prominent maladaptive personality features and defense mechanisms " . Record review of Resident #2 ' s clinical record revealed a " Behavioral Contract " , dated 09/09/14, and signed by Resident #2 as well as the Director of Nursing. It indicated that Resident #2 " will benefit by placement on the (facility ' s) ' front hall ' " . The contract indicated Resident #2 " needs to prove to staff at (facility) that she is safe to move out of the secure until to the front hall ...If (Resident #2) has no assaults on others for two weeks, has no yelling episodes that persist after one warning ...and makes no attempts at elopement for two weeks then she will be transferred as soon as logistics allow to the front hall with a wander guard in place. " The contract also indicated " ...Relapse to the prior described behaviors will mean immediate transfer to the secure unit for assault or elopement attempt. (Resident #2) will also return to the secure unit if yelling persists after one warning per episode. " Record review of Resident #2 ' s physician's order [REDACTED]. 09/02/14 22:00 (10:00 PM) " Notify (physician) by fax if Res breaks promise to me to sleep in bed not chair " Signed by Physician A on 09/02/14 09/09/14 " Res is not mentally capacitated for medical, financial, or personal decision making. This is total. May or may not be permanent. " Signed by Physician A on 09/09/14. 09/24/14 " Res may move from secure unit to front hall " . 10/6/14 " Move to unit for each behavior until Res ' d (resident) calms. Cannot reason (with) her. . . If res ' d goes to unit @ least once a day x 3 days, move to secure unit to live. " Record review of Resident #2 ' s physician notification, dated 10/06/14, revealed that at 10:00 AM the facility faxed Physician A that " Resident asked for medications, Redirected it was too early for meds. Resident began " yelling & crying stating ' you don ' t care! ' ...unable to redirect. Res ' d propelled self (up) & (down) hallway screaming & crying ... " Physician A responded on 10/07/14 " Will see in near future. Don ' t acquiesce to ' tantrums ' " . Record review of Resident #2 ' s care plan, dated 09/14/14, identified the following problems, goals, and approaches: Problem: Noncompliance with care related to " refusing to sleep in bed instead of w/c (wheelchair) " . (start date 09/02/14) Goal: Have needs met and dignity upheld daily by 90 days. Approach: Identify areas of noncompliance, identify influencing factor, Emphasize the positive aspect of being compliant, positive reinforcement, allow choices in resident care, offer psychological services if ordered, acknowledge/respect right to refuse, educate staff concerning resident rights, and notify family and MD of refusal (start date 09/02/14) Problem: Resident yells and screams at staff and throws herself to the floor (start date 10/06/14) Goal: Remain calm and not throw self in floor by 90 days. Approach: When behavior occurs, " move resident to unit for each behavior until resident calms down and don ' t try to reason with resident " and " If resident goes to unit at least once a day x ' s 3 days move to secure unit to live " . (Start date 10/06/14) In an interview with Physician A (The Facility Medical Director and Primary Care Physician for Resident #2) on 10/17/14 at 3:30 PM, he said that the order he had written on 10/06/14, regarding Resident #2 (1. Move to unit for each behavior until resident calms. Cannot reason with her. 2. If resident goes to unit at least once a day times three days, move to secure unit to live) in his opinion was not punitive. He said that if he had to show negative reinforcement to gain something positive he didn't mind doing that. He said that in his opinion was not a punitive situation. He said that resident #2 always had a lot of anxiety. He said that pretty much everything makes her anxious. He said that he has seen her throw herself out of the wheel chair to the floor just to get her way. He said that the intention of the order was that if Resident #2 displayed any behaviors like i.e., yelling or trying to throw herself out of the wheelchair that she would be moved to secure unit until that particular behavior stopped and she calmed down. He said at that point she could be brought back into the general population. He said that if Resident #2 continues to have those behaviors frequently enough that she had to go to the secured unit for three days then she would have to be transferred to the secure unit to live. This surveyor asked Physician A if he didn't feel like that was taking away her rights. Physician A said no, that he did not feel that way at all he felt like it was appropriate for Resident #2. When this surveyor asked Physician A why Resident #2 could not be taken to her room in the general population until she calmed down, he said that certainly could be an option. This surveyor asked Physician A if he thought that directive to the nursing staff could be perceived as threatening to Resident #2, as she has voiced her dislike for the secured unit. He said " no not at all that he did not feel like it was threatening in a way that was harmful " . He said that Resident #2 was aware of her behavior and that she had the capacity to understand. He said that she did not always " act as she understands, but she does " . Physician A said that " since that order has been written Resident #2 has not had to go back to the behavioral unit, that she has had zero behaviors. He feels that this is a result of that order. In an interview on 10/17/14 at approximately 3:00 PM LNV E stated that Resident #2 has not had to be sent to the secure unit since Physician A wrote the order because she knows if she displays behaviors she will have to go back to the secure unit. Resident #3 Record review of Resident #3 ' s face sheet, undated, revealed that Resident #3 is a [AGE] year old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #3 ' s Multiple Data Set (MDS) assessment, dated 10/06/14, revealed a Brief Mental Status Interview score of 15 of 15, indicating the resident is cognitively intact. The MDS indicated no mood persistence, however Resident #3 was indicated to have delusions, behavioral symptoms not directed towards others, and wandering. The MDS revealed that Resident #3 required the assistance of one person for transfers, but was able to perform mobility, dressing, eating, toilet use, and personal hygiene with supervision and setup assistance only. Resident #3 is identified by the MDS as being continent of both bowel and bladder. The MDS noted that Resident #3 received antipsychotic medications every day for the past seven days. The MDS identified Resident #3 ' s [DIAGNOSES REDACTED]. Record review of the facility ' s clinical record for Resident #3 ' s revealed a physician ' s progress note, dated 08/01/14. The progress note indicated " This resident (Resident #3) is not mentally capacitated for medical, financial, or personal decisions due to psychotic mental illness. This is total but not necessarily permanent. " Signed by Physician A Record review of the facility ' s clinical record for Resident #3 ' s revealed the following physician's order [REDACTED]. " 08/01/14 15:30 (3:30 PM) . . . Ok to place on secure unit STAT (immediately) if [MEDICAL CONDITION], assaultive, exit seeking not controlled by wander guard, or homicidal statement " (part of 8 orders signed by Physician A on 08/01/14) " 08/01/14 . . . Not mentally capacitated for medical, financial, or personal decisions-total (not necessarily permanent) " Signed by Physician A on 08/01/14 Record review of Resident #3 ' s care plan, dated 09/14/14, identified the following problems, goals, and approaches: Problem: Episodes of inappropriate behavior (start date 08/14/14). Goal: Less than (4) episodes of inappropriate behavior and no injuries to self or others over the next 90 days. Approach: Always approach calmly and unhurriedly (start date 08/14/14); Attempt to refocus behavior to something positive when exhibiting disruptive behavior (start date 08/14/14); Encourage to attend activities of choice and preference(start date 08/14/14); Notify MD (Medical Doctor) if behavior interferes with daily functioning. Not mentally capacitated for medical, financial, or perioral decisions total (not necessary permanent) (start date 08/14/14); Observe interaction with other resident ' s to prevent offensive behavior or negative resident to resident interaction. Resident prowls in others rooms and takes things that are not hers (start date 08/14/14); Provide medication as ordered by my MD (start date 08/14/14); Psychologist/Psychiatrist to provide services as ordered (start date 08/14/14); Reassure that resident is safe. OK to place in secure unit stat if [MEDICAL CONDITION] assaultive, exit seeking not controlled by wander guard or homicidal statement is made (start date 08/14/14). Record review of the facility ' s clinical record for Resident #3 ' s revealed the following nurses ' notes: 08/01/14 2100 (9:00 PM) ... " Smiles easily, cooperative & polite to staff & residents " . (No indication of [MEDICAL CONDITION], assaultive, exit seeking not controlled by wander guard, or homicidal statement) 08/02/14 11:00 AM ... " Res ' d (Resident) gets (increasingly) agitated & began hitting on wall yelling and pointing finger in Spanish. Res ' d redirected (with) diversion. " Record review of the facility ' s clinical record for Resident #3 ' s revealed no indication of homicidal statements or hypersexual, assaultive, or exit seeking behavior not controlled by wander guard documented in the nurses ' notes between 08/03/14 and 10/17/14. In an interview with the Administrator on 10/17/14 at 12:00 PM, he said he did not know that there were criteria for the secure unit. The administrator said that he felt Physician A is more than qualified to manage the secure unit but he would be looking at possibly having a psychiatrist also on the medical staff to codirect the secure unit. The administrator said that those residents that currently reside in the secure unit need to be evaluated to see if they are still appropriate to be in that unit and those that are not should be brought out into the general population. In an interview with the administrator on 10/17/14 at 12:15 PM regarding the order that was written for Resident #2 that stated she should be moved to the behavioral unit until resident calms down. If Resident #2 does go to the unit once a day for three days then Resident #2 should be transferred to the secure unit to live. The Administrator said " I do not agree with that, the secure unit should not be punitive " . He said " these types of issues will not happen in this building, it is not the right thing to do and I do not believe in it " . In an interview with Physician A on 10/17/14 at 4:00 p.m. regarding residents who are deemed incapacitated who has the legal authority to make decisions regarding the residents care, particularly consent for antipsychotic medications. Physician A said that residents should be deemed incapacitated by a judge but when that has not been done it becomes the medical team ' s responsibility to make recommendations and do whatever is appropriate for that resident. He said one of the many problems for those residents who have behavioral issues most nursing facilities will not admit those residents, so they have limited places to go. Some of them have no one as their responsible party, power of attorney or legal guardian. He said it ' s a slow

Based on Observation, interview, and record review the facility failed to provide a comfortable air temperature level between 71-81? F (degrees Fahrenheit) for the 22 residents in the facility's Secure Unit. The heating units for the Secure unit failed overnight on 2/5-6/24. The outside temperature was 19 degrees Fahrenheit. The ambient temperature in the Secure Unit dining room was 57 ?F. An Immediate Jeopardy (IJ) was identified on the Secure Unit 2/6/14. While the IJ was removed on 2/6/14, the facility remained out of compliance at a scope of potential for more than minimal harm and a severity level of pattern, because the facility had not yet monitored their plan for effectiveness. This failure could place 22 residents who resided on the Secure Unit at risk of an uncomfortable environment and increased health risks. Findings include: On 2/6/14 at 10:20 a.m. surveyor overheard a resident outside the conference room stating it was cold in the cafeteria. During an interview on 2/6/2014 at 10:30 a.m. with the Administrator and the Corporate RN Consultant, the Administrator said that on 2/5/14 at 2:45 p.m. during the Life Safety Code (LSC) inspection while testing the fire alarm system the fire panel failed to reset causing a malfunction in the heating unit. She said the heat was out in the Secure Unit. She said that the part had to be ordered. Review of the Administrators progress documentation notes dated 2/6/2014 at 7:30 a.m. Heaters were off again affecting the Secure Unit. Three of fifteen heaters were down. Temperature remains around 66? F in the common areas of the Secure Unit and 70-74? F down the hallways in the Secure Unit. The parts to repair the heater are stuck in (another city) due to weather conditions. The weather history from www.wunderground.com on 2/6/2014 at 3:15 p.m. the Temperature was 19.4? F, with a wind-chill of 10.4? F. Forecast to stay well below freezing overnight. Actual temperatures on 2/7/14 at 5:55 a.m. were 15.8? F with a wind-chill of 8.6? F. Review of the Administrators progress documentation notes dated 2/6/14 at 11:00 a.m. Still unable to find needed parts for total repair but a blower motor is available to get heating unit working. On 2/6/14 at 11:00 temperatures were taken by the Maintenance Director in the Secure Unit using a Laser temperature measurement device the results were as follows: Dining room [ROOM NUMBER]? F TV Room (across from Nurses station) 61?F Long Hallway (Rooms 49 & 51-71 - 67.8? F Short Hallway (room [ROOM NUMBER]) - 68?F Activity Room (by Dining Room) - 63?F room [ROOM NUMBER] - 63? F room [ROOM NUMBER] - 66.5? F room [ROOM NUMBER] - 62.2? F Secure Unit (zone 5) - Hallway Rooms 49-74 - 69? F During an interview on 2/6/14 at 11:50 a.m. with the Administrator regarding the heat in the secure unit, she said that it was 57? F in the Secure Unit Dining Room. She said that the residents in the Secure Unit were eating in the activity area in the Secure Unit. The temperature in the activity room at that time was 65.8? F. On 2/6/14 at 12:08 p.m. temperatures were taken by a surveyor on the secure unit as follows - room [ROOM NUMBER] near the window 63? F, room [ROOM NUMBER] 66.5? F. On 2/6/14 at 12:13 p.m. temperatures were taken by a surveyor on the secure unit as follows - room [ROOM NUMBER] - 62.2? F. On 2/6/14 at 12:15 p.m. temperature was taken by a surveyor in the day room on the Secure Unit where twenty two residents were eating, the temperature was 64.5? F On 2/6/14 at 3:00 p.m. review of the Facility Cold Alert Procedure (part of the Facility Disaster Plan) (no date) revealed the following: In the event winter weather conditions create a loss of power and heat, it is imperative the staff prevent Residents from hypothermic symptoms if room temperatures become less than 60? F. 1. The room temperatures will be measured five feet from the floor and recorded every four hours during the Cold Alert. 2. All curtains and shades may be open during the daylight hours if there is sunlight and/or a secondary light source is needed. All curtains and shades must be closed at dark. 3. If only one wing or unit is involved. Residents will be kept off the unit as much as possible. Bedfast or high-risk Residents will be temporarily transferred to other locations/rooms if space permits. If the entire facility is involved, decisions regarding evacuation will be made after discussion with the Corporate Office. 4. Residents remaining on the unit will have their vital signs checked and recorded every 2 hours while the Cold Alert is in effect. 5. Warm liquids will be available and offered to the residents. 6. Nursing will monitor all Residents for appropriate clothing and bed linens. 7. Staff will be in-serviced on the signs and symptoms of hypothermia at the time the Cold Alert is initiated. The in-service will include identifying changes in mental status, decreased body temperature, and shivering. Residents whose body temperatures decrease below 97? F will have appropriate interventions for restoring body temperature as well as notification of Physician and families. 8. Nursing will distribute blankets and warm clothing. 9. Physicians will be notified of situation and kept apprised of conditions. 10. Medical Director will be notified and updated every 30 minutes. 11. All families will be notified. On 2/6/14 at 3:00 p.m. review of the Facility's statement on loss of power, heat, and water (Part of the Facility Disaster Plan) (undated) revealed the following: Section B. Loss of Comfort heating 1. If loss is due to equipment failure in isolated area of center, Residents will be relocated to another area until repairs are made. 2. If loss is in the entire center due to interruption of public utilities (electric/natural gas) and Residents become uncomfortable, they will be placed in the beds and protected by an adequate supply of linen. 3. If loss is for extended period of time and the Residents can no longer be protected in a comfortable manner. The Residents will be evacuated to another location ... In an interview with the Administrator 2/6/14 at 3:00 p.m. the cold alert procedures were reviewed. Each area was reviewed, copies of the facility temperature logs, vital sign checks, in-service records. She said that she had begun in servicing her staff 2/5/14 at 2:45 p.m. on the Cold Alert Procedures. She said she was unable to find any portable electric heaters locally but was continuing to search. She said that she might have to go out of town for heaters. She said that the facility notified all physicians and family members. She said they were keeping the Medical Directors updated. She said that she wanted to move residents to a nearby Local Church but the corporate office had wanted to wait. In an interview with the Corporate RN Consultant 2/6/14 at 3:20 p.m. he said if needed they would be able to transfer residents to one of their sister facilities. He said they were still trying to locate portable electric heaters. In an Interview with the Administrator 2/6/14 at 3:30 p.m. she said that a Local Church was able to accommodate resident needs and they were on stand-by and ready to accept residents if a transfer were needed. Water, blankets, food and transport were all available. She said that the Corporate Director of Maintenance was driving in motors from (another city). An Immediate Jeopardy (IJ) was identified on the Secure Unit on 2/6/14 at 3:45 p.m. and the Administrator, Corporate RN Consultant and DON were informed. In an interview with the Administrator on 2/6/14 at 4:10 p.m. she said that the Corporate Director of Maintenance had arrived at the building and that he had four motors to install and expected the heat to be working in an hour. On 2/6/14 at 5:15 pm the residents were removed from the Secure Unit to the main dining room for their dinner. They were to remain in the dining room and lobby area until temperatures in the Secure Unit were up to acceptable range 71 - 81?F. On 2/6/14 at 6:13 p.m. the Co-medical Director entered facility to take vital signs and assess residents. In an interview with the Corporate Maintenance Director on 2/6/14 at 6:30 p.m. he said that the heater was up and running. He said that he will be monitoring temperatures for a while. Portable electric heaters were obtained and brought into the facility temporarily to get temperatures up to acceptable range 71 - 81? F. On 2/6/14 at 6:30 p.m. Room temperatures were taken on the Secure Unit by the Corporate Director of Maintenance using a laser temperature measurement device. The temperatures are as follows: room [ROOM NUMBER] - 60.6? F room [ROOM NUMBER] - 66.2? F room [ROOM NUMBER] - 66.9? F room [ROOM NUMBER] - 71.4? F room [ROOM NUMBER] - 68? F room [ROOM NUMBER] - 73.7? F room [ROOM NUMBER] - 71.9? F Dining Room (Secure Unit) 59.1? F, temperature directly out of the vent was 104? F. In an interview with the Administrator on 2/6/14 at 6:33 p.m. she said that every nurse's station will have the Corporate Maintenance Director's phone number and he will be available if any problems arise. On 2/6/14 at 7:30 p.m. temperatures in the Secure Unit are approximately 70? F. On 2/6/14 at 8:00 p.m. the room temperatures were taken by the Corporate Director of Maintenance using a laser temperature measurement device. The temperatures ranged from 72 to 82? F. On 2/6/14 at 8:00 p.m. residents were returned to the Secure Unit. The facility's Plan of Removal of Immediate Jeopardy was accepted 2/6/13 at 8:00 p.m. and included: 1. HVAC (Heating, Ventilation, & Air-conditioning) contractor on the roof making needed repairs at this time. 2. All Units will be operational the next 4 hours 3. Residents on the Secure Unit have been moved to warmer locations while repairs are being made. 4. Additional protective outerwear and blankets have been provided to the residents as well as warm beverages. 5. Utilization of temporary electric heaters has been implemented to provide additional warmth for the residents while repairs are being made. 6. Monitor Ambient Temperatures hourly and implement Emergency cold Alert procedures including resident vital signs Q2hrs. 7. Review Evacuation Plan if above corrective Actions is not effective. 8. Alert Sister Facilities and local facilities of the need to house the Residents if the above measures are unsuccessful (total 19 beds available). 9. Regional Maintenance Director will be in facility to assist with repairs and to identify any issues and address them. The Regional Maintenance Director will be in the facility until issue is resolved. 10. Emergency Management team alert 2/6/14 9:00 p.m. room temperatures were taken on the Secure Unit by the facility staff using a laser temperature measurement device. The temperatures ranged from 72 - 81? F. 2/6/14 the facility staff continued to take temperatures on the Secure Unit every hour from 8:00 p.m. to 5:00 am (2/7/14). The temperatures ranged from 70.5 - 82.9? F. On 2/6/14 at 10:52 p.m. during an interview with LVN F (charge nurse in Secure Unit), she said that most of the residents had returned to their rooms around 8:00 p.m. Most residents were asleep at this time. She showed the surveyors the temperature logs that she had been keeping. Temperatures were within desired range of 71-81? F. On 2/7/14 at 5:15 a.m. during an interviewed with LVN F (charge nurse in the Secure Unit), she said things had gone well, the residents were back in their rooms and were nice and warm. She presented the temperature logs for the surveyors review, the temperatures taken throughout the night ranged between 70.5? F - 81? F. The IJ was removed on 2/6/14 at 8:00 p.m. The facility remained out of compliance at a scope of potential for more than minimal harm and a severity level of pattern, because the facility had not yet monitored their plan for effectiveness. The Census in the Secure Unit was reported by the DON 2/4/14 at 7:00 p.m. to be 22.

Based on record review and interview the facility failed to consult and or notify the physician for 2 of 15 sampled residents (Resident #4 and #8) as evidenced by: a. Resident #4 was trapped in his side rail on 03/02/13 and physician was not notified until 03/27/13. b. Resident #4 was identified with soft, discolored heels on 03/27/13 and physician was not notified until 03/29/13. c. Resident #8 ' s physician was not notified/consulted when he was not given his [MEDICATION NAME] (blood thinner) on 03/13/13 and 03/15/13. This failure affected 1 resident with pressure ulcers and could affect 3 other residents identified with pressure ulcers. This failure affected 1 resident who received [MEDICATION NAME] and could affect 2 residents who received [MEDICATION NAME]. The findings included: 1. Resident #4 Entrapment in Bed Side Rails: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Further review revealed " Half rails up times two to assist in turning and repositioning " with order date of 01/30/13. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " Half rails up times two to assist in turning and repositioning. " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room (not in the secure unit) in a wheelchair. Observation on 03/19/13 at 6:00 p.m. revealed Resident #4 in his room in bed with the entire bed elevated and two one-half bed side rails in the up position. These bed side rails were positioned in the middle of the bed. Observation on 03/20/13 at 8:40 a.m. revealed CNA B and CNA C transferred Resident #4 from his wheelchair to his bed using the Hoyer lift. CNA B put both of the one-half bed side rails located in the center of the bed in the up position. In an interview on 03/20/13 at 9:15 a.m. CNA B said that Resident #4 ' s bed side rails are kept in the up position at all times because he rolls and could fall out of bed. In an interview on 03/20/13 at 9:20 a.m. Resident #4 said that the bed side rails bother him sometimes. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. The entire bed was elevated. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked in the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. Record review of Resident #4 ' s " Side Rail Assessment " dated 01/22/13 revealed: " 1. Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? No 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes (intermittent confusion, fidgeting) ... 4. Is the resident able to get in/out of bed? No 5. Is the resident able to get out of bed safely? No 6. Does the resident have a history of falls? Yes 7. Is the resident having problems with balance or poor trunk control? Yes 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help resident rise from a supine position to a sitting/standing position? No ... 11. Is there a possibility the resident will climb over the side rails? No 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? No 13. Does the resident receive any medications that would require safety precautions? No 14. Is there a risk to the resident if side rails are used? No 15. Do the side rail alternatives/interventions create more risk than side rail use? (When laying on side resident is fearful of falling out of bed and will reach nearby objects on night stand, bedside table to stabilize self unsafely) Only Intervention checked is " Reminders to use call light " Recommendations: left, right, head are checked. Comments: (Due to resident current skin status resident requires frequent turning and repositioning to left and right sides. Half rails are indicated for safety and serve as enabler for resident to assist in repositioning. " Record review of Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. revealed, " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 required half bed side rails for turning and positioning. The DON reviewed Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. ( " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " ). The DON said that she was not aware that Resident #4 had been trapped in his side rails because no one had reported this incident to her. The DON said that Resident #4 had half side rails that were positioned at the top of his bed for positioning and turning. The DON and surveyor observed Resident #4 ' s bed with the half rails positioned in the center of his bed. The DON said that she was not aware that the side rails were positioned in the center of his bed. The DON said that the side rails must have been placed in the center of his bed by Hospice when they brought the longer bed for him after he developed the bilateral heel pressure ulcers and was transferred from the secure unit to the regular unit. Resident #4 was transferred from the secure unit on 01/29/13. In an interview on 03/25/13 at 12:00 p.m. CNA E said that on 03/02/13 at 2:45 a.m. she heard a tapping noise as she was walking down hall one to go outside for a break. The tapping noise was coming from Resident #4 ' s room. CNA E said that she found Resident #4 partially on his bed with his feet up in the air, his head and right shoulder were on the floor between his bed and the wall, and his abdomen was trapped across the front part of the half side rail located in the middle of his bed. CNA E said that Resident #4 ' s was a tall man and his bed was in the high position. CNA E said that Resident #4 was incontinent of urine. CNA E said that she and LVN G helped Resident #4 get un-trapped from the side rail. CNA E said that Resident #4 had redness across the lower part of his abdomen. In an interview on 03/25/13 at 12:45 p.m. LVN G said that she had worked 03/02/13 from 6:00 p.m.-6:00 a.m. and was the only LVN on duty for Halls one and two. LVN G said that CNA E had gone to take a break when she heard her calling for help. LVN G said that she went to Resident #4 ' s room and found him trapped on his bed side rail. LVN G said that Resident #4 told her that he was looking for something under his bed. LVN G said that Resident #4 had some redness across his abdominal area. LVN G said that Resident #4 seemed fine and that she did not assess him or perform any neurological checks. LVN G said that she thought he could have been trapped for about 30 minutes because CNA E had checked him about 2:00 a.m. or so. LVN G said that she did recheck Resident #4 at 4:00 a.m. or 5:00 a.m. and he seemed fine and she reported the incident to LVN B who came on duty at 6:00 a.m. LVN G said that she did not report the incident to administration nor did she complete an incident report or an investigation regarding Resident #4 ' s entrapment in his side rails. LVN G said that she did not know that an incident/accident report had to be done on every little accident and did not think this accident required an incident/accident report even though she had some training regarding accidents. In an interview on 03/25/13 at 3:30 p.m. LVN B said that LVN G had reported to her on 03/02/13 at 6:00 a.m. shift change that Resident #4 had gotten trapped in his side rail during the night. LVN G said that she had taken his vital signs which was routine but did not do any further assessments or neurological checks. In an interview on 03/25/13 at 4:05 p.m. the Administrator said that no one had reported to her that Resident #4 had been trapped in his side rails until today and therefore there was no accident/incident report and no investigation. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. Resident #4 ' s physician said that he had not been notified about Resident #4 being trapped in the side rail (occurred 03/02/13) until Wednesday (03/27/13). Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident requires the use of ? side rails as evidenced by unable to turn self without rails. To assist with turning and repositioning self while in bed. Approach-1. Assess for the use of side rails quarterly and as needed ... " Record review of the facility provided " Nursing Guidelines: Restraints, Physical Use " dated 08/24/10 revealed, " The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident ' s target behaviors or medical symptoms. The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of rails as restraints unless necessary to treat a resident ' s medical symptoms ... 2. Restraints shall be used only for medical necessity to prevent injury to him or others following an assessment and documented lack of success with a less restrictive device ... 10. The use of restraints is identified on the resident ' s care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint to be used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every two hours; f. The plan for monitoring every 60 minutes; ... 15. A nursing assessment will show the presence of a specific medical symptom that requires the use of restraints, those symptoms that are being treated, and how the use of restraints will assist the resident in reaching his highest level of physical and psychosocial well-being. 16. A physician order for [REDACTED]. Inappropriate Restraint Orders " may use, for personal safety, to prevent falls, at family request " . Record review of the facility provided " Use of Restraints " dated 2007 page 73 revealed: " ...Physical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully ... 11. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident ' s medical symptoms.) " Record review of the facility provided " Accidents and Incidents " dated 09/20/12 page 1 revealed: " 1. An Accident/Incident Report form must be completed immediately upon facility staff awareness of the incident involving a Resident ... 2. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand-up meeting until all sections of the report are completed.. 3. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. This assessment is documented in the Nurse ' s Notes, and the Resident ' s Care Plan is updated. 4. An Accident/Incident Investigation is completed in addition to the Accident/Incident report form when staff discovers an un-witnessed accident/incident or any falls. 5. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation has been completed. 6. The DON or designee will interview all witnesses .... 10. A Fall Risk Assessment must be initiated after each fall ... 13. A neurological Assessment Flo-sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or any un-witnessed fall. For the initial 24 hours, the neurological assessment must be done every 15 minutes for 1 hour, once every 30 minutes for 2 hours, once every 1 hour times 4; and then once every shift. Following the initial 24 hours, nursing staff must document the condition of the Resident every shift for the next 48 hours (for a total of 72 hours of monitoring ... " Resident #4 Pressure Ulcers: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room in a wheelchair. Observation on 03/19/13 at 3:15 p.m. revealed Resident #4 in the front lobby in his wheelchair with glasses on and staring at a magazine. Resident #4 had green ankle socks on with the Velcro of heel protectors around his ankles and the boot part behind his legs. Both of his feet were flat on the floor. Observation on 03/20/13 at 8:00 a.m. revealed Resident #4 in his wheelchair in the hall outside of his room. Resident #4 had ankle length socks on both feet. The top of Resident #4 ' s left ankle sock was positioned across the middle of his pressure ulcer. There was no dressing on this pressure ulcer. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. Both of his heels were on the mattress even though there were two pillows positioned underneath his legs. Observation on 03/22/13 at 7:50 a.m. revealed Resident #4 in his room in bed. He had two pillows underneath both of his legs and both of his heels were on the mattress. In an interview on 03/22/13 at 7:50 a.m. Resident #4 said that his right heel hurts but he did not know why. Observation on 03/25/13 at 3:15 p.m. revealed Resident #4 in the lobby in his wheelchair with his right foot and heel resting on the wheelchair footrest and his left foot resting flat on the floor. Record review of Resident #4 ' s " Physicians Orders " dated 01/28/13 at 2130 revealed, " ...1.Per Dr. standing orders may start [MEDICATION NAME] (protein powder used to promote healing) one packet with 8 ounces of water twice daily for skin breakdown of Stage II or greater Discontinue when resolved. For pressure ulcer. 2. Heel protectors to both heels while in bed for pressure ulcers. " Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 at 0945 revealed, Move to room (out of secure unit). Apply air mattress to bed. Diagnosis - pressure ulcer. Float heels when in bed, CMP (blood test), Discontinue heel protectors, Santyl topical every day to bilateral heels till debrided then call MD for further orders, Half rails times two to bed [DIAGNOSES REDACTED]. " Santyl ointment is used for removing dead skin from wounds ... an enzymatic [MEDICATION NAME] ointment ...works by breaking down dead skin " Source dated 03/29/13: <http://www.drugs.com/cdi/santyl-ointment.html> Record review of Resident #4 ' s " Physicians Orders " dated 02/05/13 revealed, " Discontinue Santyl treatment to bilateral heels. [MEDICATION NAME] spray to bilateral heels two times daily till healed. " " [MEDICATION NAME] will relieve pain and promote healing; debrides eschar and necrotic tissue " Source dated 03/29/13: <http://www.drugs.com/pro/[MEDICATION NAME]-spray.html> Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " [MEDICATION NAME] spray to bilateral heels two times a day till healed for [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Weekly Skin Documentation " revealed the following: " Right Heel: 01/28/13 4 cm x 4 cm New, [MEDICATION NAME] two times daily, heel protectors, offload heels, 90% necrotic, red intact margins 01/30/13 - 4 cm x 4 cm Santyl every day, [MEDICATION NAME] two times daily, float heels, 90% necrotic, red intact margins (Santyl discontinued 02/05/13) 02/13/13 - 4.5 cm x 4 cm [MEDICATION NAME] spray (02/06/13) float heels, [MEDICATION NAME], wound open, Stage II, thin serous exudate, pain-2, 80% necrotic, red warm margins 02/27/13 - 3.1 cm x 2.2 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], wound scabbed, pink wound margins, pain-1 03/13/13 - 3.6 cm x 2.5 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], closed wound, unstageable, 80% necrotic, pink wound margins 03/20/13 - 3.2 cm x 2 cm [MEDICATION NAME] spray, Heel protectors, float heels, [MEDICATION NAME], scabbed wound, unstageable, necrotic, red wound margins. Left Heel: Undated 3.5 cm x 3.5 cm New, [MEDICATION NAME] two times daily, heel protectors, float heels, 90% necrotic, red intact margins Undated - 3.5 cm x 3.5 cm Santyl every day, [MEDICATION NAME] two times daily, monitor/float heels, 90% necrotic, red intact margins 02/13/13 - 5 cm x 4 cm [MEDICATION NAME] spray (date initiated-02/06/13) float heels [MEDICATION NAME], wound open, Stage II, thin serous exudate, pain-2, 80% necrotic, red warm margins 02/27/13 - 3.7 cm x 2.9 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], scabbed over, pink wound margins, pain-1 03/13/13 - 4.1 cm x 3.0 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], closed wound, unstageable, 80% necrotic, pink wound margins, pain-1 03/20/13 - no measurements documented - [MEDICATION NAME] spray, [MEDICATION NAME], heel protectors, float heels, scabbed wound, unstageable, necrotic, red wound margins. " There had been no change in treatment since 02/13/13) Record review of " Surveillance Form, Wound (Pressure Ulcer.. " dated 03/20/13 revealed Resident #4 ' s left heel measurements were 5 cm x 4 cm. Record review of Resident #4 ' s " PUSH TOOL 3.0 " (Pressure Ulcer Scale for Healing) revealed the following for the RIGHT heel: 01/28/13 - Total score - 13 02/13/13 - Total score - 14 02/20/13 - Total score - 14 03/11/13 - Total score - 13 Record review of Resident #4 ' s " PUSH TOOL 3.0 " (Pressure Ulcer Scale for Healing) revealed the following for the LEFT heel: 01/28/13 - Total score - 13 02/13/13 - Total score - 13 02/20/13 - Total score - 13 03/11/13 - Total score - 12 " Pressure Ulcer Scale for Healing (PUSH) PUSH TOOL Directions: Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing. (0=Healed - through 17) Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured. Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy. Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a " 4 " if there is any necrotic tissue present. Score as a " 3 " if there is any amount of slough present and necrotic tissue is absent. Score as a " 2 " if the wound is clean and contains granulation tissue. A superficial wound that is [MEDICATION NAME] is scored as a " 1 " . When the wound is closed, score as a " 0 " . 4 - Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 - Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 2 - Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance. 1 - [MEDICATION NAME] Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0 - Closed/Resurfaced: the wound is completely covered with epithelium (new skin). " Source dated 04/01/13: <http://www.npuap.org/wp-content/uploads/2012/02/push3.pdf> Observation on 03/21/13 at 3:15 p.m. revealed LVN B washed her hands with soap and water, applied gloves, took several incontinent wipes out of an opened and used packet from Resident #4 ' s supply in his drawer and wiped his left heel pressure ulcer, then sprayed [MEDICATION NAME] on his left pressure ulcer. LVN B repeated the same procedure on Resident #4 ' s right pressure ulcer. Both pressure ulcers were black in color with no drainage noted. " ProCure? Premoisened Premium Adult Washcloths - Incontinence supplies ...personal cleansing washcloths ... [MEDICATION NAME], alcohol-free..contains aloe and [MEDICATION NAME].. " Source dated 03/29/13: <http://procureproducts.com/> In an interview on 03/21/13 at 3:30 p.m. LVN said that she cleaned the pressure ulcer with the incontinent wipes because she had been instructed to do so by the DON In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 ' s pressure ulcer treatment included wiping the pressure ulcers with the incontinent wipes prior to applying the [MEDICATION NAME] spray. The DON said there was no physician order to clean the pressure ulcers with the incontinent wipes but that the wounds did get dirty and would need cleaning. The DON said that she did not need a physician order to clean the pressure ulcers with the incontinent wipes. Record review of Resident #4 ' s physicians orders did not reveal any pressure ulcer treatments for cleaning or dressing the heel pressure ulcers. There was no pressure ulcer treatment change since 02/05/13. Record review of " Nursing Progress Notes " revealed the following: " 01/25/13 at 4:00 p.m. Resident continues with increased weakness requires assist times 3 with transfer to/from bed/chair Res resists staff during transfers causing increased stress to him and staff increased confusion causing increased danger to self and others during transfers despite encouragement Hospice notified of need for eval of resident increased weakness for Hoyer lift. 01/27/13 at 10:18 p.m. Noted heels soft and discolored, starting to breakdown, heels offloaded to reduce pressure. 01/28/13 9:30 p.m. Noted necrotic mushy areas to bilateral heels right heel measured 4cm x 4 cm 90% necrotic tissue wound margins red intact surrounding tissue pink intact, left heel measured 3.5 cm x 3.5 cm 90% necrotic tissue wound margins red intact surrounding tissue pink intact no complaints of pain/discomfort, new order per Dr. standing orders [MEDICATION NAME] two times daily while in bed. Heel protectors to bilateral heels applied and offloaded heels at this time, faxed Dr. notified DON left message on 24 hour report to notify family in the morning. " 01/29/13 at 9:40 a.m. Hospice nurse here to evaluate resident. LVN explained that resident had pressure ulcers to bilateral heels. Hospice nurse advised and stated she would let Dr. know tomorrow when she had a meeting with him. I asked why she would be waiting till tomorrow and she stated because he hasn ' t answered his faxes. Call placed to Dr. , New order received air mattress, float heels, CMP (blood test) Santyl topical everyday till debrided and recall him for further orders. [MEDICATION NAME] one packet every day per standing orders. 01/29/13 at 12:00 p.m. New order to move to room (out of secure unit). 2.Apply air mattress to bed due to pressure ulcers 3.float heels when in bed 4.CMP (blood test) 5.Discontinue heel protectors 6.Santyl topical every day to bilateral heels til debrided then call MD for further orders [DIAGNOSES REDACTED]. 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Treatment Administration Record " dated January, 2013 revealed: " Santyl topically every day to bilateral heels till debrided then call MD for further orders, start date 01/29/13. On 01/30/13 a nurse ' s initials were circled which indicated that the treatment was not provided until 01/31/13. In an interview on 03/25/13 at 2:30 p.m. the DON said that she had spoken with the nurse who had circled the treatment on 01/30/13. The nurse said that she had actually provided the first pressure ulcer treatment (Santyl) on 01/30/13 but had failed to complete the documentation on the Treatment Administration Record. Record review of Resident #4 ' s " Nursing Progress Notes " revealed the following: " 01/30/13 at 2:30 p.m. Treatment pending Santyl medication ordered from pharmacy. 01/30/13 at 10:38 p.m. Santyl topical ointment applied to bilateral heels.. " In an interview on 03/22/13 at 10:00 a.m. Hospice CNA A said that she had been taking care of Resident #4 for about one year while he has been in the secure unit. Hospice CNA A said that the first time that she needed assistance from the staff to transfer Resident #4 to the shower was 12/31/12. Hospice CNA A said that she noticed that both of Resident #4 ' s heels were red on 01/25/13 and she reported this to the Hospice RN. Hospice CNA A said that she had not taken care of him again until 02/04/13 at which time both of his heels were black. Record review of Hospice CNA ' s visit documentation of care provided for Resident #4 revealed the following dates: " 01/15/13, 01/16/13, 01/24/13, 01/25/13, and 02/04/13. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked on the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. In an interview on 03/25/13 at 10:40 a.m. the DON said that the facility had faxed Resident #4 ' s MD on 01/28/13 regarding the newly onset heel pressure ulcers. The DON reviewed the " Nursing Progress Notes " (01/27/13 at 10:18 p.m. Noted heels soft and discolored, starting to breakdown, heels offloaded to reduce pressure) and said that she believed his pressure ulcers were identified on 01/28/13 when the heels were necrotic. The DON said that she did not know if Resident #4 ' s MD had received the fax but that she did call the MD on 01/29/13 and received orders for the pressure ulcer treatment. Record review of the facility provided fax to Resident #4 ' s MD regarding the newly identified heel pressure ulcers was dated 01/28/13 but there was no indication as to when the fax was sent and there was no response from Resident #4 ' s MD. Record review of Resident #4 ' s " Daily Pressure Ulcer Documentation " for 01/29/13, 01/31/13, 02/01/13, or 02/02/13 was blank for the Left and Right Heel. In an interview on 03/25/13 at 10:40 a.m. the DON said that three different nurses should have documented the treatment for [REDACTED]. In an interview on 03/26/13 at 9:40 a.m. the DON said that Resident #4 ' s bilateral heel pressure ulcers had improved (even though the PUSH score for the Right heel pressure ulcer was the same as initially assessed and the Left heel pressure ulcer had increased in size). The DON said that it was hard to say whe

Based on observation, interview and record review the facility failed to ensure physical restraints were not used for staff convenience and without medical necessity for one of eight residents (Resident #4) reviewed for the use of bed side rails The facility failed to ensure Resident #4 a. did not get trapped in his bed side rails, and b. had a thorough assessment and medical [DIAGNOSES REDACTED]. These deficient practices could likely prevent any resident with a physical restraint from attaining or maintaining the highest practicable level of physical and psychosocial well-being. Side rails could increase the likelihood that the resident will spend more time in bed or chair and fall when attempting to transfer from the bed or chair. Residents who attempt to exit a bed through, between, over or around side rails are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used. Source dated 09/24/12: <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf> This deficient practice could affect 5 residents identified by the facility as being physically restrained. The findings included: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Further review revealed " Half rails up times two to assist in turning and repositioning " with order date of 01/30/13. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " Half rails up times two to assist in turning and repositioning. " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room (not in the secure unit) in a wheelchair. Observation on 03/19/13 at 6:00 p.m. revealed Resident #4 in his room in bed with the entire bed elevated and two one-half bed side rails in the up position. These bed side rails were positioned in the middle of the bed. Observation on 03/20/13 at 8:40 a.m. revealed CNA B and CNA C transferred Resident #4 from his wheelchair to his bed using the Hoyer lift. CNA B put both of the one-half bed side rails located in the center of the bed in the up position. In an interview on 03/20/13 at 9:15 a.m. CNA B said that Resident #4 ' s bed side rails are kept in the up position at all times because he rolls and could fall out of bed. In an interview on 03/20/13 at 9:20 a.m. Resident #4 said that the bed side rails bother him sometimes. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. The entire bed was elevated. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked in the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. Record review of Resident #4 ' s " Side Rail Assessment " dated 01/22/13 revealed: " 1. Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? No 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes (intermittent confusion, fidgeting) ... 4. Is the resident able to get in/out of bed? No 5. Is the resident able to get out of bed safely? No 6. Does the resident have a history of falls? Yes 7. Is the resident having problems with balance or poor trunk control? Yes 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help resident rise from a supine position to a sitting/standing position? No ... 11. Is there a possibility the resident will climb over the side rails? No 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? No 13. Does the resident receive any medications that would require safety precautions? No 14. Is there a risk to the resident if side rails are used? No 15. Do the side rail alternatives/interventions create more risk than side rail use? (When laying on side resident is fearful of falling out of bed and will reach nearby objects on night stand, bedside table to stabilize self unsafely) Only Intervention checked is " Reminders to use call light " Recommendations: left, right, head are checked. Comments: (Due to resident current skin status resident requires frequent turning and repositioning to left and right sides. Half rails are indicated for safety and serve as enabler for resident to assist in repositioning. " Record review of Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. revealed, " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 required half bed side rails for turning and positioning. The DON reviewed Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. ( " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " ). The DON said that she was not aware that Resident #4 had been trapped in his side rails because no one had reported this incident to her. The DON said that Resident #4 had half side rails that were positioned at the top of his bed for positioning and turning. The DON and surveyor observed Resident #4 ' s bed with the half rails positioned in the center of his bed. The DON said that she was not aware that the side rails were positioned in the center of his bed. The DON said that the side rails must have been placed in the center of his bed by Hospice when they brought the longer bed for him after he developed the bilateral heel pressure ulcers and was transferred from the secure unit to the regular unit. Resident #4 was transferred from the secure unit on 01/29/13. In an interview on 03/25/13 at 12:00 p.m. CNA E said that on 03/02/13 at 2:45 a.m. she heard a tapping noise as she was walking down hall one to go outside for a break. The tapping noise was coming from Resident #4 ' s room. CNA E said that she found Resident #4 partially on his bed with his feet up in the air, his head and right shoulder were on the floor between his bed and the wall, and his abdomen was trapped across the front part of the half side rail located in the middle of his bed. CNA E said that Resident #4 ' s was a tall man and his bed was in the high position. CNA E said that Resident #4 was incontinent of urine. CNA E said that she and LVN G helped Resident #4 get un-trapped from the side rail. CNA E said that Resident #4 had redness across the lower part of his abdomen. In an interview on 03/25/13 at 12:45 p.m. LVN G said that she had worked 03/02/13 from 6:00 p.m.-6:00 a.m. and was the only LVN on duty for Halls one and two. LVN G said that CNA E had gone to take a break when she heard her calling for help. LVN G said that she went to Resident #4 ' s room and found him trapped on his bed side rail. LVN G said that Resident #4 told her that he was looking for something under his bed. LVN G said that Resident #4 had some redness across his abdominal area. LVN G said that Resident #4 seemed fine and that she did not assess him or perform any neurological checks. LVN G said that she thought he could have been trapped for about 30 minutes because CNA E had checked him about 2:00 a.m. or so. LVN G said that she did recheck Resident #4 at 4:00 a.m. or 5:00 a.m. and he seemed fine and she reported the incident to LVN B who came on duty at 6:00 a.m. LVN G said that she did not report the incident to administration nor did she complete an incident report or an investigation regarding Resident #4 ' s entrapment in his side rails. LVN G said that she did not know that an incident/accident report had to be done on every little accident and did not think this accident required an incident/accident report even though she had some training regarding accidents. In an interview on 03/25/13 at 3:30 p.m. LVN B said that LVN G had reported to her on 03/02/13 at 6:00 a.m. shift change that Resident #4 had gotten trapped in his side rail during the night. LVN G said that she had taken his vital signs which was routine but did not do any further assessments or neurological checks. In an interview on 03/25/13 at 4:05 p.m. the Administrator said that no one had reported to her that Resident #4 had been trapped in his side rails until today and therefore there was no accident/incident report and no investigation. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. Resident #4 ' s physician said that he had not been notified about Resident #4 being trapped in the side rail (occurred 03/02/13) until Wednesday (03/27/13). Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident requires the use of ? side rails as evidenced by unable to turn self without rails. To assist with turning and repositioning self while in bed. Approach-1. Assess for the use of side rails quarterly and as needed ... " Record review of the facility provided " Nursing Guidelines: Restraints, Physical Use " dated 08/24/10 revealed, " The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident ' s target behaviors or medical symptoms. The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of rails as restraints unless necessary to treat a resident ' s medical symptoms ... 2. Restraints shall be used only for medical necessity to prevent injury to him or others following an assessment and documented lack of success with a less restrictive device ... 10. The use of restraints is identified on the resident ' s care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint to be used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every two hours; f. The plan for monitoring every 60 minutes; ... 15. A nursing assessment will show the presence of a specific medical symptom that requires the use of restraints, those symptoms that are being treated, and how the use of restraints will assist the resident in reaching his highest level of physical and psychosocial well being. 16. A physician order [REDACTED]. Inappropriate Restraint Orders " may use, for personal safety, to prevent falls, at family request " . Record review of the facility provided " Use of Restraints " dated 2007 page 73 revealed: " ...Physical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully ... 11. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident ' s medical symptoms.) " Record review of the facility provided " Accidents and Incidents " dated 09/20/12 page 1 revealed: " 1. An Accident/Incident Report form must be completed immediately upon facility staff awareness of the incident involving a Resident ... 2. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand-up meeting until all sections of the report are completed.. 3. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. This assessment is documented in the Nurse ' s Notes, and the Resident ' s Care Plan is updated. 4. An Accident/Incident Investigation is completed in addition to the Accident/Incident report form when staff discovers an un-witnessed accident/incident or any falls. 5. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation has been completed. 6. The DON or designee will interview all witnesses .... 10. A Fall Risk Assessment must be initiated after each fall ... 13. A neurological Assessment Flo-sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or any un-witnessed fall. For the initial 24 hours, the neurological assessment must be done every 15 minutes for 1 hour, once every 30 minutes for 2 hours, once every 1 hour times 4; and then once every shift. Following the initial 24 hours, nursing staff must document the condition of the Resident every shift for the next 48 hours (for a total of 72 hours of monitoring ... " Record review of the facility provided, " Resident Census and Conditions " dated 03/20/13 revealed 5 residents with physically restraints. Record review of a list provided by the DON dated 02/26/13 revealed there was no one identified with the use of side rails.

Based on observation, interview and record review the facility failed to follow their policy to prevent neglect of two of seven Residents (Resident # 16 and 17) reviewed for neglect and The facility failed to: a) Address maladaptive behaviors of residents. b) Provide necessary services and supervision to prevent inappropriate sexual behaviors between Resident # 6 and # 16. c) Provide necessary services and supervision to prevent inappropriate sexual behaviors between Resident #6 and #17. d) Prevent the entrapment of Resident #4 in his side rails This failure could place all of the 22 residents on the secure unit at risk for neglect. The failure to prevent the side rail entrapment affected one resident and could affect 5 residents identified with restraints. Findings included: 1. Review of Resident #6's "Face Sheet" revealed a [AGE] year old male admitted to the facility 07/24/12. [DIAGNOSES REDACTED]. Review of Resident #16's "Face Sheet" revealed a [AGE] year old female admitted to the facility 10/01/09 and readmitted on [DATE] and 05/23/11. [DIAGNOSES REDACTED]. Review of Resident #17's "Face Sheet" revealed a [AGE] year old male admitted to the facility 07/24/12. [DIAGNOSES REDACTED]. Observation and interview on 03/19/13 at 11:45 a.m. revealed Resident #6 in hallway ambulating. Resident #6 was awake and alert. During initial tour with the ADON she stated that Resident #6 was on every 15 minute watches because of inappropriate sexual behaviors with Resident #17. She explained that a staff member was assigned to physically see Resident #6 every 15 minutes and document his location and behaviors, and that Resident #17 was also on every 15 minute checks. Record review of the physician orders [REDACTED].#6 to reside in secured unit due to wandering and at high elopement risk. Record Review of Progress Note dated 03/16/13 timed 0900 documentation as follows: This LVN found resident (Resident #6) in a room with another female resident (Resident #16) behind closed doors. Female resident was undressed from the waist down, and had BM (bowel movement) all over her groin area. Male resident had his zipper down and was approximately 3 ft. from female resident. Male resident did not appear to have had any contact with female resident due to he did not have any BM on his person or clothing. Female resident was taken to the shower room and examined in the perineal area. No s/sx (signs/symptoms) of irritation and redness. Male resident was taken to the television room and 15 minute monitoring began. MD (physician) notified. Male resident went to his room and spent the rest of the shift there. Signed LVN D. Record Review of nurse ' s notes for Resident # 6, dated 03/16/13 at 2210 revealed the following: Wandering in hallway, exit seeking. No complaints of pain/discomfort. Signed LVN B. No other entries for 03/16/13 were noted. During an interview and record review on 03/26/13 at 1:30 p.m. with the DON, she stated that the incident was written up and documented as an incident ... that was how it was done there. Nurses progress notes for Resident #16 revealed no evidence of documentation of the incident between Resident #6 and Resident #16. She stated that the plan to protect included putting the resident ' s on q15 minute checks. She stated that normally the residents would be separated in the facility, but both were elopement risks and they had to be kept on the secure unit of the facility. She stated that neither the Administrator nor she had any knowledge that the every 15 minute checks had been stopped. Record Review of nurse ' s notes for Resident #6, dated 03/17/13 revealed the following: 03/17/13 at 2140 Resident wandering halls, remains on q (every) 15 minute checks due to inappropriate behavior, accepting HS (hour of sleep) medications, entering other resident rooms, frequently redirected and shown own room, continues to have multiple episodes urinary incontinence, resident requires several cues to change clothes and Incontinent care. Signed LVN C. Record Review of Physician telephone order dated 03/18/13 timed at 1615 revealed the following order: D/C (discontinue) every 15 minute checks. Record review of Nurse Progress notes revealed the following entry: 3/18/13 at 2045 CNA D reported to this LVN that she opened Resident #6 ' s door and observed Resident # 6 attempting to have sexual intercourse with Resident #17, Female Resident had disrobed shorts and underwear (pull up brief) and was bent over forward over male residents bed, and male resident had pants pulled below waist line with penis out centimeters away from female residents vagina, unknown if penetration occurred. 2046 This LVN entered male resident room at this time and observed female resident naked from the waist down and male resident buttoning his pants back. CNA stated that both residents acted surprised and didn ' t immediately say what they were doing. CNA assisted female resident replace clothes, female resident was taken to own room and assisted into bed. 2049 this LVN notified DON at this time of incident and DON notified Administrator (abuse coordinator). 2055 This LVN received instructions from Administrator at this time to place male resident on one-on-one monitoring, Female resident placed on q 15 minute checks as well, and male resident brought to television room with CNA. 2110 This LVN inspected vaginal area and anus for semen, tissue disturbance or fluid, vagina and anus clean, no redness or tissue disturbance noted, 2120 Male resident penis examined for fluids or fecal matter, none noted. Both resident ' s clothes and linens removed and bagged for inspection, replaced with clean clothes and linens. 2130 Male residents wife called and notified of incident and requested she come sit with resident. Wife stated she was too ill and could not. 2135 CNA remains sitting with male resident. 2145 LVN received instructions to send female resident to ER (emergency room ) for rape kit. 2150 Guardian EMS (emergency medical service) called for transfer. 2200 Female resident interviewed and stated that she was having sex with male resident; this LVN asked if he stuck his penis inside her, she stated " I don ' t remember, I don ' t know " . 2210 Male resident interviewed and declined incident stating " he would never do that " 2235 Guardian EMS transported female resident at this time to BRMC (Brownwood Regional Medical Center) ER for rape kit. Signed LVN E. Record review of Nurses progress notes dated 03/19/13 at midnight revealed the following entry: Received verbal report for ER, Did not perform rape kit, due to external examination showed no evidence of penetration. .. Resident returned to facility and q 15 minute checks continued. Record Review of Incident /Accident report dated 03/18/13 at 2045 p.m. for Resident #6: Location of incident; Resident #6 ' s room. Resident condition before incident; confused and disoriented. Was bed rails ordered? No. Was height of bed adjustable? No. Was a restraint in use? No. Was person authorized to be at location of incident? Yes. Description of what happened: Resident engaged in sexual inappropriateness, attempting sexual intercourse. Type of Injury: No injury. Level of consciousness: alert and oriented x1(person). Physician notified at 2050. Spouse notified at 2130. Was person involved seen by physician? No. Was first aid administered? No. Was person involved taken to the hospital? No. Additional comments and/or steps taken to prevent recurrence: Resident placed on one on one monitoring and other resident placed on q 15 minute checks. Record Review of Incident /Accident report dated 03/18/13 at 2045 p.m. for Resident #17: Location of incident; Resident #6 ' s room. Resident condition before incident; confused and disoriented. Was bed rails ordered? No. Was height of bed adjustable? No. Was a restraint in use? No. Was person authorized to be at location of incident? Yes. Description of what happened: Resident engaged in sexual inappropriateness with another resident, attempting sexual intercourse. Type of Injury: No noted tissue disturbance or injury. Level of consciousness: alert and oriented x1(person). Physician notified at 2230 via fax. Daughter notified at 2300. Was person involved seen by physician? Yes, BRMC ER [DATE] 2300. Was first aid administered? No. Was person involved taken to the hospital? Yes, Guardian EMS 03/18/13 2300. Additional comments and/or steps taken to prevent recurrence: Resident placed on q 15 minute checks and other resident placed on one-on-one monitor. Record Review of Physician Notification form dated 03/18/13 at 2045 Resident #17 her Physician. From LVN E: as follows: Resident engaged in sexually inappropriate behavior with a male resident. Attempting sexual intercourse. Resident found in male resident room without pants or underwear bent forward over male resident bed, male resident penis exposed and centimeters away from resident vagina. Resident sent to BRMC ER for rape kit, vaginal exam done, no evidence of penetration. Resident on q 15 minute checks to monitor inappropriate behavior and increased libido. Signed LVN E. During an interview with the DON on 03/26/13 at 1:30 p.m., She stated that after the second incident with Resident #6 that he had been placed on one-to-one monitoring. 2. Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Further review revealed " Half rails up times two to assist in turning and repositioning " with order date of 01/30/13. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " Half rails up times two to assist in turning and repositioning. " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room (not in the secure unit) in a wheelchair. Observation on 03/19/13 at 6:00 p.m. revealed Resident #4 in his room in bed with the entire bed elevated and two one-half bed side rails in the up position. These bed side rails were positioned in the middle of the bed. Observation on 03/20/13 at 8:40 a.m. revealed CNA B and CNA C transferred Resident #4 from his wheelchair to his bed using the Hoyer lift. CNA B put both of the one-half bed side rails located in the center of the bed in the up position. In an interview on 03/20/13 at 9:15 a.m. CNA B said that Resident #4 ' s bed side rails are kept in the up position at all times because he rolls and could fall out of bed. In an interview on 03/20/13 at 9:20 a.m. Resident #4 said that the bed side rails bother him sometimes. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. The entire bed was elevated. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked in the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. Record review of Resident #4 ' s " Side Rail Assessment " dated 01/22/13 revealed: " 1. Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? No 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes (intermittent confusion, fidgeting) ... 4. Is the resident able to get in/out of bed? No 5. Is the resident able to get out of bed safely? No 6. Does the resident have a history of falls? Yes 7. Is the resident having problems with balance or poor trunk control? Yes 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help resident rise from a supine position to a sitting/standing position? No ... 11. Is there a possibility the resident will climb over the side rails? No 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? No 13. Does the resident receive any medications that would require safety precautions? No 14. Is there a risk to the resident if side rails are used? No 15. Do the side rail alternatives/interventions create more risk than side rail use? (When laying on side resident is fearful of falling out of bed and will reach nearby objects on night stand, bedside table to stabilize self unsafely) Only Intervention checked is " Reminders to use call light " Recommendations: left, right, head are checked. Comments: (Due to resident current skin status resident requires frequent turning and repositioning to left and right sides. Half rails are indicated for safety and serve as enabler for resident to assist in repositioning. " Record review of Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. revealed, " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 required half bed side rails for turning and positioning. The DON reviewed Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. ( " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " ). The DON said that she was not aware that Resident #4 had been trapped in his side rails because no one had reported this incident to her. The DON said that Resident #4 had half side rails that were positioned at the top of his bed for positioning and turning. The DON and surveyor observed Resident #4 ' s bed with the half rails positioned in the center of his bed. The DON said that she was not aware that the side rails were positioned in the center of his bed. The DON said that the side rails must have been placed in the center of his bed by Hospice when they brought the longer bed for him after he developed the bilateral heel pressure ulcers and was transferred from the secure unit to the regular unit. Resident #4 was transferred from the secure unit on 01/29/13. In an interview on 03/25/13 at 12:00 p.m. CNA E said that on 03/02/13 at 2:45 a.m. she heard a tapping noise as she was walking down hall one to go outside for a break. The tapping noise was coming from Resident #4 ' s room. CNA E said that she found Resident #4 partially on his bed with his feet up in the air, his head and right shoulder were on the floor between his bed and the wall, and his abdomen was trapped across the front part of the half side rail located in the middle of his bed. CNA E said that Resident #4 ' s was a tall man and his bed was in the high position. CNA E said that Resident #4 was incontinent of urine. CNA E said that she and LVN G helped Resident #4 get un-trapped from the side rail. CNA E said that Resident #4 had redness across the lower part of his abdomen. In an interview on 03/25/13 at 12:45 p.m. LVN G said that she had worked 03/02/13 from 6:00 p.m.-6:00 a.m. and was the only LVN on duty for Halls one and two. LVN G said that CNA E had gone to take a break when she heard her calling for help. LVN G said that she went to Resident #4 ' s room and found him trapped on his bed side rail. LVN G said that Resident #4 told her that he was looking for something under his bed. LVN G said that Resident #4 had some redness across his abdominal area. LVN G said that Resident #4 seemed fine and that she did not assess him or perform any neurological checks. LVN G said that she thought he could have been trapped for about 30 minutes because CNA E had checked him about 2:00 a.m. or so. LVN G said that she did recheck Resident #4 at 4:00 a.m. or 5:00 a.m. and he seemed fine and she reported the incident to LVN B who came on duty at 6:00 a.m. LVN G said that she did not report the incident to administration nor did she complete an incident report or an investigation regarding Resident #4 ' s entrapment in his side rails. LVN G said that she did not know that an incident/accident report had to be done on every little accident and did not think this accident required an incident/accident report even though she had some training regarding accidents. In an interview on 03/25/13 at 3:30 p.m. LVN B said that LVN G had reported to her on 03/02/13 at 6:00 a.m. shift change that Resident #4 had gotten trapped in his side rail during the night. LVN G said that she had taken his vital signs which was routine but did not do any further assessments or neurological checks. In an interview on 03/25/13 at 4:05 p.m. the Administrator said that no one had reported to her that Resident #4 had been trapped in his side rails until today and therefore there was no accident/incident report and no investigation. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. Resident #4 ' s physician said that he had not been notified about Resident #4 being trapped in the side rail (occurred 03/02/13) until Wednesday (03/27/13). Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident requires the use of ? side rails as evidenced by unable to turn self without rails. To assist with turning and repositioning self while in bed. Approach-1. Assess for the use of side rails quarterly and as needed ... " Record review of the facility provided " Nursing Guidelines: Restraints, Physical Use " dated 08/24/10 revealed, " The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident ' s target behaviors or medical symptoms. The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of rails as restraints unless necessary to treat a resident ' s medical symptoms ... 2. Restraints shall be used only for medical necessity to prevent injury to him or others following an assessment and documented lack of success with a less restrictive device ... 10. The use of restraints is identified on the resident ' s care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint to be used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every two hours; f. The plan for monitoring every 60 minutes; ... 15. A nursing assessment will show the presence of a specific medical symptom that requires the use of restraints, those symptoms that are being treated, and how the use of restraints will assist the resident in reaching his highest level of physical and psychosocial well being. 16. A physician order [REDACTED]. Inappropriate Restraint Orders " may use, for personal safety, to prevent falls, at family request " . Record review of the facility provided " Use of Restraints " dated 2007 page 73 revealed: " ...Physical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully ... 11. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident ' s medical symptoms.) " Record review of the facility provided " Accidents and Incidents " dated 09/20/12 page 1 revealed: " 1. An Accident/Incident Report form must be completed immediately upon facility staff awareness of the incident involving a Resident ... 2. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand-up meeting until all sections of the report are completed.. 3. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. This assessment is documented in the Nurse ' s Notes, and the Resident ' s Care Plan is updated. 4. An Accident/Incident Investigation is completed in addition to the Accident/Incident report form when staff discovers an un-witnessed accident/incident or any falls. 5. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation has been completed. 6. The DON or designee will interview all witnesses .... 10. A Fall Risk Assessment must be initiated after each fall ... 13. A neurological Assessment Flo-sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or any un-witnessed fall. For the initial 24 hours, the neurological assessment must be done every 15 minutes for 1 hour, once every 30 minutes for 2 hours, once every 1 hour times 4; and then once every shift. Following the initial 24 hours, nursing staff must document the condition of the Resident every shift for the next 48 hours (for a total of 72 hours of monitoring ... " Record review of the facility provided, " Resident Census and Conditions " dated 03/20/13 revealed 5 residents with physically restraints. Record review of a list provided by the DON dated 03/26/13 revealed no one had the use of side rails as restraints.

Based on observation, interview and record review the facility failed to follow and implement its abuse and neglect prohibition policy and procedures for protection and investigation of abuse and neglect for 1 of 13 sampled residents. The facility failed to ensure Resident #4 ' s entrapment in the bed side rails was reported and investigated. These deficient practices could likely prevent any resident with a physical restraint from attaining or maintaining the highest practicable level of physical and psychosocial well-being. Side rails could increase the likelihood that the resident will spend more time in bed or chair and fall when attempting to transfer from the bed or chair. Residents who attempt to exit a bed through, between, over or around side rails are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used. Source dated 09/24/12: <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf> This deficient practice affected 1 resident could affect any of the 67 residents who might have side rails that had not been identified by the DON. The findings included: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Further review revealed " Half rails up times two to assist in turning and repositioning " with order date of 01/30/13. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " Half rails up times two to assist in turning and repositioning. " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room (not in the secure unit) in a wheelchair. Observation on 03/19/13 at 6:00 p.m. revealed Resident #4 in his room in bed with the entire bed elevated and two one-half bed side rails in the up position. These bed side rails were positioned in the middle of the bed. Observation on 03/20/13 at 8:40 a.m. revealed CNA B and CNA C transferred Resident #4 from his wheelchair to his bed using the Hoyer lift. CNA B put both of the one-half bed side rails located in the center of the bed in the up position. In an interview on 03/20/13 at 9:15 a.m. CNA B said that Resident #4 ' s bed side rails are kept in the up position at all times because he rolls and could fall out of bed. In an interview on 03/20/13 at 9:20 a.m. Resident #4 said that the bed side rails bother him sometimes. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. The entire bed was elevated. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked in the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. Record review of Resident #4 ' s " Side Rail Assessment " dated 01/22/13 revealed: " 1. Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? No 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes (intermittent confusion, fidgeting) ... 4. Is the resident able to get in/out of bed? No 5. Is the resident able to get out of bed safely? No 6. Does the resident have a history of falls? Yes 7. Is the resident having problems with balance or poor trunk control? Yes 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help resident rise from a supine position to a sitting/standing position? No ... 11. Is there a possibility the resident will climb over the side rails? No 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? No 13. Does the resident receive any medications that would require safety precautions? No 14. Is there a risk to the resident if side rails are used? No 15. Do the side rail alternatives/interventions create more risk than side rail use? (When laying on side resident is fearful of falling out of bed and will reach nearby objects on night stand, bedside table to stabilize self unsafely) Only Intervention checked is " Reminders to use call light " Recommendations: left, right, head are checked. Comments: (Due to resident current skin status resident requires frequent turning and repositioning to left and right sides. Half rails are indicated for safety and serve as enabler for resident to assist in repositioning. " Record review of Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. revealed, " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 required half bed side rails for turning and positioning. The DON reviewed Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. ( " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " ). The DON said that she was not aware that Resident #4 had been trapped in his side rails because no one had reported this incident to her. The DON said that Resident #4 had half side rails that were positioned at the top of his bed for positioning and turning. The DON and surveyor observed Resident #4 ' s bed with the half rails positioned in the center of his bed. The DON said that she was not aware that the side rails were positioned in the center of his bed. The DON said that the side rails must have been placed in the center of his bed by Hospice when they brought the longer bed for him after he developed the bilateral heel pressure ulcers and was transferred from the secure unit to the regular unit. Resident #4 was transferred from the secure unit on 01/29/13. In an interview on 03/25/13 at 12:00 p.m. CNA E said that on 03/02/13 at 2:45 a.m. she heard a tapping noise as she was walking down hall one to go outside for a break. The tapping noise was coming from Resident #4 ' s room. CNA E said that she found Resident #4 partially on his bed with his feet up in the air, his head and right shoulder were on the floor between his bed and the wall, and his abdomen was trapped across the front part of the half side rail located in the middle of his bed. CNA E said that Resident #4 ' s was a tall man and his bed was in the high position. CNA E said that Resident #4 was incontinent of urine. CNA E said that she and LVN G helped Resident #4 get un-trapped from the side rail. CNA E said that Resident #4 had redness across the lower part of his abdomen. In an interview on 03/25/13 at 12:45 p.m. LVN G said that she had worked 03/02/13 from 6:00 p.m.-6:00 a.m. and was the only LVN on duty for Halls one and two. LVN G said that CNA E had gone to take a break when she heard her calling for help. LVN G said that she went to Resident #4 ' s room and found him trapped on his bed side rail. LVN G said that Resident #4 told her that he was looking for something under his bed. LVN G said that Resident #4 had some redness across his abdominal area. LVN G said that Resident #4 seemed fine and that she did not assess him or perform any neurological checks. LVN G said that she thought he could have been trapped for about 30 minutes because CNA E had checked him about 2:00 a.m. or so. LVN G said that she did recheck Resident #4 at 4:00 a.m. or 5:00 a.m. and he seemed fine and she reported the incident to LVN B who came on duty at 6:00 a.m. LVN G said that she did not report the incident to administration nor did she complete an incident report or an investigation regarding Resident #4 ' s entrapment in his side rails. LVN G said that she did not know that an incident/accident report had to be done on every little accident and did not think this accident required an incident/accident report even though she had some training regarding accidents. In an interview on 03/25/13 at 3:30 p.m. LVN B said that LVN G had reported to her on 03/02/13 at 6:00 a.m. shift change that Resident #4 had gotten trapped in his side rail during the night. LVN G said that she had taken his vital signs which was routine but did not do any further assessments or neurological checks. In an interview on 03/25/13 at 4:05 p.m. the Administrator said that no one had reported to her that Resident #4 had been trapped in his side rails until today and therefore there was no accident/incident report and no investigation. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. Resident #4 ' s physician said that he had not been notified about Resident #4 being trapped in the side rail (occurred 03/02/13) until Wednesday (03/27/13). Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident requires the use of ? side rails as evidenced by unable to turn self without rails. To assist with turning and repositioning self while in bed. Approach-1. Assess for the use of side rails quarterly and as needed ... " Record review of the facility provided " Nursing Guidelines: Restraints, Physical Use " dated 08/24/10 revealed, " The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident ' s target behaviors or medical symptoms. The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of rails as restraints unless necessary to treat a resident ' s medical symptoms ... 2. Restraints shall be used only for medical necessity to prevent injury to him or others following an assessment and documented lack of success with a less restrictive device ... 10. The use of restraints is identified on the resident ' s care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint to be used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every two hours; f. The plan for monitoring every 60 minutes; ... 15. A nursing assessment will show the presence of a specific medical symptom that requires the use of restraints, those symptoms that are being treated, and how the use of restraints will assist the resident in reaching his highest level of physical and psychosocial well being. 16. A physician order [REDACTED]. Inappropriate Restraint Orders " may use, for personal safety, to prevent falls, at family request " . Record review of the facility provided " Use of Restraints " dated 2007 page 73 revealed: " ...Physical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully ... 11. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident ' s medical symptoms.) " Record review of the facility provided " Accidents and Incidents " dated 09/20/12 page 1 revealed: " 1. An Accident/Incident Report form must be completed immediately upon facility staff awareness of the incident involving a Resident ... 2. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand-up meeting until all sections of the report are completed.. 3. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. This assessment is documented in the Nurse ' s Notes, and the Resident ' s Care Plan is updated. 4. An Accident/Incident Investigation is completed in addition to the Accident/Incident report form when staff discovers an un-witnessed accident/incident or any falls. 5. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation has been completed. 6. The DON or designee will interview all witnesses .... 10. A Fall Risk Assessment must be initiated after each fall ... 13. A neurological Assessment Flo-sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or any un-witnessed fall. For the initial 24 hours, the neurological assessment must be done every 15 minutes for 1 hour, once every 30 minutes for 2 hours, once every 1 hour times 4; and then once every shift. Following the initial 24 hours, nursing staff must document the condition of the Resident every shift for the next 48 hours (for a total of 72 hours of monitoring ... " Record review of the facility provided, " Resident Census and Conditions of Residents " dated 03/20/13 revealed 5 residents who were physically restrained. Record review of a list provided by the DON dated 03/26/13 revealed there was no one identified with the use of side rails.

Based on interviews and record review the facility failed to ensure a resident who entered the building without pressure sores did not develop pressure sores and received necessary treatment and services to promote healing for 1 of 3 sampled residents (Resident #4) reviewed for pressure ulcers. The facility failed to ensure Resident #4: a. did not develop pressure sores on each of his heels after a change in condition, and b. received timely and appropriate treatment for [REDACTED]. These failures affected 1 resident and could place 4 other resident identified with pressure ulcers. The findings included: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room in a wheelchair. Observation on 03/19/13 at 3:15 p.m. revealed Resident #4 in the front lobby in his wheelchair with glasses on and staring at a magazine. Resident #4 had green ankle socks on with the velcro of heel protectors around his ankles and the boot part behind his legs. Both of his feet were flat on the floor. Observation on 03/20/13 at 8:00 a.m. revealed Resident #4 in his wheelchair in the hall outside of his room. Resident #4 had ankle length socks on both feet. The top of Resident #4 ' s left ankle sock was positioned across the middle of his pressure ulcer. There was no dressing on this pressure ulcer. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. Both of his heels were on the mattress even though there were two pillows positioned underneath his legs. Observation on 03/22/13 at 7:50 a.m. revealed Resident #4 in his room in bed. He had two pillows underneath both of his legs and both of his heels were on the mattress. In an interview on 03/22/13 at 7:50 a.m. Resident #4 said that his right heel hurts but he did not know why. Observation on 03/25/13 at 3:15 p.m. revealed Resident #4 in the lobby in his wheelchair with his right foot and heel resting on the wheelchair footrest and his left foot resting flat on the floor. Record review of Resident #4 ' s " Physicians Orders " dated 01/28/13 at 2130 revealed, " ...1.Per Dr. standing orders may start [MEDICATION NAME] (protein powder used to promote healing) one packet with 8 ounces of water twice daily for skin breakdown of Stage II or greater Discontinue when resolved. For pressure ulcer. 2. Heel protectors to both heels while in bed for pressure ulcers. " Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 at 0945 revealed, Move to room (out of secure unit). Apply air mattress to bed. Diagnosis - pressure ulcer. Float heels when in bed, CMP (blood test), Discontinue heel protectors, Santyl topical every day to bilateral heels till debrided then call MD for further orders, Half rails times two to bed [DIAGNOSES REDACTED]. " Santyl ointment is used for removing dead skin from wounds ... an enzymatic [MEDICATION NAME] ointment ...works by breaking down dead skin " Source dated 03/29/13: <http://www.drugs.com/cdi/santyl-ointment.html> Record review of Resident #4 ' s " Physicians Orders " dated 02/05/13 revealed, " Discontinue Santyl treatment to bilateral heels. [MEDICATION NAME] spray to bilateral heels two times daily till healed. " " [MEDICATION NAME] will relieve pain and promote healing; debrides eschar and necrotic tissue " Source dated 03/29/13: <http://www.drugs.com/pro/[MEDICATION NAME]-spray.html> Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " [MEDICATION NAME] spray to bilateral heels two times a day till healed for [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Weekly Skin Documentation " revealed the following: " Right Heel: 01/28/13 4 cm x 4 cm New, [MEDICATION NAME] two times daily, heel protectors, offload heels, 90% necrotic, red intact margins 01/30/13 - 4 cm x 4 cm Santyl every day, [MEDICATION NAME] two times daily, float heels, 90% necrotic, red intact margins (Santyl discontinued 02/05/13) 02/13/13 - 4.5 cm x 4 cm [MEDICATION NAME] spray (02/06/13) float heels, [MEDICATION NAME], wound open, Stage II, thin serous exudate, pain-2, 80% necrotic, red warm margins 02/27/13 - 3.1 cm x 2.2 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], wound scabbed, pink wound margins, pain-1 03/13/13 - 3.6 cm x 2.5 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], closed wound, unstageable, 80% necrotic, pink wound margins 03/20/13 - 3.2 cm x 2 cm [MEDICATION NAME] spray, Heel protectors, float heels, [MEDICATION NAME], scabbed wound, unstageable, necrotic, red wound margins. Left Heel: Undated 3.5 cm x 3.5 cm New, [MEDICATION NAME] two times daily, heel protectors, float heels, 90% necrotic, red intact margins Undated - 3.5 cm x 3.5 cm Santyl every day, [MEDICATION NAME] two times daily, monitor/float heels, 90% necrotic, red intact margins 02/13/13 - 5 cm x 4 cm [MEDICATION NAME] spray (date initiated-02/06/13) float heels [MEDICATION NAME], wound open, Stage II, thin serous exudate, pain-2, 80% necrotic, red warm margins 02/27/13 - 3.7 cm x 2.9 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], scabbed over, pink wound margins, pain-1 03/13/13 - 4.1 cm x 3.0 cm [MEDICATION NAME] spray, float heels, [MEDICATION NAME], closed wound, unstageable, 80% necrotic, pink wound margins, pain-1 03/20/13 - no measurements documented - [MEDICATION NAME] spray, [MEDICATION NAME], heel protectors, float heels, scabbed wound, unstageable, necrotic, red wound margins. " There had been no change in treatment since 02/13/13) Record review of " Surveillance Form, Wound (Pressure Ulcer.. " dated 03/20/13 revealed Resident #4 ' s left heel measurements were 5 cm x 4 cm. Record review of Resident #4 ' s " PUSH TOOL 3.0 " (Pressure Ulcer Scale for Healing) revealed the following for the RIGHT heel: 01/28/13 - Total score - 13 02/13/13 - Total score - 14 02/20/13 - Total score - 14 03/11/13 - Total score - 13 Record review of Resident #4 ' s " PUSH TOOL 3.0 " (Pressure Ulcer Scale for Healing) revealed the following for the LEFT heel: 01/28/13 - Total score - 13 02/13/13 - Total score - 13 02/20/13 - Total score - 13 03/11/13 - Total score - 12 " Pressure Ulcer Scale for Healing (PUSH) PUSH TOOL Directions: Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudate, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing. (0=Healed - through 17) Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured. Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy. Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. Score as a " 4 " if there is any necrotic tissue present. Score as a " 3 " if there is any amount of slough present and necrotic tissue is absent. Score as a " 2 " if the wound is clean and contains granulation tissue. A superficial wound that is [MEDICATION NAME] is scored as a " 1 " . When the wound is closed, score as a " 0 " . 4 - Necrotic Tissue (Eschar): black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 - Slough: yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 2 - Granulation Tissue: pink or beefy red tissue with a shiny, moist, granular appearance. 1 - [MEDICATION NAME] Tissue: for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0 - Closed/Resurfaced: the wound is completely covered with epithelium (new skin). " Source dated 04/01/13: <http://www.npuap.org/wp-content/uploads/2012/02/push3.pdf> Observation on 03/21/13 at 3:15 p.m. revealed LVN B washed her hands with soap and water, applied gloves, took several incontinent wipes out of an opened and used packet from Resident #4 ' s supply in his drawer and wiped his left heel pressure ulcer, then sprayed [MEDICATION NAME] on his left pressure ulcer. LVN B repeated the same procedure on Resident #4 ' s right pressure ulcer. Both pressure ulcers were black in color with no drainage noted. " ProCure? Premoisened Premium Adult Washcloths - Incontinence supplies ...personal cleansing washcloths ... [MEDICATION NAME], alcohol-free..contains aloe and [MEDICATION NAME].. " Source dated 03/29/13: <http://procureproducts.com/> In an interview on 03/21/13 at 3:30 p.m. LVN said that she cleaned the pressure ulcer with the incontinent wipes because she had been instructed to do so by the DON In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 ' s pressure ulcer treatment included wiping the pressure ulcers with the incontinent wipes prior to applying the [MEDICATION NAME] spray. The DON said there was no physician order to clean the pressure ulcers with the incontinent wipes but that the wounds did get dirty and would need cleaning. The DON said that she did not need a physician order to clean the pressure ulcers with the incontinent wipes. Record review of Resident #4 ' s physicians orders did not reveal any pressure ulcer treatments for cleaning or dressing the heel pressure ulcers. There was no pressure ulcer treatment change since 02/05/13. Record review of " Nursing Progress Notes " revealed the following: " 01/25/13 at 4:00 p.m. Resident continues with increased weakness requires assist times 3 with transfer to/from bed/chair Res resists staff during transfers causing increased stress to him and staff increased confusion causing increased danger to self and others during transfers despite encouragement Hospice notified of need for eval of resident increased weakness for hoyer lift. 01/27/13 at 10:18 p.m. Noted heels soft and discolored, starting to breakdown, heels offloaded to reduce pressure. 01/28/13 9:30 p.m. Noted necrotic mushy areas to bilateral heels right heel measured 4cm x 4 cm 90% necrotic tissue wound margins red intact surrounding tissue pink intact, left heel measured 3.5 cm x 3.5 cm 90% necrotic tissue wound margins red intact surrounding tissue pink intact no complaints of pain/discomfort, new order per Dr. standing orders [MEDICATION NAME] two times daily while in bed. Heel protectors to bilateral heels applied and offloaded heels at this time, faxed Dr. notified DON left message on 24 hour report to notify family in the morning. " 01/29/13 at 9:40 a.m. Hospice nurse here to evaluate resident. LVN explained that resident had pressure ulcers to bilateral heels. Hospice nurse advised and stated she would let Dr. know tomorrow when she had a meeting with him. I asked why she would be waiting till tomorrow and she stated because he hasn ' t answered his faxes. Call placed to Dr. , New order received air mattress, float heels, CMP (blood test) Santyl topical everyday till debrided and recall him for further orders. [MEDICATION NAME] one packet every day per standing orders. 01/29/13 at 12:00 p.m. New order to move to room (out of secure unit). 2.Apply air mattress to bed due to pressure ulcers 3.float heels when in bed 4.CMP (blood test) 5.Discontinue heel protectors 6.Santyl topical every day to bilateral heels til debrided then call MD for further orders [DIAGNOSES REDACTED]. 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Treatment Administration Record " dated January, 2013 revealed: " Santyl topically every day to bilateral heels till debrided then call MD for further orders, start date 01/29/13. On 01/30/13 a nurse ' s initials were circled which indicated that the treatment was not provided until 01/31/13. In an interview on 03/25/13 at 2:30 p.m. the DON said that she had spoken with the nurse who had circled the treatment on 01/30/13. The nurse said that she had actually provided the first pressure ulcer treatment (Santyl) on 01/30/13 but had failed to complete the documentation on the Treatment Administration Record. Record review of Resident #4 ' s " Nursing Progress Notes " revealed the following: " 01/30/13 at 2:30 p.m. Treatment pending Santyl medication ordered from pharmacy. 01/30/13 at 10:38 p.m. Santyl topical ointment applied to bilateral heels.. " In an interview on 03/22/13 at 10:00 a.m. Hospice CNA A said that she had been taking care of Resident #4 for about one year while he has been in the secure unit. Hospice CNA A said that the first time that she needed assistance from the staff to transfer Resident #4 to the shower was 12/31/12. Hospice CNA A said that she noticed that both of Resident #4 ' s heels were red on 01/25/13 and she reported this to the Hospice RN. Hospice CNA A said that she had not taken care of him again until 02/04/13 at which time both of his heels were black. Record review of Hospice CNA ' s visit documentation of care provided for Resident #4 revealed the following dates: " 01/15/13, 01/16/13, 01/24/13, 01/25/13, and 02/04/13. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked on the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. In an interview on 03/25/13 at 10:40 a.m. the DON said that the facility had faxed Resident #4 ' s MD on 01/28/13 regarding the newly onset heel pressure ulcers. The DON reviewed the " Nursing Progress Notes " (01/27/13 at 10:18 p.m. Noted heels soft and discolored, starting to breakdown, heels offloaded to reduce pressure) and said that she believed his pressure ulcers were identified on 01/28/13 when the heels were necrotic. The DON said that she did not know if Resident #4 ' s MD had received the fax but that she did call the MD on 01/29/13 and received orders for the pressure ulcer treatment. Record review of the facility provided fax to Resident #4 ' s MD regarding the newly identified heel pressure ulcers was dated 01/28/13 but there was no indication as to when the fax was sent and there was no response from Resident #4 ' s MD. Record review of Resident #4 ' s " Daily Pressure Ulcer Documentation " for 01/29/13, 01/31/13, 02/01/13, or 02/02/13 was blank for the Left and Right Heel. In an interview on 03/25/13 at 10:40 a.m. the DON said that three different nurses should have documented the treatment for [REDACTED]. In an interview on 03/26/13 at 9:40 a.m. the DON said that Resident #4 ' s bilateral heel pressure ulcers had improved (even though the PUSH score for the Right heel pressure ulcer was the same as initially assessed and the Left heel pressure ulcer had increased in size). The DON said that it was hard to say whether Resident #4 ' s pressure ulcers were avoidable or unavoidable. The DON said that Resident #4 declined rapidly over a short period of time from walking to bedfast. The DON said that Resident #4 was a tall man and his feet rubbed against the footboard of his bed in the secure unit. The DON said that when Resident #4 was transferred out of the secure unit a longer bed was provided. The DON said that the heel protectors were discontinued about a month ago because it was determined that they were not helping with off- loading his heels. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. He said that Resident #4 rubbed his feet back and forth on the bed causing the pressure ulcers. He said that he liked to use a saline solution to clean the wounds and felt like the pressure ulcers should have a dressing applied. He said he was not aware that the facility was using incontinent wipes to clean the heel pressure ulcers. Record review of the facility provided " Wound Document Guidelines " dated 02/15/12 page 10 revealed: " 1. Measure wound disposable paper ruler.. 2. Measure length in centimeters ... 3. Measure width in centimeters ... 4. Measure depth in centimeters ... 5. Estimate the amount of exudate present ... 6. Document the type of tissue that is present in the wound.... 8. Document pain ... 9. Document appearance of peri-wound, including color and heat. 10. This documentation should be daily, as well as weekly, on the Wound Evaluation Flow Sheet. " Record review of facility provided " Skin System " dated 02/15/13 page 2 revealed: " ...13.If a Resident has a pressure ulcer, daily documentation on the Daily Pressure Ulcer Documentation Form will occur until the pressure Ulcer is resolved. Pay close attention to the treatment evaluation date, treatment success/failure is reviewed at least every 14 days and the physician is notified of the assessment ... 16 ...utilized Skin Treatment Protocols if the Resident ' s physician approves the plan of treatment. Clinical staff should work with the Resident ' s attending physician to implement these protocols to the maximum extent clinically appropriate. " Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident has current skin concerns as evidenced by Stage II bilateral heels, the approaches included: 1. Perform treatments per order if no improvement x 2 weeks - report to MD..10. air mattress, 11. Float heels when in bed, 12.[MEDICATION NAME] spray to bilateral heels as per doctor orders. " Record review of a list provided by the DON dated 03/26/13 revealed 5 residents had pressure ulcers.

Based on observation, interviews, and record reviews, the facility failed to ensure that 1 of 13 sampled residents (Resident #4) reviewed did not get trapped in his side rails. The facility failed to supervise, monitor, assess, and complete an accident investigation report for Resident #4. These deficient practices could likely prevent any resident with a physical restraint from attaining or maintaining the highest practicable level of physical and psychosocial well-being. Side rails could increase the likelihood that the resident will spend more time in bed or chair and fall when attempting to transfer from the bed or chair. Residents who attempt to exit a bed through, between, over or around side rails are at risk of injury or death. The potential for serious injury is more likely from a fall from a bed with raised side rails than from a fall from a bed where side rails are not used. Source dated 09/24/12: <https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf> This deficient practice could affect 5 residents identified by the facility as being physically restrained. The findings included: Record review of Resident #4 ' s " Record of Admission " dated 02/14/13 revealed an [AGE] year old male who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed [DIAGNOSES REDACTED]. Further review revealed " Half rails up times two to assist in turning and repositioning " with order date of 01/30/13. Record review of Resident #4 ' s most recent " MDS " dated 01/22/13 revealed he was severely cognitively impaired, could usually make himself understood and sometimes understand others, had little energy and trouble concentrating on things, wandered daily, was totally dependent on two staff for bed mobility and transfers, totally dependent on one person for dressing, required limited assistance of one person for locomotion on and off the unit and personal hygiene, extensive assistance of one person for toileting, was frequently incontinent of bowel and bladder, had no restraints, pressure ulcers, skin problems, no skin or ulcer treatments, and received hospice services. Resident #4 was in the secure unit. Resident #4 was a 73 inches tall and weighed 232 pounds. In an interview on 03/19/13 at 11:27 a.m. during initial tour the DON said that Resident #4 was not ambulatory, transferred with a Hoyer (mechanical) lift, was oriented to person and place but not time, had been in the secure unit, had pressure ulcers on each heel and was receiving hospice services. Record review of Resident #4 ' s " Physicians Orders " dated 01/29/13 revealed " Move to room (out of secure unit). " Record review of " Nursing Progress Notes " revealed the following: " 01/29/13 at 3:00 p.m. Resident moved to room (out of secure unit). " Record review of Resident #4 ' s " Physicians Orders " dated 03/01/13-04/15/13 revealed, " Half rails up times two to assist in turning and repositioning. " Observation on 03/19/13 at 11:27 a.m. revealed Resident #4 in the hallway outside his room (not in the secure unit) in a wheelchair. Observation on 03/19/13 at 6:00 p.m. revealed Resident #4 in his room in bed with the entire bed elevated and two one-half bed side rails in the up position. These bed side rails were positioned in the middle of the bed. Observation on 03/20/13 at 8:40 a.m. revealed CNA B and CNA C transferred Resident #4 from his wheelchair to his bed using the Hoyer lift. CNA B put both of the one-half bed side rails located in the center of the bed in the up position. In an interview on 03/20/13 at 9:15 a.m. CNA B said that Resident #4 ' s bed side rails are kept in the up position at all times because he rolls and could fall out of bed. In an interview on 03/20/13 at 9:20 a.m. Resident #4 said that the bed side rails bother him sometimes. Observation on 03/21/13 at 9:30 a.m. revealed Resident #4 in his bed with bilateral one-half bed side rails positioned in the middle of his bed in the up position. The entire bed was elevated. In an interview on 03/25/13 at 10:40 a.m. LVN C (who worked in the secure unit) said that Resident #4 had gone from using a rolling walker to a wheelchair about 2-3 weeks before he developed the heel pressure ulcers. LVN C said that Resident #4 had not been getting up out of bed on her shift (6:00 a.m. - 6:00 p.m.) for about one week prior to the development of his heel pressure ulcers. LVN C said that Resident #4 rubbed his feet and heels on the sheets. LVN C said that they had discussed using the Hoyer lift for transfers but had decided not to because he was too anxious. LVN C said that Resident had a very good appetite and ate very well. Record review of Resident #4 ' s " Side Rail Assessment " dated 01/22/13 revealed: " 1. Has resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? No 2. Does the resident have fluctuations in levels of consciousness or a cognitive deficit? Yes (intermittent confusion, fidgeting) ... 4. Is the resident able to get in/out of bed? No 5. Is the resident able to get out of bed safely? No 6. Does the resident have a history of falls? Yes 7. Is the resident having problems with balance or poor trunk control? Yes 8. Does the resident use the side rails for positioning or support? Yes 9. Does the side rail help resident rise from a supine position to a sitting/standing position? No ... 11. Is there a possibility the resident will climb over the side rails? No 12. Is there evidence (reason to believe) the resident has (or may have) a desire or reason to get out of bed? No 13. Does the resident receive any medications that would require safety precautions? No 14. Is there a risk to the resident if side rails are used? No 15. Do the side rail alternatives/interventions create more risk than side rail use? (When laying on side resident is fearful of falling out of bed and will reach nearby objects on night stand, bedside table to stabilize self unsafely) Only Intervention checked is " Reminders to use call light " Recommendations: left, right, head are checked. Comments: (Due to resident current skin status resident requires frequent turning and repositioning to left and right sides. Half rails are indicated for safety and serve as enabler for resident to assist in repositioning. " Record review of Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. revealed, " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " In an interview on 03/25/13 at 10:40 a.m. the DON said that Resident #4 required half bed side rails for turning and positioning. The DON reviewed Resident #4 ' s " Nursing Progress Notes " dated 03/02/13 at 2:45 a.m. ( " Tapping noise investigated and CNA E called for assist. Resident found leaning off the bed holding onto side rail with head on floor. Assisted back onto bed and examined no bumps or abrasions. Has redness across lower abdomen where he was bearing weight. Resident states he was looking at the rollers under his bed. 5:00 a.m. Redness across lower abdomen faded and without bruising. Denies pain or discomfort. " ). The DON said that she was not aware that Resident #4 had been trapped in his side rails because no one had reported this incident to her. The DON said that Resident #4 had half side rails that were positioned at the top of his bed for positioning and turning. The DON and surveyor observed Resident #4 ' s bed with the half rails positioned in the center of his bed. The DON said that she was not aware that the side rails were positioned in the center of his bed. The DON said that the side rails must have been placed in the center of his bed by Hospice when they brought the longer bed for him after he developed the bilateral heel pressure ulcers and was transferred from the secure unit to the regular unit. Resident #4 was transferred from the secure unit on 01/29/13. In an interview on 03/25/13 at 12:00 p.m. CNA E said that on 03/02/13 at 2:45 a.m. she heard a tapping noise as she was walking down hall one to go outside for a break. The tapping noise was coming from Resident #4 ' s room. CNA E said that she found Resident #4 partially on his bed with his feet up in the air, his head and right shoulder were on the floor between his bed and the wall, and his abdomen was trapped across the front part of the half side rail located in the middle of his bed. CNA E said that Resident #4 ' s was a tall man and his bed was in the high position. CNA E said that Resident #4 was incontinent of urine. CNA E said that she and LVN G helped Resident #4 get un-trapped from the side rail. CNA E said that Resident #4 had redness across the lower part of his abdomen. In an interview on 03/25/13 at 12:45 p.m. LVN G said that she had worked 03/02/13 from 6:00 p.m.-6:00 a.m. and was the only LVN on duty for Halls one and two. LVN G said that CNA E had gone to take a break when she heard her calling for help. LVN G said that she went to Resident #4 ' s room and found him trapped on his bed side rail. LVN G said that Resident #4 told her that he was looking for something under his bed. LVN G said that Resident #4 had some redness across his abdominal area. LVN G said that Resident #4 seemed fine and that she did not assess him or perform any neurological checks. LVN G said that she thought he could have been trapped for about 30 minutes because CNA E had checked him about 2:00 a.m. or so. LVN G said that she did recheck Resident #4 at 4:00 a.m. or 5:00 a.m. and he seemed fine and she reported the incident to LVN B who came on duty at 6:00 a.m. LVN G said that she did not report the incident to administration nor did she complete an incident report or an investigation regarding Resident #4 ' s entrapment in his side rails. LVN G said that she did not know that an incident/accident report had to be done on every little accident and did not think this accident required an incident/accident report even though she had some training regarding accidents. In an interview on 03/25/13 at 3:30 p.m. LVN B said that LVN G had reported to her on 03/02/13 at 6:00 a.m. shift change that Resident #4 had gotten trapped in his side rail during the night. LVN G said that she had taken his vital signs which was routine but did not do any further assessments or neurological checks. In an interview on 03/25/13 at 4:05 p.m. the Administrator said that no one had reported to her that Resident #4 had been trapped in his side rails until today and therefore there was no accident/incident report and no investigation. In a telephone interview on 03/28/13 at 2:30 p.m. Resident #4 ' s physician said that Resident #4 had rapidly declined, was in bed a lot and appeared to have developed the pressure ulcers over a short period of time. Resident #4 ' s physician said that he had not been notified about Resident #4 being trapped in the side rail (occurred 03/02/13) until Wednesday (03/27/13). Record review of Resident #4 ' s " Comprehensive Plan of Care " dated 01/29/13 revealed: " Resident requires the use of ? side rails as evidenced by unable to turn self without rails. To assist with turning and repositioning self while in bed. Approach-1. Assess for the use of side rails quarterly and as needed ... " Record review of the facility provided " Nursing Guidelines: Restraints, Physical Use " dated 08/24/10 revealed, " The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident ' s target behaviors or medical symptoms. The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of rails as restraints unless necessary to treat a resident ' s medical symptoms ... 2. Restraints shall be used only for medical necessity to prevent injury to him or others following an assessment and documented lack of success with a less restrictive device ... 10. The use of restraints is identified on the resident ' s care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint to be used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every two hours; f. The plan for monitoring every 60 minutes; ... 15. A nursing assessment will show the presence of a specific medical symptom that requires the use of restraints, those symptoms that are being treated, and how the use of restraints will assist the resident in reaching his highest level of physical and psychosocial well being. 16. A physician order [REDACTED]. Inappropriate Restraint Orders " may use, for personal safety, to prevent falls, at family request " . Record review of the facility provided " Use of Restraints " dated 2007 page 73 revealed: " ...Physical restraints shall only be used for the safety and well-being of the residents and only after other alternatives have been tried unsuccessfully ... 11. Should a resident not be capable of making a decision concerning the use of a restraint, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. (Note: The surrogate/sponsor may not give permission to use restraints for the sake of discipline or staff convenience or when the restraint is not necessary to treat the resident ' s medical symptoms.) " Record review of the facility provided " Accidents and Incidents " dated 09/20/12 page 1 revealed: " 1. An Accident/Incident Report form must be completed immediately upon facility staff awareness of the incident involving a Resident ... 2. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand-up meeting until all sections of the report are completed.. 3. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. This assessment is documented in the Nurse ' s Notes, and the Resident ' s Care Plan is updated. 4. An Accident/Incident Investigation is completed in addition to the Accident/Incident report form when staff discovers an un-witnessed accident/incident or any falls. 5. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation has been completed. 6. The DON or designee will interview all witnesses .... 10. A Fall Risk Assessment must be initiated after each fall ... 13. A neurological Assessment Flo-sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or any un-witnessed fall. For the initial 24 hours, the neurological assessment must be done every 15 minutes for 1 hour, once every 30 minutes for 2 hours, once every 1 hour times 4; and then once every shift. Following the initial 24 hours, nursing staff must document the condition of the Resident every shift for the next 48 hours (for a total of 72 hours of monitoring ... " Record review of " Resident Census and Condition of Residents " dated 03/20/13 revealed 5 residents were physically restrained. Record review of a list provided by the DON dated 03/26/13 revealed there was no one identified with the use of side rails.

Based on observation, interview and record review the facility failed to ensure physical restraints were not used for staff convenience and without medical necessity for 4 of 15 sampled residents (Residents #2, #1, #3, and #12). The facility failed to: a) perform a pre-restraint assessment, obtain written consent, perform quarterly restraint assessments to determine possible reduction and determine a medical necessity for Resident #2 who had a seatbelt with alarm for about 8 months resulting in a decline in her ability to ambulate. b) perform a pre-restraint assessment, quarterly restraint assessments to determine possible reduction, and determine a medical necessity for Resident #1 who had a self-release seat belt with an alarm for about 14 months. Resident #1 could not easily release the self-release seat belt. c) perform a pre-restraint assessment and determine the medical necessity for Resident #5 who had a self-release seat belt with an alarm for about 2 months. Resident #3 could not release the self-release seat belt. d) perform a pre-restraint assessment for the use of self-releasing belt with alarm for Resident #12. These deficient practices could prevent any of the seven residents with a physical restraint from attaining or maintaining the highest practicable level of physical and psychosocial well-being. Findings included: 1. Record review of Resident #2's Record of admitted d 05/02/11 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an observation on 01/16/12 at 3:00 p.m. during initial tour Resident #2 was identified by CNA A as ambulatory with the assistance of two people, dependent on a wheelchair for mobility, incontinent of bowel and bladder, alert but not oriented, and confused. CNA A said Resident #2 required assistance with a mechanical soft diet, and had experienced some weight loss. She said Resident #2 often exhibited behaviors and described them as yelling out. CNA A said Resident #2 used a seatbelt with an alarm while in her wheelchair. She said Resident #2 had sores on her heels bilaterally, and a sore on her left great toe. Resident #2 was observed to be sleeping in a low bed made of white plastic pipe with a fall matt on the floor beside her bed. Her call bell cord was seen under the foot of her bed and out of reach. Record review of Resident #2's "physician's orders [REDACTED]. Release and reposition every two hours for 10 minutes. " In an observation on 01/16/12 at 4:20 p.m., CNA B was observed to provide incontinent care to Resident #2. Resident #2 was then dressed and assisted to her wheelchair by CNA A and CNA B. No pressure relieving device was observed in the wheelchair. CNA B then applied a seatbelt to Resident #2. When questioned about Resident #2's seat belt, CNA B said she had never seen Resident #2 attempt to remove or unbuckle the seatbelt. In an observation on 01/16/12 at 4:55 p.m. Resident #2 was seated in her wheelchair in the beauty shop receiving hair services. She had a seatbelt buckled across her lap and no pressure relieving device in her chair. In an observation on 01/16/12 at 6:05 p.m. Resident #2 was seated in her wheelchair in the dining room feeding herself dinner. She had a seatbelt buckled across her lap and no pressure relieving device in her chair. In an observation on 01/17/12 at 9:00 a.m. Resident #2 was seated in her wheelchair in the hall. She was propelling herself down the hall. She had a seatbelt buckled across her lap and no pressure relieving device in her chair. In an interview on 01/17/12 at 9:38 p.m. the DON said she had been told Resident #2 was able to open her seatbelt, but had not personally assessed her. Observation on 01/17/12 at 12:45 p.m. revealed Resident #2 propelling herself from the dining area down the hall. She had a seatbelt buckled across her lap. When asked if she was able to release the belt, Resident #2 was observed to fidget and manipulate the seatbelt. Resident #2 said, "I can't. You do it for me." She was not able to release the seatbelt. In an interview on 01/17/12 at 12:55 p.m. CNA G said she had worked at the facility for years. She said she remembered when Resident #2 was able to ambulate with a walker. She said Resident #2 had experienced a fall and that was when the seatbelt was initiated. CNA G said Resident #2 was unable to remove her seatbelt. Record review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed she was able to transfer with minimal assistance of one person, walk with supervision with setup assistance, and dress with limited one person physical assistance. Resident #2's range of motion had no impairment. Record review of Resident #2's Incident/Accident Report dated 05/15/11 revealed she tripped while ambulating in her room while using a walker. Under the heading Gait and Mobility on the Incident/Accident Report, Resident #2 was identified to be independent for repositioning, transferring, and ambulation; and requiring assistance of one person for toileting. The Incident/Accident Report revealed Resident #2 said she was trying to climb over the "chair" and pointed to her walker. Resident #2 was found on the floor near her walker that was overturned. Record review of Resident #2's Physician's Telephone Orders dated 05/24/11 revealed "Resident to wear self-release seat belt while up in wheelchair with alarm to alert staff resident is attempting to transfer self ". No medical reason or frequency of removal documented in the physician's order [REDACTED]. Record review of Resident #2's Nursing Restorative Program Notes Dated May 2011 to August 2011 revealed: May 2011- Resident #2 "...is maintaining ambulation with walker ..." June 2011- Resident #2 "...getting weak while ambulating with walker ...needed to take frequent breaks ...decline in balance ..." July 2011- Resident #2 "...having trouble lifting legs ..." August 2011- Resident #2 was discharged from the Restorative Program to the Rehabilitation Department. Record review of Resident #2's Physical Therapy (PT) Notes revealed she received PT from August 2011 to October 2011. Resident #2 was discharged from PT back to the Restorative Nurse Program in October 2011. In an interview on 01/17/12 at 5:50 p.m. the Rehabilitation Director said Resident #2 had received services from the rehab department. She described Resident #2 as stronger than suspected. She said with physical therapy services Resident #2 was able to ambulate. She said Resident #2 had experienced a decline in her Activities of Daily Living (ADL) abilities since the placement of the seatbelt. In an interview on 01/18/12 at 4:00 p.m. the MDS Coordinator said she was responsible to supervise the Restorative Nursing Program. She said Resident #2 was not receiving services from the Restorative Nursing Program (RNP). When asked why Resident #2 was not receiving RNP services she said "I don't know". Record Review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed she required extensive assistance with two or more people for transfers, walk in room or corridor- activity did not occur, and extensive assistance with one person for dressing. Resident #2's range of motion had no impairment. She was identified as having no restraints. Record review of Resident #2's Minimum Data Set ((MDS) dated [DATE] revealed she was totally dependent on two or more people to physically assist to transfer, walk in room or corridor- activity did not occur, and totally dependent on two or more people to physically assist in dressing. Resident #2's range of motion had bilateral impairment to upper and lower extremities. She was identified as having no restraints. Observation on 01/17/12 at 4:30 p.m. revealed the DON assessed Resident #2's ability to self release her seatbelt. Resident #2 was unable to release the seatbelt. The DON said since Resident #2 could not remove the seatbelt herself, then the seatbelt was considered a restraint. In an interview on 01/18/12 at 11:00 a.m. the DON said Resident #2 did not have a Pre-Restraint Assessment completed prior to the use of the seatbelt. The DON said there was no documentation of Restraint Reduction Assessments being conducted quarterly for Resident #2. The DON said there was no signed consent for the use of the seatbelt in Resident #2's medical record. When asked if the use of a restraint resulted in Resident #2's inability to ambulate the DON had no response. 2. Record review of Resident #1's admission record revealed an [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed she usually could make herself understood but could only sometimes understand others, had short and long-term memory problems, was moderately cognitively impaired, continuously had difficulty focusing attention and disorganized thinking, and had no behaviors. She required extensive assistance of one person for bed mobility and personal hygiene and total assistance of two persons for transfers, dressing, and toileting. She required extensive assistance of one person for locomotion on and off the unit. She had not walked and was only able to stabilize herself with human assistance in moving from seated to standing position, moving on and off toilet, and transferring between bed and chair. She was always incontinent of bladder and bowel. She was identified as having no restraints. Record review of Resident #1's hospital "History and Physical" dated 10/11/10 revealed, "left hip pain, fell at nursing home, left [MEDICAL CONDITION], confused, lives in nursing home, ambulates with a walker. Plan - surgery." Record review of Resident #1's hospital "Discharge Summary" dated 10/16/10 revealed, "weight bearing as tolerated with walker and assistance with left lower extremity." Record review of Resident #1's "physician's orders [REDACTED]. Release and reposition every two hours for 10 minutes. " Observation on 01/16/12 at 2:50 p.m. during initial tour revealed Resident #1 in her room in her wheelchair with a self-release seat belt with alarm in place. The self-release seat belt with alarm opened like a car seat belt with a red push button located at Resident #1 waist. Observation on 01/16/12 at 5:45 p.m. revealed Resident #1 in the dining room eating dinner. The self-release seat belt with alarm was noted to be in place. Observation on 01/17/12 at 9:15 a.m. revealed Resident #1 in the front lobby watching TV. She had the self-release seat belt with alarm in place. Surveyor asked Resident #1 if she could unlock the self-release seat belt and Resident #1 picked up the loose end of the belt and said that she had never seen the belt before and did not release the belt. In an interview on 01/17/12 at 9:30 a.m. CNA C said they put the self-release belt with an alarm on Resident #1 when she was in her wheelchair and used a bed alarm when she was in bed to alert staff if she tried to get up unassisted. CNA C said that Resident #1 did not try to get up from the wheelchair as much as she did in the past because the alarm does not sound as much now. CNA C said that Resident #1 had a low bed and bed alarm because she could get up and sit up on the side of her bed without assistance. CNA C said that Resident #1 was no longer on the restorative nursing program. Observation on 01/17/12 at 2:45 p.m. revealed Resident #1 in her room in her wheelchair. Surveyor asked Resident #1 if she could unlock her self-release seat belt. CNA C and CNA E then began to encourage Resident #1 to release her seat belt by pointing to the red button that released the belt and after several attempts she did release the seat belt. Observation on 01/17/12 at 5:15 p.m. revealed Resident #1 in the dining room waiting for dinner. She had the self-release belt with alarm in place. The MDS Coordinator asked Resident #1 to release her belt. Resident #1 did not release the self-release belt. Observation on 01/17/12 at 5:17 p.m. CNA D asked Resident #1 to release her self-release belt and when she did not release, CNA D placed Resident #1's hand and finger on the red button of the self-release belt and began to encourage her to open. Resident #1 pushed the red button after about a minute. The alarm sounded. CNA D said that Resident #1 did not like to release because of the loud sound of the alarm. Record review of Resident #1's "Informed Consent for Physical Restraints" dated 10/28/10 revealed self-release seat belt when in wheelchair because high risk for falls. In an interview on 01/18/12 at 11:55 a.m. the DON said that the reason Resident #1 had a self-release seat belt with alarm was to keep Resident #1 from falling out of her wheelchair because she leaned forward. The DON said that she would look for a "pre-restraint" assessment and quarterly restraint assessments. The DON did not provide any restraint assessments for Resident #1. In an interview on 01/18/12 at 4:55 p.m. the ADON said that the "Informed Consent for Physical Restraints" dated 10/28/10 (about 14 months ago) was most likely the date that Resident #1 began using the self-release belt with the alarm. Record review of Resident #1's "Comprehensive Plan of Care" dated 01/12/12 revealed, "At Risk for Falls as Resident is using wheelchair, self-release seatbelt while up in chair to alert staff of attemping to self transfer." There were no instructions regarding releasing the seat belt as per physician's orders [REDACTED]. 3. Review of a hospital "Discharge Summary" dated 07/19/11 in Resident #3's current clinical record revealed discharge [DIAGNOSES REDACTED]. Record review of Resident #3's "Record of Admission" revealed a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an observation on initial tour on 01/16/12 at 2:30 p.m. Restorative Aide A said Resident #3 was not ambulatory, was dependent on a wheelchair for mobility, was incontinent of bowel and bladder, was confused and forgetful, had a bed and chair alarm, had recent falls and had a recent decline in his ability to perform ADLs. Review of the Physicians Orders dated 01/12/12 through 02/11/12 in Resident #3's current clinical record revealed the following: 10/19/11 - Wanderguard to be worn at all times due to risk of elopement. 11/04/11 - Bed alarm to be worn to alert staff that resident is attempting to get up without assistance. 11/04/11 - Self release seat belt while up in chair to alert staff that resident is attempting to self transfer. Release and repostition every 2 hours for 10 minutes. No medical necessity was listed for use of the self-release seat belt. Further review of the clinical record revealed no pre-restraint assessment. On 01/17/12 at 3:20 p.m. Resident #3 was sitting in his wheelchair in the dining watching an activity. The surveyor asked Resident #3 if he could release the seat belt. He did not seem to know what it was. He fumbled with his shirt tail which was sticking out from under the belt. When shown the red release button on the seat belt buckle he touched it with a trembling hand but could not push the release button. Observation on 01/17/12 at 5:15 p.m. revealed Resident #3 sitting in the dining room at a table waiting for dinner. The MDS Coordinator asked Resident #3 to release his self-release seat belt. Resident #3 looked down at the self-release seat belt and said "I can't" and again he repeated, "I can't". During an interview with the DON on 01/18/12 at 10:20 a.m. she said no pre-restraint assessment had been done on Resident #3. 4. Record review of Resident #12's Record of Admission revealed she was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of clinical record for Resident #12 revealed a physician's telephone order dated 01/06/12 for use of a wheelchair with self-releasing belt with alarm and anti-tilt bars. Review of Resident #12's MDS dated [DATE] revealed she had short and long-term memory impairment, her cognitive status was moderately impaired (decisions poor, cues/supervision required), she required extensive assistance of one person for transfers, bathing and dressing , and was frequently incontinent of bowel and bladder. Observation of Resident #12's on 01/16/12 at 1:30 p.m. revealed Resident #12 in the hallway. Resident # 12 was observed sitting in a wheelchair (w/c) with seatbelt alarm in place. Observation of Resident #12's on 01/17/12 at 8:30 a.m. 11:30 a.m. & 4:30 p.m. revealed Resident #12 in the hallway. Resident # 12 was observed sitting in a wheelchair (w/c) with seatbelt alarm in place. Observation of Resident #12's on 01/18/12 at 9:30 a.m. revealed Resident #12 in the hallway. Resident # 12 was observed ambulating without assistance, gait was fast and steady. Record review of clinical record for Resident #12 revealed a "Pre-restraining Assessment" (undated) revealed the referrals and recommendation section to be blank. 5. Record review of the facility provided "NURSING GUIDELINES: Restraints, Physical Use" dated 08/24/10 revealed the following: "The resident has the right to be free from any physical restraints imposed for the purposes of discipline or convenience, and not required to treat the resident's target behaviors or medical symptoms. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. 1. ..2. Restraints shall be used only for medical necessity to prevent injury to him/herself or others following an assessment and documented lack of success with a less restrictive device... 5. The Interdisciplinary Health Care Team performs a pre-restraint assessment and documents findings on SLP (rehabilitation communication form). 6. The SLP (facility) form has been developed to adequately assess all aspects of the resident's well-being (physical, mental, emotional, environmental, and social considerations prior to the use of a physical restraining device in order to identify the least restrictive intervention. This form is to be completed by a LVN or Licensed Physical/Occupational Therapist. 7. An informed consent SLP form is required in the event of physical restraint use ... 9. The use of restraints is identified on the resident's care plan and includes: a. The medical symptoms that warrant the need for the restraint; b. The symptoms that are being treated; c. The type of restraint used; d. When the restraint is to be used; e. The plan for release of device for exercise and toileting every 2 hours; f. The plan for monitoring every 60 minutes; and g. How the use of the restraint will assist the resident in reaching his/her highest level of physical and psychosocial well-being .... 11. On a Quarterly basis and as required, the Interdisciplinary Team will review the restraint use and potential for continued use or elimination and document findings ... 16. A physician order [REDACTED]. 17. Efforts will be made to maintain resident's strength and mobility via restorative nursing measures. Quarterly updates and care plan entries are the responsibility of the care plan team" Record review of List of Residents with seatbelt restraints provided by the DON on 01/18/12 at 1:00 p.m. revealed eight residents had self release seatbelt restraints.