Every finding on record at Laredo West Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for infection control practices. The facility failed to ensure Resident #1 had an EBP precaution/isolation sign posted outside of his door or room. The facility failed to ensure Resident #1 had an order for EBP.The facility failed to ensure Resident #2 had an EBP precaution/isolation sign posted outside of his door or room.The facility failed to ensure Resident #3 had the appropriate precaution/isolation sign posted outside of his door or room, the appropriate precaution/isolation order, and the appropriate precaution/isolation care plan. The facility failed to ensure Resident #3 was kept in isolation without a roommate while on contact precautions. The facility failed to ensure Resident #4 had the appropriate precaution/isolation sign posted outside of his door or room. The facility failed to ensure Resident #4 was not housed with a roommate who was on contact isolation. These failures could place residents at risk for cross-contamination and infection due to inappropriate precautions being used.The findings included:1. Record review of Resident #1's face sheet, dated 07/28/2026, revealed a [AGE] year-old male with an original admission date of 12/07/2023, and a current admission date of 01/30/2026. Diagnoses included Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #1's physician order summary, reviewed 07/28/2026, revealed an active order, with a start date of 01/31/2026, for wound care for moisture associated dermatitis (a condition in which the skin became irritated, and often involved itching, rashes, dry skin, or oozing blisters): buttock: use 4x4 gauze with normal saline; pat dry; apply Drapolene cream (a cream used to treat and sooth skin irritations) and leave open to air daily. Resident #1's physician order summary did not reveal an order for enhanced barrier precautions. Record review of Resident #1's Quarterly MDS assessment, dated 05/11/2026, revealed a BIMS score of 15, which revealed intact cognition. The Quarterly MDS assessment revealed Resident #1 had moisture associated skin damage. Record review of Resident #1's care plan initiated 02/11/2026, revealed Resident #1 had the need for Enhanced Barrier Precautions due to rash and moisture associated dermatitis. Interventions included place Resident #1 on EBP and ensure a sign was placed on the door to notify staff and visitors of the precautionary measures. An observation of Resident #1's room on 07/28/2026 at 2:44 PM revealed there was no EBP sign on the outside door or wall, but upon entrance to Resident #1's room the EBP sign and PPE were located on Resident #1's bathroom door. 2. Record review of Resident #2's face sheet, dated 07/28/2026, revealed an [AGE] year-old male with an admission date of 07/13/2026. Diagnoses included Dysphagia (difficulty swallowing) and Gastrostomy Status (a surgically created opening into the stomach with a tube [G-tube] placed for delivering nutrition, fluids, and/or medications). Record review of Resident #2's physician order summary, reviewed 07/28/2026, revealed an active order, with a start date of 07/14/2026, for Enhanced Barrier Precautions: use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO as well as those with increased risk of MDR (residents with wounds or indwelling medical devices), every shift. Record review of Resident #2's admission MDS assessment, dated 07/15/2026, revealed a BIMS score of 07, which revealed severely impaired cognition. The admission MDS assessment revealed Resident #2 had a feeding tube.Record review of Resident #2's care plan initiated today, 07/28/2026, revealed Resident #2 had the need for Enhanced Barrier Precautions due to a G-tube. Interventions included place Resident #2 on EBP and ensure a sign was placed on the door to notify staff and visitors of the precautionary measures. An observation of Resident #2's room on 07/28/2026 at 2:44 PM revealed there was no EBP sign on the outside door or wall, but upon entrance to Resident #2's room the EBP sign and PPE were located on Resident #2's bathroom door. Resident #2 was observed as being the roommate of Resident #1. 3. Record review of Resident #3's face sheet, dated 07/28/2026, revealed an [AGE] year-old male with an admission date of 06/18/2026. Diagnoses included Diabetes Mellitus.Record review of Resident #3's physician order summary, reviewed 07/28/2026, revealed an active order, with a start date of 07/09/2026, for Contact Precautions for MRSA (a type of bacteria which caused skin infections and was resistant to many antibiotics) in the wound to the scrotum.Record review of Resident #3's admission MDS assessment, dated 06/23/2026, revealed a BIMS score of 03, which revealed severely impaired cognition. Record review of Resident #3's care plan, initiated 07/09/2026, revealed Resident #3 had an infection of the skin (scrotum). Interventions included administer Resident #3's antibiotic as ordered. The care plan did not indicate which type of precaution or isolation Resident #3 should have been on. Record review of Resident #3's laboratory results, dated 07/08/2026, revealed Resident #3 was positive for MRSA. The results also indicated to initiate contact precautions for Resident #3. Record review of Resident #3's progress note, dated 07/15/2026, revealed Resident #3 continued Linezolid (an antibiotic to treat infections) 600 MG until 07/16/2026 and Amoxicillin-Potassium Clavulanate (an antibiotic to treat infections) until 07/21/2026 for the MRSA infection. An observation of Resident #3's room on 07/28/2026 at 10:22 AM revealed there was a Contact Isolation/Precaution sign, as well as PPE, on the entrance door to Resident #3's room. There should have been an EBP sign as Resident #3 was no longer on Contact Isolation. The observation revealed Resident #3 and Resident #4 were roommates. 4. Record review of Resident #4's face sheet, dated 07/28/2026, revealed a [AGE] year-old male with an original admission date of 02/28/2023, and a current admission date of 06/03/2026. Diagnoses included Diabetes Mellitus, Dysphagia, Gastrostomy Status, and End Stage Renal Disease (the final stage of chronic kidney disease, in which the kidneys could no longer function adequately to sustain life without treatment). Record review of Resident #4's physician order summary, reviewed 07/28/2026, revealed an active order, with a start date of 06/13/2026, for Enhanced Barrier Precautions: Use gown and gloves for high contact resident care activities for those known to be colonized or infected with a CDC targeted MDRO, as well as those with increased risk of MDR (residents with wounds or indwelling medical devices) every shift for dialysis fistula (a surgically created connection between an artery and vein) and gastrostomy tube.Record review of Resident #4's care plan initiated 08/23/2024, revealed Resident #4 had the need for Enhanced Barrier Precautions due to dialysis (a process to remove waste and excess fluids from the body) and a G-tube. Interventions included place Resident #4 on EBP and ensure a sign was placed on the door to notify staff and visitors of the precautionary measures. An observation of Resident #4's room on 07/28/2026 at 10:22 AM revealed there was a Contact Isolation/Precaution sign, as well as PPE, on the entrance door to Resident #4's room. The observation also revealed Resident #4 shared a room with Resident #3, who had been on contact isolation for MRSA. In an interview on 07/28/2026 at 3:40 PM, CNA-A stated the signs on residents' doors signified what precautions should be used for the resident, and what PPE to wear when taking care of the resident. She stated Resident #3 was on contact precautions, which meant she had to put on her PPE before going into his room. CNA-A stated the PPE was to keep from passing germs from one resident to another, and to keep them from getting infections. She stated Resident #4 should not have been kept in the same room with Resident #3 while he was on contact precautions because it increased his risk of getting the infection Resident #3 had. She stated she had not seen any signs of a skin infection on Resident #4. In an interview on 07/28/2026 at 4:06 PM, RN-B stated Resident #3 was previously on contact precautions, but he completed his antibiotics, and now he was on EBP. She initially stated she thought both his order and the sign on the door were for EBP, then stated she thought he had both a contact precautions sign and an EBP sign on his door. RN-B stated if Resident #3 still had an order for contact precautions and a contact precaution sign on his door, staff and visitors should still be applying contact precaution PPE prior to entering his room. She stated any nurse could have changed Resident #3's order back to EBP after he finished his antibiotic, but she guessed it must have been missed. RN-B also stated Resident #4 should not have been roomed with Resident #3 while he had MRSA and was on contact precautions. She stated Resident #4 had not had any signs or symptoms of MRSA. RN-B stated not following the appropriate isolations or precautions increased the residents' risks of cross-contamination and infection. In an interview on 07/28/2026 at 4:38 PM, the DON, who was also the ICP, stated Resident #1 should have an order for EBP, but maybe it was missed or overlooked. She stated the reason Resident #1, and roommate Resident #2, had their EBP sign and PPE on the bathroom door inside their room was because there was a [NAME] on the entrance door which was in the way. She stated she had not seen an issue with this as anyone would have seen the sign and PPE as soon as they walked into the residents' room. The DON initially stated Resident #3 was not on any precautions, and there had not been a contact isolation sign on his door, and the staff should not be wearing PPE into his room. She stated the staff always asked the charge nurse what precautions the residents were on so they knew what PPE to wear into the rooms. She stated the staff did not necessarily go by the sign posted on the door, but they went by what their charge nurses told them. She then stated she was not sure what precautions Resident #3 was on because she had not checked his orders, and she thought there had been both an EBP and a contact isolation sign on Resident #3's door earlier. The DON stated Resident #4 had been on EBP for a very long time, and he should not have been roomed with Resident #3 while Resident #3 had MRSA and was on contact isolation. She stated this had been done by accident and could have increased Resident #4's risk of getting an infection, especially since he was so vulnerable, but the DON stated Resident #4 had not shown any signs or symptoms of MRSA. The DON stated if the staff were not following the correct precautions or isolations, or wearing the correct PPE, this could have increased the risk of cross-contamination and infection among the residents. Record review of the facility's Infection Prevention and Control Policy, implemented 05/13/2023, revealed Policy: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and t help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Explanation and Compliance Guidelines: 1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on our infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases.Record review of the facility's Enhanced Barrier Precautions Policy, implemented 11/24/2025, revealed Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions: B. an order for enhanced barrier precautions will be obtained for residents with any of the following: i: Wounds. and/or indwelling medical devices. ii: infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply. 3. Implementation of Enhanced Barrier Precautions: A: Make gown and gloves available near or outside of the resident's room. G: Do not restrict room placement or out-of-room activities due to enhanced barrier precautions.Record review of the CDC: Long-Term Care Facilities (LTCFs): Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/2024, revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: A. Wounds or indwelling medical devices, regardless of MDRO colonization status; B. Infection or colonization with an MDRO. Contact Precautions: Contact Precautions are intended to prevent transmission of infectious agents, like MDROs, that are spread by direct or indirect contact with the resident or the resident's environment. Contact Precautions require the use of gown and gloves on every entry into a resident's room. Enhanced Barrier Precautions: Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices. Implementation: Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation.1. The facility failed to ensure that eggs were stored on the bottom shelf of the refrigerator.2. The facility failed to ensure food items in refrigerator 2 were labeled and dated.3. The facility failed to ensure that there were no personal items stored in refrigerator 2.4. The facility failed to ensure that leftovers were discarded within 72 hours.5. The facility failed to ensure that items labeled keep frozen were kept in the freezer.6. The facility failed to ensure that food items in freezer 3 were labeled and dated. 7. The facility failed to ensure the kitchen was following their policies.These failures could place residents who consumed food from the kitchen at risk for food borne illness. Observation of the facility's reach in refrigerator 1 on 5/19/2026 at 6:05am revealed A blue carton of 18 eggs was on the top shelf instead of the bottom shelf in the refrigerator.Observation of the facility's reach in refrigerator 2 on 5/19/2026 at 6:10am revealed the following:A Sysco plastic 2-gallon sized bag containing approximately 20 hot dogs was not labeled or dated.A grocery-type plastic bag was not dated or labeled and contained a plastic container with an unknown substance, in which the DA stated was her personal item.An original container labeled Smoked Chicken Salad had been opened with a date of 3/31 written on top in black marker had not been discarded within 72 hours after being opened.Observation of the facility's reach in refrigerator 3 on 5/19/2026 at 6:15am revealed an original full box of Eggo frozen buttermilk pancakes and a partial open box of Eggo frozen buttermilk pancakes stated Store frozen at 0 degrees.Observation of the facility's reach in freezer on 5/19/2026 at 6:21am revealed a white box containing approximately 10 ice cream sandwiches that were not dated.During an interview with the DA on 5/19/2026 at 6:05am, she stated they were out of eggs, and they had to run to the store and get the eggs and did not place the eggs on the correct shelf.During an interview with DA on 5/19/2026 at 6:10am, the DA stated the hot dogs should have been labeled and dated before placing the hot dogs in the refrigerator and that her personal items should be stored in the employee refrigerator, and that the chicken salad should have been discarded. The DA also stated they regularly store the Eggo pancakes in the refrigerator because microwaving the pancakes out of the freezer does not cook the pancakes evenly. The DA stated residents could get sick from eating items that are expired or have spoiled during storage.During an interview with the DM on 5/19/2026 at 2:00pm, the DM stated the expectations are for staff to follow the proper food storage processes including labeling and dating all food, keeping personal items out of the kitchen refrigerators, and to throw items away within a timely manner. The DM stated that the ice cream sandwiches and the chicken salad were bought for the residents to consume during activities, and all staff should be aware of the food storage policy and process.During an interview with the DM and the RD on 5/21/2026 at 9:00am they both stated in-services for proper storage of items (including the Eggos stored frozen, the label and dating of hotdogs, and discarding items after they are open) were in process. The RD stated it is expected for staff to throw items in the trash that have no label, are expired, or have been opened for an unknown amount of time. The RD stated if a resident was given undated or expired food, the resident could get sick but stated she had not seen that happen at this facility.During an interview with the Administrator on 5/21/26 at 2:30pm, he stated it is the responsibility of and expectation that the dietary staff followed the policy and standards set in labeling and storing food items in the kitchen. The Administrator stated he did not think the food would be served to residents as staff should be checking items again to ensure the item is safe for consumption. The Administrator stated this was a storage error, not a service error.Record review of the facility's Food Storage Policy, Policy Number 03.003, dated October 1,2018 and revised on June 1, 2019, that was provided by the facility when asked for stated in part: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal, and US Food Codes and HACCP guidelines.2. Refrigeratorsd. Date, label, and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage.e. Use all leftovers within 72 hours. Discard items that are over 72 hours old.f. Store raw meats and eggs on the bottom shelf to prevent contamination of other foods. To avoid cross-contamination, store raw or uncooked food and produce away from and below prepared or ready-to-eat food.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #61) reviewed for hazards: The facility failed to ensure Resident #61 did not have a disposable razor in his restroom. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.Findings included: Record review of Resident # 61's admission record, dated 05/19/26, reflected an [AGE] year old male admitted [DATE]. His relevant diagnoses included need for assistance with personal care, muscle weakness, and lack of coordination. Record review of Resident #61's quarterly MDS assessment, dated 04/15/26, reflected a BIMS score of 14, which indicated his cognition was intact. Resident #61 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for personal hygiene. Record review of Resident #61's quarterly care plan, dated 03/30/26 reflected:Problem: [Resident #61] has an ADL self-care performance deficit r/t left BKA, left upper limb amputation, dementia. Date initiated/revised 11/15/23. Interventions included personal hygiene routine: [Resident #61] prefers to perform own personal hygiene/oral care. Date initiated/revised on 08/19/24. During an interview and observation on 05/19/26 at 8:07 a.m., Resident #61 was observed sitting on his bed watching television. Resident #61 said he was able to dress, groom, and shave on his own. With Resident #61's permission, this Surveyor observed his restroom. A clear plastic cup with one disposable blue razor and three small tubes of toothpaste was observed on the sink. Resident #61 said he would use the razor to shave. Resident #61 was not able to say how long the razor was in the restroom. During an interview on 05/19/26 at 8:13 a.m., CNA H said Resident #61 was independent for all ADLs and only required set-up for shaving. She said whenever Resident #61 needed to shave, a CNA would get a razor from the supply room and when done, CNAs were supposed to ensure the razor was disposed of. CNA H said she would round residents every two hours or as needed and had not noticed the disposable blue razor in Resident #61's restroom and was not able to say how long it was there. CNA H said residents were not allowed to have razors in their rooms for their safety and the safety of others. She said all sharps were kept in the supply room under lock and key and only charge nurses had the key. CNA H said a negative outcome for Resident #61 having a razor in his restroom could be the possibility of cutting himself or others. CNA H said she had been in-serviced on the topic of resident safety and sharps. During an interview on 05/19/26 at 8:37 a.m., LVN G said Resident #61 was independent for his ADLs and only required set up for shaving. LVN G said sharps were not allowed in residents' rooms. LVN G said all sharps were stored in the supply room under lock and key and only charge nurses had the key. LVN G said all staff that went into Resident #61's room were responsible for to ensure no sharps were kept in residents rooms. LVN G said she would round residents every two hours or as needed but had not noticed the disposable blue razor in Resident #61's room and was not sure how long it had been there. LVN G said nursing staff had been in-serviced on the topic of resident safety and sharps. LVN G said a negative outcome for Resident #61 having a razor in his room could be that he court hurt himself or others. During an interview on 05/20/26 at 4:44 p.m., the ADON said Resident #61 was independent for most ADLs and only required set-up for shaving. The ADON said razors were not allowed to be stored in resident's rooms. She said all razors were kept under lock and key in the supply room, and only charge nurses had the key. The ADON said whenever a resident wanted to shave, their CNA would request the key from the nurse to get a razor. The ADON said Resident #61 would frequently go out on pass and when would come back he would bring things. She said they did not inspected his bags of purchased goods and that maybe he had purchased the razors and kept them in his room without letting staff now. The ADON said ultimately, it was the facility's responsibility to ensure no razors or any type of sharps were kept in a resident's room. She said housekeeping staff, CNAs, and other staff that would go into a resident's room had the responsibility of ensuring no razors or any type of sharps were in their rooms. During an interview on 05/21/26 at 8:05 a.m., the DON said Resident #61 was independent for ADLs and only required set-up for shavings. She said Resident #61 would frequently go out on pass and when he returned to the facility he would bring bags of items he had purchased. She said the nursing would not inspect his bags and they would not know what was in the bags unless Resident #61 told them. The DON said nonetheless, it was the facility's responsibility to ensure no sharps which included razors were stored in the resident's rooms. She said the facility's protocol for razors were to keep them under lock and key and only the charge nurses had the key. The DON said it was the CNAs responsibility to ensure that once a resident was done shaving, the razor was disposed of. The DON said ultimately, all staff were responsible to ensure resident's safety. The DON said all staff were in-serviced on the topic of resident safety, which included sharps. The DON said a negative outcome for Resident #1 keeping a razor in his room would be that he could hurt himself. The DON said the facility did not have a policy regarding resident safety or sharps.

Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 resident (Resident#7) reviewed for indwelling catheters. The facility failed to prevent Resident#7's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections. Findings included: Record review of Resident#7's face sheet, dated 05/20/2026, revealed a [AGE] year-old female admitted on [DATE]. Resident #7 had admitting diagnosis of neuromuscular dysfunction of the bladder, unspecified (a loss of bladder control caused by nerve damage from diseases or injuries like stroke, diabetes or spinal cord damage). Record review of Resident #7's care plan, dated 10/2/2025, revealed Resident #7 has a indwelling catheter r/t to neurogenic bladder (occurs when nerve damage interrupts the communication between your nervous system and bladder muscles), initiated 03/19/2026 and revised on 03/19/2026, with interventions including position catheter bag and tubing below the level of the bladder and away from entrance room door. Record review of Resident #7's Quarterly MDS assessment, dated 3/6/26, Section C-Cognitive patterns, revealed Resident #7 had a BIMS score of 99 which indicated Resident #7 was unable to complete the interview. Section H-Bladder and bowel revealed Resident #7 had an indwelling catheter. Record review of Resident #7's Physician Order Summary, dated 05/20/2026, revealed an order for an indwelling catheter 16 # French with 10 milliliters balloon as needed for plugged or out (a flexible, sterile tube inserted through the urethra into the bladder to continuously drain urine. The [NAME] is inflated with sterile water inside the bladder to act as an anchor, preventing the catheter from slipping out). The order instructed indwelling catheter care every shift and as needed starting 02/28/26. During an observation and interview on 05/19/2026 at 8:35 a.m., Resident #7's indwelling catheter bag was noted dragging on the floor while the resident was in her bed. Resident was not able to verbalize. During an interview on 05/19/2026 at 8:38 a.m., RN E was informed catheter bag was dragging on the floor. She stated it should not be touching the floor. She replied that a negative outcome of indwelling catheter bag being on the floor the catheter wouldn't drain well and pick up bacteria from floor. During interview with DON on 05/21/2026 at 12:10 p.m., she stated that no, it should not be touching the floor, if on the floor, the tubing and the bag should be changed immediately. She stated the negative outcome was that Resident #7 could get an infection or the bag could get ripped. The DON stated that the facility did not have a policy for indwelling catheters.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 6 (Resident #51 and Resident #29) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #51's oxygen tubing was not touching the floor on 05/19/2026. 2. The facility failed to post an Oxygen sign indicating Resident #51 received oxygen on 5/19/2026. 3. The facility failed to ensure Resident #29's oxygen was administered at the correct setting of liters per minute on 05/19/26 as ordered by the physician. These failures could place residents at risk of developing respiratory complications, a decreased quality of care, and fire hazards by not posting oxygen signs outside the residents' rooms. Findings included: 3.Record review of Resident #29's admission record, dated 05/19/26, reflected a [AGE] year-old female readmitted [DATE] and admitted [DATE]. Her relevant diagnoses included pneumonia (an infection that inflames the air sacs in one or both lungs), and respiratory failure (when lungs cannot get enough oxygen into the blood or fail to properly remove carbon dioxide from it). Record review of Resident #29's quarterly MDS assessment, dated 04/1/26, reflected a BIMS score of 13, which indicated her cognition was intact; and was on respiratory therapy. Record review of Resident #29's quarterly care plan indicated it was still in progress. Record review of Resident #29's physician's order summary, dated 05/18/26, reflected an order for Oxygen at 3 LPM via nasal cannula continuously, every shift for hypoxia related to acute and chronic respiratory failure, unspecified whether with hypoxia (deprived of adequate oxygen supply) or hypercapnia (high levels of carbon dioxide in bloodstream). Order date and start date of 05/18/26. During an interview and observation on 05/19/26 at 12:25 p.m., Resident # 29 was observed lying in bed awake, receiving oxygen via nasal cannula. Resident #29 said she required continuous oxygen. Observation indicated Resident #29's oxygen concentrator was set at 2 LPM. Resident #29 said she was not in distress. During an interview and observation on 05/19/26 at 12:32 p.m., LVN G was observed as she reviewed Resident #29's electronic medical record and said Resident #29 had an oxygen order for 3 LMP effective 05/18/26. LVN G was observed as she checked Resident #29's oxygen concentrator and said it was set at 2 LPM. LVN G said she I just checked [Resident #29's] O2 at 11:43 a.m., and it was at 98% via an oximeter. LVN G said she failed to check Resident #29's O2 settings when she had gone in her room at 11:43 a.m., to check her O2 level. LVN G said nursing staff were supposed to check the oxygen concentrator's setting per shift. LVN G said nursing staff regularly received in-services on the topic of respiratory care which included oxygen settings. LVN G said a negative outcome for Resident #29 not having her oxygen setting as ordered could be her oxygen level could drop. During an interview on 05/19/26 at 12:40 p.m., the ADON said Resident #29 was dependent on continuous oxygen. She sand nursing staff were supposed to check a resident's oxygen concentrator settings per shift to ensure it's at the correct settings. The ADON said nursing staff were regularly in-serviced on the topic of respiratory services which included oxygen settings. During an interview and observation on 05/21/26 at 7:44 a.m., the DON said Resident #29 had recently been re-admitted after a hospital stay. The DON said nursing staff were responsible in checking a resident's O2 settings per shift. The DON was observed as she reviewed Resident #29's electronic medical record and said she had a continuous oxygen order for 3 LPM via nasal cannula. The DON said a negative outcome for Resident #29 not having her O2 setting as ordered could be desaturation. The DON said the facility did not have a policy related to oxygen. Findings included: 1/2. Record review of Resident #51's face sheet, dated 05/20/2026, revealed an [AGE] year-old female admitted [DATE]. Pertinent diagnosis included Chronic Respiratory Failure with Hypoxia (an ongoing condition where your lungs cannot adequately transfer oxygen into the blood). Record review of Resident #51's Care Plan, dated 12/15/2023, revealed, Resident #51 has oxygen therapy r/t Chronic Respiratory failure with hypoxia with interventions oxygen settings: O2 via nasal Cannula, as per MD order. Record review of Resident #51's physician orders, dated 05/20/2026, revealed an order for O2 at 2-5 LPM as needed for SOB. During an observation on 05/19/2026 at 8:25 a.m., Resident #51 was in her room lying on the bed. She was wearing a nasal canula and was receiving oxygen at 2 liters per minute. The oxygen tubing was touching the floor without a protective sleeve. There was no oxygen sign posted outside of his room. During an interview on 05/19/2026 at 8:27 a.m., RN D stated she was the nurse for Resident #51. She stated that all the staff were responsible for posting the oxygen sign outside the residents' rooms. RN D stated Resident #51 did not have an oxygen sign posted outside his room. She stated all residents who were on oxygen regardless of needing it continuously or prn, they all need a sign. RN D stated that it was important for the oxygen tubing not to touch the floor because it could get contaminated and Resident #51 could get an infection. RN D stated that it was important for posting an oxygen sign outside the resident's rooms, so no one smoked and to make everyone in the facility aware there was oxygen in use inside the room for safety. During an interview on 04/14/2026 at 8:45 a.m., the DON stated that anybody could post the oxygen sign on the outside of the residents' room, but it was the responsibility of the admitting nurse. The DON stated that it was important for the oxygen sign to be posted for everyone to know that there was oxygen in use in that room. She stated that she did random compliance rounds. The DON stated she was not sure if the tubing touching the floor was against their policy. Record review of facility's policy titled, Oxygen Safety, dated 01/26/2024, revealed: It is the policy of this facility to provide a safe environment for residents, staff, and the public. This policy addresses the use and storage of oxygen and oxygen equipment. No smoking signs will be utilized to clearly identify oxygen is in use before connecting the oxygen supply, and will remain in place until oxygen administration has been discontinued.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 3 residents (Resident #11) reviewed for labeling and storage. The facility failed to put an open date for Resident #11's Insulin Glargine Solution 100 UNIT/ML on 5/19/2026. These failures could have placed residents at risk of not receiving the therapeutic effects of the medication. The findings included: Review of Resident #11's admission Record, dated 05/20/26, revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] with diagnosis including Type 2 Diabetes Mellitus with Hyperglycemia (a chronic condition where your body either resist the effects of insulin or does not produce enough of it, causing sugar to build up in your bloodstream). Review of Resident #11's Care Plan dated 01/29/26 revealed: initiated on 02/13/26 Focus: Resident #1 has Diabetes Mellitus Interventions: diabetes medication as ordered by doctor. Review of Resident #11's quarterly MDS Assessment, dated 05/06/26 revealed he had a diagnosis of Diabetes Mellitus. Review of Resident #11's Order Summary Report, dated 05/20/26, revealed Insulin Glargine Solution 100 UNIT/ML inject 20 unit subcutaneously at bedtime for Diabetes Mellitus. During an observation on 05/19/2026 at 6:13 a.m., of the A wing Hall Medication Cart with LVN C , revealed the Resident #11's Insulin Glargine Solution 100 UNIT/ML did not have an open date. During an interview on 03/18/26 at 10:32 a.m., LVN F stated that the insulin should be labeled with an open date. He stated that the person responsible for labeling the bottles was the person who initially opened them. LVN F stated that they need to know when the insulin was opened, so they know when it expires. During an interview on 05/21/2026 at 12:00 p.m., the DON stated that Insulin Glargine should have an open date. DON stated that it was important to have an open date because the medications had a life span and without an open date could not track when the insulin was opened. Record review of the facility's Medication Storage and Disposal policy, with a revision date 10/01/19, revealed all medications received from the pharmacy will have an expiration or beyond use date clearly stated on the label or medication container.

Based on observation, interview, and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for 1 of 8 resident refrigerators reviewed for refrigerator sanitation. The facility failed to ensure resident's personal refrigerators were maintained. Resident #96's personal refrigerator had 1 half pint 1 % low fat milk carton with an expiration date of 04/06/26.This failure could place residents who store food items in resident refrigerators, at risk of cross-contamination and food-borne illnesses if consumed. Finding included:Record review of Resident #96's admission record, dated 05/21/26, reflected a [AGE] year old male with an admit date of 04/15/26 and an admission date of 05/29/25. His relevant diagnoses included cerebral infarction (when blood flow to an area of the brain is disrupted, causing brain tissue to die from a lack of oxygen and nutrients), and epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures).Record review of Resident #96's quarterly MDS assessment, dated 05/07/26, reflected a BIMS score of 10, which reflected his cognition was moderately impaired.Record review of Resident #96's Refrigerator Temperature Log reflected his personal refrigerator was last inspected on 05/17/26. During an interview and observation on 05/19/26 at 8:32 a.m., Resident #96 was observed lying in bed awake. He said he was personal refrigerator where he liked to keep drinks he said the facility staff would inspect it daily and would check it's contents. Resident #96 said he was dependent on his wheelchair for mobility. He said he was dependent on staff to place something in or out of his personal refrigerator. With Resident #96's permission, this surveyor inspected the inside of his personal refrigerator and found a half a pint 1 % milk carton with an expiration date of 04/06/26. Resident #96 said he was not sure hold long the expired milk carton had been in the refrigerator. During an interview and observation on 05/19/26 at 8:40 a.m., the Environmental Supervisor said housekeeping staff were responsible to all personal refrigerators on a daily basis and to check it's contents for any expired food. The Environmental Supervisor said all personal refrigerators had a log taped to the door where the housekeeping staff would log the daily temperature. The Environmental Supervisor was not able to say how having an expired milk carton in Resident #96's personal refrigerator could negatively impact him. During an interview on 05/21/26 at 8:30 a.m., the DON said residents were allowed to have personal refrigerators in their rooms. She said the housekeeping staff were responsible to check their temperature and to check it's contents for any expired food. The DON said a negative outcome to Resident #96 for having expired food in his personal refrigerator could be he could have gotten sick. Record review of the facility's Resident Refrigerators policy dated 07/03/23, reflected:Policy: This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerator.Policy Explanation and Compliance Guidelines:.3. Staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed or refer to housekeeping staff.

Based on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 2 of 6 residents (Resident #130 and Resident #115).1. The facility failed to maintain medical records for Resident #130's progress notes, and dialysis communication sheet from 3/31/26, 4/2/26 and 4/4/26 that were complete and accurate.2. The facility failed to accurately document Resident #115's verbal behaviors towards staff in his electronic medical record This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay. The Findings included: 2.Record review of Resident #115's admission record, dated 05/19/26, reflected a [AGE] year-old male with an admission date of 08/10/18. His relevant diagnoses included dementia (an umbrella term for a decline in mental ability severe enough to interfere with daily life), cerebral infarction (occurs when blood flow an area of the brain in disrupted, causing brain tissue to die from a lack of oxygen and nutrients), absence of left upper limb, and absence of left leg below knee. Record review of Resident #115's quarterly MDS assessment dated [DATE], reflected a BIMS score of 12, which indicated his cognition was moderately impaired. Record review of Resident #115's quarterly care plan, dated 03/03/26, reflected: Problem: [Resident #115] has hx of being physically aggressive.date initiated 01/21/26 and revised on 02/13/26. Interventions included when [Resident #115] becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff walk away calmy, and approach later, date initiated 01/21/26. During an interview and observation on 05/19/26 at 8:00 a.m., Resident #115 was observed sitting in wheelchair watching television. His room had pile of items against the wall and his trash can was half full. Resident #115 emphasized he did not like anyone touching his personal belongings. During an interview on 05/19/26 at 8:21 a.m., Housekeeper J said Resident #115 would regularly curse at her and would not allow her to enter his room to clean it. She said she would report his behaviors to his charge nurse and she would notify her supervisor. Housekeeper J said Resident #115's verbal aggression towards staff was a known behavior. During an interview on 05/21/26 at 2:56 p.m., CNA H said Resident #115 had a pattern of refusing care and would get upset if staff tried entering his room. She said Resident #115 had a known behavior of yelling and cursing at staff only. CNA H said she would report his behavior to his nurse. During an interview on 05/19/26 at 8:46 a.m., LVN G said Resident #115 used his wheelchair to ambulate, preferred to stay in his room, not participate in activities, refused care, and had a known behavior of being verbally aggressive towards staff. LVN G said Resident #115 was known to yell, curse, and scream at staff if they tried to assist him or enter his room. She said CNAs would notified his charge nurse of his refusal of care and verbal aggression. LVN G said nursing staff should have documented his behavior in his electronic medical record. LVN G was not able to say who not documenting Resident #115's behavior on his electronic medical record could negatively impact him. During an interview on 05/21/26 at 3:11 p.m., LVN K said Resident #115 was hard to deal with because he had a history of being verbally aggressive towards staff. He said LVN K said whenever Resident #115 refused care, the CNAs would notify him but he had stopped documenting Resident #115's verbal behavior on his electronic medical record because it's a no win situation with him. LVN K said not documenting Resident #115's verbal behavior on his electronic medical record could negatively impact him by painting a true picture of his behaviors. During an interview on 05/21/2 at 3:50 p.m., the DON said Resident #115 was a long term resident. She said Resident #115 often refused care and had a known behavior of being verbally aggressive towards staff only. She said should document a resident's daily occurrences accurately and consistently to paint a clear picture of the resident's behavior. The DON said a negative outcome to Resident #115 not having his verbal behaviors documented could affect his MDS assessments. The DON said staff had been regularly in-serviced on the topic of documentation. Record review of the facility's Documentation in Medical Records Policy, dated 10/24/22 reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include Enough information she provided picture of the residents fathers through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: Licensed staff and interdisciplinary team members shall document all assessment, observations, and services provided in the resident's medical record in accordance with state law and facility policy Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred. Findings included: 1.Record review of Resident #130's face sheet dated 05/21/26 revealed the resident was a [AGE] year-old male originally admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (is the final, permanent stage of chronic kidney disease), Diabetes Mellitus (high blood sugar), and Heart Failure. Record review of Resident #130's care plan dated 06/17/2025 reflected focus: the resident needed hemodialysis r/t ESDR . Interventions: encourage resident to go to the scheduled dialysis appointments. Record Review of Resident #130's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating intact cognition. Resident #130 was on dialysis while a resident. Record review of Resident #1s Order Summary Report dated 05/21/2026 revealed Resident #130 had dialysis on Tuesdays, Thursdays, and Saturdays. Record review of Resident #130's dialysis communication sheets revealed no communication sheet or documentation of refusal were available for 3/31/26, 4/2/26 and 4/4/26. Record review of Resident #130's MD notes dated 4/7/26 at 3:41 p.m., revealed Patient was seen today for change in condition according to nursing patient refused hemodialysis today again since 3/28. Called patients daughter X2 left voicemail to notify of patient refusal for today. Patient seen at bed side, alert and oriented to self, place, not to time or situation, educated patient on the need to go to dialysis due to increased confusion, patient said no, wound care nurse and med aid confirmed patient refusing to go to HD. Daughter returned the call and was updated on situation, including refusal of hemodialysis, medications and on dialysis center notification of patient needing to go to ER if patient changed mind and accepted to get dialyzed. Explained and educated daughter on expected confusion due to self refusal of hemodialysis. Daughter became aggravated, requested to speak to the patient, and verbalized he was going to die if he wouldn't go to hemodialysis now. Despite this, patient continued to refuse treatment. Daughter stated she would contact emergency services despite wishes. Staff nurse notified ambulance, paramedics arrived, patient refused and daughter was notified at the time a family member was on 3way and requested transfer and fluids due to patient being an emergency despite educating patient is a dialysis patient with heart failure which fluids will be a health risk. Patients vitals stable at the moment BP: 105/ 59, resp: 18, SPO2: 96% in room air, Temp: 97.5, Heart rate 60. Patient was taken to ER and report was given by NP to charge nurse. During an interview on 5/19/26 at 6:18 p.m., LVN F stated after reviewing the progress notes there was no progress notes on the following dates 3/31/26, 4/2/26 and 4/4/26, he stated that Resident #130 was scheduled to dialysis. He stated he could not recall why and stated there should be. He said the risks of not documenting properly was the next person would not know what happened. During an interview on 5/21/26 at 12:30 p.m., the DON stated progress notes could be found in the electronic medical record. She stated her expectation was that they included the time and condition of the resident prior to leaving the facility and when the resident refused to go to the dialysis center. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. Resident #130's progress notes reviewed and revealed no documentation on 3/31/26, 4/2/26 and 4/4/26 in residents' electronic medical records. Record review of the facility's Documentation in Medical Records Policy, dated 10/24/22 reflected: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include Enough information she provided picture of the resident's behaviors through complete, accurate, and timely documentation. Policy Explanation and Compliance Guidelines: Licensed staff and interdisciplinary team members shall document all assessment, observations, and services provided in the resident's medical record in accordance with state law and facility policy Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation or care service occurred.

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, for 1 of 5 residents (Resident #11) reviewed for infection control.1. The wound care nurse failed to place a barrier between Resident #11's buttocks and his brief while providing wound care.2. The wound care nurse failed to wash her hands with soap and water after providing wound care for Resident #11.These failures could place residents at risk for infection through cross contamination of pathogens. The findings included: Record review of Resident #11's admission record on 05/21/26 reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage in subcortical hemisphere (bleeding in the functional tissue of the brain not caused by an external force), muscle wasting and atrophy (loss of muscle mass and strength), type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high), and gastrostomy status (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication). Record review of Resident #11's quarterly MDS dated [DATE] reflected no BIMS score and a Cognitive Skills for Daily Decision Making score of 3 which indicated he was severely impaired and never/rarely made decisions. Record review of Resident #11's care plan dated 01/29/26 reflected he had a pressure ulcer on his sacrum (tailbone). His goal was the pressure ulcer would show signs of healing and remained free from infection, initiated 05/08/26. Interventions included administer treatments as ordered and monitor for effectiveness, initiated 05/08/26. Record review of Resident #11's order summary on 05/19/26 reflected an order for wound care to his sacrum to be done daily ordered on 03/02/26. During an observation of wound care for Resident #11's sacral wound (a wound located on the tailbone area) on 05/20/26 at 4:36 pm, the WCN only unfastened Resident #11's brief from one side and pulled it down. She did not place a barrier between his brief and his buttocks. When the WCN finished with Resident #11's wound care, she did not wash her hands with soap and water prior to exiting his room. In an interview on 05/20/26 at 4:56 pm, the WCN stated she did not put a barrier between the wound and the brief because the wound did not touch the brief at all and the wound was covered until she removed the dressing. She stated her gloved hand did not touch the brief, either. The WCN stated there should have been a barrier between the wound and the brief in case something happened to contaminate the wound. She stated if the wound accidentally got contaminated it could cause infection. The WCN stated she did not wash her hands when she exited the room because she thought sanitizer was an option. She stated she understood the policy to indicate either hand sanitizer or hand washing. The WCN stated if hands were not washed it could cause infection. She stated in-services on wound care were done about every 2 weeks by the out of facility wound care team. She stated the facility did infection control in-services at least once a month and as needed. In an interview on 05/21/26 at 1:19 pm, the DON stated per the wound care competency check off form (which was also the policy), hand hygiene was done before wound care was started. The DON stated hand hygiene was defined as hand washing or the use of hand sanitizer. She stated the check off/policy stated hands were to be washed with soap and water once wound care was finished and before the nurse exited the room. The DON stated the nurse was supposed to place a clean barrier between the resident's wound and the resident's brief to ensure the wound did not get contaminated. She stated it was important to wash hands and place a barrier to prevent the possible spread of infection. The DON stated the WCN was checked off on wound care annually and as needed and her last check off was 04/17/26. Record review of the WCN's Wound Treatment Competency assessment dated [DATE] reflected in part: 6. Position the area to be treated. Place a clean barrier next to the resident to protect bed linen. 14. Wash hands.

Based on observation, interview, and record review the facility failed to conduct regular inspections and maintenance of resident bed frames, mattresses, and bed rails, leading to potential entrapment hazards for 1 of 8 (Resident #123) residents reviewed for safety in rooms. The facility failed to ensure Resident #123's hospital bed functioned properly, as the knee and foot sections could not be elevated. This failure could place residents at risk of injury resulting from equipment malfunction. Findings included: Record review of Resident #123's admission record, dated 05/19/26, reflected a [AGE] year-old male with an admission date of 05/15/26. His relevant diagnoses included hyperlipidemia (high levels of lipids (fats), such as cholesterol and triglycerides, in the blood), atherosclerotic heart disease of native coronary artery without angina pectoris (a condition where plaque builds up in the original heart arteries, reducing blood flow, but without causing chest pain), and rheumatoid arthritis (a chronic autoimmune disorder where the immune system mistakenly attacks the lining of the joints). Record review of Resident #123's MDS assessment was in process. Record review of Resident #123's baseline care plan, was in progress. During an interview and observation on 05/19/26 at 8:35 a.m., Resident #123 was observed lying in bed awake with his head elevated at a 30-degree angle. Resident #123 said he was upset because the knee and foot section of his hospital bed would not elevate. He said he felt his feet were swollen due to not being able to elevate them. Resident #123 stated he had been admitted to the facility short term to received physical therapy on 05/15/26. Resident #123 said that when he was first admitted , the hospital bed did not have the rails he needed to help reposition himself. He said that the facility replaced the bed the following day (05/16/26). Resident #123 was observed holding the hospital bed's hand controller and pressed the knee and foot section button, but the sections did not elevate. During an interview and observation on 05/19/26 at 8:46 a.m., LVN G was observed as she tried to press the elevate Resident #123's knee and foot section of his hospital bed using the hand controller. LVN G said, it's not working. She said the maintenance director was responsible to ensure all hospital beds were working properly. LVN G was observed as she removed Resident #123's socks to assess his feet and ankles. She said Resident #123's left ankle was a little swollen and said she was not sure if it was because he had not been able to elevate his feet, because that's where he had a surgical incision, or the sock was too tight. LVN G said Resident #123's right ankle was not swollen. LVN G was observed as she called the facility's maintenance director to Resident #123's room. LVN G said a negative outcome to Resident #123 not being able to elevate his knees and/or feet would be swelling or pain During an interview and observation on 05/19/26 at 9:00 a.m., the ADON was observed as she tried elevating Resident #123's bed using the hand controller and said, it's not working. The ADON said Resident 123's bed had been changed on 05/16/26 to one that had rails. She said she had not been advised the bed was not working properly. The ADON said she would be going to request a different bed for Resident #123 immediately. The ADON said a negative outcome for Resident #123 not being able to elevate his knees and or his feet would be pain and or swelling. During an interview on 05/19/26 at 9:20 a.m., the Maintenance Director was observed working on Resident #123's bed. The Maintenance Director said it was his responsibility to ensure all hospital beds in the facility were in working condition. He said he did not have a set schedule of when he would inspect the hospital beds. He said he would only inspect them for new admissions or when reported to him a bed was not functioning. The Maintenance Director said he had not received any work orders for Resident #123's bed. During an interview on 05/21/26 at 8:30 a.m., the DON said Resident #123 was admitted on [DATE] short term for physical therapy. She said the maintenance director was responsible to ensure all hospital beds were functioning. The DON said a negative outcome for Resident #123 not having a functioning bed could be edema (swelling). The DON said the facility did not have a policy regarding hospital beds.

Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 (Resident #67) of 6 residents reviewed for foot care. The facility failed to provide adequate foot care to Resident #67. This failure could put residents at risk for infection, impaired mobility, and poor foot health as well as a decline in their quality of life. Findings included:Record review of Resident #67's admission record, dated 05/20/26, reflected a [AGE] year-old male admitted on [DATE]. His relevant diagnoses included chronic systolic heart failure (occurs when the heart's main pumping chamber weakens and cannot contract effectively), cognitive communication deficit (difficulty with communication arising from underlying impairments in thinking process), hemiplegia ( a form of paralysis that affects only one side of the body), hemiparesis (a weakness or partial loss of movement on one side of the body), and reduced mobility.Record review of Resident #67's quarterly MDS assessment, dated 04/14/26, reflected a BIMS score of 2, which indicated his cognition was severely impaired. Resident #67 was coded as dependent (helper does all of the effort. Resident does none of the effort to complete the activity) for personal hygiene. Record review of Resident #67's quarterly care plan, dated 04/08/26, reflected:Problem: The resident has an ADL self-care performance deficit t hemiplegia, limited ROM, stroke, and cognitive impairment. Date initiated and revised 03/01/24. His interventions included bathing/showering: check nail cleanliness, length, and trim as needed on bath day and prn. Report any changes to the nurse. Date initiated 05/16/24.Record review of Resident #67's weekly skin assessments dated 04/28/26, 05/05/26, and 05/12/26, authored by the WCN reflected Foot evaluation completed and no new skin issues found on this evaluation.During an observation and interview on 05/19/26 at 7:42 a.m., Resident #67 was observed lying in bed awake. His right food was uncovered and noted his right great toenail was approximately 1.5 inches long, discolored, and curled. Resident #67 said there had been times when his bed sheet would get tangled with his long toenail and caused pain. Resident #67 was not able to say if he had notified staff his toenail was too long. During an interview on 05/19/26 at 8:05 a.m., CNA H said she was assigned to Resident #67's hall. CNA H said if she were to notice a resident needed to have their toenails trimmed, she would inform their charge nurse. She said Resident #67 was bathed by hospice CNAs. She said she provided care to Resident #67 on a daily basis and had not noticed his right foot toenail. CNA H was not able to say if there were any negative outcomes to Resident #67 having his right foot toenail long. During an interview and observation on 05/20/26 at 3:31 p.m., LVN I said she had recently been hired and was assigned to Resident #67's hall. She was observed as she assessed Resident #67's right great toe and said, It's about 2 inches long, gray with yellow in color. She was observed as she reviewed Resident #67's electronic medical record and said he did not have any orders preventing him from receiving foot care. LVN I said she had not been informed by CNAs that Resident #67 needed foot care, and she had not noticed either. LVN I said a negative outcome for Resident #67 having any toenail that long would be he could stub his toe on something, skin tear, and overall, just uncomfortable.During an interview and observation on 05/20/26 at 4:27 p.m., the ADON was observed as she entered Resident #67's room to assess his right great toenail and said, Oh wow. The ADON described Resident #67's great toenail as 5 cm long, off white, yellowish with a little dark color. The ADON said Resident #67 received hospice care. She said the hospice agency sent their CNAs to bathe him three times a week. The ADON said the hospice CNAs had not informed the facility Resident #67 needed his toenails trimmed. The ADON said even though Resident #67 received hospice, it was still the facility's responsibility to ensure proper foot care was provided. The ADON said the facility's CNAs and nursing staff had daily contact with Resident #67 and they should have noticed and reported his long toe nail. The ADON said the WCN conducted weekly skin assessments on all residents. The ADON said the facility staff had several opportunities to notice Resident #67's toenails and missed it. The ADON the facility contracted with a podiatrist to provide footcare to residents. She said facility staff would include the resident's that needed foot care on the podiatrist list. She said she did not recall Resident #67 being on the podiatrist list for a while. The ADON said a negative outcome to Resident #67 having his right great toenail that long would be pain and possibly infection.During an interview on 05/21/26 at 3:05 p.m., the WCN said she conducted weekly skin assessments on all residents. She said she would normally not note long toenails on her assessments unless they looked infected. She said during her weekly skin assessment she would look for skin breakdown, redness, bruising and discoloration. The WCN said even though Resident #67's long toenail had not been noted on his weekly skin assessments, she should have advised his charge nurse to ensure he was put on the podiatrist list. The WCN said a negative outcome to Resident #67 having his right foot great toenail that long would be the possibility of getting infected. During an interview on 05/21/26 at 3:40 p.m., the DON said Resident #67 was a hospice patient. She said even though, Resident #67 was under hospice, it was the facility's responsibility to ensure proper foot care was provided. The DON said a negative outcome to Resident #67 having his toenails long would be pain. The DON said the facility did not have a policy on foot care. During an interview on 05/21/26 at 3:40 p.m., the DON said Resident #67 received hospice care. She said even though Resident #67 received hospice, it was the facility's responsibility to ensure proper foot care was provided. The ON said a negative outcome to Resident #67 having his toenail long would be pain. The DON said the facility did not have a policy on Foot Care.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 1 (Resident #95) of 25 residents reviewed for call lights. The facility failed to ensure Resident #95 had the call light within reach while in bed in their room. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Findings included: Record review of Resident #95's face sheet, dated 05/20/2026, reflected a [AGE] year-old male with diagnoses of Type 2 Diabetes Mellitus with Hyperglycemia (a chronic condition where your body either resist the effects of insulin or does not produce enough of it, causing sugar to build up in your bloodstream), Muscle Wasting And Atrophy Multiple (a systemic condition, a nerve disorder, or severe physical deconditioning rather than a localized injury). Record review of Resident #95's Quarterly MDS assessment, dated 04/03/2026, reflected a BIMS score of 14 indicating intact cognition. Record review of Resident #95's care plan, dated 03/20/20, reflected has ADL self-care performance deficit related to disease process history of Cerebrovascular Accident (a medical term for stroke. It happens when blood flow to a part of the brain is blocked), Impaired balance, interventions: resident was totally dependent on 2 staff for transferring. During an observation on 05/19/2026 at 8:40 a.m., Resident #95's call light device was behind the bed frame and Resident #95 was not able to reach it. During an interview on 05/19/2026 at 8:45 a.m., RN D said Resident #95 usually used the call light when he needed something. She said she always made sure residents had the call light within his reach and reminded him to use it. RN D said that if a resident could not reach the call light, then they cannot get help, they may have a fall and be at risk of getting hurt. During an interview on 05/21/2026 at 12:10 p.m., the DON said that if call lights were not within reach, residents might need help and could not get it. The DON said Resident #95 was not able to call if he needed something. Record review of facility's policy titled, Call Lights: accessibility and timely response, dated: 10/13/2022, stated: The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #11 and Resident #39) of 5 residents reviewed for enteral feeding.1. The facility failed to ensure Resident #39's enteral feeding administration supplies were labeled and dated on 05/19/26.2. The facility failed to ensure Resident #11's enteral feeding administration supplies were labeled and dated on 05/20/26.These failures could affect residents receiving enteral nutrition and hydration and place them at risk of health complications and decline in health.The findings included:Record review of Resident #39's admission record on 05/21/26 reflected an [AGE] year-old male who was originally admitted to the facility on [DATE] with most recent admission on [DATE] and discharged on 05/20/26. His diagnoses included vascular dementia (problems with thought processes and memory caused by brain damage from impaired blood flow), type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high), unspecified protein-calorie malnutrition (a state of inadequate nutrient intake), aphasia and dysphagia following cerebral infarction (an impairment in the ability to speak and difficulty swallowing after a stroke), and gastrostomy status (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication).Record review of Resident #39's care plan on 05/21/26 dated 05/12/26 reflected he required tube feeding (nutrition provided through his gastric tube). The goal was he would be free of aspiration (inhalation of tube feed formula into the windpipe and lungs) through the review date. There were no interventions listed.Record review of Resident #39's order summary on 05/19/26 reflected the following orders:Enteral feed order: every 8 hours for 3 days related to gastrostomy status- Start Jevity 1.5 at 20 ml/hr and gradually advance tube feed by 10 ml every 8 to 9 hours to goal rate of 70 ml/hr for 18 hours. Downtime: 7:00 am to 1:00 pm. Ordered 05/18/26 to start 05/19/26 at 7:00 am.Enteral feed order: every 6 hours related to gastrostomy status- Flush tube with 180 of ml of water every 6 hours. Ordered 05/18/26 to start 05/18/26 at 8:00 pm.An observation on 05/19/26 at 8:56 am reflected Resident #39's tube feed administration bag was hanging on a pole with administration tubing going into a feeding tube pump running at 20 ml/hr and connected to his gastric tube. The tube feed administration bag was not labeled with his name, his tube feed formula, the rate it was supposed to be administered, how much water he was supposed to receive and how often, or the date and time the tube feed formula was started. The bag contained approximately 800 ml of tube feed formula.An inspection on 05/21/26 at 3:09 pm of the cabinet where resident's tube feed formula containers and supplies were stored reflected the cabinet contained approximately 35- 8 ounce (237 ml) cartons of Resident #39's tube feed formula. The back of the carton stated in part, Instructions for use: .Once opened, reclose, refrigerate, and use within 48 hours.Record review of Resident #11's admission record on 05/21/26 reflected a 51-[NAME]-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. His diagnoses included nontraumatic intracerebral hemorrhage in subcortical hemisphere (bleeding in the functional tissue of the brain not caused by an external force), muscle wasting and atrophy (loss of muscle mass and strength), type 2 diabetes mellitus (chronic condition that happens when blood sugar levels are persistently high), and gastrostomy status (a tube surgically implanted through the abdomen into the stomach used to provide nutrition, hydration, and medication).Record review of Resident #11's quarterly MDS dated [DATE] reflected no BIMS score and a Cognitive Skills for Daily Decision Making score of 3 which indicated he was severely impaired and never/rarely made decisions.Record review of Resident #11's care plan dated 01/29/26 reflected he required a feeding tube due to dysphagia related to a stroke. His goals included he would be free of aspiration, side effects or complications related to tube feeding. Interventions included Resident #11 was dependent on 1 staff member with tube feeding and water flushes. All initiated on 02/13/26.Record review of Resident #11's order summary on 05/19/26 reflected the following orders:Enteral Feed Order: One time a day- Glucerna 1.5 at 75 ml/hr for 20 hrs via gastric tube stationary pump. Down time: 7:00 am to 11:00 am. Turn off pump at 7:00 am. Turn on pump at 11:00 am. Started on 04/13/26 at 11:00 am.Enteral Feed Order: Every 6 hours- Flush tube with 240 ml of water. Started on 04/13/26 at 12:00 pm.An observation on 05/20/26 at 4:45 pm, reflected Resident #11's tube feed administration bag was hanging on a pole with administration tubing going into a feeding tube pump running at 75 ml/hr and connected to his gastric tube. The tube feed administration bag was not labeled with his name, his tube feed formula, the rate it was supposed to be administered, how much water he was supposed to receive and how often, or the date and time the tube feed formula was started. Resident #11's enteral feed syringe (used for medication administration and water flushes) was not dated.In an interview on 05/21/26 at 8:52 am, LVN A stated he did not notice the tube feeding formula bag was not labeled on 05/20/26. He stated it was important enteral feeding bags or containers were labeled to keep up with infection control and make sure the tube feeding formula was changed every day. LVN A stated the label was also important to know the correct formula, the rate, and when and how much water to flush.In an interview on 05/21/26 at 11:12 am, LVN G stated usually the night nurse changed the tube feeding and supplies. She stated it was the responsibility of all of the nurses to ensure everything was changed and dated correctly. LVN G stated she had not been the nurse for Resident #39.In an interview on 05/21/26 at 1:19 pm, the DON stated it was important to label tube feed bags to know what formula the resident was receiving, the flow rate and date it was changed to prevent the tube feed from spoiling. The DON stated nurses were checked off on tube feed administration upon hire and annually.In an interview on 05/21/26 at 2:06 pm, RN D stated she worked on 05/19/26 from 6:00 am to 2:00 pm. She stated she did not hang Resident #39's bag of tube feed formula. RN D stated she turned the tube feeding pump off when she got to work and she did not check the tube feed bag to see if it was labeled because she forgot. RN D stated she did not turn the tube feeding pump back on, but she did inform the nurse that she gave report to about the gradual increase in the tube feed rate. She stated it was the night nurse's responsibility to change out and label the tube feed bags. She stated it was important to label tube feeds to ensure the right resident, the right formula and that it was not hung for over 24 hours. RN D stated if the tube feed formula was up for over 24 hours it could cause stomach upset or vomiting and if the wrong formula was given it could cause gastrointestinal issues or blood sugar issues. RN D stated if she found unlabeled tube feed supplies, she discarded what was used and get all new supplies.A policy on tube feeding (enteral feeding) was requested; however, the facility was not able to provide it.A skills check off for tube feeding (enteral feeding) administration was requested; however, the facility was not able to provide it. The facility provided an Enteral Tube Site Care Competency Assessment, but it did not address enteral feeding administration or supply usage.

Based on observation, interview and record review, the facility failed to ensure residents had the right to personal privacy for 2 (Resident #1 and #2) of 5 residents reviewed for respect and dignity.The facility failed to ensure staff closed Resident #1's door to provide privacy during incontinent and wound care on 04/16/2026.The facility failed to ensure staff closed Resident #2's privacy curtain to provide privacy during incontinent care on 04/16/2026.These failures could place residents at risk of emotional or psychological distress and embarrassment.The findings included:Record review of Resident #1's face sheet, dated 04/17/2026, revealed an [AGE] year-old female with an original admission date of 03/18/2022, and a current admission date of 08/15/2025. Pertinent diagnoses included Pressure Ulcer of Sacral Region (the triangular bone area at the base of the spine) - Stage 4 and Diabetes (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #1's care plan, initiated 05/03/2023, and revised 03/19/2026, revealed Resident #1 had a Stage 4 Sacral Pressure Injury. Interventions included administer treatments as ordered and monitor for effectiveness. In an observation on 04/16/2026 at 11:00 AM, the WCN was observed to have left Resident #1's room to obtain supplies with the privacy curtain loosely pulled and the door completely open. CNA-A was at the bedside with Resident #1 who was lying exposed in bed with her gown pulled up to her breasts and her brief completely removed.Record review of Resident #2's face sheet, dated 04/17/2026, revealed a [AGE] year-old male with an admission date of 01/30/2026. Pertinent diagnoses included Hemiplegia (complete paralysis on one side of the body) and Hemiparesis (partial weakness on one side of the body) following Cerebral Infarction (a stroke which occurred when a blood clot disrupted blood flow in the brain) Affecting the Left Non-Dominant Side. Record review of Resident #2's care plan, initiated 02/11/2026, revealed Resident #2 had an ADL self-care performance deficit related to left Hemiplegia following a CVA. Interventions included Resident #2 was dependent for toileting hygiene. In an observation on 04/16/2026 at 3:04 PM, CNA-B and CNA-C were observed to perform incontinent care on Resident #2. While the CNAs had closed Resident #2's door, they had not pulled his privacy curtain, and a visitor walked in while Resident #2 was lying completely exposed in his bed. In an interview on 04/16/2026 at 2:44 PM, the WCN stated she should have made sure the privacy curtain was completely closed and the door was shut to Resident #1's room while she stepped out to grab supplies. She also stated she should have covered Resident #1 up and not left her body exposed as this could have caused her embarrassment or humiliation. In an interview on 04/16/2025 at 4:19 PM, CNA-A stated she should have covered Resident #1 with a sheet or towel when the nurse stepped out of the room instead of leaving Resident #1 completely exposed.In an interview on 04/16/2025 at 4:36 PM, CNA-B stated she should have pulled Resident #2's privacy curtain closed prior to providing incontinent care because he was completely exposed when someone entered his room because this could have caused embarrassment for him.In an interview on 04/16/2025 at 4:36 PM, CNA-C stated she and CNA-B should have made sure Resident #2's privacy curtain was pulled closed so he was not exposed during incontinent care. In an interview on 04/17/2026 at 8:10 AM, the DON stated the CNAs and nurses knew they were supposed to provide dignity and privacy for the residents by closing the privacy curtains and doors during care. They should also cover the areas of the residents' bodies where no care was being provided. Residents could feel humiliated if they were not treated with dignity or respect. Record review of facility's Perineal Care policy, implemented 10/24/2022, revealed 5. Provide privacy by pulling privacy curtain or closing room door if a private room.Record review of facility's Statement of Residents Rights, no date identified, revealed You have the right to (4) be treated with courtesy, consideration, and respect; (6) privacy. Rights Of The Elderly: (b) An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual without regard to race, religion, national origin, sex age, disability, marital status, or source of payment (g) An elderly individual is entitled to privacy while attending to personal needs. This right applies to medical treatment.

Based observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and #2) of 5 residents reviewed for infection control practices.1. The facility failed to ensure the WCN knew the correct procedures or professional practices to cleanse the wound adequately on Resident #1. 2.The facility failed to ensure the WCN, CNA-A, CNA-B and CNA-C performed proper hand hygiene when providing care to Resident #1 and Resident #2.3. The facility failed to ensure CNA-A and CNA-C did not enter clean packages or containers with contaminated gloves and not take contaminated supplies from Resident #2's room and place them back on the clean supply cart. These failures and deficient practices could place residents at risk for healthcare associated cross-contamination and the spread of infectionThe findings included:Record review of Resident #1's face sheet, dated 04/17/2026, revealed an [AGE] year-old female with an original admission date of 03/18/2022, and a current admission date of 08/15/2025. Pertinent diagnoses included Pressure Ulcer of Sacral Region (the triangular bone area at the base of the spine) - Stage 4 and Diabetes (a chronic disorder characterized by high blood sugar levels due to insufficient insulin [a crucial hormone which regulates blood sugar levels and plays a vital role in energy metabolism] production or ineffective use of insulin by the body).Record review of Resident #1's physician order summary, dated 02/03/2026, revealed an order to cleanse the wound with normal saline, pat dry, apply Iodosorb Gel (a gel used to promote healing of wounds and ulcers) and Calcium Alginate (a type of dressing which absorbs large amounts of drainage), and cover with a super absorbent dressing three times per week. Record review of Resident #1's Annual MDS Assessment, dated 03/18/2026, revealed no BIMS score as Resident #1 was rarely or never understood. The MDS also revealed Resident #1 had one or more unhealed pressure ulcers. Record review of Resident #1's care plan, initiated 05/03/2023, and revised 03/19/2026, revealed Resident #1 had a Stage 4 Sacral Pressure Injury. Interventions included administer treatments as ordered and monitor for effectiveness. In an observation on 04/16/2026 at 11:00 AM, the WCN was observed performing hand hygiene with alcohol-based hand sanitizer multiple times during wound care on Resident #1. During each hand hygiene observation throughout Resident #1's wound care, the WCN was noted to put hand sanitizer into the palm of her hand, rub both hands 1 - 4 seconds each time, then hold both hands in the air and made fists or waved them for 1 - 3 seconds each time, after which she applied clean gloves with difficulty because the gloves would stick to her still wet hands. The WCN was also noted to cleanse Resident #1's wound during this observation by making one swipe with saline soaked gauze from above the sacral wound, wiping straight down, to below the sacral wound. During this observation, CNA-A was observed to have performed hand hygiene with alcohol-based hand sanitizer for approximately 5-6 seconds, and then she applied clean gloves with difficulty due to the gloves sticking to her still wet hands. Record review of Resident #2's face sheet, dated 04/17/2026, revealed a [AGE] year-old male with an admission date of 01/30/2026. Pertinent diagnoses included Hemiplegia (complete paralysis on one side of the body) and Hemiparesis (partial weakness on one side of the body) following Cerebral Infarction (a stroke which occurred when a blood clot disrupted blood flow in the brain) Affecting the Left Non-Dominant Side. Record review of Resident #2's care plan, initiated 02/11/2026, revealed Resident #2 had an ADL self-care performance deficit related to left Hemiplegia following a CVA. Interventions included Resident #2 was dependent for toileting hygiene.In an observation on 04/16/2026 at 3:04 PM, CNA-B and CNA-C were observed to perform hand hygiene at the same time with alcohol-based hand sanitizer by squirting it in the palm of their hands and rubbing their hands for approximately 3 - 4 seconds prior to attempting to apply clean gloves to their still wet hands. CNA-C was observed to perform hand washing during the observation and only scrubbed her hands for 6 seconds. CNA-C was also observed during Resident #2's incontinent care to touch the outside, as well as re-enter the clean package of wipes multiple times with her dirty gloves, as well as carry the contaminated package of contaminated wipes out of the resident's room and placed it back on her clean supply cart. In an interview on 04/16/2026 at 2:44 PM, the WCN stated the proper way to use hand sanitizer was to pour a little bit on your hands, rub them together, and then let it dry. After reviewing the facility policy, she then stated you should use enough hand sanitizer to cover all surface areas of the hands and rub the hands together covering all surfaces until dry, which should be approximately 20 seconds. The WCN stated the proper way to cleanse a wound, after removing the dirty dressing and performing hand hygiene, should have consisted of cleaning the wound from the center out, going from cleanest to dirtiest. She stated wiping or cleaning the wound by wiping across it could have caused contamination of the wound or introduced bacteria back into it. In an interview on 04/16/2025 at 4:19 PM, CNA-A stated she should have rubbed hand sanitizer all over both hands until it was dry, and she realized she had not done this. She stated she should not have re-entered the clean wipes with her dirty gloves, then put contaminated wipes away with clean gloves. She stated this could have caused cross-contamination and infections.In an interview on 04/16/2025 at 4:36 PM, CNA-B stated she should have rubbed alcohol-based hand sanitizer for 7 seconds before applying new gloves. After she read the facility policy, she stated she should apply alcohol-based hand sanitizer to cover all surfaces of her hands, then rub her hands until they were completely dry, approximately 20 seconds.In an interview on 04/16/2025 at 4:36 PM, CNA-C stated she should apply alcohol-based hand sanitizer to cover all surfaces of her hands, then rub her hands until they were completely dry. She stated when washing her hands she should scrub them for at least 20 seconds. She stated she was unsure how long she had done each. CNA-C stated she should not have re-entered the clean package of wipes with her dirty glove, and she should not have taken the package of wipes out of the resident's room and placed it back on the cart with her clean supplies. In an interview on 04/17/2026 at 8:10 AM, the DON stated she was currently acting in the role of ICP until a new one was hired. She stated in regard to hand hygiene, the staff should put enough alcohol-based hand sanitizer on their hands to cover all surface areas of the hands, then rub all areas of hands thoroughly until dry, or approximately 20 seconds. She also stated hand washing with soap and water should consist of scrubbing the hands at least 20 seconds. The DON stated the WCN should cleanse the wound from the cleanest to dirtiest areas of the wound so as not to have caused cross-contamination or re-introduce bacteria into the wound. She also stated CNAs should not re-enter clean containers or packages of wipes with dirty gloves and should not take contaminated supplies out of resident's rooms and restock on their supply cart. The DON also stated staff had previously been in-serviced regarding infection control and hand hygiene.Record review of the facility's Wound Care Power Point presentation, revised 01/17/2022, revealed Wound Cleansing: 3. Wipe wound with gauze from the middle outward, 5. Pat the wound and peri-wound dry from the middle outward.Record review of the facility's Hand Hygiene policy, implemented 10/24/2022, revealed Policy Explanation and Compliance Guidelines: 2. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. 3. Hand Hygiene technique when using an alcohol-based hand rub: A. Apply to palm of one hand the amount of product recommended by the manufacturer. B. Rub hand together, covering all surfaces of hands and fingers until hands feel dry. C. This should take about 20 seconds.

Based on interview and record review the facility failed to ensure the comprehensive care plan was developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 5 residents (Resident #1) reviewed for care plan revisions. The facility failed to develop Resident #1's comprehensive care plan within 7 days after completion of the comprehensive assessment. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included:Record review of Resident #1's face sheet dated 03/31/26 revealed a [AGE] year-old female with admission date of 03/05/26. Diagnoses included schizophrenia (Disorder leading to psychosis such as hallucinations, delusions, social withdrawal, lack of motivation and cognitive impairment) and heart failure (chronic condition where the heart cannot pump enough blood to meet the body's needs). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #1's comprehensive care plan dated 03/31/26 revealed the care plan only addressed Resident #1's code status, sitting on the floor, a fall on 03/21/26, fall risk, bowel incontinence, a rib fracture related to a fall, bladder incontinence, and oxygen therapy. Record review of Resident #1's Care Plan history on 03/31/26 revealed Resident #1's next review date for her care plan was 03/23/26. In an interview with LVN A at 2:00 PM on 03/31/26, LVN A stated she was the Care Management Specialist at the facility. LVN A stated Resident #1 was admitted to the facility on [DATE]. LVN A stated she completed the initial MDS Assessments for residents as soon as possible, but no later than 14 days after admission. LVN A stated the initial assessment for Resident #1 was completed on 03/17/26. LVN A stated they had 7 days to complete the comprehensive care plan once the assessment was completed. LVN A stated the comprehensive care plan for Resident #1 should have been completed by 03/24/26. LVN A stated the interdisciplinary team provided input into the care plan but ultimately it was her responsibility to complete the comprehensive care plan once the assessment was completed. LVN A stated she did not complete the comprehensive care plan for Resident #1 until 03/31/26. LVN A stated she waited to complete the comprehensive care plan because she was not sure if the resident needed a change of condition assessment after a recent fall. LVN A stated a delay in completing a comprehensive care plan may lead to nurses not being up to date on how to properly care for a resident. In an interview with the DON at 2:35 PM on 03/31/26, the DON stated the comprehensive care plan contained everything a nurse needed to know to care for a resident such as ADL's, medications, diet, treatments, goals, and interventions. The DON stated it was important to complete the comprehensive care plan on time so all nurses would have the pertinent information needed to care for a resident. The DON stated the care plan Resident #1 had on the morning of 03/31/26 was insufficient as a comprehensive care plan. The DON stated the comprehensive care plan for Resident #1 should have been completed by 03/24/26. The DON stated the MDS nurse built the comprehensive care plans. Record review of the facility policy Comprehensive Care Plans dated 10/24/22 revealed the following policy: .2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS assessment.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, for 1 (Resident #1) of 4 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected she refused to eat, to shower, wound care, medications, and was noncompliant with staying repositioned on her sides.This failure could place the residents at risk of not receiving appropriate interventions and care to meet their needs.The findings included:Record review of Resident #1's face sheet dated 02/18/26 reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses that included: Alzheimer's disease (progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior), dysphagia (trouble swallowing), muscle wasting and atrophy, and other reduced mobility. Resident #1 was discharged home on [DATE]. Record review of Resident #1's MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 7, indicating severe cognitive impairment. Resident #1 had one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough). Resident #1 was dependent (helper does all of the effort) for toileting hygiene, required substantial/maximal assistance (helper does more than half the effort) for showering/bathing, personal hygiene, and required partial/moderate assistance (helper does less than half the effort) to roll left and right. Record review of Resident #1's care plan dated 02/18/26 reflected [Resident #1] had an ADL self-care performance deficit related to Alzheimer's disease. Date initiated: 07/24/25. Resident #1's care plan did not reflect Resident #1 refused to eat, to shower, wound care, medications, and was noncompliant with staying repositioned on her sides. Record review of Resident #1's progress notes dated 11/20/25-02/11/26 revealed progress notes:- On 11/20/25 at 8:31 AM, hospice aide in facility, resident refused shower/bed bath at this time-On 11/24/25 at 12:30 PM, resident refused to shower this morning. Hospice aide attempted but resident refused. Hospice then reported to nurse on duty to try and encourage resident to shower but resident refused again stating I just don't want to shower.-On 12/04/25 at 1:34 PM, resident continues to refuse showers. Hospice aide asked on duty nurse for assistance on trying to encourage resident to shower. Resident refused and began to get agitated.-On 12/21/25 at 1:30 PM, resident refusing lunch tray, substitute offered and declined.-On 12/24/25 at 4:42 PM, resident refused to eat breakfast, stated she will not eat. Nurse educated resident on importance of nutrition and not skipping meals, resident continued to refuse.-On 12/27/25 at 9:04 AM, resident ate 25% of meal, nurse explained to resident the importance of a nutritious meal, resident continued to refuse.-On 01/05/26 at 6:25 PM, resident has been allowing staff to provide incontinence care and repositioning but resident repositions self into supine position after a few minutes. Redirection ineffective. Resident stated that she will position self in the most comfortable position for her.-On 01/07/26 at 11:52 AM, resident refused breakfast, offered alternate plate but refused. RP made aware she voiced that her mother usually never ate breakfast, only a coffee with a piece of bread at time and ate until 11am.-On 01/23/26 at 6:31 PM, nurse called hospice nurse to inform of resident's poor appetite. Message left, nurse returned call and nurse informed her resident continues with poor appetite and requested a speech evaluation or other recommendations to help with residents poor appetite. Hospice nurse stated she would consult with her supervisor and call back with any orders.-On 01/25/26 at 1:30 PM, wound care to sacral ulcer completed after begging resident that dressing needed to be changed because it was soiled and peri care needed to be done. Resident refused initially but after repetitive begging resident accepted but did limit to 5 minutes.-On 01/25/26 at 2:01 PM, resident ate less than 25%, offered substitute, resident denied. Resident did drink coffee.-On 01/26/26 at 1:22 PM, resident refused to be repositioned. Attempted to educate due to sacral bedsore would promote healing. Resident continue to refuse. Denied pain.-On 01/26/26 at 6:29 PM, resident refused to eat dinner. Resident asked why she did not want dinner. Resident stated she is not hungry at the moment. Floor nurse offered an alternative meal from the kitchen resident refused and stated again she is not hungry.-On 01/27/26 at 2:48 PM, resident refused any substitutions. Attempted to encourage resident to eat but resident to decline. Resident tightens lips in order not to eat.-On 01/27/26 at 7:00 PM, resident refused to eat. Resident was offered alternative meal options and resident refused.-On 01/30/26 at 11:34 AM, resident refused medications x3.-On 02/06/26 at 8:33 PM, resident refused medications.-On 02/08/26 at 6:56 PM, resident was educated on the importance of having dressing changed, resident refusing and stating, not right now. Nurse attempted x3, however, resident continued to refuse.-On 02/09/26 at 5:26 AM, resident refused medications.-On 02/09/26 at 9:20 AM, resident refused meal. Resident was educated on importance of eating and resident still refused.-On 02/09/26 at 2:55 PM, resident refused meal. Resident was educated on importance of eating and resident still refused.-On 02/10/26 at 9:28 AM, resident refused all medications, nurse aware.-On 02/11/26 at 9:25 AM, resident refused medications x3.-On 02/11/26 at 9:28 AM, resident refused meal. In an interview on 02/18/26 at 2:50 PM, with the ADON, she said Resident #1 refused to shower and refused to eat. The ADON said if Resident #1 refused care, it should have been care planned. The ADON said the purpose of the care plan was to make sure they had the proper interventions. The ADON said the care plan explained to staff how to care for the resident. The ADON said she was not sure if Resident #1's refusals were care planned. The ADON said the MDS Nurse updated care plans. In an interview on 02/18/26 at 3:15 PM, with RN B, she said Resident #1 refused to eat, refused to shower, refused medications, and refused wound care at times. RN B said Resident #1 was noncompliant with staying on her sides when the staff would reposition her. RN B said these refusals did not help with the wound healing process. RN B said care plans were updated as needed by staff such as herself, the MDS Nurse, the ADONs, the DON, or a floor nurse. RN B said she was not sure if Resident #1's refusing care or being noncompliant was care planned. RN B said it was important to have refusals and noncompliance care planned to check the resident's progress and whether or not the interventions were working. An interview was attempted on 02/18/26 at 3:35 PM with the DON, she was unavailable as she was on personal time off. In an interview on 02/18/26 at 3:40 PM with the MDS Nurse, she said the care plans were updated by the team and different disciplinaries. The MDS Nurse said if there were any acute changes or the care plan needed to be updated, it was updated daily if needed. The MDS Nurse said if a resident was noncompliant with her care, including eating, showering, that should be included in the care plan. The MDS Nurse said she reviewed Resident #1's care plan and the behaviors as far as her refusing to shower, refusing wound care, refusing to eat, refusing medications, and refusing to stay on her sides, were not care planned. The MDS Nurse said that did not indicate that staff were not providing the care or attempting interventions. The MDS Nurse said there was no negative outcome for Resident #1, but it was important for refusals to be care planned. The MDS Nurse said the care plan was used to communicate with staff of how to care for the resident, and the goals and interventions based on the resident's needs. In an interview with on 02/18/26 at 4:00 PM with the ADM, he said Resident #1 refused meals and to be repositioned in bed. The ADM said he was unsure if Resident #1 refused other care. The ADM said staff tried to provide assistance, educated Resident #1, redirected her, and notified/followed up with the hospice agency and the RP about the refusals. The ADM said although the refusals were not care planned, there was no negative outcome for Resident #1 as staff attempted interventions. The ADM said the refusals should have been care planned so that everyone was aware. Record review of the facility's Comprehensive Care Plans policy dated 10/24/22 reflected - Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs.6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of five residents (Resident #3) reviewed for accidents and supervision.The facility failed to prevent Resident #3 from attaining alcohol-based hand rub on 12/21/2025. This failure could place residents at risk of ingesting potentially harmful ingredients due to its high alcohol content.Record review of Resident #3's admission record, dated 01/10/2026, revealed Resident #3 was admitted to the facility on [DATE]. Resident #3 was a [AGE] year-old male who was admitted to the facility with multiple diagnoses which included alcohol dependence with alcohol-induced mood disorder, alcohol dependence with unspecified alcohol-induced disorder, and alcoholic cirrhosis of liver without ascites (liver damage).Record review of Resident #3's admission MDS, dated [DATE], revealed Resident #3 had a BIMS score of 4, which indicated Resident #3 was severely cognitively impaired. Resident #3 was also coded for needing partial/moderate assistance with ADLs.Record review of Resident #3's care plan, date initiated 01/08/2026, revealed The resident has a mood problem r/t Alcohol dependence dx Goal: The resident will have improved mood state happier, calmer appearance, no s/sx of depression, anxiety or sadness) through the review date. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.) Monitor/document/report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness or helplessness, impaired judgment or safety awareness. Monitor/record/report to MD PRN acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/ eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills Monitor/record/report to MD PRN mood patterns s/sx of depression, anxiety, sad mood. Monitor/record/report to MD PRN risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Care plan did not document any history of resident consuming items he was not supposed to. Record review of Resident #3's progress notes revealed on 12/21/2025 at 04:33AM, RN A documented Note Text: Pt found stacking furniture at his bedroom door. I noticed an open bottle of hand sanitizer on his bedside table Pt stated, 'Yes I'm F***** up.' I asked the patient where he got hand sanitizer from, he stated 'Come on I'm not [bullshitting] you man.' There was no indication that Resident #3 consumed hand sanitizer only that it was in Resident #3's possession. Record review of the facility's provider investigation report, date of incident 12/21/2025, revealed the facility administrator was notified by the facility director of nursing that a bottle of hand sanitizer had been found in a resident's room on the facility's secured unit by the charge nurse. The bottle of hand sanitizer that was found had been opened and the resident vocalized to the nurse that he had ingested hand sanitizer. The resident also stated he had ingested other items which were not located in the resident's room. During the course of monitoring Resident #3, there was never any indication that emergent services were warranted nor was there any indication that Resident #3 consumed the hand sanitizer. During an interview and observation on 01/10/2026 at 10:03AM revealed Resident #3 was sitting calmly in his wheelchair with no exhibition of distress. Resident #3 stated he did not recall any event regarding hand sanitizer, and continued to state no person has ever hit, hurt, or scared him. Resident #3 stated the nurses were nice to him and was not fearful of living at the facility. Resident #3 stated he had never ingested any form of alcohol/hand sanitizer while at the facility. There was no hand sanitizers observed in Resident #3's room. During an observation on 01/10/2026 at 9:56AM observed the memory unit and all mobile hand sanitizers were locked within the nurse's medication carts under lock and key. There were no other mobile bottles of hand sanitizers in the memory unit. During an attempted phone interview on 01/09/2026 at 6:12PM and 01/10/2026 at 10:42AM and 1:18PM with RN A were unsuccessful. RN A did not return call prior to exit conference.During an attempted phone interview on 01/09/2026 at 5:04PM and 01/10/2026 at 1:11PM with CNA B, who was noted to be working on 12/21/2025 during the incident, was unsuccessful. CNA B did not return call prior to exit conference.During an attempted phone interview on 01/09/2026 at 5:08PM and 01/10/2026 at 1:14PM with CNA C, who was noted to be working on 12/21/2025 during incident, was unsuccessful. CNA C did not return call prior to exit conference.During an interview on 01/10/2026 at 1:59PM, the DON and Administrator stated RN A notified on 12/21/2025 that Resident #3 verbalized drinking multiple substances that were not kept within the facility. The DON stated RN A notified her that he saw a small bottle of hand sanitizer on Resident #3's bedside table on 12/21/2025. The DON and Administrator stated the facility quickly conducted a thorough head to toe assessment, neurological assessment, notified the physician, as well as notified the poison control hotline and per the recommendation of poison control to monitor Resident #3 for any adverse effects of hand sanitizer, and during the 72 hour course of monitoring Resident #3, there was never any adverse effects. The DON and Administrator stated there was never any indication of actual ingestion as the cap was secured on the bottle and there was no apparent large amount of hand sanitizer missing. The DON and Administrator stated they researched the effects of ingesting hand sanitizer and stated the hand sanitizer did not have detrimental consequences. The DON and Administrator stated while they conducted the investigation, they concluded the hand sanitizer was in a drawer in the nurses' station, however, they could not definitively state where the hand sanitizer was situated. The DON stated she also completed a thorough head to toe assessment herself, and there was never any evidence of Resident #3 ingesting any caustic chemicals, additionally Resident #3 never smelled of alcohol nor did he present with any change of neurological deficits or intoxication. The DON and Administrator stated the facility monitored Resident #3 for 72 hours and maintained the same cognition from when Resident #3 was admitted . The DON and Administrator reiterated there was never any evidence that Resident #3 consumed the hand sanitizer only that the hand sanitizer was in Resident #3's possession. The DON and Administrator stated the incident was an isolated event and since the event the facility has ensured all non-fixed hand sanitizer bottles were kept within the nurse's locked medication carts and no longer kept within the nurses' stations. The DON and Administrator stated Resident #3 should not have had access to the hand sanitizer as it was potentially a chemical hazard. Both stated Resident #3 may have retrieved the hand sanitizer bottle from a drawer within the nurse's station. Both stated there could have been a negative consequence on Resident #3's well-being had Resident #3 ingested the hand sanitizer, however there was never any indication of Resident #3 consuming the hand sanitizer. Both stated after the incident they educated the clinical staff that any hand sanitizer bottle not affixed on the walls must be kept in the nurse's medication cart under lock and key.Record review of the facility's, undated, general housekeeping policies, revealed all bleaches, detergents, disinfectants, insecticides, and other potentially hazardous substances are labeled and kept in a safe place accessible only to employees.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infection for one of five residents (Resident #2) reviewed for infection control.1. The facility failed to ensure CNA A removed her contaminated gloves and performed hand hygiene after touching multiple surfaces prior to initiating Resident #2's perineal care on 01/10/2026.2. The facility failed to ensure CNA A performed hand hygiene when completing perineal care to cleaning bowel movement.These failures could place residents at risk for contamination and infection.The findings include:Record review of Resident #2's admission record, dated 01/10/2026, revealed Resident #2 was admitted to the facility on [DATE]. Resident #2 was a [AGE] year-old female who was admitted to the facility with multiple diagnoses which included type 2 diabetes mellitus (persistent high level of sugar in blood), lack of coordination and muscle wasting and atrophy (loss of muscle mass and strength).Record review of Resident #2's Comprehensive MDS, dated [DATE], revealed Resident #2 had a BIMS Score of 15, which indicated Resident #2 was cognitively aware. Resident #2 needed substantial/maximal assistance with ADLs. Record review of Resident #2's care plan, date initiated 01/16/2025, revealed Problem: the resident has bowel and bladder incontinence related to Impaired Mobility, Physical limitations. Goal: the resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: BRIEF USE: The resident uses disposable briefs. Change as necessary. Clean peri-area with each incontinence episode. Monitor/document for s/sx UTI: 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. Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects.During an observation on 01/10/2026 at 11:25AM revealed CNA A washed hands, placed clean gloves on, utilized Resident #3's bed remote to lay the resident down, removed Resident #3's blanket and gown, and proceeded to retrieve cleansing wipes without changing gloves nor performing hand hygiene. CNA A then cleaned Resident #3's perineal area, rolled the front of Resident #3's brief up, turned Resident #3 to her right side, and proceeded to clean Resident #3's visible bowel movement, CNA A did not perform glove change or hand hygiene prior to turning Resident #3 to her right side. During an interview on 01/10/2026 at 11:48AM, CNA A stated during the perineal care she should have changed her gloves and performed hand hygiene after she touched the bedside remote and Resident #2's immediate surroundings. CNA A stated she forgot to perform glove change and hand hygiene because she was nervous. CNA A stated secondly, she should have changed her gloves and performed hand hygiene when going from clean area to dirty area. CNA A stated for both instances the reason she should have changed gloves and performed hand hygiene was to minimize the potential introduction of bacteria. CNA A said she would be more diligent about implementing hand hygiene throughout perineal care.During an interview on 01/10/2026 at 11:51AM, the DON stated CNA A should have removed her contaminated gloves once she touched Resident #2's immediate surroundings and when she cleaned the perineal area to the gluteal area. The DON stated the reason CNA A should have performed gloves changes and hand hygiene was to mitigate the potential exposure to infectious microorganisms. The DON stated the facility followed the CDC guidelines regarding hand hygiene. The DON stated she would rectify the perineal concern and commence a facility wide hand hygiene in-service.Record review of the facility's perineal care policy, date implemented 10/24/22, revealed no specific steps when to perform hand hygiene.Record review of the facility's Hand Hygiene policy and procedures, date implemented 10/24/22, revealed no specifics on when to perform hand hygiene.Record reviewed the facility's CNA's rounding in-service dated 05/30/2025 which revealed the facility educated the staff on incontinent care policy and procedures.Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers, updated on 02/27/2024, revealed Know when to clean your hands,Immediately before touching a patient.Before moving from work on a soiled body site to a clean body site on the same patientAfter touching a patient or patient's surroundingsAfter contact with blood, body fluids, or contaminated surfacesImmediately after glove removal.

Based on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately to the administrator of the facility and to HHSC for 1 of 3 Residents (Resident #4) reviewed for abuse. The facility staff failed to report an allegation of abuse to the administrator and HHSC within 2 hours after the allegation was made per facility policy. This deficient practice could affect any resident and could contribute to further neglect. The findings were: Record review of Resident #4's face sheet dated 05/29/24 revealed a [AGE] year-old female with an original admission date of 02/18/19. Diagnoses included Alzheimer's, fainting, Unspecified injury of the head, stomach ulcer with perforation, Dementia with behavioral disturbance, anemia (low blood count), anxiety, Diabetes, High blood pressure, malnutrition, abnormal gait and balance, curvature of the spine, repeated falls, reduced mobility, unsteadiness of feet, and assistance with personal care. Record review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. She was exit-seeking, utilized a wheelchair which she could self-propel slowly. She was dependent on staff for personal hygiene, dressing, including footwear, showering, toileting, transferring, and oral hygiene. She required set-up assistance with eating. She required substantial assistance with upper-body dressing and moderate assistance with positioning. She was always incontinent of bladder and bowel. Her active diagnosis was Non-traumatic Brain Dysfunction. Record review of Resident #4's care plan dated 04/27/20: Date Initiated: 02/01/23. The resident has an ADL self-care performance deficit. Interventions included: Date Initiated: 04/21/23 The resident requires extensive assistance by (2) staff to turn and reposition in bed, and the resident requires extensive assistance by (2) staff to move between surfaces (transfers). Date Initiated: 08/13/24. Needs a structured environment in a secure unit related to cognitive deficit. Interventions included Date Initiated: 08/13/24, Try to keep a routine such as bathing, dressing, and eating. Date Initiated: 02/01/2023. The resident has impaired cognitive function/dementia or impaired thought processes r/t Alzheimer's. Interventions included cue, reorient, and supervise as needed. Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. She required extensive and frequent redirection. Record review of Resident #4's active physician orders revealed Cilostazol Oral Tablet 100 MG (Cilostazol), Give 1 tablet by mouth one time a day for PVD (Peripheral Vascular Disease), Pharmacy, Active, 10/24/2024. Record review of Resident #4's fall risks dated from 06/16/20 to present had all been scored as high. During a phone interview with HSK C on 10/07/25 at 1:20 pm, she said she saw LVN A help Resident #4 in her seat. She said she told the resident to sit down, and LVN A put his hand on Resident #4's shoulders and lowered her back down and she got up again and LVN A put his fingers on Resident #4's chest to sit her back down. She said LVN A was not forceful with Resident #4. She said Resident #4 did not cry out or grimace. She said she did not think LVN A was trying to hurt her. She said she did not say anything to anyone. She said she told her supervisor the following afternoon because she had personal issues going on. She said she reported things to everyone all the time. She said the Abuse coordinator was the ADM. She said she was not reporting to the Abuse Coordinator because she had personal issues going on, and she just went home on [DATE], the day of the incident. She said the ADM told her she should have called him, no matter what. She said she forgot they were supposed to report things right away. Observation of Resident #4 on 10/07/25 at 9:15 am revealed she was self-propelling slowly in her wheelchair. She was smiling at nothing or no one in particular. She touched the furniture, other residents', and/or their wheelchairs as she rolled down the hallway and in the dining area. Resident #4 was easily redirected by staff. In an interview with RN E on 10/07/25 at 9:16 am, she said Resident #4 tried to get up a lot, unassisted, and often fell. She said Resident #4 could be aggressive with other staff and residents. She said sometimes, Resident #4 did not answer, but seemed to understand because she could be redirected. She said she knew LVN A and worked with him several times. She said she never saw LVN A being aggressive, but rather, had seen him being nothing but kind and patient with the residents. In an interview with LVN A on 10/07/25 at 10:50 am, he said he was the only nurse in the unit on 10/02/25 with 2 CNAs. He said CNA B was bathing residents; CNA D was in another room assisting another resident. He said he was documenting at the desk, saw the resident trying to stand from her wheelchair, and he was able to verbally redirect her. He said the resident propelled herself in her wheelchair. He said she got up again and started walking around the dining table. He said he followed her closely behind with her wheelchair in case she fell. He said the resident did this several times, and he followed her with her wheelchair each time. He said the next time she got up; he quickly had to lock the chair and position himself in front of the wheelchair and the resident because the resident was getting a little wobbly. He said he told the resident to sit down, but she became rigid and would not sit down. He said she walked some more, he followed with her wheelchair, and this time he was able to guide her back into her chair by placing his hands in her axillary and lowering her to the wheelchair seat because she was about to fall and he barely caught her to get her back in the chair. He said it was better to get her in the chair than to let her fall. He said there was not anyone else in the unit other than himself, the residents, and the 2 CNAs. He said the resident did not vocalize or act in any different way than her norm. He said he received Alzheimer's training upon hire in August and has had dementia/Alzheimer's training throughout his career since 2020. Interview with CNA B on 10/07/25 at 1:07 pm, she said Resident #4 required a lot of redirecting. She said she did not see LVN A walking behind her with a wheelchair, but remembered the resident being very agitated on 10/02/20. She said she was performing showers, and the incident happened during rounds at shift change, around 6:30 pm. She said she helped the resident back to her chair a couple of times as well. She said HSK C was not in the unit at the time of the incident on 10/02/25, but saw her come out of the unit around 8:00 pm. She said she heard 2 days later, LVN A was rough with the resident. She said she never saw LVN A be rough with anyone. She said he was a nice guy- he was quiet. She said abuse should be reported immediately to the nurse or the ADM, who was the abuse coordinator.In an interview with CNA D, on 10/07/25 at 1:40 pm, she said she was working 10/02/25, the day of the incident, in the locked unit and denied ever seeing LVN A being rough with anyone. She said abuse should be reported immediately to the nurse or the ADM, who was the abuse coordinator.In an interview with the DON on 10/07/25 at 1:45 pm, she said Resident #4 had an unwitnessed fall several days before the incident on 10/02/25, and they could not determine if the spot on Resident #4's chest was from the unwitnessed fall or the incident. Record review of safe surveys dated 10/02/25 and 10/03/25 revealed no identified concerns. All residents said they felt safe. Record review of LVN A's Personnel file revealed a hire date of 08/08/25. No counseling reports other than the suspension on 10/02/25 for this intake.Record review of the facility policy dated 07/11/25 titled Abuse, Neglect, and Exploitation under VII. Reporting/Response: A. 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: 1a. A. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on record reviews and interviews, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of five residents reviewed for medication errors. The facility failed to ensure that (RN A) did not administer 5ml (10mg) of Lorazepam (a benzodiazepine medication used to treat anxiety disorders that slows down the nervous system) instead of the physician ordered 0.5ml (1mg) of Lorazepam to Resident #1 on 04/27/25.This failure could result in residents not receiving the physician ordered dose of medications which could lead to an adverse reaction, overdose, hospitalization, or death.The findings included:Record review of Resident #1's admission record reflected a [AGE] year-old male initially admitted to the facility on [DATE] and most recently admitted on [DATE]. The only contacts listed for him were his guardian (Bill to, Responsible Party, and Emergency Contact #1) with two phone numbers, a fax number, and an email address, and himself. His diagnoses included epilepsy (a long-term (chronic) disease that causes repeated seizures due to abnormal electrical signals produced by damaged brain cells), bipolar disorder (mental health condition that causes clear shifts in moods from extremely elated, irritable, or energized to sad, indifferent, or hopeless), unspecified psychosis not due to a substance or know physiological condition (psychotic symptoms not aligned with a specific psychotic disorder or mental illness), mood disorder due to known physiological condition (a mental health condition characterized by a disturbance in mood (like depression or mania) that is directly caused by a medical or physiological condition), mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), cognitive communication deficit (difficulty with communication), cerebellar stroke syndrome (impairments in motor control and posture), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impairs a person's ability to perform daily activities). Record review of Resident #1's quarterly MDSs dated 04/22/25 and 06/25/25 reflected BIMS scores of 2 and 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 07/19/17 reflected he had a seizure disorder, potential for mood problem, was resistive to care, displayed verbal behaviors, had a communication problem and unclear speech related to diagnoses of bipolar disorder, psychosis, and history of stroke. Interventions included administer medications as ordered and observe/document for side effects and effectiveness, behavioral health consults as needed, observe for signs and symptoms of mania or hypomania racing thoughts or euphoria; increased irritability; frequent mood changes; pressured speech; flight of ideas; marked change in need for sleep; agitation or hyperactivity, and praise the resident when behavior was appropriate. Record review of Resident #1's Order Summary Report on 08/13/25 reflected the following orders:1. LORazepam Oral Concentrate 2 MG/ML (Lorazepam) Phone Give 0.5 milliliter by mouth three times a day related to mood disorder due to known physiological condition ordered on 08/04/24. 2. Narcan Nasal Liquid 4 MG/0.1 ML 1 spray Alternating nostrils STAT for Adverse Reaction/Overdose ordered on 04/27/25. 3. Neurological Checks every one hour for 24 hours, report any significant changes to hospice provider ordered on 04/27/25 to start on 04/28/25 at 12:00 am. 4. Vital Signs every hour for 24 hours, report any significant changes to hospice provider, for monitoring due to medication error ordered on 04/27/25 to start on 04/28/25 at 12:00 am.Record review of Resident #1's April 2025 eMAR reflected the following:1. RN A documented an administration of 0.5ml of Lorazepam oral concentrate 2mg/ml (1mg) by mouth on 04/27/25 at 5:30 pm. 2. RN A documented an administration of 0.2ml/8mg of Narcan 0.1ml/4mg spray to each nostril at 11:33 pm.Record review of Resident #1's handwritten Lorazepam narcotic administration log sheet reflected RN A initially documented he gave 0.5 ml (1mg) of Lorazepam oral concentrate 2mg/ml to Resident #1 by mouth at 5:30 pm, however RN A wrote over the amount given to show he gave Resident #1 5ml (10mg) of Lorazepam oral concentrate 2mg/ml by mouth at 5:30pm.Record review of Resident #1's progress notes reflected the following entries:1. 04/27/25 at 11:33 pm RN A documented, Narcan Nasal Liquid 4 MG/0.1 ML 1 spray Alternating nostrils STAT for Adverse Reaction/Overdose Narcan 4 mg to each Nostril given.2. 04/27/25 at 11:49 pm RN A documented, 1800 Medication Lorazepam 0.5 ml scheduled. Medication error--Lorazepam 5 ml was given. During Narcotic count--Error was discovered -2225. Pt. was checked and Patient was very Lethargic. V/S--B/P=130/62, P=85, R=21 and 02 at 100% via Nasal cannula D.O.N was called and informed of situation. Hospice provider was called, RN on call called back, she gave Telephone orders as follows: give Naloxone 4mg Nasal spray. Resident was assessed, Naloxone 4mg of which was administered to each nostril--3 minutes apart. Resident becoming responsive to verbal commands, will continue to monitor closely.3. 04/28/25 at 12:31 am RN A documented, RN with hospice arrived to facility and gave additional written orders 1) Neurologic checks to be completed every 1 hour and vital signs to be assessed every 1 hour as well. 2) Also, may administer another dose of Narcan if necessary.In an interview on 08/14/25 at 3:04 pm the DON stated RN A contacted her on 04/27/25 around 10:30 pm to 11:00 pm and told her about the medication error. The DON stated the next morning (04/28/25) an in-service was done with all nursing staff by the DON that was over medication administration policy and procedure and verification of the 6 rights of medication administration and a one on one in-service was done with RN A, also.In an interview on 08/14/25 at 4:14 pm LVN J stated the last in-service on medication administration was last week and narcotics were verified at the beginning and end of each shift. LVN J stated if a medication error was made, she called the provider for orders, the DON, then the family/RP. In an interview on 08/14/25 at 4:37 pm RN K stated she knew about Resident #1 and his Lorazepam overdose. RN K stated she worked the day after, and they were doing vital sign and neurological checks every hour. RN K stated she was not the nurse on Resident #1's hall on 04/28/25, but she knew Resident #1's vital signs were stable throughout her shift because she was talking with the primary nurse about it. RN K stated if she had a medication error, she immediately assessed the resident, notified the DON and/or the ADON, and notified the nurse practitioner. RN K stated if the resident was not stable or was critical, she called the physician first and if they did not answer she called the medical director. Narcotics were verified at beginning and end of shift as well as when narcotics were given. RN K stated the last in-service on medication administration was about a week ago.A telephone interview was attempted with RN A on 08/14/25, however there was no answer, and the voicemail message stated he was out of the country. A message was left with a phone number for him to return the call, but he did not return the call. In an interview on 08/14/25 at 5:20 pm Resident #1 was lying in bed with the television on. Resident #1 stated he was okay, and the staff was nice to him. Resident #1 did not recall the incident with the Lorazepam on 04/27/25.Record review of the facility's in-service documentation reflected an in-service was done by the DON with all on 04/28/25 that covered medication administration. Record review of RN A's employee record on 08/13/25 reflected he was hired on 04/10/25 and his RN license was originally issued 11/13/01; current expiration date was 02/28/27. RN A had an Employee Counseling Report dated 04/28/25 with an incident description that stated, On 04/27/25, failed to follow medication administration guidelines resulting in a medication administration error placing a resident at risk for adverse effects of an overdose. On this same day, employee carelessly documented incorrect information on same resident's chart. Employee has also not been completing all required documentation pertaining to patient care, in spite of being instructed to do so directly by his supervisors. The performance improvement plan stated this was the final warning. It was signed by RN A, the DON, the ADON, and the Human Resources Coordinator. The performance review documented on 05/28/25 stated no medication errors occurred this period and was signed by the DON. There was also documentation of a one on one in-service was done by the ADON on 04/28/25 at 2:30pm. The subject was Medication Administration Policy and Procedure, and the Return Demonstration Outcomes were: I have read Policy and Procedure for Medication Administration. I will be getting a second license nurse to verify dosage administered with every Narcotic given for 4 weeks. When in doubt, I will ask a co-worker, ADON, or DON for assistance in completing task. I will verify all information before documenting on PCC. I received a copy of the medication administration policy and procedure. It was signed by RN A and the ADON. Record review of the facility's Medication Administration Incident Report dated 04/27/25 reflected the following:The incident was discovered by RN A (the off going nurse) and RN R (the oncoming nurse) on 04/27/25 at 10:24 pm. The nurse was notified and gave a telephone order for Narcan to be administered immediately and neurologic checks and vital signs to be done every one hour for 24 hours on 04/27/25 at 10:55 pm. The Employee's statement was handwritten and signed by RN A on 04/28/25 and stated, RN A gave scheduled medication- Lorazepam 0.5ml, but I accidentally gave 5ml. Discovery of medication error was made during change of shift medication count. The Management section was handwritten and signed by the DON on 04/28/25 and stated, RN A will have another nurse witness his medication administration (narcotics) for the next 30 days. This form was also signed by the Admin on 04/28/25.Record review of the facility's medication administration policy in-service dated 04/28/25 reflected that 25 of 26 RNs and LVNs attended the training.Record review of the facility's Medication Administration Policy dated 10/24/22 reflected in part: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:3. Identify resident by photo in the MAR (medication administration record).10. Review MAR to identify medication to be administered.11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.14. Administer medication as ordered in accordance with manufacturer specifications.17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR.18. If medication is a controlled substance, sign narcotic book.19. Report and document any adverse side effects or refusals.20. Correct any discrepancies and report to nurse manager.

Based on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 6 (Resident #23 and Resident #38) residents reviewed for notification of change. The facility failed to communicate with the Registered Dietitian's recommendations to the Physician and to follow up with the physician when the physician did not return the call. These failures placed the residents at risk of worsening health conditions, continued unplanned weight loss, malnutrition, impaired skin integrity, and hospitalization . An IJ was identified on 02/08/24. The IJ template was provided to the facility on [DATE] at 6:15 pm. While the IJ was removed on 02/10/24 at 6:15 pm, the facility remained out of compliance at a scope of pattern and a scope of no actual harm with potential for more than minimal harm that is not is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. Record review of Resident #23's admission record dated 02/07/24 reflected Resident #23 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #23' diagnoses included parkinsonism (clinical syndrome that is characterized by tremor, slowed movements, rigidity), dysphagia (difficulty in swallowing), disorder of kidney and ureter (blockage in one of the tubes), psychotic disturbance, mood disturbance (characterized by delusions, hallucinations, disorganized thoughts) and anxiety (normal response to stress). Record review of the quarterly MDS dated [DATE] reflected Resident #23. -had severe cognitive impairment, - had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. -required supervision/maximal assistance with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Record review of Resident #23's care plans dated 10/24/23 reflected Resident #23 had a nutritional problem or potential nutritional problem due to risk for malnutrition. Currently on regular fortified food with breakfast and lunch, revised on 10/24/23. Interventions initiated on 02/24/23 included: -administer medications as ordered. Monitor/document for side effects and effectiveness. -administer vitamins as ordered. -monitor, record/report to MD, PRN, s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss; 3 lbs. in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, more than 19% in 6 months. -provide, serve diets as ordered. Monitor intake and record q meal. -RD to evaluate and make diet change recommendations PRN. Record review of Resident #23's weight logs reflected the following. 10/09/23 149.5 lbs. 11/09/23 140.0 lbs. 12/07/23 133.5 lbs. 01/18/24 126.0 lbs. 02/06/24 120.9 lbs. Record review of physician orders dated 11/16/23 revealed R#23's Physician DR A gave orders as per the Dietitian's recommendations. The orders were administered. R#23 continued to lose weight from December 2023 to January 2024. The orders included a complete metabolic panel lab work. Record review of the nutrition progress notes dated 12/20/23 for Resident #23 reflected resident with significant weight loss for 90 days and 180 days. Current body weight was 133.5 pounds. Ordered diet provides adequate kcal/protein. 15.2% weight loss for 90 days and 17.3% loss for 180 days notes. Weight loss has continued for 30 days but rate of loss has slowed and is non-significant at this time signifying intake may currently by adequate. Record review of the nutrition progress notes dated 01/19/24 for Resident #23 by the Dietitian Consultant reflected the follow up for weight loss. Weight loss continues for 30 days, current weight is 126 lbs. Per administration record resident is accepting 2.0 supplement as ordered. Intake likely inadequate aeb 5.6% weight loss for 30 days. Ordered diet, regular, regular texture, regular liquids consistency (fortified foods w/breakfast and lunch meals. Ordered supplement: House 2.0 (90ml tid). Recommends increase 2.0 supplement to 120ml tid for added nutritional provision, weekly weights for 30 days to monitor trend, continue diet as ordered. Record review of the progress notes dated 01/23/24 by nursing staff revealed patient with 10% weight loss in 5 months, current weight was 126 pounds, patient eats meals in room or at times attends dining room. Ordered supplement: House 2.0 (90ml tid). Response; RD review 01/19/24 pending response from pcp. Record review of progress notes dated 02/06/24 for Resident #23 by Dietary Manager reflected RD f/u for weight loss. Weight loss continues for 30 days. (4%, not significant but undesirable.) Significant weight loss x 90 days (13.6%). Record review of Resident #23's physician's orders dated 02/07/24 reflected orders: -house shakes three times a day for supplement between meals for 30 days, start date 02/07/24. -House supplement 2.0 three times a day for supplement give 120ml between meals, start date 02/06/24. -weight weekly for four weeks every Tuesday, start date 02/13/24. Interview on 02/05/24 at 2:56 pm with ADON M revealed on 01/22/24 Resident #23's physician had been called to get orders for the recommendations that were made on 01/19/24. R#23's physician did not return call, and no one followed up on calling the physician for orders. The charge nurses and ADONs were responsible to follow up on the recommendations for the residents. Interview on 02/06/24 at 11:52 am with the ADON M revealed staff had not followed up on the response from Resident #23's physician regarding the Dietitian recommendations. ADON M said no one had followed on a response from Resident #23 on 01/19/24. ADON/LVN M said it was her responsibility to ensure the orders from the physician were obtained. ADON M said they had not obtained orders from R#23's physician. Interview on 02/06/24 at 3:02 pm with the DON revealed the facility failed to follow up on Dietitian recommendations and implement interventions. These failures had a negative effect on R#23 with malnutrition, continued weight loss and deterioration in overall health. Interview on 02/08/24 at 5:00 pm with R#23's physician DR A revealed he was not informed of Resident #23's continued weight loss from November 2023 to 02/06/24. R#23's physician said he would attend the QA monthly meetings as Medical Director but had not been informed of Resident #23's significant weight loss of 13.0 % during the months of November 2023 to February 2024 until 02/05/24. This significant weight loss had the adverse effect of malnutrition, debility, susceptibility to infections. Interview on 02/08/24 at 5:35 pm with ADON A revealed she only had evidence she had notified R#23's physician about R#23's weight loss and Dietitian recommendations on 11/16/23. ADON A said she did not have any other information regarding the notification of R#23's weight loss to his physician. Record review of the facility Notification of Changes Policy dated 10/24/22 documented The purpose of this policy is to ensure the facility promptly informs the residents, consults the resident's physician, and notifies consistent with his or her or her authority, the resident's representative when there is a change requiring notification. 2.) Resident #38 Record Review of Resident #38's undated face indicated a [AGE] year-old male admitted on [DATE], readmitted [DATE] with diagnoses of multiple sclerosis (disease that causes nerve damage in the brain, spinal cord, and optic nerves that can result in numerous symptoms including numbness, mood changes, fatigue, pain, blindness, and/or paralysis), muscle wasting, dysarthria and anarthria (cannot control the muscles used for speaking), aphonia (loss of voice), gastrostomy (surgical hole in the stomach from the abdomen in which a tube is inserted to feed someone), and tracheostomy (surgical hole in the windpipe from the outside of the throat that provides an alternative airway). Record review of Resident #38's quarterly MDS dated [DATE] revealed a blank BIMS score indicating the resident is rarely/never understood and a SAMS score of 3 indicating that Resident #38 had severe cognitive impairment and required total assistance, or the physical assistance of 2 or more people for oral/ toileting/ personal hygiene, shower/bathe self, upper and lower body dressing, and bed mobility. Resident #38 was coded for weight loss of 5% or more in the last month or 10% or more in the last 6 months, weight loss not on physician prescribed weight loss regimen. Record review of Resident #38's weight record revealed he had an 11.2 pound (5.59%) severe weight loss in one month (12/16/23 to 01/18/24) and an overall 22.4 pound (10.59%) severe weight loss over a six-month period (07/18/23 to 01/18/24). 1/18/2024 16:52 189.1 Lbs 12/16/2023 22:08 200.3 Lbs 11/9/2023 17:58 200.6 Lbs 10/9/2023 16:21 203.5 Lbs 9/12/2023 08:03 207.5 Lbs 8/9/2023 15:11 207.1 Lbs 7/18/2023 16:17 211.5 Lbs Record review of RD note dated 01/19/24 read, RD follow up for tube feed and weight loss. Weight loss continues x30 days. NPO. Current body weight 189.1 lbs. Current BMI 26.4. Ordered tube feed and flushes do not satisfy estimated kcal/protein/fluid needs but needs may be overestimated aeb BMI class overweight. Tube feed likely adequate in protein but inadequate in energy aeb 5.6% weight loss x30 days. Note, weight has been consistently trending down over the last 6 months. Estimated needs: 2442-2543 kcal, 86-103 grams protein, 2579 mL fluid. Ordered tube feed TwoCal HN at 45mL/hr x18 hours; 200mL water flush every 8 hours provides: 1623 kcal, 68 grams protein, 1167 mL of fluid. Recommendation: Increase TwoCal HN to 60mL/hr x18 hours with 200mL water flushes every 4 hours, which will provide 2165 kcal, 91 grams protein, 1956 mL fluid; weekly weights for 30 days to monitor trend. Goals: adequate nutrition/ hydration via tube feed, tube feed tolerance, CBW +/- 5% for 30 days. RD to continue to monitor. Record review of Resident #38's February 2024 physician orders revealed an order dated 01/18/24 for enteral feeding, TwoCal HN at 45mL/hr via G tube stationary pump. Down time 07:00 AM to 01:00 PM and an order dated 12/14/23 Every shift flush tube with 200mL of water every 8 hours. Resident #38's February 2024 Physician's orders revealed no acknowledgement of the RD's recommendations, nor any new physician orders for increased tube feed amount. Record review on 02/07/24 at 01:27 PM revealed Nurse's notes documented 01/22/24 by LVN M/ADON that read, Resident has had a 5% weight loss in 1 month with current weight at 189.1 lbs. Previous weight 200.3 lbs. Date of last weight: 1/19/24. Resident has had a 10% weight loss in 5 months with a current weight 189.1 lbs. Previous weight 200.3 lbs. Date of last weight: 1/19/24. Current formula/supplement: HN2Cal at 45mL/hr. via g tube. Any new orders Yes/ No (neither checked) Orders: Dietary Recommendation: increase HN2Cal to 60cc/hr x 18 hrs with 200mL flushes Q4hrs (every 4 hours). There is no MD signature. The notation in the bottom right corner of the page indicated it was faxed on 01/22/24 and initialed by the nurse. Observation on 02/04/24 at 05:06 PM revealed Resident #38 was receiving TwoCalHN tube feed through his PEG tube at 45mL/hr via feeding tube pump. Observation on 02/06/24 at 03:00 PM revealed Resident #38 was receiving TwoCalHN tube feed through his PEG tube at 45mL/hr via feeding tube pump. In an interview on 2/07/24 at 02:21 PM with LVN M/ ADON B and DON, LVN M/ADON B stated in reference to the dietician recommendations dated 1/22/24 regarding Resident #38's weight loss, I am the one that put the note in. If it's not documented, I did not follow up on it. I will follow up today. Normally, I call the doctor or the nurse, usually the nurse, and inform that the resident was reviewed by the dietician, this is the situation, etc . then I send the communication with the current information and the recommendations. When asked about his responsibility as the DON and how he ensures that significant issues were followed up on, the DON responded, Lag time is an issue. Let me work with my medical director. There's a lot going on, but we need to be more diligent on documenting and making sure that things are followed up. We are revamping our morning meetings where we can document what things are still needing to be done. We're putting things in place to get better about following up. Prior to this, weight loss was one of the things reviewed in morning meetings, (intermittently) but we're looking at it once a week or every other week. Our greatest challenge is working to get the physician to respond. In an interview on 02/07/24 at 03:30 PM with RD-S she stated that she has only been working with this facility for about a month and that she comes into this facility 2 times a month. When asked to look at Resident #38's dietary recommendations dated 01/19/24, she stated that the only change she would make was to add weekly weights for a month to monitor the resident's status. To verify that the recommendations were put into place, she stated that she would look at the weekly weights. If they weren't documented, she would get with the ADON or DON and have the resident weighed while she was in the facility. Regarding the tube feedings, she would investigate the physician's orders to see if there were revisions. If there were no revisions, she would go to the RN to find out why the recommendations weren't being followed. RD-S stated she would find out if the resident did not tolerate the increase- was the resident having nausea, vomiting, or diarrhea, or some other sign or symptom indicating intolerance? RD S stated, if there was no sign of intolerance, or the recommendations just weren't followed, it could lead to malnutrition, significant weight loss, or skin break down. In a phone interview on 02/08/24 at 05:21 PM with MD X, when asked if he was aware of Resident #38's RD recommendations that were faxed to him, he stated that he did not have anything to sign right now and that he usually signs things on the weekends. He also stated he did not have anything pending. He stated that he usually physically rounds on his residents every 3 months, however his nurse practitioner went to the facility the last time which was 01/09/24. When asked specifically about Resident #38's weight loss, he stated, yes, he loses weight, then gains weight. When advised of Resident #38's amount of weight loss in 1 month and in 6 months he replied, that's too much. That's a concern. He stated that the facility had not called or sent him anything. He stated, I would expect them to text, call, or bring me the paperwork and I sign the paperwork. He stated he did not know the name of the person who takes him the paperwork, but it was usually left on his desk. An IJ was identified on 02/08/24. The IJ template was provided to the facility on [DATE] at 6:15 pm. The facility's Plan of Removal included: On February 8, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F580- Notification of Changes Resident #23, the RD assessed, and new orders were obtained from the physician on 2/6/24. Resident #38, New orders were obtained from the physician based on dietary recommendations on 2/7/24. Resident # 76, RD assessed, and new orders were obtained on 2/6/24 by the Licensed Nurse. The care plan was reviewed and updated based on the new orders. On 2/7/24, the Director of Nursing/ designee reviewed the last 30 days of RD recommendations to ensure they were communicated to the physician and acted upon. On 2/7/24, the Attending MD and resident representative were notified of residents who were identified with significant weight loss or changes and the interventions put in place. On 2/7/24, the Attending MD was notified by licensed nurse of current nutritional recommendations and implemented orders as written. On 2/8/24, All direct care staff will be re-educated by the Administrator /designee on the following topics: oAbuse and Neglect oWeight Monitoring On 2/8/24, Licensed Nurses will be re-educated by the DON/Designee on the following topics: oNotification of Changes oTimely follow up and notification to MD of nutritional recommendations and implement orders as written and plan of care updated. Completion date of re-education of all staff will be 2/8/24, in person or via telephone. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Any staff member not re-educated in person or via phone today (2/8/24), will be removed from the schedule until re-education is provided. Verification of 100% of staff re-education will be verified by the Administrator/ Designee. Director of Nursing/designee will review during the morning clinical meeting that the nutritional assessment is completed. The Attending MD and resident representative will be notified of nutritional/hydration risk identified. MD orders will be implemented as written to include but not limited to dietary recommendations based on referral and evaluations. Plan of care will be reviewed and updated as needed based on assessment and orders. The Administrator will attend the morning meeting to ensure that the DON / Clinical Interdisciplinary Team review significant weight changes and RD recommendations timely. An Ad Hoc QAPI meeting was conducted on 2/8/24 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the immediate jeopardy concerning nutrition hydration maintenance and develop the above Action Plan. We respectfully submit this action plan for removal of immediate Jeopardy. Verification of the facility's Plan of Removal: Reviewed the facility conducted 100% review of all residents 11 identified with weight loss. Record review of Resident #2's care plan, care plan revised on 02/09/2024, and updated accordingly - no concerns noted. Record review of Resident #6 was audited for weight loss. Upon record review, facility implemented order of adding house shakes three times a day, as well as weekly weights for 4 weeks. Care Plan updated and no observable concerns. Record review of Resident #23's care plan, and orders were updated and revised on 02/08/2024 to include weekly weight for 4 weeks, and house shakes three times a day. No concerns noted. Record review of Resident #38's care plan, and orders, which were both updated and implemented on 2/08/2024. No concerns noted. Record review of Resident #76's care plan, and orders, which were both updated and implemented on 02/07/2024 - no concerns noted. During an observation on 02/10/2024 at 12:15PM Observed Resident #3 being assisted to eat by CNA J no noted concerns. During an observation on 02/10/2024 at 5:39PM Observed ADON assisting Resident #23 eat his food. On the tray is soft mechanical food of chicken with gray, mash potatoes, and bread pudding. No observable concerns During an observation and interview on 02/10/2024 at 3:55PM Resident#38, observed Resident#38 in bed in lowest position, had HN 2cal tube feeding running at 60mL/HR with 200 Q4 free water flush. Observed no signs and symptoms of distress, when asked if he had any concerns, he motioned his head in a left/right motion, indicated no. During an interview on 02/10/2024@12:37PM, RN A was asked to assist with working on the floor. RN A stated prior to entering the facility, she attended an in-service on 02/09/2024 regarding steps to take if she witnessed a resident looking frail, which would be to fill out a stop and watch form noting the concern with weight and stature, followed by notifying the ADONs, DON, and Physician. RN A stated for she was also in-serviced during the same meeting about change in condition and was told to also fill out a stop and watch form, notating the change in condition followed by notifying the ADONs, DON, and physician. RN A stated if she were not able to initially get ahold of the Physician, she was instructed to then, secondly, contact the Medical Director. RN A stated she was also in-serviced to monitor the residents' weights weekly, for those that pose a weight loss concern, and that the CNAs will document the weights, and if the CNAs notice a concern, the CNAs will notify the nurse, and the nurses will follow up. During an interview on 02/10/2024 at 1:12PM, LVN A stated he was a travel nurse. LVN A stated he was in-serviced about weight loss, and the actions to take would be to notify ADON/DON, and Doctor's. LVN A stated he monitors meal intakes and if resident was not eating enough he would notify ADON/DON and physician, as well as advocate for nutritional supplementation. LVN A stated he monitors weekly weights, and that monitoring weekly weights give him a better idea on how residents were responding to the nutrition. During an interview on 02/10/2024 at 1:27PM RN B stated she was in-serviced a about 2 days ago about monitoring diet intake, weights, abuse (how to report it), how to de-escalate patient issue by removal and when needed, to separate and notify Administrator of the suspicion of abuse. RN B stated for diet, CNAs will document food intake and weights weekly, and that CNAs will give meal percentage slips to the nurses, who will then look at them to see how much the residents are eating. During an interview on 02/10/2024 at 1:30PM CNA A stated she was in-serviced 2 days ago about weight loss and change in conditions. CNA A stated she was educated to notify nurse of the concern of either weight loss or change in condition, while also filling out the stop and watch form and giving it to the nurses. CNA A stated then the nurses were to give a copy of the form to the ADONs/DON. CNA A stated the form is for change in condition concern. CNA A stated Will do monthly unless ordered weekly weights. CNA A stated she was instructed to fill out the meal percentage form for each resident and give the form to the nurses. During an interview on 02/10/2024 at1:47PM CNA B: stated she was in-serviced a couple of days ago about food meal percentage forms, negligence, and meals. CNA B: stated if a resident doesn't want to eat, give options, and if they still don't want the options, she will let the nurses and ADON/DON know. CNA B: stated she will fill out meal percentage paper and turn in the ticket to the nurses. CNA B: stated if they see anything out of the ordinary regarding a resident, she will fill out an IMPACT paper and give kit to the nurse, and nurse will follow up. During an interview on 02/10/2024 at 1:54PM CNA C stated she will document the meal percentages on the meal forms, and give to the nurses, as well as and document in the resident's charts. CNA C stated she will report to nurses if she sees something out of the ordinary, and will document in Stop and Watch paper, then give it to the nurse. During an interview on 02/10/2024 at 2:41PM ADON B, and DON stated for weight management, those that do not have weight loss issues will have monthly weights and those that do have weight loss issues will have weekly weights taken. The restorative aides will document weights in the resident's electronic health record. ADON B and DON stated they have now implemented weight management during every morning daily meeting and will follow up on imposed weight management interventions that same day during their afternoon clinical meeting. Both stated monitoring weights and change in conditions was a collaborative effort for all staff members. Both stated nurses were a part of care and will monitor weights and change in conditions diligently every shift. Both stated nurse will monitor weights, nutrition, as well as nurses are to identify weight loss or if the resident is not eating properly, and will notify RP, ADON/DON. Both stated upon reviewing weights during their daily clinical meetings, for the resident's that trigger 5-10% weight loss, their diet, care plan, and orders will be reviewed, but will immediately implement weekly weights for 4 weeks. Both stated during the clinical reviews they will also update Care Plans on the spot and provide more oversight. Both stated for the travel nurses, the plan is to add weight management, and change of condition in-services and education during the on-boarding/orientation schedule. During an observation on 02/10/2024 at 3:07PM Resident #2(audited for weight loss), was sitting in a wheelchair at the entry of her room. Resident #2 was eating graham crackers, and states she likes the food, and ate all her lunch. Resident #2 stated she has been drinking her supplemental shakes. During an interview on 02/10/2024 at 3:43PM CNA F stated she was in-serviced on 02/09/2024 about abuse/neglect and weight management. CNA F stated when residents don't want to eat, they will offer alternatives once they get approval from the nurse. CNA F stated she will notify the nurse of any resident's refusal of eating. CNA F stated she will notify the nurse of any noticed changes whether it be food or body. CNA F will use Stop & Watch forms to notify nurses and verbal as well. During an interview on 02/10/2024 at 3:51pm the HA A stated she will answer call lights but does not perform hands on patient care. The HA A stated she was in-serviced recently about abuse/neglect, dietary, and weight loss. The HA A stated if a patient is not eating, she will report the issue to the nurse. The HA A stated she will report to nurse about Change of condition utilizing Stop and watch form. The HA A stated she does not measure weights. During an interview on 02/10/2024 at 4:06PM LVN N stated she was in-serviced just recently about weight, diet, abuse/neglect, and stop and watch. LVN N stated Stop and Watch paper forms will be filled out by any clinical staff and given to the nurse taking care of the resident, as well as a copy be given to the administration staff ADON/DON/Administrator. LVN N stated nurses will address issue and notify the chain of command. LVN N stated if a resident looks [NAME], they will notify physician and make a progress note documentation, and if unable to get ahold of physician they have been instructed to contact the medical director. LVN N stated when she notices a change in condition, she will again notify the primary physician or secondly, the medical director if she cannot get ahold of the initial physician. LVN N stated she will monitor and checks orders. During an interview on 02/10/2024 at 4:22PM, CNA J stated she was in-serviced about weight loss and change of conditions. CNA J stated if she notices any change in condition she will report to nurses and DON. CNA J stated if she notices a resident getting skinny, she will report to nurse and will utilize the Stop and Watch form to give to nurses. CNA J stated she will follow the nurse's direction. During an interview on 02/10/2024 at 4:51PM RN C stated she was given a recent in-service about weight loss, and if a resident was not eating, she will notify the doctor. RN C stated she would attempt to administer a nutritional supplement shake. RN C stated she works night, and does not work with breakfast, lunch, dinner, but if she is notified in bedside shift report a nutritional concern, she will notify the incoming day nurse about monitoring for weight loss. RN C stated for change of conditions, she will notify managerial staff, and will follow up and give report to morning nurse, as well as notify the doctor to get new orders. If she cannot get a hold of doctor, will document, and will give in report in the morning to follow up to call Medical Director. During an interview on 02/10/2024 at 5:13PM LVN N stated she was given a recent in-service on abuse, change in condition, and nutrition. LVN N stated for nutrition, if you were notified of a resident not eating, notify primary care physician, offer supplemental drinks, and advocate for orders. LVN N stated she works nights, so she does not weigh residents at night, but if she notices any change of condition or weight decline, she will report to ADON/DON and document using the stop and watch form. LVN N stated if she noticed change of condition, she would perform assessment, notify physician, and ask for recommendation. If physician doesn't call back by end of shift, will notify incoming nurse and notify ADON/DON about following up. During an interview on 02/10/2024 at 5:54PM the Administrator stated two concerns were identified which was the lack in notification of change in condition, and the follow up to the change in condition. The Administrator stated, the facility began education and in-servicing on the change in condition and weight management on 02/07/24 to all direct care staff to effectively communicate notification in change as well as regarding weight management. The Administrator stated the form called Stop and Watch can be used by anyone, and its' purpose was to ensure the nurses or CNAs document the concern and give the copy of the form to the ADONs/DON who would follow up daily. The Administrator stated the nurses have been educated on if they were not able to get ahold of the initial physician, the nurses have the capability to speak to the medical director to get guidance, orders, and needs to be documented and notified to management. The Administrator stated CNAs will communicate notification of change to nurses, to give better care. The Administrator stated the Stop and Watch white form copy will go to the nurse and yellow to nurse management or ADONs. The Administrator stated he will follow up on DON, and will attend morning clinical meetings, and that the ADONs/DON were monitoring weights on a spread sheet. Record review of the facility's in-services regarding Abuse/Neglect, Change in Condition, notification of changes, and Weight Management system were conducted on 02/07/24, 02/08/24, and 02/10/24. Record review of the facility's Abuse and Neglect Policy and Procedures dated 08/15/22. Record review of the facility's Weight Management System Policy and Procedures undated. Record review of the facility's Notification of Changes Policy and Procedures dated 10/24/22. Record review of the facility's Ad Hoc meeting dated 02/08/24 topics of change of condition, notification of changes and weight loss management were reviewed, and a plan implemented. An IJ was identified on 02/08/24. The IJ template was provided to the facility on [DATE] at 6:15 pm.

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible, or resident preferences indicate otherwise for three of eight residents (Resident #23, Resident #38 and Resident #76) reviewed for nutrition. 1.) The facility failed to ensure Resident #23 did not sustain a significant weight loss of 13.64% in less than three months. 2.) The facility failed to ensure Resident #38 did not sustain a significant weight loss of 11.2 pound/5.59% weight loss in one month and an overall 22.4 pound/10.59% weight loss over six months. Staff did not follow up on an RD (Registered Dietician) recommendation to increase Resident #38's tube feeding solution order from 45 mL/hr to 60 mL/hr x 18 hours on 01/19/24 until 02/07/24, for a total of 14 days. 3.) The facility failed to ensure Resident #76 did not sustain a significant weight loss of 5.40 % in less than one month. An IJ was identified on 02/08/24. The IJ template was provided to the facility on [DATE] at 6:15 pm. While the IJ was removed on 02/10/24 at 6:15 pm, the facility remained out of compliance at a scope of a pattern and severity of no actual harm with potential for more than minimal harm that is not is not immediate jeopardy because of the facility's need to monitor and evaluate the effectiveness of the corrective systems. This failure placed residents at risk of unplanned weight loss and malnutrition. Findings include: 1.) Resident #23 Record review of Resident #23's admission record dated 02/07/24 reflected Resident #23 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #23' diagnoses included parkinsonism (clinical syndrome that is characterized by tremor, slowed movements, rigidity), dysphagia (difficulty in swallowing), disorder of kidney and ureter (blockage in one of the tubes), psychotic disturbance, mood disturbance (characterized by delusions, hallucinations, disorganized thoughts) and anxiety (normal response to stress). Record review of the quarterly MDS dated [DATE] reflected Resident #23. -had severe cognitive impairment, - had weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. -required supervision/maximal assistance with eating (the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Record review of Resident #23's care plans dated 10/24/23 reflected Resident #23 had a nutritional problem or potential nutritional problem due to risk for malnutrition. Currently on regular fortified food with breakfast and lunch, revised on 10/24/23. Interventions initiated on 02/24/23 included: -administer medications as ordered. Monitor/document for side effects and effectiveness. -administer vitamins as ordered. -monitor, record/report to MD, PRN, s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss; 3 lbs. in 1 week, more than 5% in 1 month, more than 7.5% in 3 months, more than 19% in 6 months. -provide, serve diets as ordered. Monitor intake and record q meal. -RD to evaluate and make diet change recommendations PRN. Record review of Resident #23's weight logs reflected the following. 10/09/23 149.5 lbs. 11/09/23 140.0 lbs. 12/07/23 133.5 lbs. 01/18/24 126.0 lbs. 02/06/24 120.9 lbs. Record review of meal intakes for Resident #23 reflected Resident #23 ate four of 0 -25% of meals provided, nine of 26- 50% of meals provided, twelve of 51-75% of meals provided and seven of 76-100% of meals provided between 01/25/24 and 02/06/24. Record review of the Dietitian Consultant's recommendation dated 01/22/24 for Resident #23 reflected Resident #23 had a weight loss of 10% in three months with current weight of 126 lbs from date of last weight on 01/19/24. Current diet included regular diet, multivitamin daily, vitamin C, house supplement 2.0 90 ml TID. The recommendation was faxed to facility on 01/22/24. The recommendation document indicated a space for MD signature and was left blank. The recommendation was not signed by a Dietitian Consultant. Record review of the nutrition progress notes by Dietitian Consultant dated 12/20/23 for Resident #23 reflected resident with significant weight loss for 90 days and 180 days. Current body weight was 133.5 pounds. Ordered diet provides adequate kcal/protein. 15.2% weight loss for 90 days and 17.3% loss for 180 days notes. Weight loss has continued for 30 days but rate of loss has slowed and is non-significant at this time signifying intake may currently by adequate. Record review of the nutrition progress notes dated 01/19/24 for Resident #23 by the Dietitian Consultant reflected the follow up for weight loss. Weight loss continues for 30 days, current weight is 126 lbs. Per administration record resident is accepting 2.0 supplement as ordered. Intake likely inadequate aeb 5.6% weight loss for 30 days. Ordered diet, regular, regular texture, regular liquids consistency (fortified foods w/breakfast and lunch meals. Ordered supplement: House 2.0 (90ml tid). Recommends increase 2.0 supplement to 120ml tid for added nutritional provision, weekly weights for 30 days to monitor trend, continue diet as ordered. Record review of the progress notes dated 01/23/24 by nursing staff revealed patient with 10% weight loss in 5 months, current weight was 126 pounds, patient eats meals in room or at times attends dining room. Ordered supplement: House 2.0 (90ml tid). Response; RD review 01/19/24 pending response from pcp. Record review of progress notes dated 02/06/24 for Resident #23 by Dietary Manager reflected RD f/u for weight loss. Weight loss continues for 30 days. (4%, not significant but undesirable.) Significant weight loss x 90 days (13.6%). Record review of Resident #23's physician's orders dated 02/07/24 reflected orders: -house shakes three times a day for supplement between meals for 30 days, start date 02/07/24. -House supplement 2.0 three times a day for supplement give 120ml between meals, start date 02/06/24. -weight weekly for four weeks every Tuesday, start date 02/13/24. Observation on 02/04/24 at 6:01 pm revealed Resident #23 sitting up in his bed in his room. CNA K prepared Resident #23 meal so he could eat on his own. CNA K asked Resident #23 if he wanted to eat on his own and he voiced he did. CNA K told Resident #23 someone else would come in and him eat. Observation on 02/05/24 at 12:48 pm revealed Resident #23 in his room lying down. CNA K asked Resident #23 if he wanted to eat and resident replied he did. CNA K said he did want assistance to sit up in his chair. Resident #23 sat up in his bed and said he wanted to eat on his own. Resident #23 grabbed his coffee cup and a fork and started picking at his food. AT 12:55 pm Resident #23 was observed lying in his bed, with coffee cup in hand and his meal tray on his bed. The meal contained approximately 50% of his food. Resident #23 said he did not want to eat anymore. Interview on 02/06/24 at 11:35 am with CNA L revealed Resident #23 sometimes appeared to be too weak to grab his utensils or cup and she would assist Resident #23 to eat his meals. CNA L said she had reported to the charge nurses Resident #23 sometimes needed assistance to eat his meals. Observation of Resident #23 on 02/06/24 at revealed resident was lying in bed and a snack of cookies and a glass of water was his bedside table. Resident #23 appeared confused and did not answer surveyor. Interview on 02/06/24 at 11:52 am with ADON M revealed the Dietitian made a recommendation on or about 01/19/24 for a nutritional supplement of 120 ml, add nutritional provision and weekly weights for 30 days. ADON M said she knew staff had called Resident #23's physician to get the orders for the Dietitian's recommendation. ADON M said Resident #23's physician would not return the calls made to his office and staff had to follow up and get the orders. ADON M said she did not know who had made the follow up calls to Resident #23's physician about the orders. Interview on 02/06/24 at 2:56 pm the DON and ADON M revealed ADON M said staff called Resident #23's physician to approve the recommended orders as it was noted in the progress notes on 01/23/24. ADON M said no one followed up with Resident #23's physician and the recommendations were never received as orders and were not carried out. ADON M said she had called Resident #23's physician earlier and had received the orders for the recommendations made by the Dietitian. Resident #23's physician had also ordered lab work. The DON said the nurses and the ADONs were responsible to follow up with physicians for orders. ADON M said Resident #23's ideal body weight was 157 pounds. The DON said staff failed to get the orders from physician for added nutrition, supplements and to weigh Resident #23 weekly for 30 days. Resident #23 also lost a total of 28.6 pounds in the last three months. This failure resulted in not providing Resident #23 the added nutrition beginning 01/19/24 and to miss weighing him on 01/23/24 and 01/30/24 as recommended by the Dietitian. The DON said staff did not notify his physician to address Resident #23's significant weight loss with his physician as needed. Interview on 02/07/24 at 1:27 pm with Dietitian Consultant revealed she had only been the Dietitian for the facility less than a month. The previous Dietitian Consultant had made the recommendations for Resident #23 on 01/19/24. The Dietitian Consultant said her coworker who made the recommendations on 01/19/24 had not been acted on. Resident #23 had lost 6 pounds since the recommendation had been made to 02/06/24 and had lost 28.6 pounds over the last three months. The Dietitian said she had not reviewed Resident #23's clinical chart on this visit to the facility. The Dietitian said this failure to obtain orders for the recommendations caused the resident to lose unnecessary weight due to the recommendations were not acted on. This was a negative effect on the resident when the current weight loss of 6.8 pounds could have been identified and addressed as they occurred. The Dietitian said Resident #23's weight loss had not been addressed by the facility as needed. Interview on 02/07/24 at 1:33 pm with COTA P revealed she did assessments for Resident #23, and she had currently noticed a change in Resident #23's eating, he was jumpy and sometimes agitated. COTA P said she had reported her assessments to RN O, to the Administrator and ADON M when the DON had been absent from the facility on 02/01/24. Record review of the COTA P's Occupation Therapy Treatment Encounter Notes dated 02/01/24 for Resident#23 reflected patients significant decline was reported to RN O and to Administrator, patient demonstrates significant confusion inability to follow instructions, required max assist from therapist to transfer/feed and complete hygiene/grooming. Patient also appears to be combative at times. Interview on 02/07/24 at 2:15 pm with LVN N revealed she told her staff to assist Resident #23 to eat if he was unable or did not want to eat. LVN N said she was not aware of the Dietitian's recommendations. Interview on 02/07/24 at 4:50 pm with RN O revealed she was not aware of the Dietitian's recommendations. RN O said she told staff to assist Resident #23 to eat if he was not able. 2.) Resident #38 Record Review of Resident #38's undated face indicated a [AGE] year-old male admitted on [DATE], readmitted [DATE] with diagnoses of multiple sclerosis (disease that causes nerve damage in the brain, spinal cord, and optic nerves that can result in numerous symptoms including numbness, mood changes, fatigue, pain, blindness, and/or paralysis), muscle wasting, dysarthria and anarthria (cannot control the muscles used for speaking), aphonia (loss of voice), gastrostomy (surgical hole in the stomach from the abdomen in which a tube is inserted to feed someone), and tracheostomy (surgical hole in the windpipe from the outside of the throat that provides an alternative airway). Record review of Resident #38's quarterly MDS dated [DATE] revealed a blank BIMS score indicating the resident is rarely/never understood and a SAMS score of 3 indicating that Resident #38 had severe cognitive impairment and required total assistance, or the physical assistance of 2 or more people for oral/ toileting/ personal hygiene, shower/bathe self, upper and lower body dressing, and bed mobility. Resident #38 was coded for weight loss of 5% or more in the last month or 10% or more in the last 6 months, weight loss not on physician prescribed weight loss regimen. Record review of Resident #38's weight record revealed he had an 11.2 pound (5.59%) severe weight loss in one month (12/16/23 to 01/18/24) and an overall 22.4 pound (10.59%) severe weight loss over a six-month period (07/18/23 to 01/18/24). 1/18/2024 16:52 189.1 Lbs 12/16/2023 22:08 200.3 Lbs 11/9/2023 17:58 200.6 Lbs 10/9/2023 16:21 203.5 Lbs 9/12/2023 08:03 207.5 Lbs 8/9/2023 15:11 207.1 Lbs 7/18/2023 16:17 211.5 Lbs Record review of RD note dated 01/19/24 read, RD follow up for tube feed and weight loss. Weight loss continues x30 days. NPO. Current body weight 189.1 lbs. Current BMI 26.4. Ordered tube feed and flushes do not satisfy estimated kcal/protein/fluid needs but needs may be overestimated aeb BMI class overweight. Tube feed likely adequate in protein but inadequate in energy aeb 5.6% weight loss x30 days. Note, weight has been consistently trending down over the last 6 months. Estimated needs: 2442-2543 kcal, 86-103 grams protein, 2579 mL fluid. Ordered tube feed TwoCal HN at 45mL/hr x18 hours; 200mL water flush every 8 hours provides: 1623 kcal, 68 grams protein, 1167 mL of fluid. Recommendation: Increase TwoCal HN to 60mL/hr x18 hours with 200mL water flushes every 4 hours, which will provide 2165 kcal, 91 grams protein, 1956 mL fluid; weekly weights for 30 days to monitor trend. Goals: adequate nutrition/ hydration via tube feed, tube feed tolerance, CBW +/- 5% for 30 days. RD to continue to monitor. Record review of Resident #38's February 2024 physician orders revealed an order dated 01/18/24 for enteral feeding, TwoCal HN at 45mL/hr via G tube stationary pump. Down time 07:00 AM to 01:00 PM and an order dated 12/14/23 Every shift flush tube with 200mL of water every 8 hours. Resident #38's February 2024 Physician's orders revealed no acknowledgement of the RD's recommendations, nor any new physician orders for increased tube feed amount. Record review on 02/07/24 at 01:27 PM revealed Nurse's notes documented 01/22/24 by LVN M/ADON that read, Resident has had a 5% weight loss in 1 month with current weight at 189.1 lbs. Previous weight 200.3 lbs. Date of last weight: 1/19/24. Resident has had a 10% weight loss in 5 months with a current weight 189.1 lbs. Previous weight 200.3 lbs. Date of last weight: 1/19/24. Current formula/supplement: HN2Cal at 45mL/hr. via g tube. Any new orders Yes/ No (neither checked) Orders: Dietary Recommendation: increase HN2Cal to 60cc/hr x 18 hrs with 200mL flushes Q4hrs (every 4 hours). There is no MD signature. The notation in the bottom right corner of the page indicated it was faxed on 01/22/24 and initialed by the nurse. Observation on 02/04/24 at 05:06 PM revealed Resident #38 was receiving TwoCalHN tube feed through his PEG tube at 45mL/hr via feeding tube pump. Observation on 02/06/24 at 03:00 PM revealed Resident #38 was receiving TwoCalHN tube feed through his PEG tube at 45mL/hr via feeding tube pump. In an interview on 2/07/24 at 02:21 PM with LVN M/ ADON B and DON, LVN M/ADON B stated in reference to the dietician recommendations dated 1/22/24 regarding Resident #38's weight loss, I am the one that put the note in. If it's not documented, I did not follow up on it. I will follow up today. Normally, I call the doctor or the nurse, usually the nurse, and inform that the resident was reviewed by the dietician, this is the situation, etc . then I send the communication with the current information and the recommendations. When asked about his responsibility as the DON and how he ensures that significant issues were followed up on, the DON responded, Lag time is an issue. Let me work with my medical director. There's a lot going on, but we need to be more diligent on documenting and making sure that things are followed up. We are revamping our morning meetings where we can document what things are still needing to be done. We're putting things in place to get better about following up. Prior to this, weight loss was one of the things reviewed in morning meetings, (intermittently) but we're looking at it once a week or every other week. Our greatest challenge is working to get the physician to respond. In an interview on 02/07/24 at 03:30 PM with RD-S she stated that she has only been working with this facility for about a month and that she comes into this facility 2 times a month. When asked to look at Resident #38's dietary recommendations dated 01/19/24, she stated that the only change she would make was to add weekly weights for a month to monitor the resident's status. To verify that the recommendations were put into place, she stated that she would look at the weekly weights. If they weren't documented, she would get with the ADON or DON and have the resident weighed while she was in the facility. Regarding the tube feedings, she would investigate the physician's orders to see if there were revisions. If there were no revisions, she would go to the RN to find out why the recommendations weren't being followed. RD-S stated she would find out if the resident did not tolerate the increase- was the resident having nausea, vomiting, or diarrhea, or some other sign or symptom indicating intolerance? RD S stated, if there was no sign of intolerance, or the recommendations just weren't followed, it could lead to malnutrition, significant weight loss, or skin break down. In a phone interview on 02/08/24 at 05:21 PM with MD X, when asked if he was aware of Resident #38's RD recommendations that were faxed to him, he stated that he did not have anything to sign right now and that he usually signs things on the weekends. He also stated he did not have anything pending. He stated that he usually physically rounds on his residents every 3 months, however his nurse practitioner went to the facility the last time which was 01/09/24. When asked specifically about Resident #38's weight loss, he stated, yes, he loses weight, then gains weight. When advised of Resident #38's amount of weight loss in 1 month and in 6 months he replied, that's too much. That's a concern. He stated that the facility had not called or sent him anything. He stated, I would expect them to text, call, or bring me the paperwork and I sign the paperwork. He stated he did not know the name of the person who takes him the paperwork, but it was usually left on his desk. 3.) Resident #76 Record review of the Admission Record for Resident #76 dated 02/06/24 reflected Resident #76 was readmitted to the facility on [DATE]. Resident #76 was a [AGE] year-old male with diagnoses that included Alzheimer's disease (brain disorder that causes memory loss), diabetes (high blood sugar levels), anorexia (life threatening eating disorder), and dysphagia (difficulty in swallowing). Record review of Resident #76's quarterly MDS dated [DATE] reflected. -cognitive status was severely impaired. -required substantial/maximal assistance with eating. -had weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. Record review of the care plan for Resident #76 reflected Resident #76 had a nutritional problem or potential nutritional problem related anorexia diagnosis. Interventions included. -administer medications as ordered. Monitor/Document for side effects and effectiveness. -monitor/record/report to MD PRN s/sx of malnutrition, emaciation (cachexia), muscle wasting, significant weight loss; 3 lbs. in one week, more than 5% in one month, more than 7.5% in three months, and more than 10% in six months. -RD to evaluate and make diet change recommendations PRN. Record review of Resident #76's physician orders dated 02/06/24 reflected an order for weekly weights for four weeks one time a day every Tuesday for weight loss, start date, 01/23/24. Record review of Resident #76's weight charts reflected Resident # 76 weight on 01/18/24 was 153.7 pounds and on 02/06/24 his weight was 145.4 pounds. The total weight loss was 8 pounds from 01/18/24 to 02/06/24. Observation on 02/05/24 at 1:05 pm revealed Resident #76 in his bed. Resident #76 was assisted by CNA Q. Interview on 02/05/24 at 1:30 pm with ADON M revealed Resident #76's weights had not been taken on 01/23/24 and 01/30/24 on Tuesdays as ordered by his physician. ADON M said they had overlook weighting the resident on 01/23/24 and 01/30/24. The negative outcome of not following physician orders resulted in an unwanted weight loss. Interview on 02/06/24 at 9:44 am with RN O revealed she had overlooked the physician's order to weight Resident #76 every Tuesday beginning on 01/23/24. On 02/06/24 at 11:35 am CNA L said she assisted Resident #76 to eat his meals and documented his meal intake and reported to nurse if Resident #76 ate less than 25% of his meal. Interview on 02/06/24 at 3:02 pm with ADON M and the DON revealed the orders to weight Resident #76 had not been carried as per physician orders to weigh Resident #76 weekly beginning on 01/23/24. Resident #76 had been weighed as of this date and was found to have lost eight pounds from 01/18/24 to present. The DON said staff failed to follow physician orders for Resident #76. The adverse effects for both Resident #23 and Resident #76 placed residents at risk for malnutrition, continued weight loss and deterioration in overall health for both residents. Interview on 02/07/24 at 11:26 am with Dietitian Consultant revealed Resident #76's ideal body weight was 142 pounds. Observation on 02/08/24 at 8:06 am revealed Resident #76 was assisted with his meal by ADON A. Record review of the facility policy titled Weight Management System undated reflected. Residents are weighed at admission, readmission, and per physician orders. Weekly weights may be completed for an additional three weeks (or longer if not stable) on the following. admit, readmit. Weekly weights may also be performed for weight change of 5% or more in one month or less, 7.5% in 3 months or 10% in 6 months or per physician's orders. This was determined to be an Immediate Jeopardy (IJ) on 02/08/24. The Administrator was notified. The Administrator was provided with IJ template on 02/08/24 at 6:00 pm. The following Plan of Removal submitted by the facility was accepted on 02/10/24 at 6:37 pm. The facility's Plan of Removal included: On February 8, 2024, the facility was notified by the surveyor, that an immediate jeopardy had been called and the facility needed to submit a letter of credible allegation. The Facility respectfully submits this Letter for Plan of Removal pursuant to Federal and State regulatory requirements. Submission of the Letter of Credible Allegation does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. The alleged immediate jeopardy allegations are as follows: Issue: F692 - Nutrition/Hydration Status Maintenance Resident #23, the RD assessed, and new orders were obtained from the physician on 2/6/24. Resident #38, New orders were obtained from the physician based on dietary recommendations on 2/7/24. Resident # 76, RD assessed, and new orders were obtained on 2/6/24 by the Licensed Nurse. The care plan was reviewed and updated based on the new orders. On 2/7/24, the Director of Nursing/ designee reviewed the last 30 days of RD recommendations to ensure they were communicated to the physician and acted upon. On 2/7/24, the Attending MD and resident representative were notified of residents who were identified with significant weight loss or changes and the interventions put in place. On 2/7/24, the Attending MD was notified by licensed nurse of current nutritional recommendations and implemented orders as written. On 2/8/24, All direct care staff will be re-educated by the Administrator /designee on the following topics: oAbuse and Neglect oWeight Monitoring On 2/8/24, Licensed Nurses will be re-educated by the DON/Designee on the following topics: oNotification of Changes oTimely follow up and notification to MD of nutritional recommendations and implement orders as written and plan of care updated. Completion date of re-education of all staff will be 2/8/24, in person or via telephone. Those that are PRN, Agency and/ or out on FMLA/ LOA will have the education completed prior to accepting assignment for their next scheduled shift. Any staff member not re-educated in person or via phone today (2/8/24), will be removed from the schedule until re-education is provided. Verification of 100% of staff re-education will be verified by the Administrator/ Designee. Director of Nursing/designee will review during the morning clinical meeting that the nutritional assessment is completed. The Attending MD and resident representative will be notified of nutritional/hydration risk identified. MD orders will be implemented as written to include but not limited to dietary recommendations based on referral and evaluations. Plan of care will be reviewed and updated as needed based on assessment and orders. The Administrator will attend the morning meeting to ensure that the DON / Clinical Interdisciplinary Team review significant weight changes and RD recommendations timely. An Ad Hoc QAPI meeting was conducted on 2/8/24 attended by the Administrator, DON, Medical Director and Regional Clinical Specialist to discuss the immediate jeopardy concerning nutrition hydration maintenance and develop the above Action Plan. We respectfully submit this action plan for removal of immediate Jeopardy. Verification of the facility's Plan of Removal: Reviewed the facility conducted 100% review of all residents 11 identified with weight loss. Record review of Resident #2's care plan, care plan revised on 02/09/2024, and updated accordingly - no concerns noted. Record review of Resident #6 was audited for weight loss. Upon record review, facility implemented order of adding house shakes three times a day, as well as weekly weights for 4 weeks. Care Plan updated and no observable concerns. Record review of Resident #23's care plan, and orders were updated and revised on 02/08/2024 to include weekly weight for 4 weeks, and house shakes three times a day. No concerns noted. Record review of Resident #38's care plan, and orders, which were both updated and implemented on 2/08/2024. No concerns noted. Record review of Resident #76's care plan, and orders, which were both updated and implemented on 02/07/2024 - no concerns noted. During an observation on 02/10/2024 at 12:15PM Observed Resident #3 being assisted to eat by CNA J no noted concerns. During an observation on 02/10/2024 at 5:39PM Observed ADON assisting Resident #23 eat his food. On the tray is soft mechanical food of chicken with gray, mash potatoes, and bread pudding. No observable concerns During an observation and interview on 02/10/2024 at 3:55PM Resident#38, observed Resident#38 in bed in lowest position, had HN 2cal tube feeding running at 60mL/HR with 200 Q4 free water flush. Observed no signs and symptoms of distress, when asked if he had any concerns, he motioned his head in a left/right motion, indicated no. During an interview on 02/10/2024@12:37PM, RN A was asked to assist with working on the floor. RN A stated prior to entering the facility, she attended an in-service on 02/09/2024 regarding steps to take if she witnessed a resident looking frail, which would be to fill out a stop and watch form noting the concern with weight and stature, followed by notifying the ADONs, DON, and Physician. RN A stated for she was also in-serviced during the same meeting about change in condition and was told to also fill out a stop and watch form, notating the change in condition followed by notifying the ADONs, DON, and physician. RN A stated if she were not able to initially get ahold of the Physician, she was instructed to then, secondly, contact the Medical Director. RN A stated she was also in-serviced to monitor the residents' weights weekly, for those that pose a weight loss concern, and that the CNAs will document the weights, and if the CNAs notice a concern, the CNAs will notify the nurse, and the nurses will follow up. During an interview on 02/10/2024 at 1:12PM, LVN A stated he was a travel nurse. LVN A stated he was in-serviced about weight loss, and the actions to take would be to notify ADON/DON, and Doctor's. LVN A stated he monitors meal intakes and if resident was not eating enough he would notify ADON/DON and physician, as well as advocate for nutritional supplementation. LVN A stated he monitors weekly weights, and that monitoring weekly weights give him a better idea on how residents were responding to the nutrition. During an interview on 02/10/2024 at 1:27PM RN B stated she was in-serviced a about 2 days ago about monitoring diet intake, weights, abuse (how to report it), how to de-escalate patient issue by removal and when needed, to separate and notify Administrator of the suspicion of abuse. RN B stated for diet, CNAs will document food intake and weights weekly, and that CNAs will give meal percentage slips to the nurses, who will then look at them to see how much the residents are eating. During an interview on 02/10/2024 at 1:30PM CNA A stated she was in-serviced 2 days ago about weight loss and change in conditions. CNA A stated she was educated to notify nurse of the concern of either weight loss or change in condition, while also filling out the stop and watch form and giving it to the nurses. CNA A stated then the nurses were to give a copy of the form to the ADONs/DON. CNA A stated the form is for change in condition concern. CNA A stated Will do monthly unless ordered weekly weights. CNA A stated she was instructed to fill out the meal percentage form for each resident and give the form to the nurses. During an interview on 02/10/2024 at1:47PM CNA B: stated she was in-serviced a couple of days ago about food meal percentage forms, negligence, and meals. CNA B: stated if a resident doesn't want to eat, give options, and if they still don't want the options, she will let the nurses and ADON/DON know. CNA B: stated she will fill out meal percentage paper and turn in the ticket to the nurses. CNA B: stated if they see anything out of the ordinary regarding a resident, she will fill out an IMPACT paper and give kit to the nurse, and nurse will follow up. During an interview on 02/10/2024 at 1:54PM CNA C stated she will document the meal percentages on the meal forms, and give to the nurses, as well as and document in the resident's charts. CNA C stated she will report to nurses if she sees something out of the ordinary, and will document in Stop and Watch paper, then give it to the nurse. During an interview on 02/10/2024 at 2:41PM ADON B, and DON stated for weight management, those that do not have weight loss issues will have monthly weights and those that do have weight loss issues will have weekly weights taken. The restorative aides will document weights in the resident's electronic health record. ADON B and DON stated they have n [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for two residents (R #1 and R #2) of six residents reviewed for neglect. 1.) R #1: R #1 had a fall during therapy on an Easy Stand device, sustaining a fractured left hip. -OTA [NAME] and PTA F failed to seek training on how to use an Easy Stand device prior to using it on R #1. -Rehabilitation Director (RD) H failed to ensure rehabilitation staff were properly trained and knowledgeable on the use of the Easy Stand machine. -Facility staff failed to follow the Easy Stand Manufacturer's Safety Recommendations. -Facility staff failed to seek nursing assistance for assessment and evaluation prior to moving R #1 immediately after his fall. 2.) R #2: The facility's licensed personnel did not: -properly and efficiently monitor R #2's urinary output; -did not transfer R #2 to the emergency room (ER) timely or as ordered by the physician; -place an indwelling urinary catheter correctly causing urethral rupture and gross hematuria -did not consult with R #2's physician regarding the failed attempts of urinary catheterization, urinary status or R #2's family member's request not to transfer R #2 to the ER. R #2's indwelling urinary catheter became clogged causing abdominal distension, discomfort, pain and incurred bloody urine and clots. R #2 was transferred to the hospital two days after the initial physician's orders [REDACTED]. This deficient practice could have affected 1.) residents receiving rehabilitation therapy with serious injuries, decreased quality of life and impaired physical functioning and; 2.) residents with indwelling urinary catheters and could have placed them at risk for urinary tract infection, pain, and trauma. The findings included: 1.) R #1 Review of R#1's Face Sheet dated 03/27/19 documented an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had clear speech -usually understood and understands -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -had functional limitation in range of motion - lower extremity had impairment on both sides -mobility device was a wheelchair Review of R#1's Nurse's Note dated 03/26/19 at 12:20 p.m. documented As per therapists (Occupational Therapist Assistant-OTA) [NAME] and (Physical Therapist Assistant-PTA) F, resident had a witnessed fall during therapy activity. As per resident, he stated that he was on a new machine and that the strap from his bottom came off and he fell down to the floor and bumped his head. Review of R#1's Nurse's Note dated 03/26/19 12:26 PM documented Resident was assessed by writer after fall. Resident is up to wheelchair at the nurses station. Resident was able to state that he fell from a machine he was standing on. Resident stated he felt pain all over his body and he hit his head .Resident stated he also hit his left leg and back. Resident was unable to numerically state pain but did voice he felt much dolor (pain). Review of Radiology Interpretation dated 03/26/19, revealed Significant Findings: Hips, Bilateral: Findings: There is a [MEDICAL CONDITION] femoral neck with angulation. There is osteopenia. There is angulation. Review of R #1's emergency room documentation from local hospital revealed a result date of 03/27/19 documented Chief complaint - patient /resident sent from local nursing home due to having a fracture left femur, patient fell yesterday during therapy. Interview with OTA [NAME] on 06/13/19 at 10:30 a.m. revealed OTA [NAME] said R #1 did not have a back strap and there was not enough space in front of the Easy Stand device to place the wheelchair, the machine was not locking, there was no wheelchair behind the resident, and the knee pad was not working. OTA [NAME] stated R#1 fell because there was no back strap (supports and holds resident in place), she was not aware machine should have had a back strap, she did not know how to use the machine, and she had not been inserviced on how to use the Easy Stand device. Surveyor asked OTA [NAME] if the facility's Physical Therapist had been inserviced on the use of the machine, OTA [NAME] replied no. OTA [NAME] said the first time she had ever used the Easy Stand Device was when she used it on R#1 and the booklet for instructions was not provided for her. OTA [NAME] confirmed she did not seek guidance from her supervisors on how to use the machine before she used it on R #1. Interview with PTAFon 06/13/19 at 11:08 a.m. revealed PTA F was asked by surveyor to describe what had caused R# 1's fall. PTA F said he was bent down and attempting to adjust and tighten the knee rests when the buttock strap slid down to R #1's lower legs then R #1 began to fall back. PTA F said he attempted to grab R #1's clothing to catch him but was unsuccessful. PTA F said the buttock strap had slipped down to his (R#1's) ankles when he reached the floor. Surveyor asked PTA F if he had been trained on how to use the machine in this facility, PTA F replied no. PTA F confirmed safe practice when using any new device would be to get inservice and read the equipments manual/user guide. PTA F /onfirmed he did not seek guidance from his supervisors on how to use the machine before he used it on R #1. PTA F/ said he always used a gait belt on residents he provided therapy to for support and stability. PTA F said he did not use a gait belt on R #1 during his therapy. Interview with Rehabilitation Director (RD) H on 06/13/19 at approximately 11:15 a.m. revealed she was informed via a text message informing her of R #1's fall in the rehabilitation gym. RD H said she found out R #1 was picked up off the floor, transferred in his wheelchair, and taken to the nurse's station, instead of waiting for a nurse to come to him to assess him. RD H confirmed OTA [NAME] and PTA F did not follow protocol when they moved R #1 off the floor, after his fall, prior to being assessed by a nurse. RD H said R #1 needed an immediate nursing assessment and moving him could cause an injury or worsen the injury. RD H said her interviews from staff present at the time revealed that OTA [NAME] and PTA F had R #1 standing on the Easy Stand with OTA [NAME] on R #1's left side and PTA F on R #1's right side. RD H said PTA F was attempting to tighten the loose knee pads (while R #1 was standing and leaning on the equipment) but was unsuccessful. RD H said she was told PTA F called the maintenance supervisor and at that time they were both kneeled down attempted to figure out how to adjust and tighten the knee pads. RD H said the staff turned R #1 on the machine, slightly as they were attempting to adjust it when they saw the buttocks strap slip down to his lower legs and R #1 began to fall backwards. RD H said OTA [NAME] and PTA F told her they tried to catch and break R #1's fall but were unsuccessful. RD H said It is ultimately my responsibility that all equipment in the rehab department is functioning properly. RD H said OTA [NAME] and PTA F were not provided in-service prior to using the Easy Stand on R #1. RD H confirmed an inservice should have been provided to all rehab staff, including OTA [NAME] and PTA F prior to use of the Easy Stand device. RD H said the User Guide was provided when the Easy Stand arrived to the facility, The therapy staff, including myself, had the opportunity to read the user guide, however, I guess it was not done before it was used. RD H stated after R #1's fall, various inservices regarding appropriate use of equipment and resident safety were provided to all rehab staff. RD H explained she called the manufacturer and informed them what happened and the manufacturer provided all the therapists with in-depth inservice and demonstration on the appropriate use of the machine and parts.RD H said the manufacture representative assessed the machine and added parts to it which included: a leg swivel which opened outward for machine's stability, a back support strap for patient support and stability, an adjustable table to tray, foot straps, and the the adjustment of the loose knee pads. RD H stated After evaluating the incident, in my opinion, staff should have been in-serviced on it's use prior to using the equipment for safety of the patient and therapist, ensure correct usage of the equipment, ensure knowledge of how to troubleshoot, and ensure it was in correct working condition prior to use. I believe they failed to follow proper procedures.They failed on being in-serviced on the correct use and knowledge of the machine, the correct training for lifting and transferring residents on this special machine, the appropriate protocol when a patient sustained a fall, protocols on seeking supervisors and following supervisor recommendations. Further interview with OTA [NAME] on 06/13/19 at 12:41 PM revealed she confirmed that she did not follow facility protocol when she and PTA F moved R #1 and transferred him from the floor to the wheelchair but R #1 kept telling her to pick him up. OTA [NAME] said R #1 had 20-30 degree contractures in his legs and could not walk so she and PTA F lifted R #1 up from the floor to his wheelchair. OTA [NAME] said It is important to get assessed before getting him up to ensure he is alert and make sure he does not have anything broken. The resident denied any pain, he just was anxious and wanted us to get him up from the floor. During an interview with Physical Therapist (PT) G on 06/13/19 at 4:05 p.m., when asked if he had been given an inservice training prior to using the Easy Stand device for R #1, PT G replied no. During an interview on 06/13/19 at 4:28 p.m., with the facility's Occupational Therapist Registered (OTR) I, when asked if therapy staff had been trained prior to using the Easy Stand device for R#1, OTR I stated the therapy staff were not trained prior to using the Easy Stand Device for R#1. OTR I replied the physical therapy staff were trained on how to use the Easy Stand device after R#1's incident/fall. Interview with the Administrator on 06/13/19 at 6:00 PM revealed he was made aware of the concerns identified regarding R #1 and his fall. The Administrator said he was aware and agreed that the rehabilitation department should not have used the Easy Stand without first receiving training on how to properly use it. The Administrator said the Director of Rehabilitation Services was responsible for ensuring staff were trained on the use of the equipment before it was initially used. The Administrator confirmed the Rehabilitation staff should not have moved the resident when he was on the floor, until he was assessed by the nurse. The Administrator confirmed the rehabilitation staff did not follow policy and procedures on resident care and safety that contributed to R #1's fall and injury. Review of facility's Policy/Procedure Medical Equipment Management Plan revision date (MONTH) (YEAR) indicated Testing and Service Requirement Education of proper use and /or maintenance should be provided by a qualified person . Procedure 1. All medical equipment in the facility's management program is tested for safety and performance prior to initial use .by qualified persons. 6. Training should address: - capabilities, limitations,and special application of equipment -basic operating and safety procedures for equipment use Review of owner's Manual for Easy Stand device (provided by the facility Administrator on 06/14/19 at approximately 10:30 a.m. indicated ) Introduction Intended Use - The Easy Stand .is intended to assist individual who have difficulty rising from a seated position to a standing position. This manual is an integral part of the standing system and should be read completely and thoroughly by anyone operating the unit. Safety Precautions: -Check the EasyStand periodically to ensure that all nuts, bolts and adjustable parts are tightened securely. -Never make adjustments to the EasyStand while a user is in the standing position . -Extreme movements laterally or front to back may cause the unit to tip. As of exit date 06/14/19, the facility took the following actions to correct the non-complaince by: -observation of two other residents in he facility receiving physical and occupational therapy and used therapy equipment revealed no concerns identified. -six licensed nurses were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -three licensed therapist were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, Easy Stand manufacturer training, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -two certified therapists were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, Easy Stand manufacturer training, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -as of 06/14/19, the administrator stated the Easy Stand device was removed and not made available to anyone in the facility for use. -review of physician's orders [REDACTED]. 2.) R #2 Review of R #2's Face Sheet dated 06/13/19 documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #2's (MONTH) 2019 Consolidated physician's orders [REDACTED]. Flush with 30-60 milliliters of water before and after meds, before initiating feeding or when there is an interruption of feeding to maintain tube patency; Hydration - Bolus with 150 milliliters of water every 4 hours. Review of R #2's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -was always incontinent of bladder and bowel -had a feeding tube. Review of R #2's Nurse's Note dated 04/19/19 at 10:33 AM documented As per Resident Care Specialist (RCS), upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Medical Doctor (MD) office is closed until tomorrow. Answering services couldn't even direct the call to the on call MD. Nurse Practitioner substituting for Doctor has cell phone off and not receiving call. Phone number was called x 4. Will follow up. Review of R #2's SBAR (Situation Background Assessment Request) Communication Form and Progress Note dated 04/19/19 documented Inflammation of foreskin and shaft. Verbalizes discomfort upon assessment. As per RCS, upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Will continue to monitor. MD (Medical Doctor) office is closed until tomorrow. Answering services couldn't even direct the call to the on-call MD. Np (Nurse practitioner) substituting for MD has cell phone off and not receiving call. Phone number was called x 4. Review of R #2's Comprehensive Care Plan dated 04/21/19 documented I have [MEDICAL CONDITION] .Interventions: Collect urine for culture and senstitivity and report results to medical doctor; insert foley catheter 16 french and leave in place if there is a significant amount of urine output; irrigate indwelling catheter, if no urinary return, remove existing urinary catheter and insert new urinary catheter, if no uinary return with new indwelling catheter, send to ER for evaluation. Review of R #2's Telephone Physician order [REDACTED]. Resident is alert oriented X 1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. MD made aware and gave orders for 16 French (Fr) Urinary Catheter to be inserted, and to leave it in place if a significant amount of urine was present. Ordered UA (urinalysis) Culture and Sensitivity (C & S) and to consult Urology. RP (Responsible party) made aware of clinical situation. Review of R #2's SBAR Communication Form and Progress Note dated 04/21/19 documented 8:08 AM - Resident is alert oriented X1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. Additional Nursing Notes as applicable: MD made aware and gave orders for 16 Fr Urinary Catheter to be inserted 04/19/19, and to leave it in place if a significant amount of urine was present. Ordered UA C+S and to consult Urology. Review of R #2's Nurse's Note dated 04/21/19 at 10:57 AM documented Resident alert oriented X 1, no change in cognition from baseline. 04/10 on pain scale. Resident complaining of discomfort to lower abdomen. Upon assessment there was visible distention. There was also scrotal and penile [MEDICAL CONDITION] present. MD notified and gave orders to insert a foley due to possible [MEDICAL CONDITION] and to be left in place if there was a significant amount of urine present. He also ordered for UA C&S to be collected. 16 FR (French) urinary catheter with 10CC (cubic centimeters) balloon inserted using sterile technique. Resident tolerated procedure well. There was an initial urine output of 700ML (milliliters), amber in coloration with 5 small stones present, measuring approximately 0.1cm (centimeters) in diameter. There was a total of 2300ML of urine output. This was done using intermittent volume drainage. Resident stated that he felt relief and that pain had subsided. 0/10 on pain scale. Resident in no acute distress/discomfort and will continue to be monitored. Review of R #2's Nurse's Note dated 04/21/19 documented Resident indwelling urinary catheter had 100 ml of hematuria (bloody urine), in collection bag @ 2 PM. No further urine was draining and collected and resident diaper was stained in hematuria as hematuria was draining between urethra and foley. Called MD and ordered irrigation, and if no urine produced to replace catheter, if still no urine produced to send resident to emergency room (ER). Irrigation with 100 ml of Normal Saline produced no urine and insertion of new 16 French catheter met with resistance and no urine collected verified with LVN. RP stated she wanted resident to wait for ER visit until 4/22 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Telephone Physician order [REDACTED]. If no urinary return with new indwelling catheter, send resident to ER for evaluation. Review of R #2's Nurse's Note dated 04/22/10 documented 9:00 PM - Resident indwelling urinary catheter had 100 ml of hematuria in collection bag @ 2PM. No further urine was draining and collected and resident diaper was stained in hematuria, as hematuria was draining between urethra and foley. Called (MD) and ordered irrigation, and if no urine produced to replace catheter, if still no urine produce to send resident to ER. Irrigation with 100 ml of NS produced no urine and insertion of new 16 French catheter meet with resistance and no urine collected verified with LVN. RP (responsible party) stated she wanted resident to wait for ER visit until 4/23 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Nurse's Note dated 04/22/19 documented 10:06 PM - Attempt indwelling foley catheter insertion, if unsuccessful send resident toER on ,[DATE] in the morning as per Wife. Review of R #2's Nurse's Note dated 04/23/19 documented 5:50 AM -Resident voided during 10/6 shift large quantity, dark in color no distress is noted will continue to monitor. R #2 urinated one time from 04/22/19 at 2:00 PM -04/23/19 at approximately 5:00 AM, which documentation showed he urinated one large amount (specific amount undetermined) of urine in the early morning shift of 04/23/19. R #2 continued to receive his ordered enteral feeding and at least 150 mls of water every 4 hours. Review of R #2's Nurse's Note dated 04/23/19 revealed 8:50 AM - RP in facility visiting resident. Per RP nurse to hold transfer at this time until further notice. RP made aware about resident voiding a large amount of urine during night shift. Advised RP nurse will continue to monitor output and will notify if any changes. Advised RP order to transfer is valid and may send out resident at any time if needed. Resident is currently resting comfortably without any signs of discomfort. No abdominal distention noted. No pain upon palpation. Review of R #2's Nurse's Note dated 04/23/19 documented 9:50 AM - Resident remains without a foley. Nurse monitoring output. Assisted RCS with incontinent care to resident. Appears to be voiding in diaper. Diaper noted with blood tinged stains and a medium amount of urine. During incontinent care earlier in the morning, resident voided a large amount of urine without difficulty. No abdominal distention noted. No c/o pain or discomfort. Will continue to monitor. Review of R #2's Nurse's Note dated 04/23/19 documented 3:00 PM - Resident presented scant amounts of blood clots on diaper, as well as urine that saturated diaper. Review of R #2's Nurse's Note dated 04/23/19 documented 8:00 PM - Resident diaper presented with urine, tinged blood color present. Review of R #2's Nurse's Note dated 04/24/19 documented 11:09 AM - During report night nurse notified me that resident was being monitored for [MEDICAL CONDITION] and hematuria. MD was aware of situation and had given orders to send resident to ER for further evaluation on 4/22 but RP held transfer. Upon assessment resident presented with blood clots on diaper. Called RP to notify of situation. RP agreed with MD orders to send resident to ER for further evaluation. Review of R #2's Telephone Nurse's Note dated 04/24/19 documented 11:45 AM - Resident transferred to ER for further evaluation via stretcher by ambulance. Review of R #2's Nurse's Note dated 04/24/19 documented 8:46 PM - Resident admitted to (hospital) for [DIAGNOSES REDACTED]. Review of R #2's Emergency Department Physician Document - Final Report dated 04/24/19 documented Patient presents with hematuria with onset of one week ago. Character of the hematuria is grossly bloody. Patient sent be NH (Nursing Home) due to hematuria for a week. EMS (Emergency Medical Services) reports they were told it had gotten worse over the week. Upon further investigation, was noted on medical records an order from three days ago to place a foley and send to ER if no urine output, therefore after seeing this seems the hematuria is indeed caused by iatogenic malplacement of a foley catheter .He had a foley placed at nursing home about 3 days ago, hematuria and bleeding per urethra after that, some associated low-grade temperatures, moderate to severe, no modifying factors. Significant urethral bleeding, from malpositioned balloon previously with foley trauma. Urology consulted. Review of R #2's Hospital History and Physical dated 04/24/19 documented admitting [DIAGNOSES REDACTED].Patient presented with abdominal distention, blood and clots in brief .patient complaining of pain 10/10 on pain scale .bladder scan measured 1300 ml urine in bladder .coude cath inserted ., received 1300 output with intermittent drainage, urethral trauma and rupture from previous catheterization attempts . Review of R #2's Significant Change MDS dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and personal hygiene -had an indwelling catheter and was always incontinent of bowel -had a feeding tube An observation and attempted interview with R #2 on 06/11/19 at 3:40 PM revealed he was laying in bed. R #2 was receiving tube feeding of Glucerna 1.5 at 60 milliliters per hour. R #2 was alert and oriented to self only. R #2 said he felt comfortable at the time. When asked about his recent hospital stay, R #2 stated he did not recall going to the hospital. During an interview with Hospital Social Worker (SW) D on 06/12/19 at 11:58 AM she revealed the ER physician informed her that R #2 should have been transferred to the hospital 04/22/19 for [MEDICAL CONDITION]. SW D said the physician found R #2's urethra had been traumatized from improper attempt to catherize him which caused bleeding, clotting, inflammation, and blockage that prevented urinary drainage. In an interview with Interim Director of Nurses (IDON) on 06/13/19 at 3:05 PM he said he was not fully aware of R #2's catheter situation that occurred 04/2019. After the IDON reviewed R #2's Nurse's Notes dated 04/19/19 - 04/24/19, the IDON said the nurse should have advised the spouse and informed her of the consequences of waiting on being evaluated and then the nurse should have sent the resident to the hospital as ordered by the physician. The doctor should have been made aware of the spouse's request and the urinary status of the resident at that time and that would allowed the physician to make the decision whether or not to transfer. The IDON stated By reading the nurse's notes, I can see (R #2) was not improving, he went from having blood tinged urine to having gross blood and clots and there was no definite way to know how much urine he was voiding or retaining, which would cause pain, discomfort, and severe complications for the resident. There is no evidence that the doctor was informed of the outcome of the patient from the initial call to him on 04/22/19. The nurse did not follow the orders, he should have sent him to the hospital. The IDON said after reading R #2 nurse's notes, he could not tell if R #2 was urinating an adequate amount since he did not have a catheter. The IDON said monitoring of R #2's urine output was important because he was receiving liquids by enteral feeding and water flushes via his [DEVICE], Continually providing fluids and having no output would put the resident at risk for urine retention, urine to backup into the kidneys. An interview with Registered Nurse (RN) A on 06/13/19 at 3:39 PM revealed he recalled on 04/22/19 at 2:00 PM, R #2 had a catheter already in place when RN A began his shift. RN A said during his shift he noticed R #2's urine was no longer draining into the catheter and R #2 was complaining of abdominal discomfort. RN A said he called the doctor and was told to irrigate and replace the catheter. RN A said he attempted to reinsert a catheter in R #2 but met resistance guiding in the catheter so he said he called the RP and she stated she wanted to wait to send the resident to the ER until the morning because she did not have a ride to get to the hospital. RN A said he told the RP that R #2 had not urinated and the doctor ordered to send him to the hospital but she still wanted to wait to the next morning. When RN A was asked if he contacted R #2's physician, he stated I am not sure that I did, I do not recall. I can't recall how much urine output he put out on my shift. He only had 100 milliliters in the catheter drainage bag from the prior shift and had no output on my shift, before I called the doctor. I saw some urine was leaking around the catheter and the brief had red tinged colored urine but I cannot say how much urine output he had. The urine was red tinged and pink but not bloody. RN A said he did not contact his supervisor to inform her or get further direction on whether to send the resident to the hospital, as the doctor ordered. RN A said Looking back, I should have sent him to the hospital like the doctor ordered. This was my first complicated situation with a catheter. I had not worked with catheters very much, I think this was my first one. An interview with Family Member (FM B) on 06/13/19 at 4:30 PM revealed she told RN A to hold R #2's transfer. FM B said she was told R #2 had blood-tinged urine and was not able to get a new catheter into the bladder due to resistance, but he was voiding and did not have any discomfort therefore, FM B said she did not feel that a transfer was necessary, being so late at night. FM B said she was told R #2 did not have any abdominal distention. FM B she was not told by the nurse the consequences of delayed evaluation at any time during the conversation. FM B said she was a retired licensed nurse and said she knew of the consequences that could occur from urinary distension but she was told R #2 was urinating. FM B said The nurse should have called the doctor to tell the doctor (R #2's) status and my suggestion not to transfer. An interview with Licensed Vocational Nurse (LVN) C on 06/13/19 on 5:20 PM revealed she took care of R #2 from 10 PM 04/22/19 - 6:00 AM shift on 04/23/19. LVN C said she recalled LVN A telling her during change of shift that he got an order to transfer the resident to the hospital but that the spouse did not want him transferred until the next morning. LVN C said she recalled R #2 urinated during the night once or twice requiring a brief change. LVN C said there was no way of knowing how much urine output R #2 was expelling because he was incontinent. LVN C said R #2's urine was Very dark amber and said she did not recall if there was any blood. LVN C said R #2 did not complain of any discomfort throughout the night. An interview with the Administrator on 06/13/19 at 6:00 PM revealed he was informed of the evidence found regarding R #2. The Administrator said he was aware of the incident and said All the nurse had to do was follow the doctor's order by sending (R #2) to the hospital. The Administrator said the nurses failed to follow the physician's orders [REDACTED].#2's urinary status, and consult with their supervisor about the (family member) not wanting R #2 to transfer to the hospital. Review of the facility's Abuse and Neglect Prohibition Policy and Procedure dated (MONTH) (YEAR) documented Purpose: To help ensure a resident's right to a safe and healthy environment. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . As of exit date 06/14/19, the facility took the following actions to correct the non-compliance by: -observation and interview of R #2 revealed he continued to reside in the

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two residents (R #1 and R #2) of six residents reviewed for neglect. 1.) R #1: -OTA [NAME] and PTA F failed to seek training on how to use an Easy Stand device prior to using it on R #1. -Rehabilitation Director (RD) H failed to ensure rehabilitation staff were properly trained and knowledgeable on the use of the Easy Stand machine. -Facility staff failed to follow the Easy Stand Manufacturer's Safety Recommendations. -Facility staff failed to seek nursing assistance for assessment and evaluation prior to moving R #1 immediately after his fall. As a result, R #1 had a fall during therapy on an Easy Stand device, sustaining a fractured left hip. 2.) R #2: The facility's licensed personnel did not: -properly and efficiently monitor R #2's urinary output; -did not transfer R #2 to the emergency room (ER) timely or as ordered by the physician; -place an indwelling urinary catheter correctly causing urethral rupture and gross hematuria -did not consult with R #2's physician regarding the failed attempts of urinary catheterization, urinary status or R #2's family member's request not to transfer R #2 to the ER. As a result, R #2's indwelling urinary catheter became clogged causing abdominal distension, discomfort, pain and incurred bloody urine and clots. R #2 was transferred to the hospital two days after the initial physician's orders [REDACTED]. This deficient practice could affect residents with receiving rehabilitation therapy for serious injuries resulting in decreased quality of life and impaired physical functioning and residents with indwelling urinary catheters and could place them at risk for urinary tract infection, pain, and trauma. The findings included: 1.) R #1 Review of R#1's Face Sheet dated 03/27/19 documented an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had clear speech -usually understood and understands -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -had functional limitation in range of motion - lower extremity had impairment on both sides -mobility device was a wheelchair Review of R#1's Nurse's Note dated 03/26/19 at 12:20 p.m. documented As per therapists (Occupational Therapist Assistant-OTA) [NAME] and (Physical Therapist Assistant-PTA) F, resident had a witnessed fall during therapy activity. As per resident, he stated that he was on a new machine and that the strap from his bottom came off and he fell down to the floor and bumped his head. Review of R#1's Nurse's Note dated 03/26/19 12:26 PM documented Resident was assessed by writer after fall. Resident is up to wheelchair at the nurses station. Resident was able to state that he fell from a machine he was standing on. Resident stated he felt pain all over his body and he hit his head .Resident stated he also hit his left leg and back. Resident was unable to numerically state pain but did voice he felt much dolor (pain). Review of Radiology Interpretation dated 03/26/19, revealed Significant Findings: Hips, Bilateral: Findings: There is a [MEDICAL CONDITION] femoral neck with angulation. There is osteopenia. There is angulation. Review of R #1's emergency room documentation from local hospital revealed a result date of 03/27/19 documented Chief complaint - patient /resident sent from local nursing home due to having a fracture left femur, patient fell yesterday during therapy. Interview with OTA [NAME] on 06/13/19 at 10:30 a.m. revealed OTA [NAME] said R #1 did not have a back strap and there was not enough space in front of the Easy Stand device to place the wheelchair, the machine was not locking, there was no wheelchair behind the resident, and the knee pad was not working. OTA [NAME] stated R#1 fell because there was no back strap (supports and holds resident in place), she was not aware machine should have had a back strap, she did not know how to use the machine, and she had not been inserviced on how to use the Easy Stand device. Surveyor asked OTA [NAME] if the facility's Physical Therapist had been inserviced on the use of the machine, OTA [NAME] replied no. OTA [NAME] said the first time she had ever used the Easy Stand Device was when she used it on R#1 and the booklet for instructions was not provided for her. OTA [NAME] confirmed she did not seek guidance from her supervisors on how to use the machine before she used it on R #1. Interview with PTAFon 06/13/19 at 11:08 a.m. revealed PTA F was asked by surveyor to describe what had caused R# 1's fall. PTA F said he was bent down and attempting to adjust and tighten the knee rests when the buttock strap slid down to R #1's lower legs then R #1 began to fall back. PTA F said he attempted to grab R #1's clothing to catch him but was unsuccessful. PTA F said the buttock strap had slipped down to his (R#1's) ankles when he reached the floor. Surveyor asked PTA F if he had been trained on how to use the machine in this facility, PTA F replied no. PTA F confirmed safe practice when using any new device would be to get inservice and read the equipments manual/user guide. PTA F /onfirmed he did not seek guidance from his supervisors on how to use the machine before he used it on R #1. PTA F/ said he always used a gait belt on residents he provided therapy to for support and stability. PTA F said he did not use a gait belt on R #1 during his therapy. Interview with Rehabilitation Director (RD) H on 06/13/19 at approximately 11:15 a.m. revealed she was informed via a text message informing her of R #1's fall in the rehabilitation gym. RD H said she found out R #1 was picked up off the floor, transferred in his wheelchair, and taken to the nurse's station, instead of waiting for a nurse to come to him to assess him. RD H confirmed OTA [NAME] and PTA F did not follow protocol when they moved R #1 off the floor, after his fall, prior to being assessed by a nurse. RD H said R #1 needed an immediate nursing assessment and moving him could cause an injury or worsen the injury. RD H said her interviews from staff present at the time revealed that OTA [NAME] and PTA F had R #1 standing on the Easy Stand with OTA [NAME] on R #1's left side and PTA F on R #1's right side. RD H said PTA F was attempting to tighten the loose knee pads (while R #1 was standing and leaning on the equipment) but was unsuccessful. RD H said she was told PTA F called the maintenance supervisor and at that time they were both kneeled down attempted to figure out how to adjust and tighten the knee pads. RD H said the staff turned R #1 on the machine, slightly as they were attempting to adjust it when they saw the buttocks strap slip down to his lower legs and R #1 began to fall backwards. RD H said OTA [NAME] and PTA F told her they tried to catch and break R #1's fall but were unsuccessful. RD H said It is ultimately my responsibility that all equipment in the rehab department is functioning properly. RD H said OTA [NAME] and PTA F were not provided in-service prior to using the Easy Stand on R #1. RD H confirmed an inservice should have been provided to all rehab staff, including OTA [NAME] and PTA F prior to use of the Easy Stand device. RD H said the User Guide was provided when the Easy Stand arrived to the facility, The therapy staff, including myself, had the opportunity to read the user guide, however, I guess it was not done before it was used. RD H stated after R #1's fall, various inservices regarding appropriate use of equipment and resident safety were provided to all rehab staff. RD H explained she called the manufacturer and informed them what happened and the manufacturer provided all the therapists with in-depth inservice and demonstration on the appropriate use of the machine and parts.RD H said the manufacture representative assessed the machine and added parts to it which included: a leg swivel which opened outward for machins stability, a back support strap for patient support and stability, an adjustable table to tray, foot straps, and the the adjustment of the loose knee pads. RD H stated After evaluating the incident, in my opinion, staff should have been in-serviced on it's use prior to using the equipment for safety of the patient and therapist, ensure correct usage of the equipment, ensure knowledge of how to troubleshoot, and ensure it was in correct working condition prior to use. RD H said Traditionally, we would use a gait belt, which we use for proper and efficient grasp or hold of the resident and position the wheelchair close to the resident, in (R #1's) case, behind him for landing purposes. RD H confirmed OTA [NAME] and PTA F did not use a gait belt or position the wheelchair behind the resident, Which could have changed the outcome of the incident and maybe prevented the injury. Looking back at everything that happened, it would have been useful that they had a gait belt on him so the therapist would be able to hold on to the resident and helping in stabilizing him. I would have told them to sit the resident down before they were trying to adjust the machine, they should not have done that with the patient standing on it. The wheelchair should have been directly behind him. I was told of them turning him while he was standing, I believe he should have been in a stationary position. I believe there was an unintentional harm caused to the resident. I do not believe the therapists would willingly harm the resident. I believe they failed to follow proper procedures.They failed on being in-serviced on the correct use and knowledge of the machine, the correct training for lifting and transferring residents on this special machine, the appropriate protocol when a patient sustained a fall, protocols on seeking supervisors and following supervisor recommendations. Further interview with OTA [NAME] on 06/13/19 at 12:41 PM revealed she confirmed that she did not follow facility protocol when she and PTA F moved R #1 and transferred him from the floor to the wheelchair but R #1 kept telling her to pick him up. OTA [NAME] said R #1 had 20-30 degree contractures in his legs and could not walk so she and PTA F lifted R #1 up from the floor to his wheelchair. OTA [NAME] said It is important to get assessed before getting him up to ensure he is alert and make sure he does not have anything broken. The resident denied any pain, he just was anxious and wanted us to get him up from the floor. During an interview with Physical Therapist (PT) G on 06/13/19 at 4:05 p.m., when asked if he had been given an inservice training prior to using the Easy Stand device for R #1, PT G replied no. During an interview on 06/13/19 at 4:28 p.m., with the facility's Occupational Therapist Registered (OTR) I, when asked if therapy staff had been trained prior to using the Easy Stand device for R#1, OTR I stated the therapy staff were not trained prior to using the Easy Stand Device for R#1. OTR I replied the physical therapy staff were trained on how to use the Easy Stand device after R#1's incident/fall. Interview with the Administrator on 06/13/19 at 6:00 PM revealed he was made aware of the concerns identified regarding R #1 and his fall. The Administrator said he was aware and agreed that the rehabilitation department should not have used the Easy Stand without first receiving training on how to properly use it. The Administrator said the Director of Rehabilitation Services was responsible for ensuring staff were trained on the use of the equipment before it was initially used. The Administrator confirmed the Rehabilitation staff should not have moved the resident when he was on the floor, until he was assessed by the nurse. The Administrator confirmed the rehabilitation staff did not follow policy and procedures on resident care and safety that contributed to R #1's fall and injury. Review of facility's Policy/Procedure Medical Equipment Management Plan revision date (MONTH) (YEAR) indicated Testing and Service Requirement Education of proper use and /or maintenance should be provided by a qualified person . Procedure 1. All medical equipment in the facility's management program is tested for safety and performance prior to initial use .by qualified persons. 6. Training should address: - capabilities, limitations,and special application of equipment -basic operating and safety procedures for equipment use Review of owner's Manual for Easy Stand device (provided by the facility Administrator on 06/14/19 at approximately 10:30 a.m. indicated ) Introduction Intended Use - The Easy Stand .is intended to assist individual who have difficulty rising from a seated position to a standing position. This manual is an integral part of the standing system and should be read completely and thoroughly by anyone operating the unit. Safety Precautions: -Check the EasyStand periodically to ensure that all nuts, bolts and adjustable parts are tightened securely. -Never make adjustments to the EasyStand while a user is in the standing position . -Extreme movements laterally or front to back may cause the unit to tip. 2.) R #2 Review of R #2's Face Sheet dated 06/13/19 documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #2's (MONTH) 2019 Consolidated physician's orders [REDACTED]. Flush with 30-60 milliliters of water before and after meds, before initiating feeding or when there is an interruption of feeding to maintain tube patency; Hydration - Bolus with 150 milliliters of water every 4 hours. Review of R #2's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -was always incontinent of bladder and bowel -had a feeding tube. Review of R #2's Nurse's Note dated 04/19/19 at 10:33 AM documented As per Resident Care Specialist (RCS), upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Medical Doctor (MD) office is closed until tomorrow. Answering services couldn't even direct the call to the on call MD. Nurse Practitioner substituting for Doctor has cell phone off and not receiving call. Phone number was called x 4. Will follow up. Review of R #2's SBAR (Situation Background Assessment Request) Communication Form and Progress Note dated 04/19/19 documented Inflammation of foreskin and shaft. Verbalizes discomfort upon assessment. As per RCS, upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Will continue to monitor. MD (Medical Doctor) office is closed until tomorrow. Answering services couldn't even direct the call to the on-call MD. Np (Nurse practitioner) substituting for MD has cell phone off and not receiving call. Phone number was called x 4. Review of R #2's Comprehensive Care Plan dated 04/21/19 documented I have [MEDICAL CONDITION] .Interventions: Collect urine for culture and senstitivity and report results to medical doctor; insert foley catheter 16 french and leave in place if there is a significant amount of urine output; irrigate indwelling catheter, if no urinary return, remove existing urinary catheter and insert new urinary catheter, if no uinary return with new indwelling catheter, send to ER for evaluation. Review of R #2's Telephone Physician order [REDACTED]. Resident is alert oriented X 1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. MD made aware and gave orders for 16 French (Fr) Urinary Catheter to be inserted, and to leave it in place if a significant amount of urine was present. Ordered UA (urinalysis) Culture and Sensitivity (C & S) and to consult Urology. RP (Responsible party) made aware of clinical situation. Review of R #2's SBAR Communication Form and Progress Note dated 04/21/19 documented 8:08 AM - Resident is alert oriented X1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. Additional Nursing Notes as applicable: MD made aware and gave orders for 16 Fr Urinary Catheter to be inserted 04/19/19, and to leave it in place if a significant amount of urine was present. Ordered UA C+S and to consult Urology. Review of R #2's Nurse's Note dated 04/21/19 at 10:57 AM documented Resident alert oriented X 1, no change in cognition from baseline. 04/10 on pain scale. Resident complaining of discomfort to lower abdomen. Upon assessment there was visible distention. There was also scrotal and penile [MEDICAL CONDITION] present. MD notified and gave orders to insert a foley due to possible [MEDICAL CONDITION] and to be left in place if there was a significant amount of urine present. He also ordered for UA C&S to be collected. 16 FR (French) urinary catheter with 10CC (cubic centimeters) balloon inserted using sterile technique. Resident tolerated procedure well. There was an initial urine output of 700ML (milliliters), amber in coloration with 5 small stones present, measuring approximately 0.1cm (centimeters) in diameter. There was a total of 2300ML of urine output. This was done using intermittent volume drainage. Resident stated that he felt relief and that pain had subsided. 0/10 on pain scale. Resident in no acute distress/discomfort and will continue to be monitored. Review of R #2's Nurse's Note dated 04/21/19 documented Resident indwelling urinary catheter had 100 ml of hematuria (bloody urine), in collection bag @ 2 PM. No further urine was draining and collected and resident diaper was stained in hematuria as hematuria was draining between urethra and foley. Called MD and ordered irrigation, and if no urine produced to replace catheter, if still no urine produced to send resident to emergency room (ER). Irrigation with 100 ml of Normal Saline produced no urine and insertion of new 16 French catheter met with resistance and no urine collected verified with LVN. RP stated she wanted resident to wait for ER visit until 4/22 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Telephone Physician order [REDACTED]. If no urinary return with new indwelling catheter, send resident to ER for evaluation. Review of R #2's Nurse's Note dated 04/22/10 documented 9:00 PM - Resident indwelling urinary catheter had 100 ml of hematuria in collection bag @ 2PM. No further urine was draining and collected and resident diaper was stained in hematuria, as hematuria was draining between urethra and foley. Called (MD) and ordered irrigation, and if no urine produced to replace catheter, if still no urine produce to send resident to ER. Irrigation with 100 ml of NS produced no urine and insertion of new 16 French catheter meet with resistance and no urine collected verified with LVN. RP (responsible party) stated she wanted resident to wait for ER visit until 4/23 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Nurse's Note dated 04/22/19 documented 10:06 PM - Attempt indwelling foley catheter insertion, if unsuccessful send resident toER on ,[DATE] in the morning as per Wife. Review of R #2's Nurse's Note dated 04/23/19 documented 5:50 AM -Resident voided during 10/6 shift large quantity, dark in color no distress is noted will continue to monitor. R #2 urinated one time from 04/22/19 at 2:00 PM -04/23/19 at approximately 5:00 AM, which documentation showed he urinated one large amount (specific amount undetermined) of urine in the early morning shift of 04/23/19. R #2 continued to receive his ordered enteral feeding and at least 150 mls of water every 4 hours. Review of R #2's Nurse's Note dated 04/23/19 revealed 8:50 AM - RP in facility visiting resident. Per RP nurse to hold transfer at this time until further notice. RP made aware about resident voiding a large amount of urine during night shift. Advised RP nurse will continue to monitor output and will notify if any changes. Advised RP order to transfer is valid and may send out resident at any time if needed. Resident is currently resting comfortably without any signs of discomfort. No abdominal distention noted. No pain upon palpation. Review of R #2's Nurse's Note dated 04/23/19 documented 9:50 AM - Resident remains without a foley. Nurse monitoring output. Assisted RCS with incontinent care to resident. Appears to be voiding in diaper. Diaper noted with blood tinged stains and a medium amount of urine. During incontinent care earlier in the morning, resident voided a large amount of urine without difficulty. No abdominal distention noted. No c/o pain or discomfort. Will continue to monitor. Review of R #2's Nurse's Note dated 04/23/19 documented 3:00 PM - Resident presented scant amounts of blood clots on diaper, as well as urine that saturated diaper. Review of R #2's Nurse's Note dated 04/23/19 documented 8:00 PM - Resident diaper presented with urine, tinged blood color present. Review of R #2's Nurse's Note dated 04/24/19 documented 11:09 AM - During report night nurse notified me that resident was being monitored for [MEDICAL CONDITION] and hematuria. MD was aware of situation and had given orders to send resident to ER for further evaluation on 4/22 but RP held transfer. Upon assessment resident presented with blood clots on diaper. Called RP to notify of situation. RP agreed with MD orders to send resident to ER for further evaluation. Review of R #2's Telephone Nurse's Note dated 04/24/19 documented 11:45 AM - Resident transferred to ER for further evaluation via stretcher by ambulance. Review of R #2's Nurse's Note dated 04/24/19 documented 8:46 PM - Resident admitted to (hospital) for [DIAGNOSES REDACTED]. Review of R #2's Emergency Department Physician Document - Final Report dated 04/24/19 documented Patient presents with hematuria with onset of one week ago. Character of the hematuria is grossly bloody. Patient sent be NH (Nursing Home) due to hematuria for a week. EMS (Emergency Medical Services) reports they were told it had gotten worse over the week. Upon further investigation, was noted on medical records an order from three days ago to place a foley and send to ER if no urine output, therefore after seeing this seems the hematuria is indeed caused by iatogenic malplacement of a foley catheter .He had a foley placed at nursing home about 3 days ago, hematuria and bleeding per urethra after that, some associated low-grade temperatures, moderate to severe, no modifying factors. Significant urethral bleeding, from malpositioned balloon previously with foley trauma. Urology consulted. Review of R #2's Hospital History and Physical dated 04/24/19 documented admitting [DIAGNOSES REDACTED].Patient presented with abdominal distention, blood and clots in brief .patient complaining of pain 10/10 on pain scale .bladder scan measured 1300 ml urine in bladder .coude cath inserted ., received 1300 output with intermittent drainage, urethral trauma and rupture from previous catheterization attempts . Review of R #2's Significant Change MDS dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and personal hygiene -had an indwelling catheter and was always incontinent of bowel -had a feeding tube During an observation and attempted interview with R #2 on 06/11/19 at 3:40 PM revealed he was laying in bed. R #2 was receiving tube feeding of Glucerna 1.5 at 60 milliliters per hour. R #2 was alert and oriented to self only. R #2 said he felt comfortable at the time. When asked about his recent hospital stay, R #2 stated he did not recall going to the hospital. During an interview with Hospital Social Worker (SW) D on 06/12/19 at 11:58 AM revealed the ER physician informed her that R #2 should have been transferred to the hospital 04/22/19 for [MEDICAL CONDITION]. SW D said the physician found R #2's urethra had been traumatized from improper attempt to catherize him which caused bleeding, clotting, inflammation, and blockage that prevented urinary drainage. In an interview with Interim Director of Nurses (IDON) on 06/13/19 at 3:05 PM he said he was not fully aware of R #2's catheter situation that occurred 04/2019. After the IDON reviewed R #2's Nurse's Notes dated 04/19/19 - 04/24/19, the IDON said the nurse should have advised the spouse and informed her of the consequences of waiting on being evaluated and then the nurse should have sent the resident to the hospital as ordered by the physician. The doctor should have been made aware of the spouse's request and the urinary status of the resident at that time and that would allowed the physician to make the decision whether or not to transfer. The IDON stated By reading the nurse's notes, I can see (R #2) was not improving, he went from having blood tinged urine to having gross blood and clots and there was no definite way to know how much urine he was voiding or retaining, which would cause pain, discomfort, and severe complications for the resident. There is no evidence that the doctor was informed of the outcome of the patient from the initial call to him on 04/22/19. The nurse did not follow the orders, he should have sent him to the hospital. The IDON said after reading R #2 nurse's notes, he could not tell if R #2 was urinating an adequate amount since he did not have a catheter. The IDON said monitoring of R #2's urine output was important because he was receiving liquids by enteral feeding and water flushes via his [DEVICE], Continually providing fluids and having no output would put the resident at risk for urine retention, urine to backup into the kidneys. An interview with Registered Nurse (RN) A on 06/13/19 at 3:39 PM revealed he recalled on 04/22/19 at 2:00 PM, R #2 had a catheter already in place when RN A began his shift. RN A said during his shift he noticed R #2's urine was no longer draining into the catheter and R #2 was complaining of abdominal discomfort. RN A said he called the doctor and was told to irrigate and replace the catheter. RN A said he attempted to reinsert a catheter in R #2 but met resistance guiding in the catheter so he said he called the RP and she stated she wanted to wait to send the resident to the ER until the morning because she did not have a ride to get to the hospital. RN A said he told the RP that R #2 had not urinated and the doctor ordered to send him to the hospital but she still wanted to wait to the next morning. When RN A was asked if he contacted R #2's physician, he stated I am not sure that I did, I do not recall. I can't recall how much urine output he put out on my shift. He only had 100 milliliters in the catheter drainage bag from the prior shift and had no output on my shift, before I called the doctor. I saw some urine was leaking around the catheter and the brief had red tinged colored urine but I cannot say how much urine output he had. The urine was red tinged and pink but not bloody. RN A said he did not contact his supervisor to inform her or get further direction on whether to send the resident to the hospital, as the doctor ordered. RN A said Looking back, I should have sent him to the hospital like the doctor ordered. This was my first complicated situation with a catheter. I had not worked with catheters very much, I think this was my first one. Interview with Family Member (FM B) on 06/13/19 at 4:30 PM revealed she confirmed she told RN A to hold R #2's transfer. FM B said she was told R #2 had blood-tinged urine and was not able to get a new catheter into the bladder due to resistance, but he was voiding and did not have any discomfort therefore, FM B said she did not feel that a transfer was necessary, being so late at night. FM B said she was told R #2 did not have any abdominal distention. FM B she was not told by the nurse the consequences of delayed evaluation at any time during the conversation. FM B said she was a retired licensed nurse and said she knew of the consequences that could occur from urinary distension but she was told R #2 was urinating. FM B said The nurse should have called the doctor to tell the doctor (R #2's) status and my suggestion not to transfer. Interview with Licensed Vocational Nurse (LVN) C on 06/13/19 on 5:20 PM revealed she stated she took care of R #2 from 10 PM 04/22/19 - 6:00 AM shift on 04/23/19. LVN C said she recalled LVN A telling her during change of shift that he got an order to transfer the resident to the hospital but that the spouse did not want him transferred until the next morning. LVN C said she recalled R #2 urinated during the night once or twice requiring a brief change. LVN C said there was no way of knowing how much urine output R #2 was expelling because he was incontinent. LVN C said R #2's urine was Very dark amber and said she did not recall if there was any blood. LVN C said R #2 did not complain of any discomfort throughout the night. Interview with the Administrator on 06/13/19 at 6:00 PM revealed he was informed of the evidence found regarding R #2. The Administrator said he was aware of the incident and said All the nurse had to do was follow the doctor's order by sending (R #2) to the hospital. The Administrator said the nurses failed to follow the physician's orders [REDACTED].#2's urinary status, and consult with their supervisor about the (family member) not wanting R #2 to transfer to the hospital. The facility's Abuse and Neglect Prohibition Policy and Procedure dated (MONTH) (YEAR) documented Purpose: To help ensure a resident's right to a safe and healthy environment. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two residents (R #1 and R #2) of six residents reviewed for neglect. 1.) R #1: -OTA [NAME] and PTA F failed to seek training on how to use an Easy Stand device prior to using it on R #1. -Rehabilitation Director (RD) H failed to ensure rehabilitation staff were properly trained and knowledgeable on the use of the Easy Stand machine. -Fac

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one resident (R #2) of two residents reviewed for urinary catheters, in that: The facility's licensed personnel failed to: -properly and efficiently monitor R #2's urinary output; -did not transfer R #2 to the emergency room (ER) timely or as ordered by the physician; -place an indwelling urinary catheter correctly causing urethral rupture and gross hematuria -did not consult with R #2's physician regarding the failed attempts of urinary catheterization, urinary status, or R #2's family member's request not to transfer R #2 to the ER. R #2's indwelling urinary catheter became clogged causing abdominal distension, discomfort, pain and incurred bloody urine and clots. R #2 was transferred to the hospital two days after the initial physician's orders [REDACTED]. This deficient practice could have placed residents with indwelling urinary catheters at risk for abdominal distention, discomfort, pain, and urethral trauma. The findings included: Review of R #2's Face Sheet dated 06/13/19 documented an [AGE] year-old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #2's (MONTH) 2019 Consolidated physician's orders [REDACTED]. Flush with 30-60 milliliters of water before and after meds, before initiating feeding or when there is an interruption of feeding to maintain tube patency; Hydration - Bolus with 150 milliliters of water every 4 hours. Review of R #2's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -was always incontinent of bladder and bowel -had a feeding tube. Review of R #2's Nurse's Note dated 04/19/19 at 10:33 AM documented As per Resident Care Specialist (RCS), upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Medical Doctor (MD) office is closed until tomorrow. Answering services couldn't even direct the call to the on call MD. Nurse Practitioner substituting for Doctor has cell phone off and not receiving call. Phone number was called x 4. Will follow up. Review of R #2's SBAR (Situation Background Assessment Request) Communication Form and Progress Note dated 04/19/19 documented Inflammation of foreskin and shaft. Verbalizes discomfort upon assessment. As per RCS, upon changing the resident, penis was noted swollen. Therefore, upon assessment, inflammation to shaft and foreskin was noted and upon assessing resident did verbalize discomfort. No drainage nor foul odor noted. Will continue to monitor. MD (Medical Doctor) office is closed until tomorrow. Answering services couldn't even direct the call to the on-call MD. Np (Nurse practitioner) substituting for MD has cell phone off and not receiving call. Phone number was called x 4. Review of R #2's Comprehensive Care Plan dated 04/21/19 documented I have [MEDICAL CONDITION] .Interventions: Collect urine for culture and senstitivity and report results to medical doctor; insert foley catheter 16 french and leave in place if there is a significant amount of urine output; irrigate indwelling catheter, if no urinary return, remove existing urinary catheter and insert new urinary catheter, if no uinary return with new indwelling catheter, send to ER for evaluation. Review of R #2's Telephone Physician order [REDACTED]. Resident is alert oriented X 1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. MD made aware and gave orders for 16 French (Fr) Urinary Catheter to be inserted, and to leave it in place if a significant amount of urine was present. Ordered UA (urinalysis) Culture and Sensitivity (C & S) and to consult Urology. RP (Responsible party) made aware of clinical situation. Review of R #2's SBAR Communication Form and Progress Note dated 04/21/19 documented 8:08 AM - Resident is alert oriented X1, no change in cognition from baseline. Resident complaining of discomfort to lower abdomen. Upon assessment, there was distention visible. Additional Nursing Notes as applicable: MD made aware and gave orders for 16 Fr Urinary Catheter to be inserted 04/19/19, and to leave it in place if a significant amount of urine was present. Ordered UA C+S and to consult Urology. Review of R #2's Nurse's Note dated 04/21/19 at 10:57 AM documented Resident alert oriented X 1, no change in cognition from baseline. 04/10 on pain scale. Resident complaining of discomfort to lower abdomen. Upon assessment there was visible distention. There was also scrotal and penile [MEDICAL CONDITION] present. MD notified and gave orders to insert a foley due to possible [MEDICAL CONDITION] and to be left in place if there was a significant amount of urine present. He also ordered for UA C&S to be collected. 16 FR (French) urinary catheter with 10CC (cubic centimeters) balloon inserted using sterile technique. Resident tolerated procedure well. There was an initial urine output of 700ML (milliliters), amber in coloration with 5 small stones present, measuring approximately 0.1cm (centimeters) in diameter. There was a total of 2300ML of urine output. This was done using intermittent volume drainage. Resident stated that he felt relief and that pain had subsided. 0/10 on pain scale. Resident in no acute distress/discomfort and will continue to be monitored. Review of R #2's Nurse's Note dated 04/21/19 documented Resident indwelling urinary catheter had 100 ml of hematuria (bloody urine), in collection bag @ 2 PM. No further urine was draining and collected and resident diaper was stained in hematuria as hematuria was draining between urethra and foley. Called MD and ordered irrigation, and if no urine produced to replace catheter, if still no urine produced to send resident to emergency room (ER). Irrigation with 100 ml of Normal Saline produced no urine and insertion of new 16 French catheter met with resistance and no urine collected verified with LVN. RP stated she wanted resident to wait for ER visit until 4/22 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Telephone Physician order [REDACTED]. If no urinary return with new indwelling catheter, send resident to ER for evaluation. Review of R #2's Nurse's Note dated 04/22/10 documented 9:00 PM - Resident indwelling urinary catheter had 100 ml of hematuria in collection bag @ 2PM. No further urine was draining and collected and resident diaper was stained in hematuria, as hematuria was draining between urethra and foley. Called (MD) and ordered irrigation, and if no urine produced to replace catheter, if still no urine produce to send resident to ER. Irrigation with 100 ml of NS produced no urine and insertion of new 16 French catheter meet with resistance and no urine collected verified with LVN. RP (responsible party) stated she wanted resident to wait for ER visit until 4/23 in the morning (as RP has no transportation), unless resident was in discomfort/distress. Review of R #2's Nurse's Note dated 04/22/19 documented 10:06 PM - Attempt indwelling foley catheter insertion, if unsuccessful send resident toER on ,[DATE] in the morning as per Wife. Review of R #2's Nurse's Note dated 04/23/19 documented 5:50 AM -Resident voided during 10/6 shift large quantity, dark in color no distress is noted will continue to monitor. R #2 urinated one time from 04/22/19 at 2:00 PM -04/23/19 at approximately 5:00 AM, which documentation showed he urinated one large amount (specific amount undetermined) of urine in the early morning shift of 04/23/19. R #2 continued to receive his ordered enteral feeding and at least 150 mls of water every 4 hours. Review of R #2's Nurse's Note dated 04/23/19 revealed 8:50 AM - RP in facility visiting resident. Per RP nurse to hold transfer at this time until further notice. RP made aware about resident voiding a large amount of urine during night shift. Advised RP nurse will continue to monitor output and will notify if any changes. Advised RP order to transfer is valid and may send out resident at any time if needed. Resident is currently resting comfortably without any signs of discomfort. No abdominal distention noted. No pain upon palpation. Review of R #2's Nurse's Note dated 04/23/19 documented 9:50 AM - Resident remains without a foley. Nurse monitoring output. Assisted RCS with incontinent care to resident. Appears to be voiding in diaper. Diaper noted with blood tinged stains and a medium amount of urine. During incontinent care earlier in the morning, resident voided a large amount of urine without difficulty. No abdominal distention noted. No c/o pain or discomfort. Will continue to monitor. Review of R #2's Nurse's Note dated 04/23/19 documented 3:00 PM - Resident presented scant amounts of blood clots on diaper, as well as urine that saturated diaper. Review of R #2's Nurse's Note dated 04/23/19 documented 8:00 PM - Resident diaper presented with urine, tinged blood color present. Review of R #2's Nurse's Note dated 04/24/19 documented 11:09 AM - During report night nurse notified me that resident was being monitored for [MEDICAL CONDITION] and hematuria. MD was aware of situation and had given orders to send resident to ER for further evaluation on 4/22 but RP held transfer. Upon assessment resident presented with blood clots on diaper. Called RP to notify of situation. RP agreed with MD orders to send resident to ER for further evaluation. Review of R #2's Telephone Nurse's Note dated 04/24/19 documented 11:45 AM - Resident transferred to ER for further evaluation via stretcher by ambulance. Review of R #2's Nurse's Note dated 04/24/19 documented 8:46 PM - Resident admitted to (hospital) for [DIAGNOSES REDACTED]. Review of R #2's Emergency Department Physician Document - Final Report dated 04/24/19 documented Patient presents with hematuria with onset of one week ago. Character of the hematuria is grossly bloody. Patient sent be NH (Nursing Home) due to hematuria for a week. EMS (Emergency Medical Services) reports they were told it had gotten worse over the week. Upon further investigation, was noted on medical records an order from three days ago to place a foley and send to ER if no urine output, therefore after seeing this seems the hematuria is indeed caused by iatogenic malplacement of a foley catheter .He had a foley placed at nursing home about 3 days ago, hematuria and bleeding per urethra after that, some associated low-grade temperatures, moderate to severe, no modifying factors. Significant urethral bleeding, from malpositioned balloon previously with foley trauma. Urology consulted. Review of R #2's Hospital History and Physical dated 04/24/19 documented admitting [DIAGNOSES REDACTED].Patient presented with abdominal distention, blood and clots in brief .patient complaining of pain 10/10 on pain scale .bladder scan measured 1300 ml urine in bladder .coude cath inserted ., received 1300 output with intermittent drainage, urethral trauma and rupture from previous catheterization attempts . Review of R #2's Significant Change MDS dated [DATE] documented he: -had unclear speech -had a brief interview of mental status score of 9 (moderately impaired cognition) -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and personal hygiene -had an indwelling catheter and was always incontinent of bowel -had a feeding tube An observation and attempted interview with R #2 on 06/11/19 at 3:40 PM revealed he was laying in bed. R #2 was receiving tube feeding of Glucerna 1.5 at 60 milliliters per hour. R #2 was alert and oriented to self only. R #2 said he felt comfortable at the time. When asked about his recent hospital stay, R #2 stated he did not recall going to the hospital. An interview with Hospital Social Worker (SW) D on 06/12/19 at 11:58 AM revealed the ER physician informed her that R #2 should have been transferred to the hospital 04/22/19 for [MEDICAL CONDITION]. SW D said the physician found R #2's urethra had been traumatized from improper attempt to catherize him which caused bleeding, clotting, inflammation, and blockage that prevented urinary drainage. In an interview with Interim Director of Nurses (IDON) on 06/13/19 at 3:05 PM he said he was not fully aware of R #2's catheter situation that occurred 04/2019. After the IDON reviewed R #2's Nurse's Notes dated 04/19/19 - 04/24/19, the IDON said the nurse should have advised the spouse and informed her of the consequences of waiting on being evaluated and then the nurse should have sent the resident to the hospital as ordered by the physician. The doctor should have been made aware of the spouse's request and the urinary status of the resident at that time and that would allowed the physician to make the decision whether or not to transfer. The IDON stated By reading the nurse's notes, I can see (R #2) was not improving, he went from having blood tinged urine to having gross blood and clots and there was no definite way to know how much urine he was voiding or retaining, which would cause pain, discomfort, and severe complications for the resident. There is no evidence that the doctor was informed of the outcome of the patient from the initial call to him on 04/22/19. The nurse did not follow the orders, he should have sent him to the hospital. The IDON said after reading R #2 nurse's notes, he could not tell if R #2 was urinating an adequate amount since he did not have a catheter. The IDON said monitoring of R #2's urine output was important because he was receiving liquids by enteral feeding and water flushes via his [DEVICE], Continually providing fluids and having no output would put the resident at risk for urine retention, urine to backup into the kidneys. An interview with Registered Nurse (RN) A on 06/13/19 at 3:39 PM revealed he recalled on 04/22/19 at 2:00 PM, R #2 had a catheter already in place when RN A began his shift. RN A said during his shift he noticed R #2's urine was no longer draining into the catheter and R #2 was complaining of abdominal discomfort. RN A said he called the doctor and was told to irrigate and replace the catheter. RN A said he attempted to reinsert a catheter in R #2 but met resistance guiding in the catheter so he said he called the RP and she stated she wanted to wait to send the resident to the ER until the morning because she did not have a ride to get to the hospital. RN A said he told the RP that R #2 had not urinated and the doctor ordered to send him to the hospital but she still wanted to wait to the next morning. When RN A was asked if he contacted R #2's physician, he stated I am not sure that I did, I do not recall. I can't recall how much urine output he put out on my shift. He only had 100 milliliters in the catheter drainage bag from the prior shift and had no output on my shift, before I called the doctor. I saw some urine was leaking around the catheter and the brief had red tinged colored urine but I cannot say how much urine output he had. The urine was red tinged and pink but not bloody. RN A said he did not contact his supervisor to inform her or get further direction on whether to send the resident to the hospital, as the doctor ordered. RN A said Looking back, I should have sent him to the hospital like the doctor ordered. This was my first complicated situation with a catheter. I had not worked with catheters very much, I think this was my first one. An interview with Family Member (FM B) on 06/13/19 at 4:30 PM revealed she told RN A to hold R #2's transfer. FM B said she was told R #2 had blood-tinged urine and was not able to get a new catheter into the bladder due to resistance, but he was voiding and did not have any discomfort therefore, FM B said she did not feel that a transfer was necessary, being so late at night. FM B said she was told R #2 did not have any abdominal distention. FM B she was not told by the nurse the consequences of delayed evaluation at any time during the conversation. FM B said she was a retired licensed nurse and said she knew of the consequences that could occur from urinary distension but she was told R #2 was urinating. FM B said The nurse should have called the doctor to tell the doctor (R #2's) status and my suggestion not to transfer. An interview with Licensed Vocational Nurse (LVN) C on 06/13/19 on 5:20 PM revealed she took care of R #2 from 10 PM 04/22/19 - 6:00 AM shift on 04/23/19. LVN C said she recalled LVN A telling her during change of shift that he got an order to transfer the resident to the hospital but that the spouse did not want him transferred until the next morning. LVN C said she recalled R #2 urinated during the night once or twice requiring a brief change. LVN C said there was no way of knowing how much urine output R #2 was expelling because he was incontinent. LVN C said R #2's urine was Very dark amber and said she did not recall if there was any blood. LVN C said R #2 did not complain of any discomfort throughout the night. An interview with the Administrator on 06/13/19 at 6:00 PM revealed he was informed of the evidence found regarding R #2. The Administrator said he was aware of the incident and said All the nurse had to do was follow the doctor's order by sending (R #2) to the hospital. The Administrator said the nurses failed to follow the physician's orders [REDACTED].#2's urinary status, and consult with their supervisor about the (family member) not wanting R #2 to transfer to the hospital. Review of the facility's Abuse and Neglect Prohibition Policy and Procedure dated (MONTH) (YEAR) documented Purpose: To help ensure a resident's right to a safe and healthy environment. Neglect means a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility's undated Indwelling Urinary Catheter Policy and Procedure did not include procedures for [MEDICAL CONDITION]. As of exit date 06/14/19, the facility took the following actions to correct the non-compliance by: -observation and interview of R #2 revealed he continued to reside in the facility (at the time of this investigation) no longer had an indwelling urinary catheter. -observation of two other residents in the facility with indwelling urinary catheters receiving catheter care and monitoring revealed no concerns identified. -review of the facility in-services on indwelling urinary catheter insertion, care, and monitoring, communication, change in condition, and physician notification of change in condition revealed all nursing personnel were in-serviced on 04/26/19. -six licensed nurses were interviewed stating they had received training on indwelling urinary catheter insertion, care, and monitoring, abuse and neglect, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -five certified nurse aides were interviewed stating they had received training on indwelling urinary catheter insertion, care, and monitoring, abuse and neglect, communication, and change in condition. These staff represented all shifts. -review of two sampled resident's, with indwelling urinary catheters, revealed physician's orders [REDACTED].

Based on observation, record review and interview, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one Resident (R#2) of 2 residents reviewed for falls and accident hazards. R #1 had a fall during therapy on an Easy Stand device, sustaining a fractured left hip. -OTA [NAME] and PTA F failed to seek training on how to use an Easy Stand device prior to using it on R #1. -Rehabilitation Director (RD) H failed to ensure rehabilitation staff were properly trained and knowledgeable on the use of the Easy Stand machine. -Facility staff failed to follow the Easy Stand Manufacturer's Safety Recommendations. -Facility staff failed to seek nursing assistance for assessment and evaluation prior to moving R #1 immediately after his fall. This deficient practice could have affected residents receiving rehabilitation therapy with serious injuries, decreased quality of life and impaired physical functioning. The findings included: Review of R#1's Face Sheet dated 03/27/19 documented an [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented he: -had clear speech -usually understood and understands -was totally dependent on staff with one or two staff physical support for bed mobility, transfers, dressing, eating, and required extensive assistance for personal hygiene -had functional limitation in range of motion - lower extremity had impairment on both sides -mobility device was a wheelchair Review of R#1's Nurse's Note dated 03/26/19 at 12:20 p.m. documented As per therapists (Occupational Therapist Assistant-OTA) [NAME] and (Physical Therapist Assistant-PTA) F, resident had a witnessed fall during therapy activity. As per resident, he stated that he was on a new machine and that the strap from his bottom came off and he fell down to the floor and bumped his head. Review of R#1's Nurse's Note dated 03/26/19 12:26 PM documented Resident was assessed by writer after fall. Resident is up to wheelchair at the nurses station. Resident was able to state that he fell from a machine he was standing on. Resident stated he felt pain all over his body and he hit his head .Resident stated he also hit his left leg and back. Resident was unable to numerically state pain but did voice he felt much dolor (pain). Review of Radiology Interpretation dated 03/26/19, revealed Significant Findings: Hips, Bilateral: Findings: There is a [MEDICAL CONDITION] femoral neck with angulation. There is osteopenia. There is angulation. Review of R #1's emergency room documentation from local hospital revealed a result date of 03/27/19 documented Chief complaint - patient /resident sent from local nursing home due to having a fracture left femur, patient fell yesterday during therapy. Interview with OTA [NAME] on 06/13/19 at 10:30 a.m. revealed OTA [NAME] said R #1 did not have a back strap and there was not enough space in front of the Easy Stand device to place the wheelchair, the machine was not locking, there was no wheelchair behind the resident, and the knee pad was not working. OTA [NAME] stated R#1 fell because there was no back strap (supports and holds resident in place), she was not aware machine should have had a back strap, she did not know how to use the machine, and she had not been inserviced on how to use the Easy Stand device. Surveyor asked OTA [NAME] if the facility's Physical Therapist had been inserviced on the use of the machine, OTA [NAME] replied no. OTA [NAME] said the first time she had ever used the Easy Stand Device was when she used it on R#1 and the booklet for instructions was not provided for her. OTA [NAME] confirmed she did not seek guidance from her supervisors on how to use the machine before she used it on R #1. Interview with PTAFon 06/13/19 at 11:08 a.m. revealed PTA F was asked by surveyor to describe what had caused R# 1's fall. PTA F said he was bent down and attempting to adjust and tighten the knee rests when the buttock strap slid down to R #1's lower legs then R #1 began to fall back. PTA F said he attempted to grab R #1's clothing to catch him but was unsuccessful. PTA F said the buttock strap had slipped down to his (R#1's) ankles when he reached the floor. Surveyor asked PTA F if he had been trained on how to use the machine in this facility, PTA F replied no. PTA F confirmed safe practice when using any new device would be to get inservice and read the equipments manual/user guide. PTA F /onfirmed he did not seek guidance from his supervisors on how to use the machine before he used it on R #1. PTA F/ said he always used a gait belt on residents he provided therapy to for support and stability. PTA F said he did not use a gait belt on R #1 during his therapy. Interview with Rehabilitation Director (RD) H on 06/13/19 at approximately 11:15 a.m. revealed she was informed via a text message informing her of R #1's fall in the rehabilitation gym. RD H said she found out R #1 was picked up off the floor, transferred in his wheelchair, and taken to the nurse's station, instead of waiting for a nurse to come to him to assess him. RD H confirmed OTA [NAME] and PTA F did not follow protocol when they moved R #1 off the floor, after his fall, prior to being assessed by a nurse. RD H said R #1 needed an immediate nursing assessment and moving him could cause an injury or worsen the injury. RD H said her interviews from staff present at the time revealed that OTA [NAME] and PTA F had R #1 standing on the Easy Stand with OTA [NAME] on R #1's left side and PTA F on R #1's right side. RD H said PTA F was attempting to tighten the loose knee pads (while R #1 was standing and leaning on the equipment) but was unsuccessful. RD H said she was told PTA F called the maintenance supervisor and at that time they were both kneeled down attempted to figure out how to adjust and tighten the knee pads. RD H said the staff turned R #1 on the machine, slightly as they were attempting to adjust it when they saw the buttocks strap slip down to his lower legs and R #1 began to fall backwards. RD H said OTA [NAME] and PTA F told her they tried to catch and break R #1's fall but were unsuccessful. RD H said It is ultimately my responsibility that all equipment in the rehab department is functioning properly. RD H said OTA [NAME] and PTA F were not provided in-service prior to using the Easy Stand on R #1. RD H confirmed an inservice should have been provided to all rehab staff, including OTA [NAME] and PTA F prior to use of the Easy Stand device. RD H said the User Guide was provided when the Easy Stand arrived to the facility, The therapy staff, including myself, had the opportunity to read the user guide, however, I guess it was not done before it was used. RD H stated after R #1's fall, various inservices regarding appropriate use of equipment and resident safety were provided to all rehab staff. RD H explained she called the manufacturer and informed them what happened and the manufacturer provided all the therapists with in-depth inservice and demonstration on the appropriate use of the machine and parts.RD H said the manufacture representative assessed the machine and added parts to it which included: a leg swivel which opened outward for machine's stability, a back support strap for patient support and stability, an adjustable table to tray, foot straps, and the the adjustment of the loose knee pads. RD H stated After evaluating the incident, in my opinion, staff should have been in-serviced on it's use prior to using the equipment for safety of the patient and therapist, ensure correct usage of the equipment, ensure knowledge of how to troubleshoot, and ensure it was in correct working condition prior to use. I believe they failed to follow proper procedures.They failed on being in-serviced on the correct use and knowledge of the machine, the correct training for lifting and transferring residents on this special machine, the appropriate protocol when a patient sustained a fall, protocols on seeking supervisors and following supervisor recommendations. Further interview with OTA [NAME] on 06/13/19 at 12:41 PM revealed she did not follow facility protocol when she and PTA F moved R #1 and transferred him from the floor to the wheelchair but R #1 kept telling her to pick him up. OTA [NAME] said R #1 had 20-30 degree contractures in his legs and could not walk so she and PTA F lifted R #1 up from the floor to his wheelchair. OTA [NAME] said It is important to get assessed before getting him up to ensure he is alert and make sure he does not have anything broken. The resident denied any pain, he just was anxious and wanted us to get him up from the floor. During an interview with Physical Therapist (PT) G on 06/13/19 at 4:05 p.m., when asked if he had been given an inservice training prior to using the Easy Stand device for R #1, PT G replied no. During an interview on 06/13/19 at 4:28 p.m., with the facility's Occupational Therapist Registered (OTR) I, when asked if therapy staff had been trained prior to using the Easy Stand device for R#1, OTR I stated the therapy staff were not trained prior to using the Easy Stand Device for R#1. OTR I replied the physical therapy staff were trained on how to use the Easy Stand device after R#1's incident/fall. An interview with the Administrator on 06/13/19 at 6:00 PM revealed he was made aware of the concerns identified regarding R #1 and his fall. The Administrator said he was aware and agreed that the rehabilitation department should not have used the Easy Stand without first receiving training on how to properly use it. The Administrator said the Director of Rehabilitation Services was responsible for ensuring staff were trained on the use of the equipment before it was initially used. The Administrator confirmed the Rehabilitation staff should not have moved the resident when he was on the floor, until he was assessed by the nurse. The Administrator confirmed the rehabilitation staff did not follow policy and procedures on resident care and safety that contributed to R #1's fall and injury. Review of facility's Policy/Procedure Medical Equipment Management Plan revision date (MONTH) (YEAR) indicated Testing and Service Requirement Education of proper use and /or maintenance should be provided by a qualified person . Procedure 1. All medical equipment in the facility's management program is tested for safety and performance prior to initial use .by qualified persons. 6. Training should address: - capabilities, limitations,and special application of equipment -basic operating and safety procedures for equipment use Review of owner's Manual for Easy Stand device (provided by the facility Administrator on 06/14/19 at approximately 10:30 a.m. indicated): Introduction Intended Use - The Easy Stand .is intended to assist individual who have difficulty rising from a seated position to a standing position. This manual is an integral part of the standing system and should be read completely and thoroughly by anyone operating the unit. Safety Precautions: -Check the EasyStand periodically to ensure that all nuts, bolts and adjustable parts are tightened securely. -Never make adjustments to the EasyStand while a user is in the standing position . -Extreme movements laterally or front to back may cause the unit to tip. As of exit date 06/14/19, the facility took the following actions to correct the non-complaince by: -observation of two other residents in he facility receiving physical and occupational therapy and used therapy equipment revealed no concerns identified. -six licensed nurses were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -three licensed therapist were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, Easy Stand manufacturer training, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -two certified therapists were interviewed stating they had received training on abuse and neglect, safety awareness program, falls, Easy Stand manufacturer training, lifts and transfers, communication, change in condition, and physician notification of change in condition. These staff represented all shifts. -as of 06/14/19, the administrator stated the Easy Stand device was removed and not made available to anyone in the facility for use. -review of physician's orders [REDACTED].

Based on interview and record review the facility failed to receive adequate supervision to prevent and be free from accidents for 1 (#1) of 3 residents reviewed for behavior management and supervision in that: Supervise Resident #1 when she wandered into the back courtyard Resident #1 was found in a back courtyard with symptoms of heatstroke This deficient practice could affect 2 residents who are confused and wander in the facility and have access to the courtyard areas at all times and result in physiological and bodily injury. The findings were: Review of Resident #1's electronic face sheet dated 9/29/17 revealed she was admitted on [DATE] revealed she was admitted with [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive plan of care dated 2/16/16 and reviewed on 4/16/17 revealed under Focus .I have a potential safety and fall risk related to: safety related to wandering, potential for falls .decreased safety awareness .Goal .I will be observed for wandering/elopement behavior and other safety concerns and remain safe within the facility .interventions .observe frequently during increased wandering to ensure safety. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed she scored a 12 which placed her at risk. Review of Resident #1's physician orders [REDACTED]. Review of Resident #1's change in condition (SBAR) for Situation, Background, Assessment and Recommendation dated 9/14/17 at 10:26 p.m. revealed that situation .elevated temperature, elevated pulse, extended sun exposure .this started on 9/14/17 .since this started has gotten .worse. Review of vital signs under the assessment revealed a pulse of 112, respiratory rate of 22 and a temporal temperature (A forehead (temporal) scanner is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature) of 104 degrees Fahrenheit. Further review under the assessment .resident noted in outside courtyard sitting in sun during evening shift sitting on grass. Apparent signs of redness to extremities and upper thoracic area .unable to follow commands, resident in vocal distress to be removed from area .given orders to send to emergency room for observation and evaluation. Review of Resident #1's Discharge Summary from the hospital dated 9/16/17 revealed Diagnoses: [REDACTED].patient was found to be volume depleted and dehydrated .labs revealed chemistry with sodium 132 (normal 135 to 145) and potassium 5.2 (normal 3.6-5.2) .aggressive intravenous rehydration therapy was initiated, and kayexalate was administered for hyperkalemia. Review of the facility incident report dated 9/14/17 revealed the resident was found at 3:45 p.m. Review of the facility investigation report (undated) revealed that the resident was seen by two staff members inside the facility during a staff meeting in C Wing, and the resident proceeded to continue wheeling herself into D Wing's television room. Resident #1 then opened the patio door in D Wing and went outside to the patio .when the aide went to get Resident #1 for her shower she could not find her and found her in the patio area sitting on the grass next to her wheelchair, and went to get the RN A. Observation on 9/27/17 at 11:30 a.m. revealed Resident #1 in her wheel chair rolling about the facility and had a wanderguard in place on her left wrist. Interview on 9/27/17 at 12:40 p.m. with RN C, she stated that since the incident with Resident #1, the staff had an in-service and was supposed to now make hourly rounds and check on residents. Interview with CNA B on 9/28/17 at 11:40 p.m., she stated that she worked on 9/14/17 and the last time she saw Resident #1 was at 1:45 p.m., and she had her hat on crooked and she fixed it before the resident wheeled off. She said she felt like there was enough staff to supervise residents like Resident #1, but that staff needed to be more vigilant. Interview on 9/29/17 with the Administrator at 09:30 a.m. as to why he did not report the incident with Resident #1, he stated that she did not appear to have any obvious injuries. Interview on 9/29/17 at 1:55 p.m. with RN A revealed that he came into the facility at 2:00 p.m. there was an activity in the lobby on 09/14/17 for staff about rewards and staff lost about 20 minutes with that. He said that the facility had showers that day, and someone brought it to my attention, they couldn't find Resident #1. Based on documentation the estimation was that she was out in the courtyard for two hours. Within 30 minutes, a CNA told him Resident #1 was in the courtyard and to just come. He said Resident #1 was on the grass with her shirt and shoes off, it was hot. He stated that he just tried to get her to the hospital quickly because her temporal temperature was 104 degrees Fahrenheit (F). The temporal thermometer registers approximately .5 to 1 degree lower than an oral temp. He stated that since the incident with resident #1, staff do hourly checks on the courtyards and Resident #1. Observation on 9/29/17 at 2:00 p.m. with RN A of the courtyard where Resident #1 was found revealed it was located in the back of the facility and was entered through a small television room, and was about 100 feet wide by 300 feet long with no visibility from the facility except for resident rooms and through the television room. There was one small tree in the courtyard and he pointed out where Resident #1 was located which was about 7 feet to the left side of the small tree. Review of the weather for Laredo for 9/14/17 from https://www.wunderground.com/history/airport/KLRD/2017/9/29/MonthlyCalendar.html revealed the temperature was 106 degrees Fahrenheit and average humidity for that day 39. A calculated heat index of 123 degrees which is what it would feel like for someone (http://www.weather.gov/epz/wxcalc_heatindex). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Heat stroke can kill or cause damage to the brain and other internal organs. (https://www.webmd.com/a-to-z-guides/heat-stroke-symptoms-and-treatment). Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility took action to correct the deficiency on 9/15/17 with in-services provided to staff on supervision and hourly checks of the courtyards. Increased monitoring and supervision was provided by administration of staff for monitoring residents who wander. The DON provided information on 9/29/17 that there were two residents who are confused and wander in the main area of the facility.

Based on interview and record review the facility failed to prevent neglect for 1 (#1) of 3 residents reviewed for behavior management and supervision in that: Supervise Resident #1 when she wandered into the back courtyard Resident #1 was found in a back courtyard with symptoms of heatstroke This deficient practice could affect 2 residents who are confused and wander in the facility and have access to the courtyard areas at all times and result in physiological and bodily injury. The findings were: Review of Resident #1's electronic face sheet dated 9/29/17 revealed she was admitted on [DATE] revealed she was admitted with [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive plan of care dated 2/16/16 and reviewed on 4/16/17 revealed under Focus .I have a potential safety and fall risk related to: safety related to wandering, potential for falls .decreased safety awareness .Goal .I will be observed for wandering/elopement behavior and other safety concerns and remain safe within the facility .interventions .observe frequently during increased wandering to ensure safety. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed she scored a 12 which placed her at risk. Review of Resident #1's physician orders [REDACTED]. Review of Resident #1's change in condition (SBAR) for Situation, Background, Assessment and Recommendation dated 9/14/17 at 10:26 p.m. revealed that situation .elevated temperature, elevated pulse, extended sun exposure .this started on 9/14/17 .since this started has gotten .worse. Review of vital signs under the assessment revealed a pulse of 112, respiratory rate of 22 and a temporal temperature (A forehead (temporal) scanner is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature) of 104 degrees Fahrenheit. Further review under the assessment .resident noted in outside courtyard sitting in sun during evening shift sitting on grass. Apparent signs of redness to extremities and upper [MEDICATION NAME] area .unable to follow commands, resident in vocal distress to be removed from area .given orders to send to emergency room for observation and evaluation. Review of Resident #1's Discharge Summary from the hospital dated 9/16/17 revealed Diagnoses: [REDACTED].patient was found to be volume depleted and dehydrated .labs revealed chemistry with sodium 132 (normal 135 to 145) and potassium 5.2 (normal 3.6-5.2) .aggressive intravenous rehydration therapy was initiated, and [MEDICATION NAME] was administered for [MEDICAL CONDITION]. Review of the facility incident report dated 9/14/17 revealed the resident was found at 3:45 p.m. Review of the facility investigation report (undated) revealed that the resident was seen by two staff members inside the facility during a staff meeting in C Wing, and the resident proceeded to continue wheeling herself into D Wing's television room. Resident #1 then opened the patio door in D Wing and went outside to the patio .when the aide went to get Resident #1 for her shower she could not find her and found her in the patio area sitting on the grass next to her wheelchair, and went to get the RN A. Observation on 9/27/17 at 11:30 a.m. revealed Resident #1 in her wheel chair rolling about the facility and had a wanderguard in place on her left wrist. Interview on 9/27/17 at 12:40 p.m. with RN C, she stated that since the incident with Resident #1, the staff had an in-service and was supposed to now make hourly rounds and check on residents. Interview with CNA B on 9/28/17 at 11:40 p.m., she stated that she worked on 9/14/17 and the last time she saw Resident #1 was at 1:45 p.m., and she had her hat on crooked and she fixed it before the resident wheeled off. She said she felt like there was enough staff to supervise residents like Resident #1, but that staff needed to be more vigilant. Interview on 9/29/17 with the Administrator at 09:30 a.m. as to why he did not report the incident with Resident #1, he stated that she did not appear to have any obvious injuries. Interview on 9/29/17 at 1:55 p.m. with RN A revealed that he came into the facility at 2:00 p.m. there was an activity in the lobby on 09/14/17 for staff about rewards and staff lost about 20 minutes with that. He said that the facility had showers that day, and someone brought it to my attention, they couldn't find Resident #1. Based on documentation the estimation was that she was out in the courtyard for two hours. Within 30 minutes, a CNA told him Resident #1 was in the courtyard and to just come. He said Resident #1 was on the grass with her shirt and shoes off, it was hot. He stated that he just tried to get her to the hospital quickly because her temporal temperature was 104 degrees Fahrenheit (F). The temporal thermometer registers approximately .5 to 1 degree lower than an oral temp. He stated that since the incident with resident #1, staff do hourly checks on the courtyards and Resident #1. Observation on 9/29/17 at 2:00 p.m. with RN A of the courtyard where Resident #1 was found revealed it was located in the back of the facility and was entered through a small television room, and was about 100 feet wide by 300 feet long with no visibility from the facility except for resident rooms and through the television room. There was one small tree in the courtyard and he pointed out where Resident #1 was located which was about 7 feet to the left side of the small tree. Review of the weather for Laredo for 9/14/17 from https://www.wunderground.com/history/airport/KLRD/2017/9/29/MonthlyCalendar.html revealed the temperature was 106 degrees Fahrenheit and average humidity for that day 39. A calculated heat index of 123 degrees which is what it would feel like for someone (http://www.weather.gov/epz/wxcalc_heatindex). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Heat stroke can kill or cause damage to the brain and other internal organs. (https://www.webmd.com/a-to-z-guides/heat-stroke-symptoms-and-treatment). Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility took action to correct the deficiency on 9/15/17 with in-services provided to staff on supervision and hourly checks of the courtyards. Increased monitoring and supervision was provided by administration of staff for monitoring residents who wander. The DON provided information on 9/29/17 that there were two residents who are confused and wander in the main area of the facility.

Based on interview and record review the facility failed to develop and implement written policies and procedures to prevent neglect for 1 (R#1) of 3 residents reviewed for behavior management and supervision in that: Superivse Resident #1 when she wandered into the back courtyard Resident #1 was found in a back courtyard with symptoms of heatstroke This deficient practice could affect 2 residents who are confused and wander in the facility and have access to the courtyard areas at all times and result in physiological and bodily injury. The findings were: Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of Resident #1's electronic face sheet dated 9/29/17 revealed she was admitted on [DATE] revealed she was admitted with [DIAGNOSES REDACTED]. Review of Resident #1's comprehensive plan of care dated 2/16/16 and reviewed on 4/16/17 revealed under Focus .I have a potential safety and fall risk related to: safety related to wandering, potential for falls .decreased safety awareness .Goal .I will be observed for wandering/elopement behavior and other safety concerns and remain safe within the facility .interventions .observe frequently during increased wandering to ensure safety. Review of Resident #1's Elopement Risk assessment dated [DATE] revealed she scored a 12 which placed her at risk. Review of Resident #1's physician orders [REDACTED]. Review of Resident #1's change in condition (SBAR) for Situation, Background, Assessment and Recommendation dated 9/14/17 at 10:26 p.m. revealed that situation .elevated temperature, elevated pulse, extended sun exposure .this started on 9/14/17 .since this started has gotten .worse. Review of vital signs under the assessment revealed a pulse of 112, respiratory rate of 22 and a temporal temperature (A forehead (temporal) scanner is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature) of 104 degrees Fahrenheit. Further review under the assessment .resident noted in outside courtyard sitting in sun during evening shift sitting on grass. Apparent signs of redness to extremities and upper [MEDICATION NAME] area .unable to follow commands, resident in vocal distress to be removed from area .given orders to send to emergency room for observation and evaluation. Review of Resident #1's Discharge Summary from the hospital dated 9/16/17 revealed Diagnoses: [REDACTED].patient was found to be volume depleted and dehydrated .labs revealed chemistry with sodium 132 (normal 135 to 145) and potassium 5.2 (normal 3.6-5.2) .aggressive intravenous rehydration therapy was initiated, and [MEDICATION NAME] was administered for [MEDICAL CONDITION]. Review of the facility incident report dated 9/14/17 revealed the resident was found at 3:45 p.m. Review of the facility investigation report (undated) revealed that the resident was seen by two staff members inside the facility during a staff meeting in C Wing, and the resident proceeded to continue wheeling herself into D Wing's television room. Resident #1 then opened the patio door in D Wing and went outside to the patio .when the aide went to get Resident #1 for her shower she could not find her and found her in the patio area sitting on the grass next to her wheelchair, and went to get the RN A. Observation on 9/27/17 at 11:30 a.m. revealed Resident #1 in her wheel chair rolling about the facility and had a wanderguard in place on her left wrist. Interview on 9/27/17 at 12:40 p.m. with RN C, she stated that since the incident with Resident #1, the staff had an in-service and was supposed to now make hourly rounds and check on residents. Interview with CNA B on 9/28/17 at 11:40 p.m., she stated that she worked on 9/14/17 and the last time she saw Resident #1 was at 1:45 p.m., and she had her hat on crooked and she fixed it before the resident wheeled off. She said she felt like there was enough staff to supervise residents like Resident #1, but that staff needed to be more vigilant. Interview on 9/29/17 with the Administrator at 09:30 a.m. as to why he did not report the incident with Resident #1, he stated that she did not appear to have any obvious injuries. Interview on 9/29/17 at 1:55 p.m. with RN A revealed that he came into the facility at 2:00 p.m. there was an activity in the lobby on 09/14/17 for staff about rewards and staff lost about 20 minutes with that. He said that the facility had showers that day, and someone brought it to my attention, they couldn't find Resident #1. Based on documentation the estimation was that she was out in the courtyard for two hours. Within 30 minutes, a CNA told him Resident #1 was in the courtyard and to just come. He said Resident #1 was on the grass with her shirt and shoes off, it was hot. He stated that he just tried to get her to the hospital quickly because her temporal temperature was 104 degrees Fahrenheit (F). The temporal thermometer registers approximately .5 to 1 degree lower than an oral temp. He stated that since the incident with resident #1, staff do hourly checks on the courtyards and Resident #1. Observation on 9/29/17 at 2:00 p.m. with RN A of the courtyard where Resident #1 was found revealed it was located in the back of the facility and was entered through a small television room, and was about 100 feet wide by 300 feet long with no visibility from the facility except for resident rooms and through the television room. There was one small tree in the courtyard and he pointed out where Resident #1 was located which was about 7 feet to the left side of the small tree. Review of the weather for Laredo for 9/14/17 from https://www.wunderground.com/history/airport/KLRD/2017/9/29/MonthlyCalendar.html revealed the temperature was 106 degrees Fahrenheit and average humidity for that day 39. A calculated heat index of 123 degrees which is what it would feel like for someone (http://www.weather.gov/epz/wxcalc_heatindex). Heat stroke is a form of hyperthermia or heat-related illness, an abnormally elevated body temperature with accompanying physical symptoms including changes in the nervous system function. Unlike heat cramps and heat exhaustion, two other forms of hyperthermia that are less severe, heat stroke is a true medical emergency that is often fatal if not properly and promptly treated. Heat stroke is also sometimes referred to as heatstroke or sun stroke. Severe hyperthermia is defined as a body temperature of 104 F (40 C) or higher. Heat stroke can kill or cause damage to the brain and other internal organs. (https://www.webmd.com/a-to-z-guides/heat-stroke-symptoms-and-treatment). Review of the facility's Abuse Protocol (undated) revealed Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a Patient/Resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility took action to correct the deficiency on 9/15/17 with in-services provided to staff on supervision and hourly checks of the courtyards.Increased monitoring and supervision was provided by administration of staff for monitoring residents who wander. The DON on 9/29/17 provided the information that there were two residents who are confused and wander in the main area of the facility.

Based on observation, interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of: The Administrator failed to: -ensure nurses were competent on skin management guidelines -supervise the leadership of the Director of Nurses (DON) -ensure the DON followed up to make sure weekly skin assessments were done correctly -ensure there was a weekly at risk meeting to address pressure ulcers -implement policies and procedures related to neglect -ensure interventions were in place to prevent additional falls and or injuries The above failure resulted in an Immediate Jeopardy (IJ) situation on 06/27/17. While the IJ was removed on 06/28/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 15 residents with pressure ulcers and 58 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. This failure could place nine of the 21 residents on wing C (secure unit) with falls or history of falls at risk for additional falls and injuries. The findings included: Interview with the facility Administrator during entrance conference on 06/22/17 at 2:03 p.m. revealed the facility did not have a DON or Assistant DON (ADON). The Administrator said the DON resigned approximately two days prior to the surveyor's entrance. On 06/28/17 at approximately 4:30 p.m.,surveyor asked the facility Administrator the following questions: 1. What training did you (facility Administrator) ensure the nurses had in order to care for residents with pressure ulcers and falls. The Administrator said annual training provided to staff and staff were trained as needed. The Administrator stated he would check for training done before the former DON left the facility. 2. How did you ensure the nurses were competent in their skills in caring for residents with pressure ulcers and falls. The Administrator said nurses were competent. The DON should follow up to make sure weekly skin assessment were being done correctly. 3. What type of plan was in place for pressure ulcers and falls. The Administrator said should have weekly at risk meeting to address residents with pressure ulcers and falls. The former DON did not plan the the risk meeting to address residents with pressure ulcers and falls. 4. Has there been any types of in-services on pressure ulcers and falls. The Administrator said not that he (Administrator) was aware of. 5. What resources are available to you and your staff. The Administrator said training on skin management can be done by consultants for nurses, aides (certified nurse aides) and RCS's (resident care specialists). 6. What type of procedure is there to make sure the nursing needs of the resident's are being met. The Administrator said doing rounds,Administration meeting with nurses (DON and ADON) to identify which residents are high risk for pressure ulcers. 7. How do you think this IJ came about. The Administrator said staff were not being trained, the DON did not follow up to make sure weekly skin assessments were done correctly,and there were no weekly at risk meeting to address pressure ulcers. 8. Were you aware of the IJ for pressure ulcers. The facility Administrator said he was aware weekly skin assessment logs were not being done. 9. Were you aware of the situation (substandard quality of care /SCQ) for falls. The Administrator said yes,one too many falls for resident(s) and interventions were not in place to prevent additional falls or injuries. R #3: R #3's Face Sheet dated 06/22/17 documented an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., nutrition, and medication administration), and Generalized Muscle Weakness. R #3's Nursing Admission Data Collection dated 06/02/17 documented Right Heel pressure ulcer: length- 6.0 X 5.5 cm (centimeters) .Left heel pressure ulcer- 5.0 X 4.0 cm, healed sacral ulcer . R #3's Order Summary Report dated 06/02/17 documented Cleanse unstageable pressure ulcer to right and left heel with normal saline/wound cleanser, pat dry with gauze, paint with [MEDICATION NAME], cover with [MEDICATION NAME] foam dressing every other day and PRN (as needed) until healed Stage 2 left buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift Stage 2 right buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift .Vitamin A per [DEVICE] q (every) am, Vitamin C one tablet per [DEVICE] daily q am, Zinc tablet per [DEVICE] q am for wound healing . R #3's Braden Scale for Predicting Pressure Sore Risk dated 06/02/17 revealed a score of 12, Scoring: High Risk= 10-12. R #3's Initial Care Plan initiated 06/03/17 documented: -I have an ADL (Activity of Daily Living) self-care performance deficit related to Dementia- Bed Mobility: the resident is totally dependent on two staff for repositioning and turning in bed and as necessary . -I have limited physical mobility related to left sided weakness . -I have potential/actual skin issues .Interventions: Notify MD of changes in wound, observe wound healing, provide wound care per orders, skin checks weekly per facility protocol, document findings . *R #3's care plan did not specifically address his pressure ulcers nor did the care plan address interventions for preventative care to prevent new or worsening of pressure ulcers. R #3's Minimum Data Set ((MDS) dated [DATE] revealed R #3: -Usually made self understood and understood others. -Had a Brief Interview of Mental Status (BIMS) of 07 (severely impaired cognition). -Required total dependence with two person physical assist for bed mobility, transfers, and toilet use. R #3 required total dependence with one person physical assist for dressing and personal hygiene. -Had impairment on both sides of both upper and lower extremities. -Was always incontinent of bowel and bladder. -Was 64 inches tall and 135 pounds. -Was at risk for developing pressure ulcers and entered the facility with two Unstageable pressure ulcer. -Skin and Ulcer Treatments: Turning/Repositioning Program, Nutrition and Hydration Intervention, Pressure Ulcer Care, Application of nonsurgical dressings and ointments and medications, application of dressings to feet. R #3's Weekly Skin Pressure Ulcer Report dated 06/14/17 documented Date of Onset: 06/14/17, New Pressure Ulcer, Acquired at the facility, Sacrum Stage 1 pressure ulcer, 1 X 0.5 X 0 cm, Description: Pressure ulcer to left buttock serous fluid to wound bed. No foul odor noted. Proximal tissue color pink distal redness with undefined wound edges. Surrounding [MEDICATION NAME] tissue, Surrounding skin away from the wound edges with maceration (soften skin from being wet); Right buttock Stage 1: Date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 0.8 X 0.3 X 0 cm, suspected sacral ulcer right buttock ulcer, 100% beefy red in color. Undefined wound edges. Macerated surrounding skin. No foul odor to wound. No drainage noted.This document included the definitions of: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcers covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #3's Weekly Pressure Ulcer Record dated 06/21/17 documented Date of Onset: 06/21/17, new pressure ulcer, acquired at the facility, Right Buttock Stage 2: 3.0 X 1.6 X 0 cm, pink-red wound bed without slough .Date of Onset: 06/02/17, admitted with, Right Heel: 6.5 X 6.0 x 0 Unstageable eschar to wound bed, bruising and redness to wound edges, wound bed black, no odor, no drainage, wound edges dark red/purple, response to treatment: no change .Date of Onset: 06/02/17, existing, admitted with, Left Heel: 4.3 X 4.4 X 0 cm Unstageable, eschar to wound bed with redness and non-blanchable skin to surrounding skin, scant drainage, redness to surrounding skin, response to treatment: no change . Interview with Licensed Vocational Nurse (LVN) H on 06/22/17 at 3:10 p.m. revealed she was caring for R #3. LVN H reviewed R #3's most current Pressure Ulcer Report dated 06/21/17 and said out loud He (R #3) has a right heel unstageable found on admission on 06/02/17 that measured 6.5 X 4.5 X 0.0 cm on 06/08/17 and 4.3 X 4.4 X 0.0 cm on 06/21/17. His left heel unstageable was found on admission on 06/02/17 and it measured 3.5 X 3.0 X 0 cm on 06/08/17 and 6.5 X 6.0 X 0 cm on 06/21/17. He also has a right buttock Stage 2 acquired in-house on 06/21/17 that measured 3.0 X 1.6 X 0 cm and a left buttock Stage 2 acquired in-house on 06/21/17 that measured 1.0 X 1.0 X 0. cm. LVN H said she would perform R #3's wound care on his heels shortly. Observation of R #3 on 06/22/17 at 3:14 p.m. revealed he laid on his back on a similar mattress as every other resident had on their bed. R #3's head of bed was slightly elevated and had one flat pillow under his left shoulder. R #3's hips and buttocks rested flat on the mattress. R #3's eyes were closed. R #3 did not respond to verbal stimuli. R #3 had a flat pillow under his knees however, both of his heels rested on the bed. At 3:16 p.m., LVN H entered R #3's room and began wound care. LVN H picked up R #3's left heel off the bed and unwrapped the kerlix dressing. LVN H exposed R #3's left heel that was entirely black and purple in color and provided treatment as ordered. LVN H picked up R #3's right heel off the bed and unwrapped it of the kerlix dressing. The right heel was 100% covered with a black colored cap with redness on the surrounding tissue at approximately 11-2 o'clock. As LVN H cleansed each heel, R #3 pulled each foot away every time she wiped the area. LVN H asked R #3 if he had pain but R #3 replied No. LVN H said she was sure he has some pain when I touch or press on the heel since he is pulling away. LVN H placed a pillow under R #3's calves and walked out of the room. Observation of R #3 on 06/22/17 at 4:15 p.m. revealed R #3 laid on his back with his head of bed slightly elevated with one flat pillow under his left shoulder and with one flat pillow under his calves however, both heels and buttocks remained resting on the mattress. Observation of R #3 on 06/22/17 at 5:46 p.m. revealed R #3 again laid on his back with one flat pillow under his left shoulder and his head slightly elevated as seen earlier and one flat pillow underneath his calves. R #3's heel rested on the mattress, applying pressure to his pressure ulcers on his heels. Simultaneous interview with Certified Nurse Aide (CNA) I and LVN H on 06/22/17 at 5:47 p.m. revealed both staff knew R #3 had pressure ulcers on both heels and his buttocks. LVN H said R #3 should be repositioned every two hours. CNA I said she had not repositioned R #3 since approximately 3:00 - 3:15 p.m. CNA I said she knew R #3 was due to reposition but was assisting with dinner trays. CNA I and LVN H both said they place a pillow under R #3's legs to keep his heels raised off the bed to prevent pressure on the heels. Upon the surveyor's request, LVN H accompanied the surveyor to R #3's room and found a pillow under R #3's calves with his heels resting on the mattress and a flat pillow under R #3's left shoulder with his hips and buttocks resting on the mattress. LVN H confirmed the one pillow was not effective in relieving pressure off the heels. LVN H also confirmed the one pillow under R #3's left shoulder was there in attempt to relieve pressure off his buttocks but was unsuccessful since the pillow was too flat. LVN H said the facility did not have any positioning devices to use other than pillows. LVN H stated she would locate more pillows for R #3. LVN H stated if R #3's ulcers were not relieved of pressure from the bed, his ulcers could worsen or acquire new ones. R #3's Care Plan revised 06/22/17 documented I have Stage 2 pressure ulcers to left and right buttocks and unstageable to left and right heels .Interventions: Administer treatments as ordered and observe for effectiveness, Assess/record/observe wound healing. Measure where possible. Report improvements and declines to MD, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation of Registered Nurse (RN) A providing R #1 with wound care on 06/23/17 at 10:42 a.m. revealed she measured R #3's left buttock ulcer and said out loud Left Stage 2 measures 1.0 X 1.0 X 0 centimeters. Right buttock Stage 2 measures 3.4 X 2.2 X 0 centimeters. The right buttock grew in length and width since admission and when I last measured it on 06/21/17. The wound bed is red without any drainage or odor and the surrounding skin is of normal skin color. The right heel unstageable measures 6.4 X 7.5 X 0 centimeters, it has 100% eschar cap with redness to surrounding skin and bruising at 5 o'clock, and redness at 6-9 o'clock. He said he has pain to the heel. The right heel has grown in length and width since his last measurements. The left heel unstageable measures 5.0 X 5.5 X 0 centimeters. The heel has approximately 75% eschar in wound bed, redness to wound edges from 9-3 o'clock and bruising and non-blanchable redness from 3-9 o'clock. There is blanchable redness at 6 o'clock. His left heel grew in width. Observation of R #3 on 06/27/17 at 8:29 a.m. revealed R #3 laid on his right side with one pillow behind his left back and one pillow under his calves with his left heel resting on the mattress. At 8:32 a.m., CNA J entered R #3's room and stated she repositioned R #3 approximately one hour ago from his back to his right side. The surveyor asked CNA J if R #3's heels are appropriately elevated off the bed; CNA J said No, his left heel is on the bed. CNA J added a pillow between R #3's ankles and plumped the pillow under his calves which elevated both heels off the mattress. Interview with RN A on 06/23/17 at 3:00 p.m. revealed she reviewed and compared R #3's Weekly Pressure Ulcer Reports. RN A said His left and right heel got slightly wider compared to his admission measurements. His left and right buttocks ulcers were acquired in the facility. He should have his heels off loaded with pillows to relieve pressure off his heels to cure the ulcers. RN A reviewed R #3's care plan and said frequently meant every 2 hours. RN A said R #3's care plan did not have specific preventative interventions for his heels. Interview with Physician K on 06/27/17 at 10:02 a.m. revealed he was aware of R #3's pressure ulcer progression. Physician K stated It is not realistic for a facility as big as this one to ensure the patients are turned every two hours, even though that is what's supposed to happen. Physician K said Of course, if pressure is not relieved frequently over a bony body part then an ulcer would certainly get worse or develop one. Not off-loading of an affected area would impede in wound healing and wound development. Physician K said other than being immobile and not repositioning frequently, there was no other explanation why R #3 would acquire his ulcers to his buttocks. R #4: R #4's Face Sheet dated 06/22/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Care Plan dated 03/29/17 documented: -I have a potential for pressure ulcer development related to decreased mobility, bowel and bladder incontinence .Interventions: Complete a full body check weekly and document, elevate lower extremities with pillows off-loading bilateral legs every shift, follow policy and procedures for the prevention/treatment of [REDACTED].>-I have a Stage 3 pressure ulcer to my sacrum area related to immobility and incontinence .Interventions: Administer treatments as ordered and observe for effectiveness, cleanse with wound cleanser, pat dry and apply puracol and cover with gauze and secure with [MEDICATION NAME]. Assess/record/observe wound healing. Measure length, width, and depth where possible . R #4's MDS dated [DATE] revealed R #4: -Had unclear speech -Rarely/never made self understood and sometimes understands others -Has short and long term memory problems and moderately impaired cognitive skills for daily decision making. -Requires total dependence with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -Was always incontinent of bladder and bowel. -Is at risk of pressure ulcers and had no pressure ulcers. R #4's Head to Toe Skin Check dated 06/12/17 documented Intact Skin; no skin breakdown noted upon assessment at this time . R #4's Situation Background Assessment Request (SBAR) dated 06/14/17 documented Resident presents with newly assessed pressure ulcer to the sacral area on 06/14/17. Resident is incontinent of bowel and bladder and completely dependent on staff for care. Resident is bedbound status requires total assistance with all ADLs. Physician notified 06/14/17 at 2:00 p.m. New Orders: Cleanse site with wound cleanser, pat dry, apply puracol, cover with gauze, and secure with [MEDICATION NAME] daily and prn until healed. R #4's Weekly Pressure Ulcer Report dated 06/14/17 documented Sacrum, date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 3.8 X 1.0 cm- Stage 3. 80% granulation with 20% slough tissue scant amount of serosanguinous drainage and pink wound edges .Response to treatment: new pressure ulcer- no previous response for comparison. R #4's June 2017 Order Summary Report documented Cleanse sacral wound with wound cleanser, pat dry, place Puracol (collagen dressing), cover with gauze, apply sure prep to perimeter and secure with [MEDICATION NAME] (clear self-adhesive dressing) daily and prn until healed- order date 06/14/17 R #4's Weekly Pressure Ulcer Record dated 06/21/17 documented Sacrum Stage 3 pressure ulcer- 4.0 X 0.4 cm. Maceration present to surrounding wound bed. 100% granulation present, no foul odor. Observation of R #4 on 06/22/17 at 2:42 p.m. revealed R #4 was being provided incontinent care by CNAs M and N. R #4 was able to make eye contact but did not respond verbally nor by gestures to communicate. CNA M stated R #4 did not speak and was not able to reposition herself. Staff positioned R #4 on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 3:55 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 4:45 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 5:33 p.m. revealed she continued to lay on her left side with a pillow behind her back. At 5:35 p.m., LVN Q and CNA N entered R #4's room and provided incontinent care and repositioned her on her right side. LVN Q stated R #4 was to be repositioned every two hours to prevent pressure ulcer development. CNA N said she thought she last positioned R #4 at approximately 3:00 p.m. CNA N was informed of the time R #4 was last repositioned then said I was coming when another resident asked me to take her to the dining room. Observation of R #4, while she received wound care by LVN O, on 06/23/17 at 11:17 a.m. revealed LVN O cleansed R #4's sacral ulcer and said It measures 3.1 X 0.6 centimeters, the wound bed is red and it has pink wound edges. It has 100% granulation with maceration around the outer wound bed. It looks like she has some slight discomfort when the area is manipulated due to her flinching when I touch it. LVN Q said she did not know how R #4 acquired a Stage 3 in the facility without it being noticed prior to progressing to a Stage 3. LVN O stated pressure ulcers do not form at a Stage 3, They begin at a Stage 1 then progress to a higher stage. Interview with RN A on 06/23/17 at 3:25 p.m. revealed she stated she could not respond why R #3 acquired a Stage 3 pressure ulcer. RN A said Either the wound was not identified upon admission or during the weekly skin assessment checks. It is not possible to spontaneously develop a Stage 3 or an unstageable pressure ulcer without previous signs of the ulcer at an earlier stage. After reviewing R #4's care plan, RN A said No her care plan does not address prevention interventions for pressure ulcers. R #5: R #5's Face Sheet dated 06/22/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE] for [MEDICAL CONDITION], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Nursing Admission Data Collection dated 02/17/17 revealed R #5 did not have any pressure ulcers identified upon admission. R #5's Care Plan dated 03/01/17 documented: -I have actual skin issues related to multiple bruising upon admission .Interventions: Notify MD of changes in wound or emerging wounds, provide wound care/preventative skin care per order, skin checks weekly, Turn and reposition frequently to decrease pressure. -I have an ADL self-care performance deficit related to muscle weakness from [MEDICAL CONDITION] .Interventions: Bathing/showering- I require one staff to provide shower, Bed Mobility- I require supervision one staff for repositioning and turning in bed, Dressing- I require extensive assistance of one staff for dressing . R #5's Head to Toe Skin Check dated 04/07/17 documented No skin breakdown noted upon assessment. R #5's Re-Admission Head to Toe Skin Check dated 05/02/17 documented Skin intact, dry skin and scabbing to left heel. Left upper buttock with dry scab. R #5's Braden Scale for Prediction Pressure Ulcer Risk dated 05/02/17 revealed a score of 16 At Risk= 15-18. R #5's physician's orders [REDACTED]. R #5's Quarterly MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and usually understood others -Had a BIMS score of 8 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was not at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Significant Change MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and understood others -Had a BIMS score of 9 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Head to Toe Skin Check dated 05/13/17 documented Skin Integrity: New Pressure Ulcer- Sacrum 3.0 X 1.5 X 0 cm. Open sacral wound noted, no signs/symptoms of infection, no drainage or active bleeding noted. *There was no documentation of the stage of the pressure ulcer. R #5's SBAR Communication Form and Progress Note dated 05/13/17 documented The change in condition: New Sacral Ulcer, started on 05/13/17. Male resident is restless, constantly rolling and shifting off bed, becomes easily upset, needs frequent repositioning and adjusting .MD made aware . R #5's Physician order [REDACTED]. R #5's Weekly Pressure Ulcer Record dated 05/17/17 documented New pressure ulcer acquired at facility 05/13/17- Sacrum: Stage 2 pressure- 2.0 X 3.2 X 0 cm. 10% Eschar, 90% granulation, no foul odor, scant serosanguinous drainage, no depth to site. Normal skin surrounding wound. *The presence of eschar in the wound did not meet the definition of a Stage 2 pressure ulcer. The ulcer has deteriorated and was incorrectly staged. R #5's SBAR Communication Form and Progress Note dated 05/22/17 documented Situation: New Stage 2 left heel pressure ulcer. Resident was in shower when voiced discomfort to left heel upon tactile stimuli. Upon assessment resident noted with Stage 2 left heel ulcer .Called MD. New Orders: Left heel Stage 2: Cleanse with normal saline/wound cleanser, pat dry, apply Therahoney to heel, cover with gauze, secure with Kerlix and tape daily and prn until healed. R #5's Telephone physician's orders [REDACTED]. Promod liquid nutritional supplement- 60 milliliters TID (three times a day) for wounds . R #5's revised Care Plan dated 05/23/17 documented I have a pressure ulcer to my sacral stage 3 area and left heel stage 2 .Interventions: Complete a full body check weekly and document, Observe/document/report any changes in skin status; appearance, color, wound healing, signs/symp of infection, wound size, stage. Provide incontinent care after each episode. *R #5's care plan did not include specific individualized preventative interventions to provide pressure relief to his Left heel and sacrum. R #5's care plan did not include any resistance/refusal of treatment. R #5's Weekly Pressure Ulcer Record dated 06/01/17 documented Sacrum Stage 3 Pressure Ulcer: 3.0 X 3.0 X 0 cm. 100% slough present in wound bed, small serous drainage, pink surrounding wound edges . Specialty interventions: Positioning Devices: extra pillows. R #5's June 2017 Order Summary Report documented Cleanse left heel with wound cleanser, pat dry, apply sure prep daily and leave open to air every day shift for Suspected Deep Tissue Injury .Cleanse sacral site with wound cleanser, pat dry, apply Santyl ointment, cover with gauze, apply skin prep to outer skin and secure with [MEDICATION NAME] daily and prn every day shift for pressure ulcer .order date 06/02/17 . R #5's Head to Toe Skin Check dated 06/03/17 documented Left heel: Suspected Deep Tissue Injury. *This document did not have a thorough description or measurements of the ulcer. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Left heel Suspected Deep Tissue Injury: 1.5 X 2.2 cm. 100% eschar tissue, black wound bed, no drainage. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Sacrum Stage 3: 3.0 X 2.5 X 0.3 cm. 100% yellow slough with maceration to wound edges from 4-7 o'clock with moderate serous drainage. White/gray/pallor wound edges. *According to the measurements, this wound has developed new depth. R #5's Weekly Pressure Ulcer Record dated 06/14/17 documented Sacrum Stage 3: 2.9 X 2.3 X 0.2 cm, 90% yellow slough tissue with 10% granulation tissue, moderate serous drainage, maceration noted to 5-7 o'clock. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Sacrum Stage 3: 3.0 X 2.0 X 1.0 cm, continues with 90% yellow slough tissue with 10% granulation tissue, maceration to wound edges. *According to the measurements, this wound's depth has increased in size. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Left heel Suspected Deep Tissue Injury: 1.3 X 1.8 X 0 cm, wound bed covered with 100% black eschar, no foul odor, no drainage, wound edges are black. Observation of R #5 on 06/22/17 at 3:54 p.m. revealed R #5 laid on his back in bed. R #5 was alert and oriented to person and place only. R #5 complained of pain to his left heel. R #5 described his pain as throbbing. R #5 had one pillow under his head and one flat pillow under his calves. R #5's heels rested on the mattress. There were no other pillows in R #5's room. Observation of R #5 on 06/22/17 at 5:30 p.m. revealed R #5 continued to lay on his back with one flat pillow under his calves however, his heels continued to rest on the mattress. Observation of R #5, receiving wound care by LVN O, on 06/22/17 at 12:00 p.m. revealed LVN O presented R #5's left heel which had a black intact hardened cap over the heel with dry peeling skin over and around the entire ulcer. LVN O said There is 100% black eschar with dryness around the wound with dry peeling skin over the wound. It measures 2.0 X 1.5 centimeters. As LVN O cleansed R #5's left heel, R #5 pulled his foot away and acknowledged It hurts. LVN O repositioned R #5 to his left side and presented R #5's sacral area. R #5's sacrum had approximately 90-95% of yellow tissue on the wound bed and some red tissue present on the right side of the wound. The surrounding tissue of the entire wound edges was white and wrinkled. The surrounding skin around the wound bed was dark burgundy in color. LVN O began to cleanse the area and again R #5 tightened his buttocks and said Ouch, it hurts. LVN O stated It has 90% yellow slough and about 10% granulation within the wound bed, the surrounding tissue is really macerated, white in color. It measures 3.0 X 1.9 centimeters. I saw it last week, the burgundy area was blanchable then but not it's not and the burgundy area did not extend that far out from the wound bed, it was only around the edges of the wound bed. The non-blanchable burgundy color definitely extends farther than it did last week. Upon the surveyor's request, LVN measured the non-blanchable burgundy colored area surrounding the wound and said At 12 o'clock it measures 1.2, at 3 o'clock it's 1.5, at 6 o'clock it's 1.2, and at 9 o'clock it's 2.0 centimeters. LVN O stated she thought R #5's sacral ulcer looked worse than last week. Interview with RN A on 06/23/17 at 3:20 p.m. revealed she reviewed R #5's Weekly Pressure Ulcer Reports with the surveyor. RN A confirmed R #5's left heel that was staged as a Suspected Deep Tissue Injury was incorrectly staged and should have been staged as an unstageable due to the eschar that was present. RN A said R #5's left heel Appeared to increase in length a(TRUNCATED)

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for four residents (R #3, R #4, R #5, and R #6) of five residents reviewed for pressure ulcers. The facility did not: -Ensure R #3's bilateral heels and buttocks were offloaded. R #3's community acquired bilateral heel unstageables that grew in size. R #3 developed a left and right buttock Stage 1 pressure ulcer, while in the facility, that deteriorated into Stage 2 ulcers. -Ensure R #3's initial care plan addressed his pressure ulcers or include specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #3 was not provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #4 was repositioned at least every two hours as per the facility's policy. -Identify R #4 had developed a pressure ulcer to her sacrum, prior to initially identifying it at a Stage 3 despite daily incontinent care and/or baths by staff. -Ensure R #4's care plan included specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #4 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #5's sacrum were offloaded. R #5 developed a Stage 2 pressure ulcer to his sacrum 11 days after re-admission to the facility. -Document the stage of his sacral ulcer on his initial assessment. -Correctly stage R #5's sacral ulcer. The facility documented R #5's Stage 2 ulcer as having eschar, which no longer met the definition of a stage 2 yet, the ulcer continued to be identified as a Stage 2. R #5's sacrum ulcer deteriorated and the facility documented the ulcer as a Stage 3 then to a Suspected Deep Tissue Injury (SDTI). R #5's sacral ulcer was incorrectly staged as a SDTI, rather than an Unstageable, by definition. -Ensure R #5's left heel was offloaded. R #5 developed a Stage 2 pressure ulcer to his left heel that deteriorated to a SDTI. -Ensure R #5's care plan included specific individualized preventative interventions to provide pressure relief to his left heel and sacrum. -Ensure R #5 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Correctly recognize/identify R #6's sacral ulcer. Staff documented the ulcer to have slough and continued to identify it as a Stage 2, which did not meet the definition of a stage 2 pressure ulcer. R #6 developed a Stage 2 pressure ulcer to his sacrum while in the facility which deteriorated to a Stage 4, upon discharge. -Correctly identify R #6's facility-acquired stage 2 left heel ulcer that was identified to have slough yet, staff continued to be identified as a Stage 2 pressure ulcer, instead of a Stage 3. -Ensure R #6's care plan included specific individualized preventative interventions for pressure relief of R #6's sacrum and left heel. -Perform a conduct and document a thorough assessment of R #6's pressure ulcer upon discharge. The facility's last assessment of R #6's pressure ulcer was five days prior to his discharge and was identified as a Stage 3 however, the ulcer was identified by his physician to have a Stage 4 pressure ulcer. R #6 was discharged from the facility on 05/29/17. -Consult with R #6's physician of his deteriorating sacral pressure ulcer. The above failures resulted in an Immediate Jeopardy (IJ) situation on 06/27/17. While the IJ was removed on 06/28/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 15 residents with pressure ulcers and 58 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: Interview with the facility Administrator during entrance conference on 06/22/17 at 2:03 p.m. revealed the facility did not have a Director of Nurses (DON) or Assistant DON (ADON). The Administrator said the DON resigned approximately two days prior to the surveyor's entrance. R #3: R #3's Face Sheet dated 06/22/17 documented an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., nutrition, and medication administration), and Generalized Muscle Weakness. R #3's Nursing Admission Data Collection dated 06/02/17 documented Right Heel pressure ulcer: length- 6.0 X 5.5 cm (centimeters) .Left heel pressure ulcer- 5.0 X 4.0 cm, healed sacral ulcer . R #3's Order Summary Report dated 06/02/17 documented Cleanse unstageable pressure ulcer to right and left heel with normal saline/wound cleanser, pat dry with gauze, paint with [MEDICATION NAME], cover with [MEDICATION NAME] foam dressing every other day and PRN (as needed) until healed Stage 2 left buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift Stage 2 right buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift .Vitamin A per [DEVICE] q (every) am, Vitamin C one tablet per [DEVICE] daily q am, Zinc tablet per [DEVICE] q am for wound healing . R #3's Braden Scale for Predicting Pressure Sore Risk dated 06/02/17 revealed a score of 12, Scoring: High Risk= 10-12. R #3's Initial Care Plan initiated 06/03/17 documented: -I have an ADL (Activity of Daily Living) self-care performance deficit related to Dementia- Bed Mobility: the resident is totally dependent on two staff for repositioning and turning in bed and as necessary . -I have limited physical mobility related to left sided weakness . -I have potential/actual skin issues .Interventions: Notify MD of changes in wound, observe wound healing, provide wound care per orders, skin checks weekly per facility protocol, document findings . *R #3's care plan did not specifically address his pressure ulcers nor did the care plan address interventions for preventative care to prevent new or worsening of pressure ulcers. R #3's Minimum Data Set ((MDS) dated [DATE] revealed R #3: -Usually made self understood and understood others. -Had a Brief Interview of Mental Status (BIMS) of 07 (severely impaired cognition). -Required total dependence with two person physical assist for bed mobility, transfers, and toilet use. R #3 required total dependence with one person physical assist for dressing and personal hygiene. -Had impairment on both sides of both upper and lower extremities. -Was always incontinent of bowel and bladder. -Was 64 inches tall and 135 pounds. -Was at risk for developing pressure ulcers and entered the facility with two Unstageable pressure ulcer. -Skin and Ulcer Treatments: Turning/Repositioning Program, Nutrition and Hydration Intervention, Pressure Ulcer Care, Application of nonsurgical dressings and ointments and medications, application of dressings to feet. R #3's Weekly Skin Pressure Ulcer Report dated 06/14/17 documented Date of Onset: 06/14/17, New Pressure Ulcer, Acquired at the facility, Sacrum Stage 1 pressure ulcer, 1 X 0.5 X 0 cm, Description: Pressure ulcer to left buttock serous fluid to wound bed. No foul odor noted. Proximal tissue color pink distal redness with undefined wound edges. Surrounding [MEDICATION NAME] tissue, Surrounding skin away from the wound edges with maceration (soften skin from being wet); Right buttock Stage 1: Date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 0.8 X 0.3 X 0 cm, suspected sacral ulcer right buttock ulcer, 100% beefy red in color. Undefined wound edges. Macerated surrounding skin. No foul odor to wound. No drainage noted.This document included the definitions of: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcers covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #3's Weekly Pressure Ulcer Record dated 06/21/17 documented Date of Onset: 06/21/17, new pressure ulcer, acquired at the facility, Right Buttock Stage 2: 3.0 X 1.6 X 0 cm, pink-red wound bed without slough .Date of Onset: 06/02/17, admitted with, Right Heel: 6.5 X 6.0 x 0 Unstageable eschar to wound bed, bruising and redness to wound edges, wound bed black, no odor, no drainage, wound edges dark red/purple, response to treatment: no change .Date of Onset: 06/02/17, existing, admitted with, Left Heel: 4.3 X 4.4 X 0 cm Unstageable, eschar to wound bed with redness and non-blanchable skin to surrounding skin, scant drainage, redness to surrounding skin, response to treatment: no change . Interview with Licensed Vocational Nurse (LVN) H on 06/22/17 at 3:10 p.m. revealed she was caring for R #3. LVN H reviewed R #3's most current Pressure Ulcer Report dated 06/21/17 and said out loud He (R #3) has a right heel unstageable found on admission on 06/02/17 that measured 6.5 X 4.5 X 0.0 cm on 06/08/17 and 4.3 X 4.4 X 0.0 cm on 06/21/17. His left heel unstageable was found on admission on 06/02/17 and it measured 3.5 X 3.0 X 0 cm on 06/08/17 and 6.5 X 6.0 X 0 cm on 06/21/17. He also has a right buttock Stage 2 acquired in-house on 06/21/17 that measured 3.0 X 1.6 X 0 cm and a left buttock Stage 2 acquired in-house on 06/21/17 that measured 1.0 X 1.0 X 0. cm. LVN H said she would perform R #3's wound care on his heels shortly. Observation of R #3 on 06/22/17 at 3:14 p.m. revealed he laid on his back on a similar mattress as every other resident had on their bed. R #3's head of bed was slightly elevated and had one flat pillow under his left shoulder. R #3's hips and buttocks rested flat on the mattress. R #3's eyes were closed. R #3 did not respond to verbal stimuli. R #3 had a flat pillow under his knees however, both of his heels rested on the bed. At 3:16 p.m., LVN H entered R #3's room and began wound care. LVN H picked up R #3's left heel off the bed and unwrapped the kerlix dressing. LVN H exposed R #3's left heel that was entirely black and purple in color and provided treatment as ordered. LVN H picked up R #3's right heel off the bed and unwrapped it of the kerlix dressing. The right heel was 100% covered with a black colored cap with redness on the surrounding tissue at approximately 11-2 o'clock. As LVN H cleansed each heel, R #3 pulled each foot away every time she wiped the area. LVN H asked R #3 if he had pain but R #3 replied No. LVN H said she was sure he has some pain when I touch or press on the heel since he is pulling away. LVN H placed a pillow under R #3's calves and walked out of the room. Observation of R #3 on 06/22/17 at 4:15 p.m. revealed R #3 laid on his back with his head of bed slightly elevated with one flat pillow under his left shoulder and with one flat pillow under his calves however, both heels and buttocks remained resting on the mattress. Observation of R #3 on 06/22/17 at 5:46 p.m. revealed R #3 again laid on his back with one flat pillow under his left shoulder and his head slightly elevated as seen earlier and one flat pillow underneath his calves. R #3's heel rested on the mattress, applying pressure to his pressure ulcers on his heels. Simultaneous interview with Certified Nurse Aide (CNA) I and LVN H on 06/22/17 at 5:47 p.m. revealed both staff knew R #3 had pressure ulcers on both heels and his buttocks. LVN H said R #3 should be repositioned every two hours. CNA I said she had not repositioned R #3 since approximately 3:00 - 3:15 p.m. CNA I said she knew R #3 was due to reposition but was assisting with dinner trays. CNA I and LVN H both said they place a pillow under R #3's legs to keep his heels raised off the bed to prevent pressure on the heels. Upon the surveyor's request, LVN H accompanied the surveyor to R #3's room and found a pillow under R #3's calves with his heels resting on the mattress and a flat pillow under R #3's left shoulder with his hips and buttocks resting on the mattress. LVN H confirmed the one pillow was not effective in relieving pressure off the heels. LVN H also confirmed the one pillow under R #3's left shoulder was there in attempt to relieve pressure off his buttocks but was unsuccessful since the pillow was too flat. LVN H said the facility did not have any positioning devices to use other than pillows. LVN H stated she would locate more pillows for R #3. LVN H stated if R #3's ulcers were not relieved of pressure from the bed, his ulcers could worsen or acquire new ones. R #3's Care Plan revised 06/22/17 documented I have Stage 2 pressure ulcers to left and right buttocks and unstageable to left and right heels .Interventions: Administer treatments as ordered and observe for effectiveness, Assess/record/observe wound healing. Measure where possible. Report improvements and declines to MD, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation of Registered Nurse (RN) A providing R #1 with wound care on 06/23/17 at 10:42 a.m. revealed she measured R #3's left buttock ulcer and said out loud Left Stage 2 measures 1.0 X 1.0 X 0 centimeters. Right buttock Stage 2 measures 3.4 X 2.2 X 0 centimeters. The right buttock grew in length and width since admission and when I last measured it on 06/21/17. The wound bed is red without any drainage or odor and the surrounding skin is of normal skin color. The right heel unstageable measures 6.4 X 7.5 X 0 centimeters, it has 100% eschar cap with redness to surrounding skin and bruising at 5 o'clock, and redness at 6-9 o'clock. He said he has pain to the heel. The right heel has grown in length and width since his last measurements. The left heel unstageable measures 5.0 X 5.5 X 0 centimeters. The heel has approximately 75% eschar in wound bed, redness to wound edges from 9-3 o'clock and bruising and non-blanchable redness from 3-9 o'clock. There is blanchable redness at 6 o'clock. His left heel grew in width. Observation of R #3 on 06/27/17 at 8:29 a.m. revealed R #3 laid on his right side with one pillow behind his left back and one pillow under his calves with his left heel resting on the mattress. At 8:32 a.m., CNA J entered R #3's room and stated she repositioned R #3 approximately one hour ago from his back to his right side. The surveyor asked CNA J if R #3's heels are appropriately elevated off the bed; CNA J said No, his left heel is on the bed. CNA J added a pillow between R #3's ankles and plumped the pillow under his calves which elevated both heels off the mattress. Interview with RN A on 06/23/17 at 3:00 p.m. revealed she reviewed and compared R #3's Weekly Pressure Ulcer Reports. RN A said His left and right heel got slightly wider compared to his admission measurements. His left and right buttocks ulcers were acquired in the facility. He should have his heels off loaded with pillows to relieve pressure off his heels to cure the ulcers. RN A reviewed R #3's care plan and said frequently meant every 2 hours. RN A said R #3's care plan did not have specific preventative interventions for his heels. Interview with Physician K on 06/27/17 at 10:02 a.m. revealed he was aware of R #3's pressure ulcer progression. Physician K stated It is not realistic for a facility as big as this one to ensure the patients are turned every two hours, even though that is what's supposed to happen. Physician K said Of course, if pressure is not relieved frequently over a bony body part then an ulcer would certainly get worse or develop one. Not off-loading of an affected area would impede in wound healing and wound development. Physician K said other than being immobile and not repositioning frequently, there was no other explanation why R #3 would acquire his ulcers to his buttocks. R #4: R #4's Face Sheet dated 06/22/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Care Plan dated 03/29/17 documented: -I have a potential for pressure ulcer development related to decreased mobility, bowel and bladder incontinence .Interventions: Complete a full body check weekly and document, elevate lower extremities with pillows off-loading bilateral legs every shift, follow policy and procedures for the prevention/treatment of [REDACTED].>-I have a Stage 3 pressure ulcer to my sacrum area related to immobility and incontinence .Interventions: Administer treatments as ordered and observe for effectiveness, cleanse with wound cleanser, pat dry and apply puracol and cover with gauze and secure with [MEDICATION NAME]. Assess/record/observe wound healing. Measure length, width, and depth where possible . R #4's MDS dated [DATE] revealed R #4: -Had unclear speech -Rarely/never made self understood and sometimes understands others -Has short and long term memory problems and moderately impaired cognitive skills for daily decision making. -Requires total dependence with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -Was always incontinent of bladder and bowel. -Is at risk of pressure ulcers and had no pressure ulcers. R #4's Head to Toe Skin Check dated 06/12/17 documented Intact Skin; no skin breakdown noted upon assessment at this time . R #4's Situation Background Assessment Request (SBAR) dated 06/14/17 documented Resident presents with newly assessed pressure ulcer to the sacral area on 06/14/17. Resident is incontinent of bowel and bladder and completely dependent on staff for care. Resident is bedbound status requires total assistance with all ADLs. Physician notified 06/14/17 at 2:00 p.m. New Orders: Cleanse site with wound cleanser, pat dry, apply puracol, cover with gauze, and secure with [MEDICATION NAME] daily and prn until healed. R #4's Weekly Pressure Ulcer Report dated 06/14/17 documented Sacrum, date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 3.8 X 1.0 cm- Stage 3. 80% granulation with 20% slough tissue scant amount of serosanguinous drainage and pink wound edges .Response to treatment: new pressure ulcer- no previous response for comparison. R #4's June 2017 Order Summary Report documented Cleanse sacral wound with wound cleanser, pat dry, place Puracol (collagen dressing), cover with gauze, apply sure prep to perimeter and secure with [MEDICATION NAME] (clear self-adhesive dressing) daily and prn until healed- order date 06/14/17 R #4's Weekly Pressure Ulcer Record dated 06/21/17 documented Sacrum Stage 3 pressure ulcer- 4.0 X 0.4 cm. Maceration present to surrounding wound bed. 100% granulation present, no foul odor. Observation of R #4 on 06/22/17 at 2:42 p.m. revealed R #4 was being provided incontinent care by CNAs M and N. R #4 was able to make eye contact but did not respond verbally nor by gestures to communicate. CNA M stated R #4 did not speak and was not able to reposition herself. Staff positioned R #4 on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 3:55 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 4:45 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 5:33 p.m. revealed she continued to lay on her left side with a pillow behind her back. At 5:35 p.m., LVN Q and CNA N entered R #4's room and provided incontinent care and repositioned her on her right side. LVN Q stated R #4 was to be repositioned every two hours to prevent pressure ulcer development. CNA N said she thought she last positioned R #4 at approximately 3:00 p.m. CNA N was informed of the time R #4 was last repositioned then said I was coming when another resident asked me to take her to the dining room. Observation of R #4, while she received wound care by LVN O, on 06/23/17 at 11:17 a.m. revealed LVN O cleansed R #4's sacral ulcer and said It measures 3.1 X 0.6 centimeters, the wound bed is red and it has pink wound edges. It has 100% granulation with maceration around the outer wound bed. It looks like she has some slight discomfort when the area is manipulated due to her flinching when I touch it. LVN Q said she did not know how R #4 acquired a Stage 3 in the facility without it being noticed prior to progressing to a Stage 3. LVN O stated pressure ulcers do not form at a Stage 3, They begin at a Stage 1 then progress to a higher stage. Interview with RN A on 06/23/17 at 3:25 p.m. revealed she stated she could not respond why R #3 acquired a Stage 3 pressure ulcer. RN A said Either the wound was not identified upon admission or during the weekly skin assessment checks. It is not possible to spontaneously develop a Stage 3 or an unstageable pressure ulcer without previous signs of the ulcer at an earlier stage. After reviewing R #4's care plan, RN A said No her care plan does not address prevention interventions for pressure ulcers. R #5: R #5's Face Sheet dated 06/22/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE] for [MEDICAL CONDITION], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Nursing Admission Data Collection dated 02/17/17 revealed R #5 did not have any pressure ulcers identified upon admission. R #5's Care Plan dated 03/01/17 documented: -I have actual skin issues related to multiple bruising upon admission .Interventions: Notify MD of changes in wound or emerging wounds, provide wound care/preventative skin care per order, skin checks weekly, Turn and reposition frequently to decrease pressure. -I have an ADL self-care performance deficit related to muscle weakness from [MEDICAL CONDITION] .Interventions: Bathing/showering- I require one staff to provide shower, Bed Mobility- I require supervision one staff for repositioning and turning in bed, Dressing- I require extensive assistance of one staff for dressing . R #5's Head to Toe Skin Check dated 04/07/17 documented No skin breakdown noted upon assessment. R #5's Re-Admission Head to Toe Skin Check dated 05/02/17 documented Skin intact, dry skin and scabbing to left heel. Left upper buttock with dry scab. R #5's Braden Scale for Prediction Pressure Ulcer Risk dated 05/02/17 revealed a score of 16 At Risk= 15-18. R #5's physician's orders [REDACTED]. R #5's Quarterly MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and usually understood others -Had a BIMS score of 8 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was not at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Significant Change MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and understood others -Had a BIMS score of 9 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Head to Toe Skin Check dated 05/13/17 documented Skin Integrity: New Pressure Ulcer- Sacrum 3.0 X 1.5 X 0 cm. Open sacral wound noted, no signs/symptoms of infection, no drainage or active bleeding noted. *There was no documentation of the stage of the pressure ulcer. R #5's SBAR Communication Form and Progress Note dated 05/13/17 documented The change in condition: New Sacral Ulcer, started on 05/13/17. Male resident is restless, constantly rolling and shifting off bed, becomes easily upset, needs frequent repositioning and adjusting .MD made aware . R #5's Physician order [REDACTED]. R #5's Weekly Pressure Ulcer Record dated 05/17/17 documented New pressure ulcer acquired at facility 05/13/17- Sacrum: Stage 2 pressure- 2.0 X 3.2 X 0 cm. 10% Eschar, 90% granulation, no foul odor, scant serosanguinous drainage, no depth to site. Normal skin surrounding wound. *The presence of eschar in the wound did not meet the definition of a Stage 2 pressure ulcer. The ulcer has deteriorated and was incorrectly staged. R #5's SBAR Communication Form and Progress Note dated 05/22/17 documented Situation: New Stage 2 left heel pressure ulcer. Resident was in shower when voiced discomfort to left heel upon tactile stimuli. Upon assessment resident noted with Stage 2 left heel ulcer .Called MD. New Orders: Left heel Stage 2: Cleanse with normal saline/wound cleanser, pat dry, apply Therahoney to heel, cover with gauze, secure with Kerlix and tape daily and prn until healed. R #5's Telephone physician's orders [REDACTED]. Promod liquid nutritional supplement- 60 milliliters TID (three times a day) for wounds . R #5's revised Care Plan dated 05/23/17 documented I have a pressure ulcer to my sacral stage 3 area and left heel stage 2 .Interventions: Complete a full body check weekly and document, Observe/document/report any changes in skin status; appearance, color, wound healing, signs/symp of infection, wound size, stage. Provide incontinent care after each episode. *R #5's care plan did not include specific individualized preventative interventions to provide pressure relief to his Left heel and sacrum. R #5's care plan did not include any resistance/refusal of treatment. R #5's Weekly Pressure Ulcer Record dated 06/01/17 documented Sacrum Stage 3 Pressure Ulcer: 3.0 X 3.0 X 0 cm. 100% slough present in wound bed, small serous drainage, pink surrounding wound edges . Specialty interventions: Positioning Devices: extra pillows. R #5's June 2017 Order Summary Report documented Cleanse left heel with wound cleanser, pat dry, apply sure prep daily and leave open to air every day shift for Suspected Deep Tissue Injury .Cleanse sacral site with wound cleanser, pat dry, apply Santyl ointment, cover with gauze, apply skin prep to outer skin and secure with [MEDICATION NAME] daily and prn every day shift for pressure ulcer .order date 06/02/17 . R #5's Head to Toe Skin Check dated 06/03/17 documented Left heel: Suspected Deep Tissue Injury. *This document did not have a thorough description or measurements of the ulcer. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Left heel Suspected Deep Tissue Injury: 1.5 X 2.2 cm. 100% eschar tissue, black wound bed, no drainage. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Sacrum Stage 3: 3.0 X 2.5 X 0.3 cm. 100% yellow slough with maceration to wound edges from 4-7 o'clock with moderate serous drainage. White/gray/pallor wound edges. *According to the measurements, this wound has developed new depth. R #5's Weekly Pressure Ulcer Record dated 06/14/17 documented Sacrum Stage 3: 2.9 X 2.3 X 0.2 cm, 90% yellow slough tissue with 10% granulation tissue, moderate serous drainage, maceration noted to 5-7 o'clock. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Sacrum Stage 3: 3.0 X 2.0 X 1.0 cm, continues with 90% yellow slough tissue with 10% granulation tissue, maceration to wound edges. *According to the measurements, this wound's depth has increased in size. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Left heel Suspected Deep Tissue Injury: 1.3 X 1.8 X 0 cm, wound bed covered with 100% black eschar, no foul odor, no drainage, wound edges are black. Observation of R #5 on 06/22/17 at 3:54 p.m. revealed R #5 laid on his back in bed. R #5 was alert and oriented to person and place only. R #5 complained of pain to his left heel. R #5 described his pain as throbbing. R #5 had one pillow under his head and one flat pillow under his calves. R #5's heels rested on the mattress. There were no other pillows in R #5's room. Observation of R #5 on 06/22/17 at 5:30 p.m. revealed R #5 continued to lay on his back with one flat pillow under his calves however, his heels continued to rest on the mattress. Observation of R #5, receiving wound care by LVN O, on 06/22/17 at 12:00 p.m. revealed LVN O presented R #5's left heel which had a black intact hardened cap over the heel with dry peeling skin over and around the entire ulcer. LVN O said There is 100% black eschar with dryness around the wound with dry peeling skin over the wound. It measures 2.0 X 1.5 centimeters. As LVN O cleansed R #5's left heel, R #5 pulled his foot away and acknowledged It hurts. LVN O repositioned R #5 to his left side and presented R #5's sacral area. R #5's sacrum had approximately 90-95% of yellow tissue on the wound bed and some red tissue present on the right side of the wound. The surrounding tissue of the entire wound edges was white and wrinkled. The surrounding skin around the wound bed was dark burgundy in color. LVN O began to cleanse the area and again R #5 tightened his buttocks and said Ouch, it hurts. LVN O stated It has 90% yellow slough and about 10% granulation within the wound bed, the surrounding tissue is really macerated, white in color. It measures 3.0 X 1.9 centimeters. I saw it last week, the burgundy area was blanchable then but not it's not and the burgundy area did not extend that far out from the wound bed, it was only around the edges of the wound bed. The non-blanchable burgundy color definitely extends farther than it did last week. Upon the s(TRUNCATED)

Based on observation, interview, and record review, the facility failed to review and revise the residents' comprehensive care plan to include accurate objectives to meet their medical, nursing, mental and psychosocial needs that were identified in the comprehensive care plans for four Residents (R #3, R #4, R #5, and R #6) out of eight residents reviewed for comprehensive care plans. R #3, R #4, R #5, and R #6's care plans did not include specific individualized preventive interventions to prevent the development or deterioration of pressure ulcers. The failure could result in lower quality of care and quality of life for 15 residents identified with pressure ulcers and 58 residents identified as receiving preventive skin care. The findings included: R #3: R #3's Face Sheet dated 06/22/17 documented an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., nutrition, and medication administration), and Generalized Muscle Weakness. R #3's Nursing Admission Data Collection dated 06/02/17 documented Right Heel pressure ulcer: length- 6.0 X 5.5 cm (centimeters) .Left heel pressure ulcer- 5.0 X 4.0 cm, healed sacral ulcer . R #3's Order Summary Report dated 06/02/17 documented Cleanse unstageable pressure ulcer to right and left heel with normal saline/wound cleanser, pat dry with gauze, paint with [MEDICATION NAME], cover with [MEDICATION NAME] foam dressing every other day and PRN (as needed) until healed Stage 2 left buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift Stage 2 right buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift .Vitamin A per [DEVICE] q (every) am, Vitamin C one tablet per [DEVICE] daily q am, Zinc tablet per [DEVICE] q am for wound healing . R #3's Braden Scale for Predicting Pressure Sore Risk dated 06/02/17 revealed a score of 12, Scoring: High Risk= 10-12. R #3's Initial Care Plan initiated 06/03/17 documented: -I have an ADL (Activity of Daily Living) self-care performance deficit related to Dementia- Bed Mobility: the resident is totally dependent on two staff for repositioning and turning in bed and as necessary . -I have limited physical mobility related to left sided weakness . -I have potential/actual skin issues .Interventions: Notify MD of changes in wound, observe wound healing, provide wound care per orders, skin checks weekly per facility protocol, document findings . *R #3's care plan did not specifically address his pressure ulcers nor did the care plan address interventions for preventative care to prevent new or worsening of pressure ulcers. R #3's Minimum Data Set ((MDS) dated [DATE] revealed R #3: -Usually made self understood and understood others. -Had a Brief Interview of Mental Status (BIMS) of 07 (severely impaired cognition). -Required total dependence with two person physical assist for bed mobility, transfers, and toilet use. R #3 required total dependence with one person physical assist for dressing and personal hygiene. -Had impairment on both sides of both upper and lower extremities. -Was always incontinent of bowel and bladder. -Was 64 inches tall and 135 pounds. -Was at risk for developing pressure ulcers and entered the facility with two Unstageable pressure ulcer. -Skin and Ulcer Treatments: Turning/Repositioning Program, Nutrition and Hydration Intervention, Pressure Ulcer Care, Application of nonsurgical dressings and ointments and medications, application of dressings to feet. R #3's Weekly Skin Pressure Ulcer Report dated 06/14/17 documented Date of Onset: 06/14/17, New Pressure Ulcer, Acquired at the facility, Sacrum Stage 1 pressure ulcer, 1 X 0.5 X 0 cm, Description: Pressure ulcer to left buttock serous fluid to wound bed. No foul odor noted. Proximal tissue color pink distal redness with undefined wound edges. Surrounding [MEDICATION NAME] tissue, Surrounding skin away from the wound edges with maceration (soften skin from being wet); Right buttock Stage 1: Date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 0.8 X 0.3 X 0 cm, suspected sacral ulcer right buttock ulcer, 100% beefy red in color. Undefined wound edges. Macerated surrounding skin. No foul odor to wound. No drainage noted.This document included the definitions of: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcers covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #3's Weekly Pressure Ulcer Record dated 06/21/17 documented Date of Onset: 06/21/17, new pressure ulcer, acquired at the facility, Right Buttock Stage 2: 3.0 X 1.6 X 0 cm, pink-red wound bed without slough .Date of Onset: 06/02/17, admitted with, Right Heel: 6.5 X 6.0 x 0 Unstageable eschar to wound bed, bruising and redness to wound edges, wound bed black, no odor, no drainage, wound edges dark red/purple, response to treatment: no change .Date of Onset: 06/02/17, existing, admitted with, Left Heel: 4.3 X 4.4 X 0 cm Unstageable, eschar to wound bed with redness and non-blanchable skin to surrounding skin, scant drainage, redness to surrounding skin, response to treatment: no change . Interview with Licensed Vocational Nurse (LVN) H on 06/22/17 at 3:10 p.m. revealed she was caring for R #3. LVN H reviewed R #3's most current Pressure Ulcer Report dated 06/21/17 and said out loud He (R #3) has a right heel unstageable found on admission on 06/02/17 that measured 6.5 X 4.5 X 0.0 cm on 06/08/17 and 4.3 X 4.4 X 0.0 cm on 06/21/17. His left heel unstageable was found on admission on 06/02/17 and it measured 3.5 X 3.0 X 0 cm on 06/08/17 and 6.5 X 6.0 X 0 cm on 06/21/17. He also has a right buttock Stage 2 acquired in-house on 06/21/17 that measured 3.0 X 1.6 X 0 cm and a left buttock Stage 2 acquired in-house on 06/21/17 that measured 1.0 X 1.0 X 0. cm. LVN H said she would perform R #3's wound care on his heels shortly. Observation of R #3 on 06/22/17 at 3:14 p.m. revealed he laid on his back on a similar mattress as every other resident had on their bed. R #3's head of bed was slightly elevated and had one flat pillow under his left shoulder. R #3's hips and buttocks rested flat on the mattress. R #3's eyes were closed. R #3 did not respond to verbal stimuli. R #3 had a flat pillow under his knees however, both of his heels rested on the bed. At 3:16 p.m., LVN H entered R #3's room and began wound care. LVN H picked up R #3's left heel off the bed and unwrapped the kerlix dressing. LVN H exposed R #3's left heel that was entirely black and purple in color and provided treatment as ordered. LVN H picked up R #3's right heel off the bed and unwrapped it of the kerlix dressing. The right heel was 100% covered with a black colored cap with redness on the surrounding tissue at approximately 11-2 o'clock. As LVN H cleansed each heel, R #3 pulled each foot away every time she wiped the area. LVN H asked R #3 if he had pain but R #3 replied No. LVN H said she was sure he has some pain when I touch or press on the heel since he is pulling away. LVN H placed a pillow under R #3's calves and walked out of the room. Observation of R #3 on 06/22/17 at 4:15 p.m. revealed R #3 laid on his back with his head of bed slightly elevated with one flat pillow under his left shoulder and with one flat pillow under his calves however, both heels and buttocks remained resting on the mattress. Observation of R #3 on 06/22/17 at 5:46 p.m. revealed R #3 again laid on his back with one flat pillow under his left shoulder and his head slightly elevated as seen earlier and one flat pillow underneath his calves. R #3's heel rested on the mattress, applying pressure to his pressure ulcers on his heels. Simultaneous interview with Certified Nurse Aide (CNA) I and LVN H on 06/22/17 at 5:47 p.m. revealed both staff knew R #3 had pressure ulcers on both heels and his buttocks. LVN H said R #3 should be repositioned every two hours. CNA I said she had not repositioned R #3 since approximately 3:00 - 3:15 p.m. CNA I said she knew R #3 was due to reposition but was assisting with dinner trays. CNA I and LVN H both said they place a pillow under R #3's legs to keep his heels raised off the bed to prevent pressure on the heels. Upon the surveyor's request, LVN H accompanied the surveyor to R #3's room and found a pillow under R #3's calves with his heels resting on the mattress and a flat pillow under R #3's left shoulder with his hips and buttocks resting on the mattress. LVN H confirmed the one pillow was not effective in relieving pressure off the heels. LVN H also confirmed the one pillow under R #3's left shoulder was there in attempt to relieve pressure off his buttocks but was unsuccessful since the pillow was too flat. LVN H said the facility did not have any positioning devices to use other than pillows. LVN H stated she would locate more pillows for R #3. LVN H stated if R #3's ulcers were not relieved of pressure from the bed, his ulcers could worsen or acquire new ones. R #3's Care Plan revised 06/22/17 documented I have Stage 2 pressure ulcers to left and right buttocks and unstageable to left and right heels .Interventions: Administer treatments as ordered and observe for effectiveness, Assess/record/observe wound healing. Measure where possible. Report improvements and declines to MD, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation of Registered Nurse (RN) A providing R #1 with wound care on 06/23/17 at 10:42 a.m. revealed she measured R #3's left buttock ulcer and said out loud Left Stage 2 measures 1.0 X 1.0 X 0 centimeters. Right buttock Stage 2 measures 3.4 X 2.2 X 0 centimeters. The right buttock grew in length and width since admission and when I last measured it on 06/21/17. The wound bed is red without any drainage or odor and the surrounding skin is of normal skin color. The right heel unstageable measures 6.4 X 7.5 X 0 centimeters, it has 100% eschar cap with redness to surrounding skin and bruising at 5 o'clock, and redness at 6-9 o'clock. He said he has pain to the heel. The right heel has grown in length and width since his last measurements. The left heel unstageable measures 5.0 X 5.5 X 0 centimeters. The heel has approximately 75% eschar in wound bed, redness to wound edges from 9-3 o'clock and bruising and non-blanchable redness from 3-9 o'clock. There is blanchable redness at 6 o'clock. His left heel grew in width. Observation of R #3 on 06/27/17 at 8:29 a.m. revealed R #3 laid on his right side with one pillow behind his left back and one pillow under his calves with his left heel resting on the mattress. At 8:32 a.m., CNA J entered R #3's room and stated she repositioned R #3 approximately one hour ago from his back to his right side. The surveyor asked CNA J if R #3's heels are appropriately elevated off the bed; CNA J said No, his left heel is on the bed. CNA J added a pillow between R #3's ankles and plumped the pillow under his calves which elevated both heels off the mattress. Interview with RN A on 06/23/17 at 3:00 p.m. revealed she reviewed and compared R #3's Weekly Pressure Ulcer Reports. RN A said His left and right heel got slightly wider compared to his admission measurements. His left and right buttocks ulcers were acquired in the facility. He should have his heels off loaded with pillows to relieve pressure off his heels to cure the ulcers. RN A reviewed R #3's care plan and said the word frequently referred to every 2 hours. RN A said R #3's care plan did not have specific preventative interventions for his heels. Interview with Physician K on 06/27/17 at 10:02 a.m. revealed he was aware of R #3's pressure ulcer progression. Physician K stated It is not realistic for a facility as big as this one to ensure the patients are turned every two hours, even though that is what's supposed to happen. Physician K said since R #3 was receiving feeding via [DEVICE] and was immobile and debilitated, It is hard to minimize pressure ulcer development. Physician K said since R #3 was on a [DEVICE], immobile, and debilitated, he recommended R #3's family to place him on hospice but the family refused. Physician K said Of course, if pressure is not relieved frequently over a bony body part then an ulcer would certainly get worse or develop one. Not off-loading of an affected area would impede in wound healing and wound development. Physician K said other than being immobile and not repositioning frequently, there was no other explanation why R #3 would acquire his ulcers to his buttocks. R #4: R #4's Face Sheet dated 06/22/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Care Plan dated 03/29/17 documented: -I have a potential for pressure ulcer development related to decreased mobility, bowel and bladder incontinence .Interventions: Complete a full body check weekly and document, elevate lower extremities with pillows off-loading bilateral legs every shift, follow policy and procedures for the prevention/treatment of [REDACTED].>-I have a Stage 3 pressure ulcer to my sacrum area related to immobility and incontinence .Interventions: Administer treatments as ordered and observe for effectiveness, cleanse with wound cleanser, pat dry and apply puracol and cover with gauze and secure with [MEDICATION NAME]. Assess/record/observe wound healing. Measure length, width, and depth where possible . R #4's MDS dated [DATE] revealed R #4: -Had unclear speech -Rarely/never made self understood and sometimes understands others -Has short and long term memory problems and moderately impaired cognitive skills for daily decision making. -Requires total dependence with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -Was always incontinent of bladder and bowel. -Is at risk of pressure ulcers and had no pressure ulcers. R #4's Head to Toe Skin Check dated 06/12/17 documented Intact Skin; no skin breakdown noted upon assessment at this time . R #4's Situation Background Assessment Request (SBAR) dated 06/14/17 documented Resident presents with newly assessed pressure ulcer to the sacral area on 06/14/17. Resident is incontinent of bowel and bladder and completely dependent on staff for care. Resident is bedbound status requires total assistance with all ADLs. Physician notified 06/14/17 at 2:00 p.m. New Orders: Cleanse site with wound cleanser, pat dry, apply puracol, cover with gauze, and secure with [MEDICATION NAME] daily and prn until healed. R #4's Weekly Pressure Ulcer Report dated 06/14/17 documented Sacrum, date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 3.8 X 1.0 cm- Stage 3. 80% granulation with 20% slough tissue scant amount of serosanguinous drainage and pink wound edges .Response to treatment: new pressure ulcer- no previous response for comparison. R #4's June 2017 Order Summary Report documented Cleanse sacral wound with wound cleanser, pat dry, place Puracol (collagen dressing), cover with gauze, apply sure prep to perimeter and secure with [MEDICATION NAME] (clear self-adhesive dressing) daily and prn until healed- order date 06/14/17 R #4's Weekly Pressure Ulcer Record dated 06/21/17 documented Sacrum Stage 3 pressure ulcer- 4.0 X 0.4 cm. Maceration present to surrounding wound bed. 100% granulation present, no foul odor. Observation of R #4 on 06/22/17 at 2:42 p.m. revealed R #4 was being provided incontinent care by CNAs M and N. R #4 was able to make eye contact but did not respond verbally nor by gestures to communicate. CNA M stated R #4 did not speak and was not able to reposition herself. Staff positioned R #4 on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 3:55 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 4:45 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 5:33 p.m. revealed she continued to lay on her left side with a pillow behind her back. At 5:35 p.m., LVN Q and CNA N entered R #4's room and provided incontinent care and repositioned her on her right side. LVN Q stated R #4 was to be repositioned every two hours to prevent pressure ulcer development. CNA N said she thought she last positioned R #4 at approximately 3:00 p.m. CNA N was informed of the time R #4 was last repositioned then said I was coming when another resident asked me to take her to the dining room. Observation of R #4, while she received wound care by LVN O, on 06/23/17 at 11:17 a.m. revealed LVN O cleansed R #4's sacral ulcer and said It measures 3.1 X 0.6 centimeters, the wound bed is red and it has pink wound edges. It has 100% granulation with maceration around the outer wound bed. It looks like she has some slight discomfort when the area is manipulated due to her flinching when I touch it. LVN Q said she did not know how R #4 acquired a Stage 3 in the facility without it being noticed prior to progressing to a Stage 3. LVN O stated pressure ulcers do not form at a Stage 3, They begin at a Stage 1 then progress to a higher stage. Interview with RN A on 06/23/17 at 3:25 p.m. revealed she stated she could not respond why R #3 acquired a Stage 3 pressure ulcer. RN A said Either the wound was not identified upon admission or during the weekly skin assessment checks. It is not possible to spontaneously develop a Stage 3 or an unstageable pressure ulcer without previous signs of the ulcer at an earlier stage. After reviewing R #4's care plan, RN A said No her care plan does not address prevention interventions for pressure ulcers. R #5: R #5's Face Sheet dated 06/22/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE] for [MEDICAL CONDITION], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Nursing Admission Data Collection dated 02/17/17 revealed R #5 did not have any pressure ulcers identified upon admission. R #5's Care Plan dated 03/01/17 documented: -I have actual skin issues related to multiple bruising upon admission .Interventions: Notify MD of changes in wound or emerging wounds, provide wound care/preventative skin care per order, skin checks weekly, Turn and reposition frequently to decrease pressure. -I have an ADL self-care performance deficit related to muscle weakness from [MEDICAL CONDITION] .Interventions: Bathing/showering- I require one staff to provide shower, Bed Mobility- I require supervision one staff for repositioning and turning in bed, Dressing- I require extensive assistance of one staff for dressing . R #5's Head to Toe Skin Check dated 04/07/17 documented No skin breakdown noted upon assessment. R #5's Re-Admission Head to Toe Skin Check dated 05/02/17 documented Skin intact, dry skin and scabbing to left heel. Left upper buttock with dry scab. R #5's Braden Scale for Prediction Pressure Ulcer Risk dated 05/02/17 revealed a score of 16 At Risk= 15-18. R #5's physician's orders [REDACTED]. R #5's Quarterly MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and usually understood others -Had a BIMS score of 8 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was not at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Significant Change MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and understood others -Had a BIMS score of 9 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Head to Toe Skin Check dated 05/13/17 documented Skin Integrity: New Pressure Ulcer- Sacrum 3.0 X 1.5 X 0 cm. Open sacral wound noted, no signs/symptoms of infection, no drainage or active bleeding noted. *There was no documentation of the stage of the pressure ulcer. R #5's SBAR Communication Form and Progress Note dated 05/13/17 documented The change in condition: New Sacral Ulcer, started on 05/13/17. Male resident is restless, constantly rolling and shifting off bed, becomes easily upset, needs frequent repositioning and adjusting .MD made aware . R #5's Physician order [REDACTED]. R #5's Weekly Pressure Ulcer Record dated 05/17/17 documented New pressure ulcer acquired at facility 05/13/17- Sacrum: Stage 2 pressure- 2.0 X 3.2 X 0 cm. 10% Eschar, 90% granulation, no foul odor, scant serosanguinous drainage, no depth to site. Normal skin surrounding wound. *The presence of eschar in the wound did not meet the definition of a Stage 2 pressure ulcer. The ulcer has deteriorated and was incorrectly staged. R #5's SBAR Communication Form and Progress Note dated 05/22/17 documented Situation: New Stage 2 left heel pressure ulcer. Resident was in shower when voiced discomfort to left heel upon tactile stimuli. Upon assessment resident noted with Stage 2 left heel ulcer .Called MD. New Orders: Left heel Stage 2: Cleanse with normal saline/wound cleanser, pat dry, apply Therahoney to heel, cover with gauze, secure with Kerlix and tape daily and prn until healed. R #5's Telephone physician's orders [REDACTED]. Promod liquid nutritional supplement- 60 milliliters TID (three times a day) for wounds . R #5's revised Care Plan dated 05/23/17 documented I have a pressure ulcer to my sacral stage 3 area and left heel stage 2 .Interventions: Complete a full body check weekly and document, Observe/document/report any changes in skin status; appearance, color, wound healing, signs/symp of infection, wound size, stage. Provide incontinent care after each episode. *R #5's care plan did not include specific individualized preventative interventions to provide pressure relief to his Left heel and sacrum. R #5's care plan did not include any resistance/refusal of treatment. R #5's Weekly Pressure Ulcer Record dated 06/01/17 documented Sacrum Stage 3 Pressure Ulcer: 3.0 X 3.0 X 0 cm. 100% slough present in wound bed, small serous drainage, pink surrounding wound edges . Specialty interventions: Positioning Devices: extra pillows. R #5's June 2017 Order Summary Report documented Cleanse left heel with wound cleanser, pat dry, apply sure prep daily and leave open to air every day shift for Suspected Deep Tissue Injury .Cleanse sacral site with wound cleanser, pat dry, apply Santyl ointment, cover with gauze, apply skin prep to outer skin and secure with [MEDICATION NAME] daily and prn every day shift for pressure ulcer .order date 06/02/17 . R #5's Head to Toe Skin Check dated 06/03/17 documented Left heel: Suspected Deep Tissue Injury. *This document did not have a thorough description or measurements of the ulcer. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Left heel Suspected Deep Tissue Injury: 1.5 X 2.2 cm. 100% eschar tissue, black wound bed, no drainage. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Sacrum Stage 3: 3.0 X 2.5 X 0.3 cm. 100% yellow slough with maceration to wound edges from 4-7 o'clock with moderate serous drainage. White/gray/pallor wound edges. *According to the measurements, this wound has developed new depth. R #5's Weekly Pressure Ulcer Record dated 06/14/17 documented Sacrum Stage 3: 2.9 X 2.3 X 0.2 cm, 90% yellow slough tissue with 10% granulation tissue, moderate serous drainage, maceration noted to 5-7 o'clock. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Sacrum Stage 3: 3.0 X 2.0 X 1.0 cm, continues with 90% yellow slough tissue with 10% granulation tissue, maceration to wound edges. *According to the measurements, this wound's depth has increased in size. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Left heel Suspected Deep Tissue Injury: 1.3 X 1.8 X 0 cm, wound bed covered with 100% black eschar, no foul odor, no drainage, wound edges are black. Observation of R #5 on 06/22/17 at 3:54 p.m. revealed R #5 laid on his back in bed. R #5 was alert and oriented to person and place only. R #5 complained of pain to his left heel. R #5 described his pain as throbbing. R #5 had one pillow under his head and one flat pillow under his calves. R #5's heels rested on the mattress. There were no other pillows in R #5's room. Observation of R #5 on 06/22/17 at 5:30 p.m. revealed R #5 continued to lay on his back with one flat pillow under his calves however, his heels continued to rest on the mattress. Observation of R #5, receiving wound care by LVN O, on 06/22/17 at 12:00 p.m. revealed LVN O presented R #5's left heel which had a black intact hardened cap over the heel with dry peeling skin over and around the entire ulcer. LVN O said There is 100% black eschar with dryness around the wound with dry peeling skin over the wound. It measures 2.0 X 1.5 centimeters. As LVN O cleansed R #5's left heel, R #5 pulled his foot away and acknowledged It hurts. LVN O repositioned R #5 to his left side and presented R #5's sacral area. R #5's sacrum had approximately 90-95% of yellow tissue on the wound bed and some red tissue present on the right side of the wound. The surrounding tissue of the entire wound edges was white and wrinkled. The surrounding skin around the wound bed was dark burgundy in color. LVN O began to cleanse the area and again R #5 tightened his buttocks and said Ouch, it hurts. LVN O stated It has 90% yellow slough and about 10% granulation within the wound bed, the surrounding tissue is really macerated, white in color. It measures 3.0 X 1.9 centimeters. I saw it last week, the burgundy area was blanchable then but not it's not and the burgundy area did not extend that far out from the wound bed, it was only around the edges of the wound bed. The non-blanchable burgundy color definitely extends farther than it did last week. Upon the surveyor's request, LVN measured the non-blanchable burgundy colored area surrounding the wound and said At 12 o'clock it measures 1.2, at 3 o'clock it's 1.5, at 6 o'clock it's 1.2, and at 9 o'clock it's 2.0 centimeters. LVN O stated she thought R #5's sacral ulcer looked worse than last week. Interview with RN A on 06/23/17 at 3:20 p.m. revealed she reviewed R #5's Weekly Pressure Ulcer Reports with the surveyor. RN A confirmed R #5's left heel that was staged as a Suspected Deep Tissue Injury was incorrectly staged and should have been staged as an unstageable due to the eschar that was present. RN A said R #5's left heel Appeared to increase in length and the sacrum ulcer deteriorated since it acquired a depth after it was initially found. RN A confirmed R #5's sacrum ulcer deteriorated from a stage 2 to a stage 3. R #6: R #6's Face Sheet dated 06/27/17 documented a [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. the circulatory system) of Deep Vein of Unspecified Upper Extremity. R #6's Hospital Transfer and Referral Record dated 02/14/17 documented Skin: Bilateral bruising to upper extremities. Stage 2 sacral ulcer . R #6's Initial Admission Order Summary Report dated 02/14/17 revealed no orders for any treatment of [REDACTED]. R #6's Initial Weekly Pressure Ulcer Report dated 02/14/17 documented Date of Onset: 02/14/17, existing pressure ulcer, admitted with, Sacrum Stage 2- 0.3 X 0.3 X 0.3 cm. Pressure ulcer red, some blanchable and unblanchable. R #6's physician's orders [REDACTED]. R #6's Care Plan dated 02/17/17 documented I have skin issues related to bowel and bladder incontinence .Interventions: Notify MD of changes or emerging wounds, observe wound healing, provide wound care/preventative skin care per order. *R #6's orders did not include any preventative skin care. R #6's Physician's Telephone Orders dated 02/18/17 documented Zinc Sulfate 220 mg (milligrams) per [DEVICE] daily. Vitamin C 500 mg per [DEVICE] twice a day. R #6's Head to Toe Skin Check dated 02/22/17 documented resolved Stage 2 pressure ulcer to sacrum. R#6's Admission MDS dated [DATE] documented: -Usually made self understood and understands others -Had a BIMS score of 3 (severe cognitive impairment) -Required extensive assistance with two person physical assist for bed mobility, transfer, eating and toilet use. R #6 was totally dependent with two person physical assist for dressing and personal hygiene. -R #6 had an indwelling catheter and was always incontinent of bowel -R #6 was at risk of developing pressure ulcers and was admitted with one Stage 2. R #6's SBAR Communication Form and Progress Note dated 03/13/17 documented Situation: New sacral pressure, Stage 2, started on 03/13/17. Things that make a condition or symptom worse are generalized fragile skin, total care .Phys(TRUNCATED)

Based on record review and interview, the facility failed to ensure residents have the right to be free from neglect for four residents (R #3, R #4, R #5, and R #6) of five residents reviewed for pressure ulcers and two residents (R #1 and R #2) of three residents reviewed for accidents and injuries. The facility did not: -Ensure R #3's bilateral heels and buttocks were offloaded. R #3's community acquired bilateral heel unstageables that grew in size. R #3 developed a left and right buttock Stage 1 pressure ulcer, while in the facility, that deteriorated into Stage 2 ulcers. -Ensure R #3's initial care plan addressed his pressure ulcers or include specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #3 was not provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #4 was repositioned at least every two hours as per the facility's policy. -Identify R #4 had developed a pressure ulcer to her sacrum, prior to initially identifying it at a Stage 3 despite daily incontinent care and/or baths by staff. -Ensure R #4's care plan included specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #4 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #5's sacrum were offloaded. R #5 developed a Stage 2 pressure ulcer to his sacrum 11 days after re-admission to the facility. -Document the stage of his sacral ulcer on his initial assessment. -Correctly stage R #5's sacral ulcer. The facility documented R #5's Stage 2 ulcer as having eschar, which no longer met the definition of a stage 2 yet, the ulcer continued to be identified as a Stage 2. R #5's sacrum ulcer deteriorated and the facility documented the ulcer as a Stage 3 then to a Suspected Deep Tissue Injury (SDTI). R #5's sacral ulcer was incorrectly staged as a SDTI, rather than an Unstageable, by definition. -Ensure R #5's left heel was offloaded. R #5 developed a Stage 2 pressure ulcer to his left heel that deteriorated to a SDTI. -Ensure R #5's care plan included specific individualized preventative interventions to provide pressure relief to his left heel and sacrum. -Ensure R #5 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Correctly recognize/identify R #6's sacral ulcer. Staff documented the ulcer to have slough and continued to identify it as a Stage 2, which did not meet the definition of a stage 2 pressure ulcer. R #6 developed a Stage 2 pressure ulcer to his sacrum while in the facility which deteriorated to a Stage 4, upon discharge. -Correctly identify R #6's facility-acquired stage 2 left heel ulcer that was identified to have slough yet, staff continued to be identified as a Stage 2 pressure ulcer, instead of a Stage 3. -Ensure R #6's care plan included specific individualized preventative interventions for pressure relief of R #6's sacrum and left heel. -Perform or document a thorough assessment of R #6's pressure ulcer upon discharge. The facility's last assessment of R #6's pressure ulcer was five days prior to his discharge and was identified as a Stage 3 however, the ulcer was identified by his physician to have a Stage 4 pressure ulcer. R #6 was discharged from the facility on 05/29/17. -Consult with R #6's physician of his deteriorating sacral pressure ulcer. The above failures resulted in an Immediate Jeopardy (IJ) situation on 06/27/17. While the IJ was removed on 06/28/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 15 residents with pressure ulcers and 58 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. R #1: R#1 had a total of 7 falls (2 unwitnessed falls and 5 witnessed falls) from 04/11/17 through 06/14/17. R #2: R#2 had a total of 16 falls (8 unwitnessed falls and 8 witnessed falls ) from 01/04/17 through 06/24/17. This failure could place nine of the 21 residents on wing C (secure unit) with a history of falls at risk for additional falls and injuries. The findings included: Review of the facility's Abuse Neglect Prohibition Policy revised September 2001 revealed Policy Each resident has the right to be free from .neglect. Neglect means failure to provide goods and services necessary to avoid physical harm . The facility's Skin Management Policy and Procedure dated August 2012 documented Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Staging classification: The following Staging Classification is consistent with the National Pressure Ulcer Advisory Panel (NPUAP): -Stage 1: An observable pressure related to alteration of intact skin whose indicators as compared to an adjacent or opposite areas on the body may include changes in one or more of the following: skin temperature, tissue consistence and/or sensation; the ulcer appears as a defined area of persistent redness in lightly pigmented skin . -Stage 2: Partial thickness of skin loss involving epidermis and/or dermis; the ulcer is superficial and presents clinically as abrasion, blister, or shallow crater .Slough is not found on Stage 2 ulcers. In addition, a Stage 2 blister may be intact or open serum filled. A blood blister is considered to be a suspected Deep Tissue Injury (DTI). -Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. A Stage 3 may include tunneling or undermining. -Stage 4: Full thickness loss of skin with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures. -Unstageable: When eschar is present, accurate staging is not possible until the eschar has sloughed or the wound has been debrided. Identify/document as eschar covered area, unable to determine depth and stage, etc. Eschar in the wound bed may be tan, brown, or black in color. Unstageable wounds may be covered by yellow, tan, gray, green, or brown slough. -Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue. May open and deteriorate rapidly even with optimal treatment. Practice Guidelines: 1. Upon admission, all residents are assessed for skin integrity by completing a head to toe physical assessment of skin condition and completing the Braden Scale for Predicting Pressure Sore Risk . 3. Appropriate preventive surfaces of beds, wheelchairs, etc. will be implemented on all residents at risk (score of 18 or less on the Braden Scale), and the interventions documented on the Care Plan. 4. Residents admitted with skin impairments will have: a. Appropriate interventions implemented to promote healing; b. A physician's orders [REDACTED]. c. Wound location and characteristics documented in the Nursing Notes; d. Referral to Rehabilitation Services; e. Their family notified of presence impairment. 5. In addition, the following forms are completed and placed with the resident's Treatment Record: a. Pressure Ulcer: Weekly Pressure Ulcer Record b. Non-Pressure Ulcer Skin Condition Record 6. A Care Plan is developed upon admission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown, The Care Plan should address, but is not limited to: Hydration, Nutrition, Preventive devices, Physical activity, Pain, Positioning requirements, Proper body alignment. 7. Wounds are tracked as acquired (developed in-house or admitted with and are assessed and documented on the Weekly Pressure Ulcer Record). 8. The Licensed Nurse will document daily monitoring of all pressure ulcers on the Treatment Administration Record (TAR). 9. A physician's orders [REDACTED]. 12. A nutritional evaluation will be completed within 7 days of admission on all residents identified at risk or with compromised skin integrity . 14. Ongoing monitoring and continuous quality improvement will be achieved by the Interdisciplinary Team . 16. Skin Assessments: a. Weekly Skin Check will be transcribed onto the Treatment Record including the day and shift on which the check will be conducted. b. Completion of the weekly skin assessment will be noted on the TAR with the LVN's initials. c. Skin assessments will be documented weekly on the Head to Toe Skin Check form .Alterations or changes in skin integrity, any break in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds etc, are to be recorded on the Head to Toe Skin Check form. d. A change in condition form is to be completed and new physician's orders [REDACTED]. e. It is recommended that skin assessments be completed when a resident will be out of the facility for more than 4 hours. Findings and follow-up, if needed, are to be documented in the Nurses' Notes. 17. The nurse will assure treatments, interventions, Care Plan, and the appropriate skin documentation records are initiated in a timely manner according to Practice Guidelines. 18. Pressure ulcers are measured and staged weekly in accordance with the Practice Guidelines . 20. The assigned IDT member will ensure communication to other staff of the results of the review and any changes to the Plan of Care. Management of Tissue Loads Through Positioning: 1. Avoid positioning a resident directly on a pressure ulcer whenever possible. 2. Use positioning devices. Devices (pillows, blanket rolls, etc.) should be used to completely raise the pressure sore area, i.e., heel and back of the head, completely off of the support surface. Use of these devices may reduce the need for a pressure reducing mattress or overlay (Stage 3 or higher). 3. Establish an individualized turning schedule based on the resident's clinical condition. 4. Assess for risk of developing additional ulcers. a. Totally relieve heel pressure by elevation of the heel completely off of the bed surface. b. Prevent direct contact between bony prominence and support surface. Factors to consider when choosing a support surface: -Therapeutic benefit associated with the product; -Residents' clinical condition; . Pressure Reduction: 1. Change position in bed every two hours or chair every one hour for dependent residents. 2. Use turn sheet/draw sheet for repositioning. This will prevent shearing. 3. Utilize pressure reducing mattress or pressure reducing overlay. 4. Provide pressure-relieving device on wheelchair/chair/recliner. 5. Consider elevating heel(s) off of the bed with pillow or use of heel protectors . Implement an individualized schedule for turning and positioning . According to the National Pressure Ulcer Advisory Panel website (http://www.npuap.org/resources/educational-and-clinical-resources/pressure-injury-staging-illustrations/) searched on 07/01/17 revealed: Pressure Injury Prevention Points: Risk Assessment: 1 Consider bedfast and chairfast individuals to be at risk for development of pressure injury. 2 Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within 8 hours after admission). 3 Refine the assessment by including these additional risk factors: A. Fragile skin B. Existing pressure injury of any stage, including those ulcers that have healed or are closed C. Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use D. Pain in areas of the body exposed to pressure . 5 Develop a plan of care based on the areas of risk, rather than on the total risk assessment score. For example, if the risk stems from immobility, address turning, repositioning, and the support surface. If the risk is from malnutrition, address those problems. Skin Care: .Avoid positioning an individual on an area of [DIAGNOSES REDACTED] or pressure injury Repositioning and Mobilization: 1 Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. 2 Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure and the individual's preferences. 3 Consider lengthening t/e turning schedule during the night to allow for uninterrupted sleep/ 4 Turn the individual into a 30-degree side lying position, and use your hand to determine if the sacrum is off the bed 5 Avoid positioning the individual on body areas with pressure injury. 6 Ensure that the heels are free from the bed. 7 Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size and weight of the individual when choosing a support surface. 8 Continue to reposition an individual when placed on any support surface. 9 Use a breathable incontinence pad when using microclimate management surfaces. 10 Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs. 11 Reposition weak or immobile individuals in chairs hourly Review of the facility's policy/procedure Fall Management revised August 2013 revealed Overview Each resident resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls.The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, .and calculation of resident falls. Interview with the facility Administrator during entrance conference on 06/22/17 at 2:03 p.m. revealed the facility did not have a Director of Nurses (DON) or Assistant DON (ADON). The Administrator said the DON resigned approximately two days prior to the surveyor's entrance. R #3: R #3's Face Sheet dated 06/22/17 documented an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., nutrition, and medication administration), and Generalized Muscle Weakness. R #3's Nursing Admission Data Collection dated 06/02/17 documented Right Heel pressure ulcer: length- 6.0 X 5.5 cm (centimeters) .Left heel pressure ulcer- 5.0 X 4.0 cm, healed sacral ulcer . R #3's Order Summary Report dated 06/02/17 documented Cleanse unstageable pressure ulcer to right and left heel with normal saline/wound cleanser, pat dry with gauze, paint with [MEDICATION NAME], cover with [MEDICATION NAME] foam dressing every other day and PRN (as needed) until healed Stage 2 left buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift Stage 2 right buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift .Vitamin A per [DEVICE] q (every) am, Vitamin C one tablet per [DEVICE] daily q am, Zinc tablet per [DEVICE] q am for wound healing . R #3's Braden Scale for Predicting Pressure Sore Risk dated 06/02/17 revealed a score of 12, Scoring: High Risk= 10-12. R #3's Initial Care Plan initiated 06/03/17 documented: -I have an ADL (Activity of Daily Living) self-care performance deficit related to Dementia- Bed Mobility: the resident is totally dependent on two staff for repositioning and turning in bed and as necessary . -I have limited physical mobility related to left sided weakness . -I have potential/actual skin issues .Interventions: Notify MD of changes in wound, observe wound healing, provide wound care per orders, skin checks weekly per facility protocol, document findings . *R #3's care plan did not specifically address his pressure ulcers nor did the care plan address interventions for preventative care to prevent new or worsening of pressure ulcers. R #3's Minimum Data Set ((MDS) dated [DATE] revealed R #3: -Usually made self understood and understood others. -Had a Brief Interview of Mental Status (BIMS) of 07 (severely impaired cognition). -Required total dependence with two person physical assist for bed mobility, transfers, and toilet use. R #3 required total dependence with one person physical assist for dressing and personal hygiene. -Had impairment on both sides of both upper and lower extremities. -Was always incontinent of bowel and bladder. -Was 64 inches tall and 135 pounds. -Was at risk for developing pressure ulcers and entered the facility with two Unstageable pressure ulcer. -Skin and Ulcer Treatments: Turning/Repositioning Program, Nutrition and Hydration Intervention, Pressure Ulcer Care, Application of nonsurgical dressings and ointments and medications, application of dressings to feet. R #3's Weekly Skin Pressure Ulcer Report dated 06/14/17 documented Date of Onset: 06/14/17, New Pressure Ulcer, Acquired at the facility, Sacrum Stage 1 pressure ulcer, 1 X 0.5 X 0 cm, Description: Pressure ulcer to left buttock serous fluid to wound bed. No foul odor noted. Proximal tissue color pink distal redness with undefined wound edges. Surrounding [MEDICATION NAME] tissue, Surrounding skin away from the wound edges with maceration (soften skin from being wet); Right buttock Stage 1: Date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 0.8 X 0.3 X 0 cm, suspected sacral ulcer right buttock ulcer, 100% beefy red in color. Undefined wound edges. Macerated surrounding skin. No foul odor to wound. No drainage noted.This document included the definitions of: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcers covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #3's Weekly Pressure Ulcer Record dated 06/21/17 documented Date of Onset: 06/21/17, new pressure ulcer, acquired at the facility, Right Buttock Stage 2: 3.0 X 1.6 X 0 cm, pink-red wound bed without slough .Date of Onset: 06/02/17, admitted with, Right Heel: 6.5 X 6.0 x 0 Unstageable eschar to wound bed, bruising and redness to wound edges, wound bed black, no odor, no drainage, wound edges dark red/purple, response to treatment: no change .Date of Onset: 06/02/17, existing, admitted with, Left Heel: 4.3 X 4.4 X 0 cm Unstageable, eschar to wound bed with redness and non-blanchable skin to surrounding skin, scant drainage, redness to surrounding skin, response to treatment: no change . Interview with Licensed Vocational Nurse (LVN) H on 06/22/17 at 3:10 p.m. revealed she was caring for R #3. LVN H reviewed R #3's most current Pressure Ulcer Report dated 06/21/17 and said out loud He (R #3) has a right heel unstageable found on admission on 06/02/17 that measured 6.5 X 4.5 X 0.0 cm on 06/08/17 and 4.3 X 4.4 X 0.0 cm on 06/21/17. His left heel unstageable was found on admission on 06/02/17 and it measured 3.5 X 3.0 X 0 cm on 06/08/17 and 6.5 X 6.0 X 0 cm on 06/21/17. He also has a right buttock Stage 2 acquired in-house on 06/21/17 that measured 3.0 X 1.6 X 0 cm and a left buttock Stage 2 acquired in-house on 06/21/17 that measured 1.0 X 1.0 X 0. cm. LVN H said she would perform R #3's wound care on his heels shortly. Observation of R #3 on 06/22/17 at 3:14 p.m. revealed he laid on his back on a similar mattress as every other resident had on their bed. R #3's head of bed was slightly elevated and had one flat pillow under his left shoulder. R #3's hips and buttocks rested flat on the mattress. R #3's eyes were closed. R #3 did not respond to verbal stimuli. R #3 had a flat pillow under his knees however, both of his heels rested on the bed. At 3:16 p.m., LVN H entered R #3's room and began wound care. LVN H picked up R #3's left heel off the bed and unwrapped the kerlix dressing. LVN H exposed R #3's left heel that was entirely black and purple in color and provided treatment as ordered. LVN H picked up R #3's right heel off the bed and unwrapped it of the kerlix dressing. The right heel was 100% covered with a black colored cap with redness on the surrounding tissue at approximately 11-2 o'clock. As LVN H cleansed each heel, R #3 pulled each foot away every time she wiped the area. LVN H asked R #3 if he had pain but R #3 replied No. LVN H said she was sure he has some pain when I touch or press on the heel since he is pulling away. LVN H placed a pillow under R #3's calves and walked out of the room. Observation of R #3 on 06/22/17 at 4:15 p.m. revealed R #3 laid on his back with his head of bed slightly elevated with one flat pillow under his left shoulder and with one flat pillow under his calves however, both heels and buttocks remained resting on the mattress. Observation of R #3 on 06/22/17 at 5:46 p.m. revealed R #3 again laid on his back with one flat pillow under his left shoulder and his head slightly elevated as seen earlier and one flat pillow underneath his calves. R #3's heel rested on the mattress, applying pressure to his pressure ulcers on his heels. Simultaneous interview with Certified Nurse Aide (CNA) I and LVN H on 06/22/17 at 5:47 p.m. revealed both staff knew R #3 had pressure ulcers on both heels and his buttocks. LVN H said R #3 should be repositioned every two hours. CNA I said she had not repositioned R #3 since approximately 3:00 - 3:15 p.m. CNA I said she knew R #3 was due to reposition but was assisting with dinner trays. CNA I and LVN H both said they place a pillow under R #3's legs to keep his heels raised off the bed to prevent pressure on the heels. Upon the surveyor's request, LVN H accompanied the surveyor to R #3's room and found a pillow under R #3's calves with his heels resting on the mattress and a flat pillow under R #3's left shoulder with his hips and buttocks resting on the mattress. LVN H confirmed the one pillow was not effective in relieving pressure off the heels. LVN H also confirmed the one pillow under R #3's left shoulder was there in attempt to relieve pressure off his buttocks but was unsuccessful since the pillow was too flat. LVN H said the facility did not have any positioning devices to use other than pillows. LVN H stated she would locate more pillows for R #3. LVN H stated if R #3's ulcers were not relieved of pressure from the bed, his ulcers could worsen or acquire new ones. R #3's Care Plan revised 06/22/17 documented I have Stage 2 pressure ulcers to left and right buttocks and unstageable to left and right heels .Interventions: Administer treatments as ordered and observe for effectiveness, Assess/record/observe wound healing. Measure where possible. Report improvements and declines to MD, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation of Registered Nurse (RN) A providing R #1 with wound care on 06/23/17 at 10:42 a.m. revealed she measured R #3's left buttock ulcer and said out loud Left Stage 2 measures 1.0 X 1.0 X 0 centimeters. Right buttock Stage 2 measures 3.4 X 2.2 X 0 centimeters. The right buttock grew in length and width since admission and when I last measured it on 06/21/17. The wound bed is red without any drainage or odor and the surrounding skin is of normal skin color. The right heel unstageable measures 6.4 X 7.5 X 0 centimeters, it has 100% eschar cap with redness to surrounding skin and bruising at 5 o'clock, and redness at 6-9 o'clock. He said he has pain to the heel. The right heel has grown in length and width since his last measurements. The left heel unstageable measures 5.0 X 5.5 X 0 centimeters. The heel has approximately 75% eschar in wound bed, redness to wound edges from 9-3 o'clock and bruising and non-blanchable redness from 3-9 o'clock. There is blanchable redness at 6 o'clock. His left heel grew in width. Observation of R #3 on 06/27/17 at 8:29 a.m. revealed R #3 laid on his right side with one pillow behind his left back and one pillow under his calves with his left heel resting on the mattress. At 8:32 a.m., CNA J entered R #3's room and stated she repositioned R #3 approximately one hour ago from his back to his right side. The surveyor asked CNA J if R #3's heels are appropriately elevated off the bed; CNA J said No, his left heel is on the bed. CNA J added a pillow between R #3's ankles and plumped the pillow under his calves which elevated both heels off the mattress. Interview with RN A on 06/23/17 at 3:00 p.m. revealed she reviewed and compared R #3's Weekly Pressure Ulcer Reports. RN A said His left and right heel got slightly wider compared to his admission measurements. His left and right buttocks ulcers were acquired in the facility. He should have his heels off loaded with pillows to relieve pressure off his heels to cure the ulcers. RN A reviewed R #3's care plan and said frequently meant every 2 hours. RN A said R #3's care plan did not have specific preventative interventions for his heels. Interview with Physician K on 06/27/17 at 10:02 a.m. revealed he was aware of R #3's pressure ulcer progression. Physician K stated It is not realistic for a facility as big as this one to ensure the patients are turned every two hours, even though that is what's supposed to happen. Physician K said Of course, if pressure is not relieved frequently over a bony body part then an ulcer would certainly get worse or develop one. Not off-loading of an affected area would impede in wound healing and wound development. Physician K said other than being immobile and not repositioning frequently, there was no other explanation why R #3 would acquire his ulcers to his buttocks. R #4: R #4's Face Sheet dated 06/22/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Care Plan dated 03/29/17 documented: -I have a potential for pressure ulcer development related to decreased mobility, bowel and bladder incontinence .Interventions: Complete a full body check weekly and document, elevate lower extremities with pillows off-loading bilateral legs every shift, follow policy and procedures for the prevention/treatment of [REDACTED].>-I have a Stage 3 pressure ulcer to my sacrum area related to immobility and incontinence .Interventions: Administer treatments as ordered and observe for effectiveness, cleanse with wound cleanser, pat dry and apply puracol and cover with gauze and secure with [MEDICATION NAME]. Assess/record/observe wound healing. Measure length, width, and depth where possible . R #4's MDS dated [DATE] revealed R #4: -Had unclear speech -Rarely/never made self understood and sometimes understands others -Has short and long term memory problems and moderately impaired cognitive skills for daily decision making. -Requires total dependence with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -Was always incontinent of bladder and bowel. -Is at risk of pressure ulcers and had no pressure ulcers. R #4's Head to Toe Skin Check dated 06/12/17 documented Intact Skin; no skin breakdown noted upon assessment at this time . R #4's Situation Background Assessment Request (SBAR) dated 06/14/17 documented Resident presents with newly assessed pressure ulcer to the sacral area on 06/14/17. Resident is incontinent of bowel and bladder and completely dependent on staff for care. Resident is bedbound status requires total assistance with all ADLs. Physician notified 06/14/17 at 2:00 p.m. New Orders: Cleanse site with wound cleanser, pat dry, apply puracol, cover with gauze, and secure with [MEDICATION NAME] daily and prn until healed. R #4's Weekly Pressure Ulcer Report dated 06/14/17 documented Sacrum, date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 3.8 X 1.0 cm- Stage 3. 80% granulation with 20% slough tissue scant amount of serosanguinous drainage and pink wound edges .Response to treatment: new pressure ulcer- no previous response for comparison. R #4's June 2017 Order Summary Report documented Cleanse sacral wound with wound cleanser, pat dry, place Puracol (collagen dressing), cover with gauze, apply sure prep to perimeter and secure with [MEDICATION NAME] (clear self-adhesive dressing) daily and prn until healed- order date 06/14/17 R #4's Weekly Pressure Ulcer Record dated 06/21/17 documented Sacrum Stage 3 pressure ulcer- 4.0 X 0.4 cm. Maceration present to surrounding wound bed. 100% granulation present, no foul odor. Observation of R #4 on 06/22/17 at 2:42 p.m. revealed R #4 was being provided incontinent care by CNAs M and N. R #4 was able to make eye contact but did not respond verbally nor by gestures to communicate. CNA M stated R #4 did not speak and was not able to reposition herself. Staff positioned R #4 on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 3:55 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 4:45 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 5:33 p.m. revealed she continued to lay on her left side with a pillow behind her back. At 5:35 p.m., LVN Q and CNA N entered R #4's room and provided incontinent care and repositioned her on her right side. LVN Q stated R #4 was to be repositioned every two hours to prevent pressure ulcer development. CNA N said she thought she last positioned R #4 at appro(TRUNCATED)

Based on record review and interview, the facility failed to ensure residents have the right to be free from neglect for four residents (R #3, R #4, R #5, and R #6) of five residents reviewed for pressure ulcers and two residents (R #1 and R #2) of three residents reviewed for falls, accidents, and injuries. The facility did not: -Ensure R #3's bilateral heels and buttocks were offloaded. R #3's community acquired bilateral heel unstageables that grew in size. R #3 developed a left and right buttock Stage 1 pressure ulcer, while in the facility, that deteriorated into Stage 2 ulcers. -Ensure R #3's initial care plan addressed his pressure ulcers or include specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #3 was not provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #4 was repositioned at least every two hours as per the facility's policy. -Identify R #4 had developed a pressure ulcer to her sacrum, prior to initially identifying it at a Stage 3 despite daily incontinent care and/or baths by staff. -Ensure R #4's care plan included specific individualized preventative interventions to prevent new or worsening of pressure ulcers. -Ensure R #4 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Ensure R #5's sacrum were offloaded. R #5 developed a Stage 2 pressure ulcer to his sacrum 11 days after re-admission to the facility. -Document the stage of his sacral ulcer on his initial assessment. -Correctly stage R #5's sacral ulcer. The facility documented R #5's Stage 2 ulcer as having eschar, which no longer met the definition of a stage 2 yet, the ulcer continued to be identified as a Stage 2. R #5's sacrum ulcer deteriorated and the facility documented the ulcer as a Stage 3 then to a Suspected Deep Tissue Injury (SDTI). R #5's sacral ulcer was incorrectly staged as a SDTI, rather than an Unstageable, by definition. -Ensure R #5's left heel was offloaded. R #5 developed a Stage 2 pressure ulcer to his left heel that deteriorated to a SDTI. -Ensure R #5's care plan included specific individualized preventative interventions to provide pressure relief to his left heel and sacrum. -Ensure R #5 was provided with a specialized pressure relieving air mattress for his ulcers per the facility's policy and procedure. -Correctly recognize/identify R #6's sacral ulcer. Staff documented the ulcer to have slough and continued to identify it as a Stage 2, which did not meet the definition of a stage 2 pressure ulcer. R #6 developed a Stage 2 pressure ulcer to his sacrum while in the facility which deteriorated to a Stage 4, upon discharge. -Correctly identify R #6's facility-acquired stage 2 left heel ulcer that was identified to have slough yet, staff continued to be identified as a Stage 2 pressure ulcer, instead of a Stage 3. -Ensure R #6's care plan included specific individualized preventative interventions for pressure relief of R #6's sacrum and left heel. -Perform or document a thorough assessment of R #6's pressure ulcer upon discharge. The facility's last assessment of R #6's pressure ulcer was five days prior to his discharge and was identified as a Stage 3 however, the ulcer was identified by his physician to have a Stage 4 pressure ulcer. R #6 was discharged from the facility on 05/29/17. -Consult with R #6's physician of his deteriorating sacral pressure ulcer. The above failures resulted in an Immediate Jeopardy (IJ) situation on 06/27/17. While the IJ was removed on 06/28/17, the facility remained out of compliance at actual harm with a scope identified as pattern. The facility was continuing to monitor to ensure continued implementation of their plan of removal. These failures could affect 15 residents with pressure ulcers and 58 residents receiving preventative skin care and place them at risk for developing new pressure ulcers or a decline in existing pressure ulcers. R #1: R#1 had a total of 7 falls (2 unwitnessed falls and 5 witnessed falls) from 04/11/17 through 06/14/17. R #2: R#2 had a total of 16 falls (8 unwitnessed falls and 8 witnessed falls ) from 01/04/17 through 06/24/17. This failure could place nine of the 21 residents on wing C (secure unit) with a history of falls at risk for additional falls and injuries. The findings included: Interview with the facility Administrator during entrance conference on 06/22/17 at 2:03 p.m. revealed the facility did not have a Director of Nurses (DON) or Assistant DON (ADON). The Administrator said the DON resigned approximately two days prior to the surveyor's entrance. R #3: R #3's Face Sheet dated 06/22/17 documented an [AGE] year-old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]., nutrition, and medication administration), and Generalized Muscle Weakness. R #3's Nursing Admission Data Collection dated 06/02/17 documented Right Heel pressure ulcer: length- 6.0 X 5.5 cm (centimeters) .Left heel pressure ulcer- 5.0 X 4.0 cm, healed sacral ulcer . R #3's Order Summary Report dated 06/02/17 documented Cleanse unstageable pressure ulcer to right and left heel with normal saline/wound cleanser, pat dry with gauze, paint with [MEDICATION NAME], cover with [MEDICATION NAME] foam dressing every other day and PRN (as needed) until healed Stage 2 left buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift Stage 2 right buttock: cleanse with normal saline, pat dry with gauze, apply [MEDICATION NAME] border daily until healed every day shift .Vitamin A per [DEVICE] q (every) am, Vitamin C one tablet per [DEVICE] daily q am, Zinc tablet per [DEVICE] q am for wound healing . R #3's Braden Scale for Predicting Pressure Sore Risk dated 06/02/17 revealed a score of 12, Scoring: High Risk= 10-12. R #3's Initial Care Plan initiated 06/03/17 documented: -I have an ADL (Activity of Daily Living) self-care performance deficit related to Dementia- Bed Mobility: the resident is totally dependent on two staff for repositioning and turning in bed and as necessary . -I have limited physical mobility related to left sided weakness . -I have potential/actual skin issues .Interventions: Notify MD of changes in wound, observe wound healing, provide wound care per orders, skin checks weekly per facility protocol, document findings . *R #3's care plan did not specifically address his pressure ulcers nor did the care plan address interventions for preventative care to prevent new or worsening of pressure ulcers. R #3's Minimum Data Set ((MDS) dated [DATE] revealed R #3: -Usually made self understood and understood others. -Had a Brief Interview of Mental Status (BIMS) of 07 (severely impaired cognition). -Required total dependence with two person physical assist for bed mobility, transfers, and toilet use. R #3 required total dependence with one person physical assist for dressing and personal hygiene. -Had impairment on both sides of both upper and lower extremities. -Was always incontinent of bowel and bladder. -Was 64 inches tall and 135 pounds. -Was at risk for developing pressure ulcers and entered the facility with two Unstageable pressure ulcer. -Skin and Ulcer Treatments: Turning/Repositioning Program, Nutrition and Hydration Intervention, Pressure Ulcer Care, Application of nonsurgical dressings and ointments and medications, application of dressings to feet. R #3's Weekly Skin Pressure Ulcer Report dated 06/14/17 documented Date of Onset: 06/14/17, New Pressure Ulcer, Acquired at the facility, Sacrum Stage 1 pressure ulcer, 1 X 0.5 X 0 cm, Description: Pressure ulcer to left buttock serous fluid to wound bed. No foul odor noted. Proximal tissue color pink distal redness with undefined wound edges. Surrounding [MEDICATION NAME] tissue, Surrounding skin away from the wound edges with maceration (soften skin from being wet); Right buttock Stage 1: Date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 0.8 X 0.3 X 0 cm, suspected sacral ulcer right buttock ulcer, 100% beefy red in color. Undefined wound edges. Macerated surrounding skin. No foul odor to wound. No drainage noted.This document included the definitions of: Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage 1: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage 3: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcers covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #3's Weekly Pressure Ulcer Record dated 06/21/17 documented Date of Onset: 06/21/17, new pressure ulcer, acquired at the facility, Right Buttock Stage 2: 3.0 X 1.6 X 0 cm, pink-red wound bed without slough .Date of Onset: 06/02/17, admitted with, Right Heel: 6.5 X 6.0 x 0 Unstageable eschar to wound bed, bruising and redness to wound edges, wound bed black, no odor, no drainage, wound edges dark red/purple, response to treatment: no change .Date of Onset: 06/02/17, existing, admitted with, Left Heel: 4.3 X 4.4 X 0 cm Unstageable, eschar to wound bed with redness and non-blanchable skin to surrounding skin, scant drainage, redness to surrounding skin, response to treatment: no change . Interview with Licensed Vocational Nurse (LVN) H on 06/22/17 at 3:10 p.m. revealed she was caring for R #3. LVN H reviewed R #3's most current Pressure Ulcer Report dated 06/21/17 and said out loud He (R #3) has a right heel unstageable found on admission on 06/02/17 that measured 6.5 X 4.5 X 0.0 cm on 06/08/17 and 4.3 X 4.4 X 0.0 cm on 06/21/17. His left heel unstageable was found on admission on 06/02/17 and it measured 3.5 X 3.0 X 0 cm on 06/08/17 and 6.5 X 6.0 X 0 cm on 06/21/17. He also has a right buttock Stage 2 acquired in-house on 06/21/17 that measured 3.0 X 1.6 X 0 cm and a left buttock Stage 2 acquired in-house on 06/21/17 that measured 1.0 X 1.0 X 0. cm. LVN H said she would perform R #3's wound care on his heels shortly. Observation of R #3 on 06/22/17 at 3:14 p.m. revealed he laid on his back on a similar mattress as every other resident had on their bed. R #3's head of bed was slightly elevated and had one flat pillow under his left shoulder. R #3's hips and buttocks rested flat on the mattress. R #3's eyes were closed. R #3 did not respond to verbal stimuli. R #3 had a flat pillow under his knees however, both of his heels rested on the bed. At 3:16 p.m., LVN H entered R #3's room and began wound care. LVN H picked up R #3's left heel off the bed and unwrapped the kerlix dressing. LVN H exposed R #3's left heel that was entirely black and purple in color and provided treatment as ordered. LVN H picked up R #3's right heel off the bed and unwrapped it of the kerlix dressing. The right heel was 100% covered with a black colored cap with redness on the surrounding tissue at approximately 11-2 o'clock. As LVN H cleansed each heel, R #3 pulled each foot away every time she wiped the area. LVN H asked R #3 if he had pain but R #3 replied No. LVN H said she was sure he has some pain when I touch or press on the heel since he is pulling away. LVN H placed a pillow under R #3's calves and walked out of the room. Observation of R #3 on 06/22/17 at 4:15 p.m. revealed R #3 laid on his back with his head of bed slightly elevated with one flat pillow under his left shoulder and with one flat pillow under his calves however, both heels and buttocks remained resting on the mattress. Observation of R #3 on 06/22/17 at 5:46 p.m. revealed R #3 again laid on his back with one flat pillow under his left shoulder and his head slightly elevated as seen earlier and one flat pillow underneath his calves. R #3's heel rested on the mattress, applying pressure to his pressure ulcers on his heels. Simultaneous interview with Certified Nurse Aide (CNA) I and LVN H on 06/22/17 at 5:47 p.m. revealed both staff knew R #3 had pressure ulcers on both heels and his buttocks. LVN H said R #3 should be repositioned every two hours. CNA I said she had not repositioned R #3 since approximately 3:00 - 3:15 p.m. CNA I said she knew R #3 was due to reposition but was assisting with dinner trays. CNA I and LVN H both said they place a pillow under R #3's legs to keep his heels raised off the bed to prevent pressure on the heels. Upon the surveyor's request, LVN H accompanied the surveyor to R #3's room and found a pillow under R #3's calves with his heels resting on the mattress and a flat pillow under R #3's left shoulder with his hips and buttocks resting on the mattress. LVN H confirmed the one pillow was not effective in relieving pressure off the heels. LVN H also confirmed the one pillow under R #3's left shoulder was there in attempt to relieve pressure off his buttocks but was unsuccessful since the pillow was too flat. LVN H said the facility did not have any positioning devices to use other than pillows. LVN H stated she would locate more pillows for R #3. LVN H stated if R #3's ulcers were not relieved of pressure from the bed, his ulcers could worsen or acquire new ones. R #3's Care Plan revised 06/22/17 documented I have Stage 2 pressure ulcers to left and right buttocks and unstageable to left and right heels .Interventions: Administer treatments as ordered and observe for effectiveness, Assess/record/observe wound healing. Measure where possible. Report improvements and declines to MD, Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Observation of Registered Nurse (RN) A providing R #1 with wound care on 06/23/17 at 10:42 a.m. revealed she measured R #3's left buttock ulcer and said out loud Left Stage 2 measures 1.0 X 1.0 X 0 centimeters. Right buttock Stage 2 measures 3.4 X 2.2 X 0 centimeters. The right buttock grew in length and width since admission and when I last measured it on 06/21/17. The wound bed is red without any drainage or odor and the surrounding skin is of normal skin color. The right heel unstageable measures 6.4 X 7.5 X 0 centimeters, it has 100% eschar cap with redness to surrounding skin and bruising at 5 o'clock, and redness at 6-9 o'clock. He said he has pain to the heel. The right heel has grown in length and width since his last measurements. The left heel unstageable measures 5.0 X 5.5 X 0 centimeters. The heel has approximately 75% eschar in wound bed, redness to wound edges from 9-3 o'clock and bruising and non-blanchable redness from 3-9 o'clock. There is blanchable redness at 6 o'clock. His left heel grew in width. Observation of R #3 on 06/27/17 at 8:29 a.m. revealed R #3 laid on his right side with one pillow behind his left back and one pillow under his calves with his left heel resting on the mattress. At 8:32 a.m., CNA J entered R #3's room and stated she repositioned R #3 approximately one hour ago from his back to his right side. The surveyor asked CNA J if R #3's heels are appropriately elevated off the bed; CNA J said No, his left heel is on the bed. CNA J added a pillow between R #3's ankles and plumped the pillow under his calves which elevated both heels off the mattress. Interview with RN A on 06/23/17 at 3:00 p.m. revealed she reviewed and compared R #3's Weekly Pressure Ulcer Reports. RN A said His left and right heel got slightly wider compared to his admission measurements. His left and right buttocks ulcers were acquired in the facility. He should have his heels off loaded with pillows to relieve pressure off his heels to cure the ulcers. RN A reviewed R #3's care plan and said frequently meant every 2 hours. RN A said R #3's care plan did not have specific preventative interventions for his heels. Interview with Physician K on 06/27/17 at 10:02 a.m. revealed he was aware of R #3's pressure ulcer progression. Physician K stated It is not realistic for a facility as big as this one to ensure the patients are turned every two hours, even though that is what's supposed to happen. Physician K said Of course, if pressure is not relieved frequently over a bony body part then an ulcer would certainly get worse or develop one. Not off-loading of an affected area would impede in wound healing and wound development. Physician K said other than being immobile and not repositioning frequently, there was no other explanation why R #3 would acquire his ulcers to his buttocks. R #4: R #4's Face Sheet dated 06/22/17 documented a [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. R #4's Care Plan dated 03/29/17 documented: -I have a potential for pressure ulcer development related to decreased mobility, bowel and bladder incontinence .Interventions: Complete a full body check weekly and document, elevate lower extremities with pillows off-loading bilateral legs every shift, follow policy and procedures for the prevention/treatment of [REDACTED].>-I have a Stage 3 pressure ulcer to my sacrum area related to immobility and incontinence .Interventions: Administer treatments as ordered and observe for effectiveness, cleanse with wound cleanser, pat dry and apply puracol and cover with gauze and secure with [MEDICATION NAME]. Assess/record/observe wound healing. Measure length, width, and depth where possible . R #4's MDS dated [DATE] revealed R #4: -Had unclear speech -Rarely/never made self understood and sometimes understands others -Has short and long term memory problems and moderately impaired cognitive skills for daily decision making. -Requires total dependence with two person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. -Was always incontinent of bladder and bowel. -Is at risk of pressure ulcers and had no pressure ulcers. R #4's Head to Toe Skin Check dated 06/12/17 documented Intact Skin; no skin breakdown noted upon assessment at this time . R #4's Situation Background Assessment Request (SBAR) dated 06/14/17 documented Resident presents with newly assessed pressure ulcer to the sacral area on 06/14/17. Resident is incontinent of bowel and bladder and completely dependent on staff for care. Resident is bedbound status requires total assistance with all ADLs. Physician notified 06/14/17 at 2:00 p.m. New Orders: Cleanse site with wound cleanser, pat dry, apply puracol, cover with gauze, and secure with [MEDICATION NAME] daily and prn until healed. R #4's Weekly Pressure Ulcer Report dated 06/14/17 documented Sacrum, date of onset: 06/14/17, new pressure ulcer, acquired at the facility, 3.8 X 1.0 cm- Stage 3. 80% granulation with 20% slough tissue scant amount of serosanguinous drainage and pink wound edges .Response to treatment: new pressure ulcer- no previous response for comparison. R #4's June 2017 Order Summary Report documented Cleanse sacral wound with wound cleanser, pat dry, place Puracol (collagen dressing), cover with gauze, apply sure prep to perimeter and secure with [MEDICATION NAME] (clear self-adhesive dressing) daily and prn until healed- order date 06/14/17 R #4's Weekly Pressure Ulcer Record dated 06/21/17 documented Sacrum Stage 3 pressure ulcer- 4.0 X 0.4 cm. Maceration present to surrounding wound bed. 100% granulation present, no foul odor. Observation of R #4 on 06/22/17 at 2:42 p.m. revealed R #4 was being provided incontinent care by CNAs M and N. R #4 was able to make eye contact but did not respond verbally nor by gestures to communicate. CNA M stated R #4 did not speak and was not able to reposition herself. Staff positioned R #4 on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 3:55 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 4:45 p.m. revealed she continued to lay on her left side with a pillow behind her back. Observation of R #4 on 06/22/17 at 5:33 p.m. revealed she continued to lay on her left side with a pillow behind her back. At 5:35 p.m., LVN Q and CNA N entered R #4's room and provided incontinent care and repositioned her on her right side. LVN Q stated R #4 was to be repositioned every two hours to prevent pressure ulcer development. CNA N said she thought she last positioned R #4 at approximately 3:00 p.m. CNA N was informed of the time R #4 was last repositioned then said I was coming when another resident asked me to take her to the dining room. Observation of R #4, while she received wound care by LVN O, on 06/23/17 at 11:17 a.m. revealed LVN O cleansed R #4's sacral ulcer and said It measures 3.1 X 0.6 centimeters, the wound bed is red and it has pink wound edges. It has 100% granulation with maceration around the outer wound bed. It looks like she has some slight discomfort when the area is manipulated due to her flinching when I touch it. LVN Q said she did not know how R #4 acquired a Stage 3 in the facility without it being noticed prior to progressing to a Stage 3. LVN O stated pressure ulcers do not form at a Stage 3, They begin at a Stage 1 then progress to a higher stage. Interview with RN A on 06/23/17 at 3:25 p.m. revealed she stated she could not respond why R #3 acquired a Stage 3 pressure ulcer. RN A said Either the wound was not identified upon admission or during the weekly skin assessment checks. It is not possible to spontaneously develop a Stage 3 or an unstageable pressure ulcer without previous signs of the ulcer at an earlier stage. After reviewing R #4's care plan, RN A said No her care plan does not address prevention interventions for pressure ulcers. R #5: R #5's Face Sheet dated 06/22/17 documented a [AGE] year-old male initially admitted to the facility on [DATE], discharged to the hospital on [DATE] for [MEDICAL CONDITION], and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Nursing Admission Data Collection dated 02/17/17 revealed R #5 did not have any pressure ulcers identified upon admission. R #5's Care Plan dated 03/01/17 documented: -I have actual skin issues related to multiple bruising upon admission .Interventions: Notify MD of changes in wound or emerging wounds, provide wound care/preventative skin care per order, skin checks weekly, Turn and reposition frequently to decrease pressure. -I have an ADL self-care performance deficit related to muscle weakness from [MEDICAL CONDITION] .Interventions: Bathing/showering- I require one staff to provide shower, Bed Mobility- I require supervision one staff for repositioning and turning in bed, Dressing- I require extensive assistance of one staff for dressing . R #5's Head to Toe Skin Check dated 04/07/17 documented No skin breakdown noted upon assessment. R #5's Re-Admission Head to Toe Skin Check dated 05/02/17 documented Skin intact, dry skin and scabbing to left heel. Left upper buttock with dry scab. R #5's Braden Scale for Prediction Pressure Ulcer Risk dated 05/02/17 revealed a score of 16 At Risk= 15-18. R #5's physician's orders [REDACTED]. R #5's Quarterly MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and usually understood others -Had a BIMS score of 8 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was not at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Significant Change MDS dated [DATE] documented: -R #5 had clear speech -Usually made self understood and understood others -Had a BIMS score of 9 (moderately impaired cognition) -Required limited assistance with one person physical assist for bed mobility, transfer dressing and personal hygiene -Was always incontinent -Was at risk of developing pressure ulcers. Zero ulcers on assessment. R #5's Head to Toe Skin Check dated 05/13/17 documented Skin Integrity: New Pressure Ulcer- Sacrum 3.0 X 1.5 X 0 cm. Open sacral wound noted, no signs/symptoms of infection, no drainage or active bleeding noted. *There was no documentation of the stage of the pressure ulcer. R #5's SBAR Communication Form and Progress Note dated 05/13/17 documented The change in condition: New Sacral Ulcer, started on 05/13/17. Male resident is restless, constantly rolling and shifting off bed, becomes easily upset, needs frequent repositioning and adjusting .MD made aware . R #5's Physician order [REDACTED]. R #5's Weekly Pressure Ulcer Record dated 05/17/17 documented New pressure ulcer acquired at facility 05/13/17- Sacrum: Stage 2 pressure- 2.0 X 3.2 X 0 cm. 10% Eschar, 90% granulation, no foul odor, scant serosanguinous drainage, no depth to site. Normal skin surrounding wound. *The presence of eschar in the wound did not meet the definition of a Stage 2 pressure ulcer. The ulcer has deteriorated and was incorrectly staged. R #5's SBAR Communication Form and Progress Note dated 05/22/17 documented Situation: New Stage 2 left heel pressure ulcer. Resident was in shower when voiced discomfort to left heel upon tactile stimuli. Upon assessment resident noted with Stage 2 left heel ulcer .Called MD. New Orders: Left heel Stage 2: Cleanse with normal saline/wound cleanser, pat dry, apply Therahoney to heel, cover with gauze, secure with Kerlix and tape daily and prn until healed. R #5's Telephone physician's orders [REDACTED]. Promod liquid nutritional supplement- 60 milliliters TID (three times a day) for wounds . R #5's revised Care Plan dated 05/23/17 documented I have a pressure ulcer to my sacral stage 3 area and left heel stage 2 .Interventions: Complete a full body check weekly and document, Observe/document/report any changes in skin status; appearance, color, wound healing, signs/symp of infection, wound size, stage. Provide incontinent care after each episode. *R #5's care plan did not include specific individualized preventative interventions to provide pressure relief to his Left heel and sacrum. R #5's care plan did not include any resistance/refusal of treatment. R #5's Weekly Pressure Ulcer Record dated 06/01/17 documented Sacrum Stage 3 Pressure Ulcer: 3.0 X 3.0 X 0 cm. 100% slough present in wound bed, small serous drainage, pink surrounding wound edges . Specialty interventions: Positioning Devices: extra pillows. R #5's June 2017 Order Summary Report documented Cleanse left heel with wound cleanser, pat dry, apply sure prep daily and leave open to air every day shift for Suspected Deep Tissue Injury .Cleanse sacral site with wound cleanser, pat dry, apply Santyl ointment, cover with gauze, apply skin prep to outer skin and secure with [MEDICATION NAME] daily and prn every day shift for pressure ulcer .order date 06/02/17 . R #5's Head to Toe Skin Check dated 06/03/17 documented Left heel: Suspected Deep Tissue Injury. *This document did not have a thorough description or measurements of the ulcer. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Left heel Suspected Deep Tissue Injury: 1.5 X 2.2 cm. 100% eschar tissue, black wound bed, no drainage. R #5's Weekly Pressure Ulcer Record dated 06/07/17 documented Sacrum Stage 3: 3.0 X 2.5 X 0.3 cm. 100% yellow slough with maceration to wound edges from 4-7 o'clock with moderate serous drainage. White/gray/pallor wound edges. *According to the measurements, this wound has developed new depth. R #5's Weekly Pressure Ulcer Record dated 06/14/17 documented Sacrum Stage 3: 2.9 X 2.3 X 0.2 cm, 90% yellow slough tissue with 10% granulation tissue, moderate serous drainage, maceration noted to 5-7 o'clock. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Sacrum Stage 3: 3.0 X 2.0 X 1.0 cm, continues with 90% yellow slough tissue with 10% granulation tissue, maceration to wound edges. *According to the measurements, this wound's depth has increased in size. R #5's Weekly Pressure Ulcer Report dated 06/21/17 documented Left heel Suspected Deep Tissue Injury: 1.3 X 1.8 X 0 cm, wound bed covered with 100% black eschar, no foul odor, no drainage, wound edges are black. Observation of R #5 on 06/22/17 at 3:54 p.m. revealed R #5 laid on his back in bed. R #5 was alert and oriented to person and place only. R #5 complained of pain to his left heel. R #5 described his pain as throbbing. R #5 had one pillow under his head and one flat pillow under his calves. R #5's heels rested on the mattress. There were no other pillows in R #5's room. Observation of R #5 on 06/22/17 at 5:30 p.m. revealed R #5 continued to lay on his back with one flat pillow under his calves however, his heels continued to rest on the mattress. Observation of R #5, receiving wound care by LVN O, on 06/22/17 at 12:00 p.m. revealed LVN O presented R #5's left heel which had a black intact hardened cap over the heel with dry peeling skin over and around the entire ulcer. LVN O said There is 100% black eschar with dryness around the wound with dry peeling skin over the wound. It measures 2.0 X 1.5 centimeters. As LVN O cleansed R #5's left heel, R #5 pulled his foot away and acknowledged It hurts. LVN O repositioned R #5 to his left side and presented R #5's sacral area. R #5's sacrum had approximately 90-95% of yellow tissue on the wound bed and some red tissue present on the right side of the wound. The surrounding tissue of the entire wound edges was white and wrinkled. The surrounding skin around the wound bed was dark burgundy in color. LVN O began to cleanse the area and again R #5 tightened his buttocks and said Ouch, it hurts. LVN O stated It has 90% yellow slough and about 10% granulation within the wound bed, the surrounding tissue is really macerated, white in color. It measures 3.0 X 1.9 centimeters. I saw it last (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive device to prevent an accident for two Residents, R#1 and R#2, of three residents reviewed for accidents and hazards. 1. The facility failed to implement interventions to prevent additional falls (s) after each of R#1's falls. R#1 had a total of 7 falls (2 unwitnessed falls and 5 witnessed falls) from 04/11/17 through 06/14/17. The facility failed to implement interventions to prevent additional falls (s) after each of R#2's falls. R#2 had a total of 16 falls (8 unwitnessed falls and 8 witnessed falls ) from 01/04/17 through 06/24/17. This failure could place 9 of the 21 residents on wing C (secure unit) with falls or history of falls at risk for additional falls and injuries. The findings were: R#1 R#1's Admission Record dated 06/23/17 indicated she was [AGE] years old, R#1 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated, R#1 had clear speech, sometimes understood and could usually understand. R#1 required extensive physical assistance by two persons for bed mobility and transfer. Under Balance during Transitions and Walking, the MDS indicated R#1 was not steady and only able to stabilize with staff assistance for surface -to-surface-transfer (transfer between bed and chair or wheelchair).Under Functional Limitation in Range of Motion, the MDS indicated R#1 had an impairment on both sides (lower extremity) , (hip,ankle,ankle,foot.) R#1 had a BIMS (brief interview for mental status // a test given that helps determine a resident's cognitive understanding)) score of 03 indicates severely impaired cognition -decisions poor; cues/supervision required. 1. Record review of R#1's Interdisciplinary Post Fall Review for fall on 02/19/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a witnessed fall at 11:14 a.m. with no injury. R#1's fall occurred in the hallway (no specific hallway indicated). Description of fall --R#1 was pushing wheel chair in the hallway when she (R#1) lost her balance and fell to her right side .Intervention recommendation -care plan revision. 2. Record review of R#1's Interdisciplinary Post Fall Review for fall on 03/27/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a witnessed fall with possible bead injury at 5:05 p.m. R#1's fall occurred in the hallway (no specific hallway indicated). Description of fall R#1 wandered into other residents room, other resident pushed resident (R#1) out of the room resident(R#1) fell backwards and hit head small 1/2 inch laceration to back of head, bleeding present hematoma present around laceration. Intervention recommendation -care plan revision. 3. Record review of R#1's Interdisciplinary Post Fall Review for fall on 04/11/17,completed by former Director of Nurses,Registered Nurse (RN) A,RN B,Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a unwitnessed fall with no injury at 12:35 p.m. R#1's fall occurred in R#1's room. Description of fall R#1's bed was at the lowest position . R#1's knees were on the floor and her upper body was on the bed. R#1 did not hit her head. It appears as if she (R#1) slipped from the bed. Intervention recommendation - care plan revision. 4. Record review of R#1's Interdisciplinary Post Fall Review for fall on 05/13/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a witnessed fall with possible head injury at 6:53 a.m. R#1's fall occurred in R#1's room. Description of fall R#1 is in the facility for long term care, does require special attention and continuous monitoring and assistance with ADLs (activities of daily living) to prevent falls or injury. In this case, R#1 ambulating unassisted in room (R#1's room) , tripped, and fell hitting head on bed foot board. R#1 may possibly have head injury. X-rays ordered and awaiting results. Bruise noted to area along pain upon palpation to rt (right) lateral side of 3rd through 5th. and rt. lateral side hip. will continue to monitor for pain and decline. Intervention recommendation - care plan revision. 5. Record review of R#1's Interdisciplinary Post Fall Review for fall on 06/06/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a witnessed fall with laceration to skull / in house treatment at 8:16 p.m R#1's fall occurred in the dining room. Description of fall R#1 was sitting on dining room chair, attempted unassisted transfer and slipped and fell ; hitting self on head on wall. R#1 with laceration to skull. Intervention recommendation - care plan revision. 6. Record review of R#1's Interdisciplinary Post Fall Review for fall on 06/14/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a unwitnessed fall with no injury at 11:50 p.m R#1's fall occurred when R#1 was in another room. Description of fall RCS (Resident Care Specialist) noted R#1 on floor.Intervention recommendation - care plan revision. 7. Record review of R#1's Interdisciplinary Post Fall Review for fall on 06/17/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#1 had a witnessed fall with laceration to skull. In house treatment provided at 12:13 p.m . R#1's fall occurred when R#1 was outside in patio. Description of fall RCS (Resident Care Specialist) noted R#1 on floor.Intervention recommendation - care plan revision. R#1's care plan updated 03/10/17 indicated: 1. Focus R#1 requires assistance with ADLs related to cognitive deficits,dx (diagnosis) of dementia. Interventions - provide assistance as required for completion of ADL task. 2. Focus R#1 had a potential for safety and fall risk related to :cognitive deficits. Intervention -- initiate safety checks as indicated, observe for exit seeking behaviors and provide diversional activities, and observe frequently during increased wandering to ensure safety 3. Focus R#1 had an ADL self-care performance deficit r/t (related to) Dementia. Interventions--Bed mobility - R#1 requires extensive assistance by (2) staff to turn and reposition in bed and as necessary, Dressing - R#1 required extensive assistance by (2) staff to dress . and Transfer - R#1 required extensive assistance of (2) staff for transferring 4. Focus R#1 had limited mobility r/t osteoarthritis Interventions-Locomotion - R#1 required extensive assistance by (2) staff for locomotion, for redirection, safety awareness,and provide supportive care, assistance with mobility as needed 5. Focus R#1 was an elopement risk/wanderer r/t (related to) Dementia . Intervention observe location art regular and frequent intervals. Document wandering behavior and attempted diversional interventions. 6. Focus R#1 was a high risk for falls r/t balance and gait unsteady .Intervention-anticipate and meet the resident's needs. 7. Focus R#1 had a head laceration .Intervention--observe/document/report . change in mental status, New onset: confusion,sleepiness, inability to maintain posture, agitation., and tab alarm placed on bed for prevention of falls. Surveyor at the time of exit from the facility (on 06/28/17 at 5:30 p.m.) was not provided any updated care plans for R#1. R#2 R#2's Admission Record dated 06/23/17 indicated he was [AGE] years old, R#2 was originally admitted on [DATE] with the [DIAGNOSES REDACTED]. R#2's Annual Minimum Data Set ((MDS) dated [DATE] indicated, R#2 had clear speech, usually understood and could usually understand. R#2 required extensive physical assistance by two persons for bed mobility and transfer. Under Balance during Transitions and Walking, the MDS indicated R#2 was not steady and only able to stabilize with staff assistance for surface -to-surface-transfer (transfer between bed and chair or wheelchair).Under Functional Limitation in Range of Motion, the MDS indicated R#2 had an impairment on both sides (lower extremity) , (hip, ankle, ankle, foot.) R#2 had a BIMS (brief interview for mental status) score of 06 (severe impairment) for prior assessment reference date of 03/17/17. 1. Record review of R#2's Resident Event for fall on 01/04/17,completed by RN F revealed R#2 had a unwitnessed fall at 1:00 p.m R#2's fall occurred while he (R#2) was using his wheelchair on wing C patio. Intervention resident education. 2. Record review of R#2's Resident Event for fall on 01/23/17,completed by LVN G revealed R#2 had a unwitnessed fall at 7:45 p.m R#2's fall occurred in the hall (no specific hall was indicated) R#2 fell from wheelchair to ground on right lateral side while trying to stand from sitting position. Intervention resident education. 3. Record review of R#2's Interdisciplinary Post Fall Review for fall on 02/14/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall with no injury at 6:26 p.m R#2's fall occurred in the hallway (no specific hallway indicated). Description of fall R#2 next to wheelchair on floor sitting no distress, attempted to get up from wheelchair. Intervention recommendation - care plan revision. 4. Record review of R#2's Interdisciplinary Post Fall Review for fall on 03/17/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall with no injury at 11:23 a.m. R#2's fall occurred in the hallway (no specific hallway indicated). Description of fall R#2 suffered witnessed fall, was attempting to sit back on wheelchair, however wheelchair moved back and resident landed sitting on floor.Intervention recommendation - care plan revision. 5. Record review of R#2's Interdisciplinary Post Fall Review for fall on 04/20/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall with no injury at 8:30 p.m. R#2's fall occurred in the hallway (no specific hallway indicated). Description of fall R#2 lying on floor on left side.Intervention recommendation - care plan revision. 6. Record review of R#2's Interdisciplinary Post Fall Review for fall on 04/26/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall with no injury at 12:40 p.m R#2's fall occurred in the hallway (no specific hallway indicated). Description of fall R#2 was standing requesting to get a ride home.Intervention recommendation - care plan revision. 7. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/07/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall with no injury at 4:04 p.m R#2's fall occurred outside the facility. Description of fall R#2 sitting on step of entrance to building. Intervention recommendation - care plan revision. 8. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/08/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B,Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall with no injury at 4:0 p.m R#2's fall occurred in his room. Description of fall R#2 sitting on floor next to wheelchair. Intervention recommendation - care plan revision. 9. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/15/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall with no injury at 7:00 p.m R#2's fall occurred in hallway (no specific hallway indicated) Description of fall R#2 was sitting on wheelchair and attempt to get up and landed on buttock right side. Intervention recommendation - care plan revision. 10. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/19/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall with no injury at 10:14 p.m R#2's fall occurred in his room. Description of fall R#2 sitting on wheelchair attempted to sit up and landed on floor matte.Intervention recommendation - care plan revision. 11. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/20/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall at 9:01 a.m . R#2's fall occurred in his room. Description of fall R#2 was found on floor in bedroom area, stated was attempting to transfer self to wheelchair. R#2 noted with bump on right side of head . Intervention recommendation - care plan revision. 12. Record review of R#2's Interdisciplinary Post Fall Review for fall on 05/24/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall at 1:35 p.m. R#2's fall occurred in his room. Description of fall R#2 was witnessed slipping off chair, attempting to transfer unassisted, landed sitting position on floor .Intervention recommendation - care plan revision. 13. Record review of R#2's Interdisciplinary Post Fall Review for fall on 06/04/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall at 2:22 p.m. R#2's fall occurred at the nurse station. Description of fall R#2 was witnessed slipping off chair, attempting to transfer unassisted, landed sitting position on floor. Intervention recommendation - care plan revision. 14. Record review of R#2's Interdisciplinary Post Fall Review for fall on 06/06/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall with laceration to skull / in house treatment at 8:16 p.m R#2's fall occurred in the dining room. Description of fall R#1 was sitting on dining room chair,attempted unassisted transfer and slipped and fell ; hitting self on head on wall. R#2 with laceration to skull. Intervention recommendation - care plan revision. 15. Record review of R#2's Interdisciplinary Post Fall Review for fall on 06/20/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had a witnessed fall at 4:40 p.m. R#2's fall occurred in the hallway (no specific hallway indicated.) . Description of fall R#2 was witnessed slipping off chair, attempting to rise from wheelchair went forward and landed on wall and fell to floor slowly.Intervention recommendation - care plan revision. 16. Record review of R#2's Interdisciplinary Post Fall Review for fall on 06/23/17,completed by former Director of Nurses,Registered Nurse (RN) A, RN B, Administrator (Adm.), Licensed Vocational Nurse (LVN) C, LVN D, and Rehabilitation Manager (RM) E revealed R#2 had an unwitnessed fall at 4:40 p.m. R#2's fall occurred in his room . Description of fall R#2 noted on floor on the left side of the body.Intervention recommendation - care plan revision. R#2's care plan date initiated : 02/17/17 and revision on : 04/10/17 indicated 1. Focus R#2 requires assistance with ADLs related to general weakness Interventions - provide assistance as required for completion of ADL task. 2. Focus R#2 had weakness and difficulties in walking Intervention -- therapeutic activities, gait training, wheelchair mobility and manual therapy 3. Focus R#2 1 had actual safety and fall risk related to : multiple falls, and cognitive deficits Interventions--alarm/bed chair, attempt to keep at nurses station and offer coloring books and gum, floor mats 4. Focus R#2 had limited mobility dx of wedge compression fracture 5th vertebra Interventions-Locomotion - R#2 required extensive assistance by (2) staff to walk, totally dependent on (2) staff for locomotion using wheelchair. Surveyor at the time of exit from the facility (on 06/28/17 at 5:30 p.m.) was not provided any updated care plans for R#2. Review of the facility's policy/procedure Fall Management revised August 2013 revealed Overview Each resident resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls.The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, .and calculation of resident falls. The facility Adm. on 06/22/17 at approximately 2:00 p.m.,stated the DON's last day at the facility was 06/21/17. On 06/23/17 at 9:57 a.m., RN A stated intervention such as re-direction was not likely to work for R#1 due to her cognitive status. On 06/23/17 at 9:57 a.m., RN A stated intervention such as re-direction was more likely to work for R#2. The facility did not have an interim DON until 06/28/17 and no other staff interviews were conducted. The facility's CMS (Centers for Medicare and Medicaid) /Sample Roster (802) form (received on 06/27/17)indicated there were 22 residents with falls . Review of the facility's Incident/Accident Report for 01/01/17 through 06/27/17 revealed 9 of the 21 residents who resided in wing C (secured unit) had falls or history of falls.

Citation Text for Tag 0224, Regulation FF09 Sanchez-Mushel, Rosa Based on observations, interviews and record reviews, the facility failed to develop and implement their written policies and procedures that prohibit neglect for two (R#1 and #2) out of eight residents reviewed for neglect. 1. The facility failed to provide one on one supervision for R#1 and as a result R#1 displayed several incidents of resident to resident verbal, physical and sexual aggression. R#1 pushed R#2 in her wheelchair against her will. 2. The facility did not protect R#2 from R#1 and as a result she was afraid, suffered emotional distress with crying spells and was fearful of leaving her room. These deficient practices could affect 119 residents from physical and emotional trauma to the residents. The findings were: The facility's policy, Sexual Behavior revised date: December 2005 under Procedure, the policy stated staff would identify a resident's sexual expressions and behavior and should determine the appropriateness of the resident's behavior. As soon as inappropriate behavior was identified and if it was an abusive situation, letter b in the policy stated do what is necessary to protect the alleged victim and other residents. The facility's undated Abuse and Neglect Prohibition Policy documented: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -Physical abuse includes hitting, slapping, pinching, and kicking, It also includes controlling behavior through corporal punishment. Procedure: A. Screening .2. the facility will screen for potentially abusive individuals involved with the resident who are not providing a professioanl service. 3. The facility will screen for potentially abusive residents . C. Prevention: 1. Residents, families and staff will be able to report concerns, incidents, and grievances without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. 3. Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misa((ropriation of resident property, and intervene as appropriate. 4. Staff identified as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. D. Identification: 1. The facility Quality Improvement Committee will investigate occurrences, patterns, and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. 2. The facility Supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, that are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum od aggression . E. Investigation: 1. The facility will conduct an investigation of an alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state, as per state regulations. 4. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of property, identified through analysis conducted by the Performance Improvement Committee, with intervention, reporting or policy/procedure modification conducted as appropriate. F. The facility will protect residents from harm during the investigation. 2. The facility will make referrals to the appropriate state agencies as appropriate, to ensure the protection of the resident or resident property The facility's undated Resident's Rights Under State Law documented .The elderly has the right to be free from abuse, neglect, and exploitation . The facility's Centers for Medicare and Medicaid Services (CMS): Residents Census and Conditions of Residents Form-672 documented 8 residents receiving respiratory/oxygen therapy. 1.) R #1: R#1's Face Sheet dated 05/26/15 indicated he was admitted on [DATE] with the [DIAGNOSES REDACTED].) R#1 was listed as his own responsible party. R#1's Care Plan-Depression/Anxiety/Sad Mood dated 11/10/15 indicated he had a history of [REDACTED]. and notify MD as needed. R#1's Care Plan-Behavior Symptoms dated 11/10/15 indicated exhibition of behavioral symptoms of physical abuse. Target behaviors indicated included delusions. The approaches checked were: Use firm, gentle voice; identify self to individual prior to initiating care; give simple, clear directions, repeat as needed; Ignore verbal outbursts; Modify environment, situations, and/or treatment to minimize external stressors; Redirect as needed; Be alert for triggers of potential evidence of pending behavioral episodes and Notify MD as needed. At the bottom of this Care Plan dated 02/03/16, handwritten documentation stated R#1 was placed on one to one observation on 02/02/16 due to increased aggressive behavior. R#1's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech, was able to make himself understood and would usually understand others. R#1 was able to identify the correct month and day, but missed the year by 2-5 years. The MDS indicated R#1 had no behavioral symptoms. The MDS also indicated R#1 was able to transfer; walk in room; walk in the corridor and locomotion on the unit with supervision, but also indicated his mobility device was a wheelchair. Review of Incident Investigation Worksheet, date received 02/03/16 indicated R#1 was alert and oriented times three; ambulatory without assistance, history of verbal, physical, sexual and inappropriate behavior and had [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#2, mentioned on the Worksheet was a [AGE] years old female; alert and oriented times three; in a wheelchair; no behavioral issues and had anxiety. The Worksheet indicated the facility first learned of the incident on 02/02/16 at 9:40 p.m. The allegation was that R#2 reported that R#1 offered to push her wheelchair to the laundry room. R#1 stopped the wheelchair and started to pull R#2's hair back in a very hard manner. R#1 whispered in R#2's ear that R#1 was going to take R#2 into a room and start kissing R#2 on the neck and she would like it. R#2 reported she told R#1 to stop and leave her alone, but R#1 continued to push the wheelchair into the laundry room. R#1 then wheeled R#2 into the lobby against her will. R#2 tried to get away, but was not able to. R#1 then threaten R#2, telling her that R#1 would go into R#2's room at night to hit her, break her leg and kill her. The Incident Worksheet indicated Medication Aide (MA) C was a witness. The Worksheet also stated R#1 was placed on one to one supervision; a psychological evaluation and eviction notice was given to R#1 and the transfer process had begun. The Worksheet indicated a similar incident had occurred on 01/30/16 and that the physician, family and police were notified. The facility's Provider Investigation Report faxed to state office on 02/03/16 indicated R#1's functional ability was no assistance required; level of supervision was no special supervision. R#1 was independently ambulatory, interview able and capable of making informed decisions. R#1 had a history of [REDACTED]. R#2's functional ability was extensive assistance required; no special supervision; not independently ambulatory; interview able and capable of making informed decisions. The description of the allegation was the same, but also mentioned R#1 had stated he would hit another female resident, (R#11) he did not like and a nurse he had a relationship with because she was looking for it. Under Assessment, the report stated the Social Worker (SW) had assessed R#2 the morning after the incident and R#2 was showing emotional distress, experiencing crying spells, hands shaking and scared to get out of her room. A psychological evaluation would be done on R#2, according to the report. A Concern Form included in the Provider Investigation Report dated 02/02/16 written by the night time Licensed Vocational Nurse (LVN) M indicated R#2 was afraid to take her medications that night in fear of getting too sleepy and not being able to hear the door open. R#2 had also requested her name be taken off the door so R#1 wouldn't be able to find her. An interview form by the SW included in the report dated 02/03/16 at 2:00 p.m. with R#1 indicated R#1 denied all the allegations, and stated he did not know what the SW was talking about. A Psychological Report dated 02/04/16 on R#2 was included in the Provider Investigation Report by Licensed Clinical Psychologist (LCP.) The report indicated R#2 was sad and in distress. R#2 was crying, but was able to compose herself. Under Mental Status, the report indicated R#2 had a sad mood; affect was congruent with her mood, crying on several occasions during the assessment. Thought processes and content were clear, logical, rational and well organized. No evidence of hallucinations or delusions. R#2's appetite was somewhat diminished by her report. R#2 reported having some trouble sleeping due to the alleged perpetrator threatening her, and indicating that he would again try the same behavior. R#2 reported having some bad dreams. Her memory was said to be excellent; Judgment-good to excellent; Insight-Appropriate and reality based; Abstract Reasoning-Good and Problem Solving-Good to excellent. In summary, LCP indicated there was no evidence of mental illness and his recommendation was to keep R#1 away from R#2. Review of the Social Progress Notes written by the SW dated 01/28/15 indicated SW had spoken to R#1 regarding his inappropriate comments towards staff and residents. Social Progress Notes dated 05/20/15 indicated sexual inappropriate comments from R#1 were addressed. The note stated R#1 indicated he was sorry and would not do that anymore. Concern Form dated 08/02/15 indicated R#1 had been in an altercation with R#11. R#11 had a skin tear to the left hand and R#1 had a superficial skin tear to his nose and chin. Interview on 08/05/15 at 8:40 a.m. indicated R#1 was going into his room when he noticed R#11 inside his room. R#1 stated he tried to take her out and R#11 scratched R#1, so he responded by scratching R#11. Observation of R#11 on 04/14/16 at approximately 7:00 p.m. indicated the resident was confused and was attempting to find her room. R#11 was wandering from room to room. There was no interview on R#11 with the concern form. Concern Form-Action completed by the SW on 08/06/15 indicated R#1 got very upset because R#11 was in his room. The form indicated he tried to take R#11 out of the room and both had started to hit each other. The actions taken were that R#1 was moved to another wing; a psychological evaluation to be requested; labs to be requested; R#1's medications would be checked and R#1 to be evicted /transferred to another facility. Psychology Note dated 08/06/15 by LCP on R#1 indicated R#1 admitted to feeling depressed and appeared anxious and fearful. R#1 seemed concerned that he would be discharged . The SW had indicated that was not the case. R#1 reported that in the past he had experienced visual, tactile and auditory hallucinations and delusions. R#1 was aware that he could be impulsive, irritable and aggressive. R#1 had recalled two incidents when he had aggressive interactions with patients; in actuality, the LCP wrote that there had been four incidences of aggressive behavior. The note further stated R#1 had a history of [REDACTED]. The LCP was also requesting a UA, since R#1 was complaining of frequent urination and dribbling. The LCP indicated R#1 could benefit from a low dose of a mood stabilizing medication which could minimize impulsivity and aggressiveness. The LCP stated on the report that the fact that R#1 had engaged in four separate acts of aggression while in the nursing home, there was no guarantee the recommended medication would stop the behaviors in the future. There was no documentation to indicate R#1 was seen by psychological services for counseling or any other treatment for [REDACTED].#1 was receiving antidepressant medication. Social Progress Notes dated 08/13/15 indicated R#1 continued being inappropriate with staff and had been showing verbal and physical aggressiveness during past days. The note indicated that labs showed ammonia levels were high and UA (urinalysis) indicated a UTI (urinary tract infection.) The note indicated R#1had been assessed by Psychological Services. The note further stated the SW and the Assistant Director of Nurses (ADON) had spoken to R#1 about the possibility of being evicted if the behaviors continued. Concern Form dated 01/10/16 written by LVN N indicated she was concerned with R#1's inappropriate behavior towards her. LVN N stated she felt R#1's behavior was out of control and she was afraid his behavior could affect her job and her nursing license. LVN N added R#1 had a history of [REDACTED]. Concern Form-Action completed on 01/13/16 by the SW indicated she had spoken to R#1 concerning his comments of love towards the nurse. R#1 reported LVN N was crazy and he denied saying those things. The SW then wrote that she had spoken to the DON and the ADON about her concerns that R#1 was having delusions towards the nurse, and requested the DON speak to the nurse about keeping her distance from R#1. Concern Form dated 01/28/16 written by CNA P indicated R#1 had attempted to push R#13 inside his room. CNA P indicated she had notified the nurse and the nurse went to get R#13 away from R#1. In this same Concern Form, CNA P stated R#1 had commented to her that he could warm her up if she was cold when R#1 saw CNA P wearing a jacket. CNA P stated another male resident had told R#1 that he needed to respect the staff. Concern Form dated 01/28/16 written by MA Q indicated R#1 and R#5 were sitting at the same table in the dining room when she heard R#1 tell R#5, come on baby and pulled his shirt up. MA Q wrote she heard him say this several times, but he would turn to see if anyone was looking at him. He then came up to MA Q and told her in Spanish, that R#5 would not listen. MA Q indicated she notified the DON of R#1's behavior. Concern Form-Action dated 01/28/16 written by the SW indicated the actions taken were: MD made aware; interviewed staff; interviewed R#1 and labs ordered for possible high ammonia levels. Interview with R#1 indicated he denied all the allegations, except for calling R#5 baby. R#1 indicated he was trying to calm her down by calling her baby, but denied lifting his shirt to her. R#1 also denied trying to force R#13 into his room and any inappropriate behavior towards a female nurse. Nurse's Note dated 01/28/16 written by the DON indicated R#1 was noted with increased verbal and physical aggressive behavior. The DON wrote R#1 also continued to be sexually inappropriate with other residents that were confused and who were unable to report incidents. The note stated the MD was reminded R#1 had a history of [REDACTED]. The DON requested orders for ammonia level and for a UA. Orders were given by the MD. The DON reported on the note that she asked if R#1 would be a good candidate for [MEDICATION NAME]. The MD stated probably not due to R#1's history of liver cirrohois. The MD stated to continue forward with the discharge process. Concern Form dated 02/01/16 written in Spanish by CNA O indicated R#1 had been verbally abusive to two other residents (R#5 and R#12) during meal time. The form stated R#1 became angry when she confronted him about his behavior and he started yelling and insulting CNA O. No Concern-Action Form attached on this concern. Social Progress Note dated 02/03/16 by the SW indicated she had received the concern from the DON on the allegation that R#1 abused a female resident (R#2.) The SW wrote the investigation was in progress and the case would be reported to the state. Concern Form-Action dated 02/03/16 indicated the SW had met with R#1 concerning his inappropriate behaviors, and he kept denying everything. R#1 was advised to stay away from R#2 and that he would continue on one to one supervision. At this time R#2 was notified about his eviction notice and transfer plans. Social Progress Note dated 02/04/16 indicated R#1 had been accepted to another nursing home and he would be transferred on that day. A telephone call was made to R#2 on 04/13/16 at 10:20 a.m. R#2 stated she would not talk to me through the telephone. R#2 stated she had waited at the facility for the state to show, and we never did. Now, R#2 stated she was unwilling to talk to the surveyor unless the surveyor came to her home. R#2 stated she would report the surveyor if the surveyor did not go to her home. MA C stated on 04/13/16 at 5:45 p.m. that she saw R#1 and R#2 in the small lobby on the day of the allegation at about 5:00 p.m. R#2 told MA C to take her to get her medications. R#2 told MA C that R#1 was crazy and that R#2 was afraid of R#1. MA C stated R#2 looked scared and had labored breathing. MA C also stated R#1 was able to walk. R#2 had been in an accident and could only propel herself with one hand. MA C stated R#2 was at the facility for rehabilitation services. At that point she took R#2 to the nurse in charge. MA C stated she was later asked by the ADON if she would stay to supervise R#1 on a one to one basis, which she did. The SW reported on 04/14/16 at 10:00 a.m. R#1 had made comments to staff and female residents and his behavior had become more frequent. On 01/28/16, the SW stated R#1 had tried to kiss R#5, who had a [DIAGNOSES REDACTED].) The SW stated she did not remember if R#1 had been referred for psychological services prior to the last incident. The SW stated R#1 did have a [DIAGNOSES REDACTED].#1 was residing in Wing A, but had been moved due to aggressive behavior towards R#11, who wandered into his room and whispering into R#14's ear where no one could hear, but would upset R#14. Also due to issues with a nurse on that wing that he thought he had a relationship with. The SW stated she would talk to R#1, but he would always deny the allegations. The SW stated the facility was going to evict R#1 but when his ammonia levels showed they were high, they decided not to evict him, since high ammonia levels can make a person act differently or aggressive. The SW stated that the police had been called during the last incident with R#2 and the police told R#1 to stay in his room or he would be arrested. The SW stated R#2 had requested to talk to the police, but the police did not talk to her. R#2 later stated she wanted to press charges against R#1, but since R#1 had been transferred to a different city, the police stated it was out of their jurisdiction. The DON stated on 04/14/16 at 11:30 a.m. R#1 did have a history of physical aggressive behaviors toward vulnerable females, who couldn't verbalize their needs. The DON stated the team did not want to evict R#1 if his behavior was caused by a medical problem, since someone on the team stated R#1 had rights also. The DON stated R#1 did have a high ammonia level that could have been contributing to his behavior. The DON stated R#1 had been relocated to Wing C after incidents with R#11 and R#12. The DON stated, after reviewing R#1's closed record that she could not find any documentation to support what the facility had done to protect the residents from R#1. A telephone call was made to R#2 on 04/14/16 at 5:50 p.m. Again R#2 refused to talk to the surveyor. R#2 stated the surveyor would need to go to R#2's house for her to talk to the surveyor. The DON reported 04/14/16 at 6:55 p.m. that R#1's behavior was not being monitored. The DON brought Compressed Behavior Report, reference date range: 08/01/15-12/31/15 with Behavioral Symptoms listed as physical, verbal and other symptoms. Under these titles zeros were documented. The DON reported at this time, the facility only had a policy on Sexual Behavior in residents, no policy on aggressive behavior in residents. Chapa, Laura

Based on observations, interviews and record reviews, the facility failed to develop and implement their policies and procedures that prohibit neglect for two (R#1 and #2) out of eight residents reviewed for neglect. 1. The facility failed to provide one on one supervision for R#1 and as a result R#1 displayed several incidents of resident to resident verbal, physical and sexual aggression. R#1 pushed R#2 in her wheelchair against her will. 2. The facility did not protect R#2 from R#1 and as a result she was afraid, suffered emotional distress with crying spells and was fearful of leaving her room. These deficient practices could affect 119 residents from physical and emotional trauma to the residents. The findings were: 1.) R #1: R#1's Face Sheet dated 05/26/15 indicated he was admitted on [DATE] with the [DIAGNOSES REDACTED].) R#1 was listed as his own responsible party. R#1's Care Plan-Depression/Anxiety/Sad Mood dated 11/10/15 indicated he had a history of [REDACTED]. and notify MD as needed. R#1's Care Plan-Behavior Symptoms dated 11/10/15 indicated exhibition of behavioral symptoms of physical abuse. Target behaviors indicated included delusions. The approaches checked were: Use firm, gentle voice; identify self to individual prior to initiating care; give simple, clear directions, repeat as needed; Ignore verbal outbursts; Modify environment, situations, and/or treatment to minimize external stressors; Redirect as needed; Be alert for triggers of potential evidence of pending behavioral episodes and Notify MD as needed. At the bottom of this Care Plan dated 02/03/16, handwritten documentation stated R#1 was placed on one to one observation on 02/02/16 due to increased aggressive behavior. R#1's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech, was able to make himself understood and would usually understand others. R#1 was able to identify the correct month and day, but missed the year by 2-5 years. The MDS indicated R#1 had no behavioral symptoms. The MDS also indicated R#1 was able to transfer; walk in room; walk in the corridor and locomotion on the unit with supervision, but also indicated his mobility device was a wheelchair. Review of Incident Investigation Worksheet, date received 02/03/16 indicated R#1 was alert and oriented times three; ambulatory without assistance, history of verbal, physical, sexual and inappropriate behavior and had [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#2, mentioned on the Worksheet was a [AGE] years old female; alert and oriented times three; in a wheelchair; no behavioral issues and had anxiety. The Worksheet indicated the facility first learned of the incident on 02/02/16 at 9:40 p.m. The allegation was that R#2 reported that R#1 offered to push her wheelchair to the laundry room. R#1 stopped the wheelchair and started to pull R#2's hair back in a very hard manner. R#1 whispered in R#2's ear that R#1 was going to take R#2 into a room and start kissing R#2 on the neck and she would like it. R#2 reported she told R#1 to stop and leave her alone, but R#1 continued to push the wheelchair into the laundry room. R#1 then wheeled R#2 into the lobby against her will. R#2 tried to get away, but was not able to. R#1 then threaten R#2, telling her that R#1 would go into R#2's room at night to hit her, break her leg and kill her. The Incident Worksheet indicated Medication Aide (MA) C was a witness. The Worksheet also stated R#1 was placed on one to one supervision; a psychological evaluation and eviction notice was given to R#1 and the transfer process had begun. The Worksheet indicated a similar incident had occurred on 01/30/16 and that the physician, family and police were notified. The facility's Provider Investigation Report faxed to state office on 02/03/16 indicated R#1's functional ability was no assistance required; level of supervision was no special supervision. R#1 was independently ambulatory, interview able and capable of making informed decisions. R#1 had a history of [REDACTED]. R#2's functional ability was extensive assistance required; no special supervision; not independently ambulatory; interview able and capable of making informed decisions. The description of the allegation was the same, but also mentioned R#1 had stated he would hit another female resident, (R#11) he did not like and a nurse he had a relationship with because she was looking for it. Under Assessment, the report stated the Social Worker (SW) had assessed R#2 the morning after the incident and R#2 was showing emotional distress, experiencing crying spells, hands shaking and scared to get out of her room. A psychological evaluation would be done on R#2, according to the report. A Concern Form included in the Provider Investigation Report dated 02/02/16 written by the night time Licensed Vocational Nurse (LVN) M indicated R#2 was afraid to take her medications that night in fear of getting too sleepy and not being able to hear the door open. R#2 had also requested her name be taken off the door so R#1 wouldn't be able to find her. An interview form by the SW included in the report dated 02/03/16 at 2:00 p.m. with R#1 indicated R#1 denied all the allegations, and stated he did not know what the SW was talking about. A Psychological Report dated 02/04/16 on R#2 was included in the Provider Investigation Report by Licensed Clinical Psychologist (LCP.) The report indicated R#2 was sad and in distress. R#2 was crying, but was able to compose herself. Under Mental Status, the report indicated R#2 had a sad mood; affect was congruent with her mood, crying on several occasions during the assessment. Thought processes and content were clear, logical, rational and well organized. No evidence of hallucinations or delusions. R#2's appetite was somewhat diminished by her report. R#2 reported having some trouble sleeping due to the alleged perpetrator threatening her, and indicating that he would again try the same behavior. R#2 reported having some bad dreams. Her memory was said to be excellent; Judgment-good to excellent; Insight-Appropriate and reality based; Abstract Reasoning-Good and Problem Solving-Good to excellent. In summary, LCP indicated there was no evidence of mental illness and his recommendation was to keep R#1 away from R#2. Review of the Social Progress Notes written by the SW dated 01/28/15 indicated SW had spoken to R#1 regarding his inappropriate comments towards staff and residents. Social Progress Notes dated 05/20/15 indicated sexual inappropriate comments from R#1 were addressed. The note stated R#1 indicated he was sorry and would not do that anymore. Concern Form dated 08/02/15 indicated R#1 had been in an altercation with R#11. R#11 had a skin tear to the left hand and R#1 had a superficial skin tear to his nose and chin. Interview on 08/05/15 at 8:40 a.m. indicated R#1 was going into his room when he noticed R#11 inside his room. R#1 stated he tried to take her out and R#11 scratched R#1, so he responded by scratching R#11. Observation of R#11 on 04/14/16 at approximately 7:00 p.m. indicated the resident was confused and was attempting to find her room. R#11 was wandering from room to room. There was no interview on R#11 with the concern form. Concern Form-Action completed by the SW on 08/06/15 indicated R#1 got very upset because R#11 was in his room. The form indicated he tried to take R#11 out of the room and both had started to hit each other. The actions taken were that R#1 was moved to another wing; a psychological evaluation to be requested; labs to be requested; R#1's medications would be checked and R#1 to be evicted /transferred to another facility. Psychology Note dated 08/06/15 by LCP on R#1 indicated R#1 admitted to feeling depressed and appeared anxious and fearful. R#1 seemed concerned that he would be discharged . The SW had indicated that was not the case. R#1 reported that in the past he had experienced visual, tactile and auditory hallucinations and delusions. R#1 was aware that he could be impulsive, irritable and aggressive. R#1 had recalled two incidents when he had aggressive interactions with patients; in actuality, the LCP wrote that there had been four incidences of aggressive behavior. The note further stated R#1 had a history of [REDACTED]. The LCP was also requesting a UA, since R#1 was complaining of frequent urination and dribbling. The LCP indicated R#1 could benefit from a low dose of a mood stabilizing medication which could minimize impulsivity and aggressiveness. The LCP stated on the report that the fact that R#1 had engaged in four separate acts of aggression while in the nursing home, there was no guarantee the recommended medication would stop the behaviors in the future. There was no documentation to indicate R#1 was seen by psychological services for counseling or any other treatment for [REDACTED].#1 was receiving antidepressant medication. Social Progress Notes dated 08/13/15 indicated R#1 continued being inappropriate with staff and had been showing verbal and physical aggressiveness during past days. The note indicated that labs showed ammonia levels were high and UA (urinalysis) indicated a UTI (urinary tract infection.) The note indicated R#1had been assessed by Psychological Services. The note further stated the SW and the Assistant Director of Nurses (ADON) had spoken to R#1 about the possibility of being evicted if the behaviors continued. Concern Form dated 01/10/16 written by LVN N indicated she was concerned with R#1's inappropriate behavior towards her. LVN N stated she felt R#1's behavior was out of control and she was afraid his behavior could affect her job and her nursing license. LVN N added R#1 had a history of [REDACTED]. Concern Form-Action completed on 01/13/16 by the SW indicated she had spoken to R#1 concerning his comments of love towards the nurse. R#1 reported LVN N was crazy and he denied saying those things. The SW then wrote that she had spoken to the DON and the ADON about her concerns that R#1 was having delusions towards the nurse, and requested the DON speak to the nurse about keeping her distance from R#1. Concern Form dated 01/28/16 written by CNA P indicated R#1 had attempted to push R#13 inside his room. CNA P indicated she had notified the nurse and the nurse went to get R#13 away from R#1. In this same Concern Form, CNA P stated R#1 had commented to her that he could warm her up if she was cold when R#1 saw CNA P wearing a jacket. CNA P stated another male resident had told R#1 that he needed to respect the staff. Concern Form dated 01/28/16 written by MA Q indicated R#1 and R#5 were sitting at the same table in the dining room when she heard R#1 tell R#5, come on baby and pulled his shirt up. MA Q wrote she heard him say this several times, but he would turn to see if anyone was looking at him. He then came up to MA Q and told her in Spanish, that R#5 would not listen. MA Q indicated she notified the DON of R#1's behavior. Concern Form-Action dated 01/28/16 written by the SW indicated the actions taken were: MD made aware; interviewed staff; interviewed R#1 and labs ordered for possible high ammonia levels. Interview with R#1 indicated he denied all the allegations, except for calling R#5 baby. R#1 indicated he was trying to calm her down by calling her baby, but denied lifting his shirt to her. R#1 also denied trying to force R#13 into his room and any inappropriate behavior towards a female nurse. Nurse's Note dated 01/28/16 written by the DON indicated R#1 was noted with increased verbal and physical aggressive behavior. The DON wrote R#1 also continued to be sexually inappropriate with other residents that were confused and who were unable to report incidents. The note stated the MD was reminded R#1 had a history of [REDACTED]. The DON requested orders for ammonia level and for a UA. Orders were given by the MD. The DON reported on the note that she asked if R#1 would be a good candidate for [MEDICATION NAME]. The MD stated probably not due to R#1's history of liver cirrohois. The MD stated to continue forward with the discharge process. Concern Form dated 02/01/16 written in Spanish by CNA O indicated R#1 had been verbally abusive to two other residents (R#5 and R#12) during meal time. The form stated R#1 became angry when she confronted him about his behavior and he started yelling and insulting CNA O. No Concern-Action Form attached on this concern. Social Progress Note dated 02/03/16 by the SW indicated she had received the concern from the DON on the allegation that R#1 abused a female resident (R#2.) The SW wrote the investigation was in progress and the case would be reported to the state. Concern Form-Action dated 02/03/16 indicated the SW had met with R#1 concerning his inappropriate behaviors, and he kept denying everything. R#1 was advised to stay away from R#2 and that he would continue on one to one supervision. At this time R#2 was notified about his eviction notice and transfer plans. Social Progress Note dated 02/04/16 indicated R#1 had been accepted to another nursing home and he would be transferred on that day. A telephone call was made to R#2 on 04/13/16 at 10:20 a.m. R#2 stated she would not talk to me through the telephone. R#2 stated she had waited at the facility for the state to show, and we never did. Now, R#2 stated she was unwilling to talk to the surveyor unless the surveyor came to her home. R#2 stated she would report the surveyor if the surveyor did not go to her home. MA C stated on 04/13/16 at 5:45 p.m. that she saw R#1 and R#2 in the small lobby on the day of the allegation at about 5:00 p.m. R#2 told MA C to take her to get her medications. R#2 told MA C that R#1 was crazy and that R#2 was afraid of R#1. MA C stated R#2 looked scared and had labored breathing. MA C also stated R#1 was able to walk. R#2 had been in an accident and could only propel herself with one hand. MA C stated R#2 was at the facility for rehabilitation services. At that point she took R#2 to the nurse in charge. MA C stated she was later asked by the ADON if she would stay to supervise R#1 on a one to one basis, which she did. The SW reported on 04/14/16 at 10:00 a.m. R#1 had made comments to staff and female residents and his behavior had become more frequent. On 01/28/16, the SW stated R#1 had tried to kiss R#5, who had a [DIAGNOSES REDACTED].) The SW stated she did not remember if R#1 had been referred for psychological services prior to the last incident. The SW stated R#1 did have a [DIAGNOSES REDACTED].#1 was residing in Wing A, but had been moved due to aggressive behavior towards R#11, who wandered into his room and whispering into R#14's ear where no one could hear, but would upset R#14. Also due to issues with a nurse on that wing that he thought he had a relationship with. The SW stated she would talk to R#1, but he would always deny the allegations. The SW stated the facility was going to evict R#1 but when his ammonia levels showed they were high, they decided not to evict him, since high ammonia levels can make a person act differently or aggressive. The SW stated that the police had been called during the last incident with R#2 and the police told R#1 to stay in his room or he would be arrested. The SW stated R#2 had requested to talk to the police, but the police did not talk to her. R#2 later stated she wanted to press charges against R#1, but since R#1 had been transferred to a different city, the police stated it was out of their jurisdiction. The DON stated on 04/14/16 at 11:30 a.m. R#1 did have a history of physical aggressive behaviors toward vulnerable females, who couldn't verbalize their needs. The DON stated the team did not want to evict R#1 if his behavior was caused by a medical problem, since someone on the team stated R#1 had rights also. The DON stated R#1 did have a high ammonia level that could have been contributing to his behavior. The DON stated R#1 had been relocated to Wing C after incidents with R#11 and R#12. The DON stated, after reviewing R#1's closed record that she could not find any documentation to support what the facility had done to protect the residents from R#1. A telephone call was made to R#2 on 04/14/16 at 5:50 p.m. Again R#2 refused to talk to the surveyor. R#2 stated the surveyor would need to go to R#2's house for her to talk to the surveyor. The DON reported 04/14/16 at 6:55 p.m. that R#1's behavior was not being monitored. The DON brought Compressed Behavior Report, reference date range: 08/01/15-12/31/15 with Behavioral Symptoms listed as physical, verbal and other symptoms. Under these titles zeros were documented. The DON reported at this time, the facility only had a policy on Sexual Behavior in residents, no policy on aggressive behavior in residents. The facility's policy, Sexual Behavior revised date: December 2005 under Procedure, the policy stated staff would identify a resident's sexual expressions and behavior and should determine the appropriateness of the resident's behavior. As soon as inappropriate behavior was identified and if it was an abusive situation, letter b in the policy stated do what is necessary to protect the alleged victim and other residents. The Texas Department of Aging and Disability Services Provider Letter 14-13 dated 08/19/14 under the heading, Attention to Early Warning Signs stated that if a resident begins to exhibit inappropriate behavior, the facility must assess the resident and promptly intervene, taking appropriate action to protect other residents. The facility's undated Abuse and Neglect Prohibition Policy documented: - Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -Sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault. -Physical abuse includes hitting, slapping, pinching, and kicking, It also includes controlling behavior through corporal punishment. Procedure: A. Screening .2. the facility will screen for potentially abusive individuals involved with the resident who are not providing a professioanl service. 3. The facility will screen for potentially abusive residents . C. Prevention: 1. Residents, families and staff will be able to report concerns, incidents, and grievances without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect or misappropriation of resident property is at risk for occurring. 3. Staff will be instructed to report any signs of stress from family and other individuals involved with the resident that may lead to abuse, neglect, or misa((ropriation of resident property, and intervene as appropriate. 4. Staff identified as being self injurious or exhibiting abusive behavior, which require professional services not provided in the facility, will be reviewed by the physician and treatment plans modified as appropriate. D. Identification: 1. The facility Quality Improvement Committee will investigate occurrences, patterns, and trends that may indicate the presence of abuse, neglect or misappropriation of resident property and to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. 2. The facility Supervisory staff will integrate into the supervisory process monitoring the behavior of staff members and residents, that are indicative of high stress levels that may lead to abuse/neglect or may escalate a continuum od aggression . E. Investigation: 1. The facility will conduct an investigation of an alleged abuse/neglect or misappropriation of resident property in accordance with state law. 2. The facility will report such allegations to the state, as per state regulation. 3. The facility will report all investigation findings to the state, as per state regulations. 4. The facility will investigate all patterns, trends or incidents that suggest the possible presence of abuse, neglect or misappropriation of property, identified through analysis conducted by the Performance Improvement Committee, with intervention, reporting or policy/procedure modification conducted as appropriate. F. The facility will protect residents from harm during the investigation. 2. The facility will make referrals to the appropriate state agencies as appropriate, to ensure the protection of the resident or resident property The facility's undated Resident's Rights Under State Law documented .The elderly has the right to be free from abuse, neglect, and exploitation .

Based on observations, interviews and record reviews, the facility failed to ensure that each resident received adequate supervision for one resident (R#1) who required one to one supervision of 10 residents reviewed to prevent risk of injuries to other residents. 1. The facility failed to provide one on one supervision for R#1 and as a result R#1 displayed several incidents of resident to resident verbal, physical and sexual aggression. R#1 pushed R#2 in her wheelchair against her will. 2. The facility did not protect R#2 from R#1 and as a result she was afraid, suffered emotional distress with crying spells and was fearful of leaving her room. The failure to protect residents caused physical and emotional trauma to the residents. The findings were: R#1's Face Sheet dated 05/26/15 indicated he was admitted on [DATE] with the [DIAGNOSES REDACTED].) R#1 was listed as his own responsible party. R#1's Annual Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech, was able to make himself understood and would usually understand others. R#1 was able to identify the correct month and day, but missed the year by 2-5 years. The MDS indicated R#1 had no behavioral symptoms. The MDS also indicated R#1 was able to transfer; walk in room; walk in the corridor and locomotion on the unit with supervision, but also indicated his mobility device was a wheelchair. R#1's Care Plan-Depression/Anxiety/Sad Mood dated 11/10/15 indicated he had a history of [REDACTED]. and notify MD as needed. R#1's Care Plan-Behavior Symptoms dated 11/10/15 indicated exhibition of behavioral symptoms of physical abuse. Target behaviors indicated included delusions. The approaches checked were: Use firm, gentle voice; identify self to individual prior to initiating care; give simple, clear directions, repeat as needed; Ignore verbal outbursts; Modify environment, situations, and/or treatment to minimize external stressors; Redirect as needed; Be alert for triggers of potential evidence of pending behavioral episodes and Notify MD as needed. At the bottom of this Care Plan dated 02/03/16, handwritten documentation stated R#1 was placed on one to one observation on 02/02/16 due to increased aggressive behavior. Review of Incident Investigation Worksheet, date received 02/03/16 indicated R#1 was alert and oriented times three; ambulatory without assistance, history of verbal, physical, sexual and inappropriate behavior and had [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#2, mentioned on the Worksheet was a [AGE] years old female; alert and oriented times three; in a wheelchair; no behavioral issues and had anxiety. The Worksheet indicated the facility first learned of the incident on 02/02/16 at 9:40 p.m. The allegation was that R#2 reported that R#1 offered to push her wheelchair to the laundry room. R#1 stopped the wheelchair and started to pull R#2's hair back in a very hard manner. R#1 whispered in R#2's ear that R#1 was going to take R#2 into a room and start kissing R#2 on the neck and she would like it. R#2 reported she told R#1 to stop and leave her alone, but R#1 continued to push the wheelchair into the laundry room. R#1 then wheeled R#2 into the lobby against her will. R#2 tried to get away, but was not able to. R#1 then threaten R#2, telling her that R#1 would go into R#2's room at night to hit her, break her leg and kill her. The Incident Worksheet indicated Medication Aide (MA) C was a witness. The Worksheet also stated R#1 was placed on one to one supervision; a psychological evaluation and eviction notice was given to R#1 and the transfer process had begun. The Worksheet indicated a similar incident had occurred on 01/30/16 and that the physician, family and police were notified. The facility's Provider Investigation Report faxed to state office on 02/03/16 indicated R#1's functional ability was no assistance required; level of supervision was no special supervision. R#1 was independently ambulatory, interview able and capable of making informed decisions. R#1 had a history of [REDACTED]. R#2's functional ability was extensive assistance required; no special supervision; not independently ambulatory; interview able and capable of making informed decisions. The description of the allegation was the same, but also mentioned R#1 had stated he would hit another female resident, (R#11) he did not like and a nurse he had a relationship with because she was looking for it. Under Assessment, the report stated the Social Worker (SW) had assessed R#2 the morning after the incident and R#2 was showing emotional distress, experiencing crying spells, hands shaking and scared to get out of her room. A psychological evaluation would be done on R#2, according to the report. A Concern Form included in the Provider Investigation Report dated 02/02/16 written by the night time Licensed Vocational Nurse (LVN) M indicated R#2 was afraid to take her medications that night in fear of getting too sleepy and not being able to hear the door open. R#2 had also requested her name be taken off the door so R#1 wouldn't be able to find her. An interview form by the SW included in the report dated 02/03/16 at 2:00 p.m. with R#1 indicated R#1 denied all the allegations, and stated he did not know what the SW was talking about. A Psychological Report dated 02/04/16 on R#2 was included in the Provider Investigation Report by Licensed Clinical Psychologist (LCP.) The report indicated R#2 was sad and in distress. R#2 was crying, but was able to compose herself. Under Mental Status, the report indicated R#2 had a sad mood; affect was congruent with her mood, crying on several occasions during the assessment. Thought processes and content were clear, logical, rational and well organized. No evidence of hallucinations or delusions. R#2's appetite was somewhat diminished by her report. R#2 reported having some trouble sleeping due to the alleged perpetrator threatening her, and indicating that he would again try the same behavior. R#2 reported having some bad dreams. Her memory was said to be excellent; Judgment-good to excellent; Insight-Appropriate and reality based; Abstract Reasoning-Good and Problem Solving-Good to excellent. In summary, LCP indicated there was no evidence of mental illness and his recommendation was to keep R#1 away from R#2. Review of the Social Progress Notes written by the SW dated 01/28/15 indicated SW had spoken to R#1 regarding his inappropriate comments towards staff and residents. Social Progress Notes dated 05/20/15 indicated sexual inappropriate comments from R#1 were addressed. The note stated R#1 indicated he was sorry and would not do that anymore. Concern Form dated 08/02/15 indicated R#1 had been in an altercation with R#11. R#11 had a skin tear to the left hand and R#1 had a superficial skin tear to his nose and chin. Interview on 08/05/15 at 8:40 a.m. indicated R#1 was going into his room when he noticed R#11 inside his room. R#1 stated he tried to take her out and R#11 scratched R#1, so he responded by scratching R#11. Observation of R#11 on 04/14/16 at approximately 7:00 p.m. indicated the resident was confused and was attempting to find her room. R#11 was wandering from room to room. There was no interview on R#11 with the concern form. Concern Form-Action completed by the SW on 08/06/15 indicated R#1 got very upset because R#11 was in his room. The form indicated he tried to take R#11 out of the room and both had started to hit each other. The actions taken were that R#1 was moved to another wing; a psychological evaluation to be requested; labs to be requested; R#1's medications would be checked and R#1 to be evicted /transferred to another facility. Psychology Note dated 08/06/15 by LCP on R#1 indicated R#1 admitted to feeling depressed and appeared anxious and fearful. R#1 seemed concerned that he would be discharged . The SW had indicated that was not the case. R#1 reported that in the past he had experienced visual, tactile and auditory hallucinations and delusions. R#1 was aware that he could be impulsive, irritable and aggressive. R#1 had recalled two incidents when he had aggressive interactions with patients; in actuality, the LCP wrote that there had been four incidences of aggressive behavior. The note further stated R#1 had a history of [REDACTED]. The LCP was also requesting a UA, since R#1 was complaining of frequent urination and dribbling. The LCP indicated R#1 could benefit from a low dose of a mood stabilizing medication which could minimize impulsivity and aggressiveness. The LCP stated on the report that the fact that R#1 had engaged in four separate acts of aggression while in the nursing home, there was no guarantee the recommended medication would stop the behaviors in the future. There was no documentation to indicate R#1 was seen by psychological services for counseling or any other treatment for [REDACTED].#1 was receiving antidepressant medication. Social Progress Notes dated 08/13/15 indicated R#1 continued being inappropriate with staff and had been showing verbal and physical aggressiveness during past days. The note indicated that labs showed ammonia levels were high and UA (urinalysis) indicated a UTI (urinary tract infection.) The note indicated R#1had been assessed by Psychological Services. The note further stated the SW and the Assistant Director of Nurses (ADON) had spoken to R#1 about the possibility of being evicted if the behaviors continued. Concern Form dated 01/28/16 written by CNA P indicated R#1 had attempted to push R#13 inside his room. CNA P indicated she had notified the nurse and the nurse went to get R#13 away from R#1. In this same Concern Form, CNA P stated R#1 had commented to her that he could warm her up if she was cold when R#1 saw CNA P wearing a jacket. CNA P stated another male resident had told R#1 that he needed to respect the staff. Concern Form dated 01/28/16 written by MA Q indicated R#1 and R#5 were sitting at the same table in the dining room when she heard R#1 tell R#5, come on baby and pulled his shirt up. MA Q wrote she heard him say this several times, but he would turn to see if anyone was looking at him. He then came up to MA Q and told her in Spanish, that R#5 would not listen. MA Q indicated she notified the DON of R#1's behavior. Concern Form-Action dated 01/28/16 written by the SW indicated the actions taken were: MD made aware; interviewed staff; interviewed R#1 and labs ordered for possible high ammonia levels. Interview with R#1 indicated he denied all the allegations, except for calling R#5 baby. R#1 indicated he was trying to calm her down by calling her baby, but denied lifting his shirt to her. R#1 also denied trying to force R#13 into his room and any inappropriate behavior towards a female nurse. Nurse's Note dated 01/28/16 written by the DON indicated R#1 was noted with increased verbal and physical aggressive behavior. The DON wrote R#1 also continued to be sexually inappropriate with other residents that were confused and who were unable to report incidents. The note stated the MD was reminded R#1 had a history of [REDACTED]. The DON requested orders for ammonia level and for a UA. Orders were given by the MD. The DON reported on the note that she asked if R#1 would be a good candidate for Provera. The MD stated probably not due to R#1's history of liver cirrohois. The MD stated to continue forward with the discharge process. Concern Form-Action dated 02/03/16 indicated the SW had met with R#1 concerning his inappropriate behaviors, and he kept denying everything. R#1 was advised to stay away from R#2 and that he would continue on one to one supervision. At this time R#2 was notified about his eviction notice and transfer plans. Social Progress Note dated 02/04/16 indicated R#1 had been accepted to another nursing home and he would be transferred on that day. A telephone call was made to R#2 on 04/13/16 at 10:20 a.m. R#2 stated she would not talk to surveyor through the telephone. R#2 stated she had waited at the facility for the state to show, and they never did. Now, R#2 stated she was unwilling to talk to the surveyor and declined the interview. MA C stated on 04/13/16 at 5:45 p.m. that she saw R#1 and R#2 in the small lobby on the day of the allegation at about 5:00 p.m. R#2 told MA C to take her to get her medications. R#2 told MA C that R#1 was crazy and that R#2 was afraid of R#1. MA C stated R#2 looked scared and had labored breathing. MA C also stated R#1 was able to walk. R#2 had been in an accident and could only propel herself with one hand. MA C stated R#2 was at the facility for rehabilitation services. At that point she took R#2 to the nurse in charge. MA C stated she was later asked by the ADON if she would stay to supervise R#1 on a one to one basis, which she did. The SW stated on 04/14/16 at 10:00 a.m. R#1 had made comments to staff and female residents and his behavior had become more frequent. On 01/28/16, the SW stated R#1 had tried to kiss R#5, who had a [DIAGNOSES REDACTED].) The SW stated she did not remember if R#1 had been referred for psychological services prior to the last incident. The SW stated R#1 did have a [DIAGNOSES REDACTED].#1 was residing in Wing A, but had been moved due to aggressive behavior towards R#11, who wandered into his room and whispering into R#14's ear where no one could hear, but would upset R#14. Also due to issues with a nurse on that wing that he thought he had a relationship with. The SW stated she would talk to R#1, but he would always deny the allegations. The SW stated the facility was going to evict R#1 but when his ammonia levels showed they were high, they decided not to evict him, since high ammonia levels can make a person act differently or aggressive. The SW stated that the police had been called during the last incident with R#2 and the police told R#1 to stay in his room or he would be arrested. The SW stated R#2 had requested to talk to the police, but the police did not talk to her. R#2 later stated she wanted to press charges against R#1, but since R#1 had been transferred to a different city, the police stated it was out of their jurisdiction. The DON stated on 04/14/16 at 11:30 a.m. R#1 did have a history of physical aggressive behaviors toward vulnerable females, who couldn't verbalize their needs. The DON stated the team did not want to evict R#1 if his behavior was caused by a medical problem, since someone on the team stated R#1 had rights also. The DON stated R#1 did have a high ammonia level that could have been contributing to his behavior. The DON stated R#1 had been relocated to Wing C after incidents with R#11 and R#12. The DON stated, after reviewing R#1's closed record that she could not find any documentation to support what the facility had done to protect the residents from R#1. A telephone call was made to R#2 on 04/14/16 at 5:50 p.m. Again R#2 refused to talk to the surveyor. R#2 stated the surveyor would need to go to R#2's house for her to talk to the surveyor. The DON stated 04/14/16 at 6:55 p.m. that R#1's behavior was not being monitored. The DON brought Compressed Behavior Report, reference date range: 08/01/15-12/31/15 with a Behavioral Symptoms listed as physical, verbal and other symptoms. Under these titles zeros were documented. The DON reported at this time, the facility only had a policy on Sexual Behavior in residents, no policy on aggressive behavior in residents. The facility's Centers for Medicare and Medicaid Services (CMS): Residents Census and Conditions of Residents Form-672 documented 119 residents in the facility.

Based on observation, interview, and record review, the facility failed to provide services in accordance with each resident's written plan of care for one of seven sampled residents (R #6) who required the assistance of staff for positioning and transfers. R #6's care plans and assessments indicated the facility was to provide R #6 with the assistance of two persons for transfers, dressing, and toileting. Staff performed a one person transfer and provided incontinent care with one person assistance. Shortly after this was provided, R #6 complained of pain, exhibited a swollen left knee, and was diagnosed with [REDACTED]. The direct care staff reference sheet (Cardex) did not contain information consistent with R #6's care plan and provided staff conflicting information related to how to transfer R #6. This failure could have affected the 69 residents of the facility who required staff assistance for transfers, placing them at risk for injury. The findings included: Review of R #6's face sheet dated 07-03-15 revealed R #6 was a [AGE] year old female. Review of R #6's Comprehensive Plan of Care for activities of daily living dated 12-23-14 and reviewed 02-24-15 and 05-18-15 revealed R #6 required extensive assistance of two plus staff for bed mobility, transfers, toileting, and dressing. Review of R #6's Comprehensive Plan of Care for [MEDICAL CONDITION] dated 02-24-15 and reviewed 05-18-15 revealed R #6 is at risk for Spontaneous Fractures. The goal of the care plan was to keep R #6 safe, comfortable and functional, without fractures over the next 92 days. Approaches included assisting R #6 carefully when providing care. Review of R #6's care plan for falls dated 02-23-15 and reviewed 02-24-15 and 05-27-15 revealed R #6 was at risk for falls due to falls on 02-01-15 and 05-25-15, a history of fractures and use of [MEDICAL CONDITION] medication. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6 could sometimes make herself understood by others (ability limited to making concrete requests) --R #6 could sometimes understand others (responds adequately to simple, direct communication only) --R #6 had impairment in range of motion in both lower extremities --R #6 required extensive assistance (resident involved, but staff provide weight-bearing support) from two or more persons for transfers, including to/from bed and wheelchair --R #6's locomotion on unit (movement between locations in room and adjacent corridor) resident involved in activity, staff provide weight-bearing support --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) resident involved in activity, staff provide weight-bearing support Review of R #6's Nursing Weekly/Monthly Summary dated February 2015 and April 2015 revealed: --R #6's mental status described as confused with short-term memory loss --R #6 was incontinent of bowel and bladder --R #6 required the assistance of two staff for transfers Review of R #6's Resident Transfer Evaluations dated 12-05-14 and 02-14-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, but could sit on her bedside with partial support from a rail or person. Review of facility's Incident/Accident Report Log for the period of 04-01-15 to 07-02-15 revealed one injury of unknown origin, which involved R #6 having experienced a fracture identified on 04-30-15. Review of facility's Provider Investigation Report (PIR) # 5 dated 05-01-15 revealed R #6's [DIAGNOSES REDACTED]. The PIR indicated R #6 required extensive assistance with functional ability, she was not independently ambulatory, nor did she have the capacity to make informed decisions. The PIR further indicated R #6 had a history of [REDACTED]. According to the PIR, R #6 expressed pain to Resident Care Specialist (RCS) A on 04-29-15 at 11:00 p.m. and was assessed to have a swollen left knee on 04-30-15 at 4:30 a.m. On 04-30-15 at approximately 6:00 p.m. according to the PIR, R #6 was diagnosed with [REDACTED]. The PIR stated R #6 did not suffer any fall and staff had no incidents with R #6. The PIR added that the only unusual event staff noticed was that family members visited R #6 on 04-29-15 and took R #6 around the facility via wheelchair, after which R #6 was put on bed. Attached to the PIR was documentation of the Assistant Director of Nurses' (ADON's) interview with RCS B dated 04-30-15 at 5:00 p.m., in which RCS B indicated she had transferred R #6 from wheelchair to bed using a gait belt, with no issues reported upon transfer. The PIR contained no review of R #6's care plans, assessments or direct care reference sheet (Cardex) and did not identify RCS B provided care contrary to the care plan. The PIR also did not identify that R #6's symptoms appeared after receiving care contrary R #6's care plans. During interview on 07-06-15 at 1:11 p.m. with the ADON, ADON said she believed pages were missing from the copy of the PIR provided to surveyor. At 1:19 p.m., the ADON provided additional pages missing from surveyor's copy of PIR (consisted of three pages of documented interviews). The ADON stated surveyor now had complete copy of facility's PIR # 5 related to R #6's fractured femur. Review of R #6's x-ray report dated 04-30-15 revealed she was diagnosed with [REDACTED]. On 07-03-15 at 2:40 p.m., interview with Family Member (FM) Z and FM Y revealed they visited R #6 on the afternoon of 04-29-15, during which R #6 was seated in her wheelchair while the family wheeled her around the facility and front porch area. FM Z stated when the family left between 5:00 p.m. and 6:00 p.m. on 04-29-15, R #6 was in good spirits and had not complained of pain or discomfort. FM Z stated R #6 did not fall or bump her leg during their visit. FM Z stated when the family left the facility, a staff member (could not recall name) told them that someone would place R #6 back in bed after the family left. FM Z said the facility called on 04-30-15 and informed FM Z that R #6 had a fractured femur, and the facility did not know how the fracture occurred. FM Z and Y stated they were concerned there was no explanation for how R #6 acquired the fracture. Interview with RCS B on 07-06-15 at 1:34 p.m. revealed she worked from 2:00 p.m. to 10:00 p.m. on 04-29-15 and was assigned to care for R #6. RCS B stated she recalled R #6's family visited R #6 that afternoon, and R #6 was tired after the visit. RCS B said she transferred R #6 to bed the evening of 04-29-15, changed R #6's clothing, and R #6 was tranquil afterward. RCS B said no one assisted assisted her with R #6. RCS B said R #6 did not complain or cry when being transferred or changed. RCS B said she checked on R #6 before leaving that night, and R #6 was asleep. Interview with RCS A on 07-06-15 at 1:40 p.m. revealed she worked from 10:00 p.m. on 04-29-15 to 6:00 a.m. on 04-30-15. RCS A stated she checked on R #6 at approximately 11:00 p.m. on 04-29-15, and R #6 complained of pain to her left leg. RCS A said she reported this to nursing staff and asked if any incidents had occurred. RCS A said she was told nothing had occurred. RCS A said she and RCS C approached R #6 on 04-30-15 at 12:30 a.m. to change her. R #6 refused to allow staff to change her, and RCS A observed R #6's left knee to be swollen. RCS A said nursing staff assessed R #6, gave R #6 medication, and R #6 fell asleep. RCS A said at 4:30 a.m. on 04-30-15, R #6 stated it hurts referring to R #6's left knee. Interview with RCS C on 07-06-15 at 1:20 p.m. revealed RCS A asked RCS C to assist with changing R #6 on 04-30-15 after midnight, but when they pulled back the covers on R #6, they observed R #6's left knee was swollen and slightly red. RCS C said when she attempted to touch R #6, R #6 exclaimed loudly and expressed pain, so RCS A summoned a nurse to assess R #6. RCS C stated R #6 used to be able to stand and transfer with the use of a gait belt, but at the time of the incident on 04-30-15 R #6 required the assistance of two staff for transfers and changing because R #6 could be unpredictable and combative. RCS C stated this was why she was assisting RCS A. Interview with the ADON on 07-06-15 at 2:49 p.m. revealed the facility informed direct care staff (RCS) of residents' care plan information via Cardex (direct care reference sheet ). Each resident's Cardex sheet was kept in a binder at the nurses' station of each hallway for staff to use as a reference, and staff reviewed the Cardex of their assigned residents at the beginning of each shift. Review of R #6's Resident Care Cardex Worksheet (admitted [DATE]) located in the D-Hall Cardex binder revealed two hand-written entries under the section of Mobility, which also had checkmarks by the words transfer, assist, bed, chair, 1 person and 2 person. First, there was an entry in pen that read bed mobility and transfers with gait belt, which had a line drawn through it in pencil. In front of that entry was the date 04-30-15, written in pencil. A second entry, written entirely in pencil and dated 04-30-15 read, Hoyer (mechanical device to assist with transfers) 2 person + and was located below the first entry. Interview with the ADON on 07-06-15 at 3:57 p.m. revealed the first entry, which was written in pen and marked through with a pencil line, should have had D/C by it to indicate it was discontinued as of 04-30-15. The ADON said usually entries on the Cardex were written in pencil and erased when discontinued. The ADON said since the first entry was written with a pen, a line was drawn through and D/C should have been written by it to clarify the entry was no longer current. The ADON stated that as of 04-30-15, the Cardex directed staff to provide R #6 with the assistance of two persons and a Hoyer, based on the second entry dated 04-30-15. Review of Cardex with the ADON on 07-06-15 at 5:05 p.m. revealed D/C written next to the 04-30-15 pen entry bed mobility and transfers with gait belt. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6's ability to transfer (how resident moves between surfaces, including to/from bed or wheelchair did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion on unit (movement between locations in room and adjacent corridor) did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) did not occur or family and/or non-facility staff provided care 100% of the time Review of R #6's Resident Transfer Evaluation dated 05-11-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, and was no longer able to sit on bedside without full back and head support. Caregivers had to perform 100% of the task of transferring. Review of Form 672 Resident Census and Conditions of Residents dated 07-01-15 revealed 69 residents who required the assistance of one or more staff for transfers.

Based on interview, and record review, the facility failed to implement policies and procedures prohibiting neglect for one of seven sampled residents (R #6) who required the assistance of staff for positioning and transfers and failed to thoroughly investigate one of one injury of unknown origin which occurred in the last three months. Facility staff transferred R #6 using one person, but R #6 was assessed as requiring 2 persons for transfers. R #6 later complained of pain and was diagnosed with [REDACTED].#6's care plan and direct care staff reference sheet regarding the number of people needed to transfer R #6. The investigation did not review R #6's assessed needs compared to services provided regarding activities of daily living (transfers, dressing) at the time of R #6's diagnosed femure fracture. The failure to implement policies and procedures prohibiting neglect could have affected the 69 residents of the facility who required staff assistance for transfers. The findings included: Review of facility's Abuse and Neglect Prohibition Policy (no date) revealed each resident had the right to be free from neglect. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Abuse and Neglect Prohibition Policy Teaching Tool indicates on page 4 of 11, .even unintended lack of service that causes harm will be deemed neglect. The Policy further indicates the facility will, conduct an investigation of an alleged abuse/neglect .in accordance with state law. The policy also contained investigation tools for conducting investigations, specifically related to interviewing witnesses. The Guidelines for Interviewing indicated, The information should focus on the issues identified in the medical record review, the occurrences, and the interviewee's role and responsibilities in the patient care. The guidelines further indicate the investigator should Focus on possible deviations in the standard of care. Review of R #6's face sheet dated 07-03-15 revealed R #6 was a [AGE] year old female. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6 could sometimes make herself understood by others (ability limited to making concrete requests) --R #6 could sometimes understand others (responds adequately to simple, direct communication only) --R #6 had impairment in range of motion in both lower extremities --R #6 required extensive assistance (resident involved, but staff provide weight-bearing support) from two or more persons for transfers, including to/from bed and wheelchair --R #6's locomotion on unit (movement between locations in room and adjacent corridor) resident involved in activity, staff provide weight-bearing support --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) resident involved in activity, staff provide weight-bearing support Review of R #6's Nursing Weekly/Monthly Summary dated February 2015 and April 2015 revealed: --R #6's mental status described as confused with short-term memory loss --R #6 was incontinent of bowel and bladder --R #6 required the assistance of two staff for transfers Review of R #6's Fall Risk Evaluations dated 12-05-14, 02-14-15, and 05-11-15 revealed R #6 was at high risk for falls. Review of R #6's Resident Transfer Evaluations dated 12-05-14 and 02-14-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, but could sit on her bedside with partial support from a rail or person. Review of R #6's Comprehensive Plan of Care for activities of daily living dated 12-23-14 and reviewed 02-24-15 and 05-18-15 revealed R #6 required extensive assistance of two plus staff for bed mobility, transfers, toileting, and dressing. Review of R #6's Comprehensive Plan of Care for [MEDICAL CONDITION] dated 02-24-15 and reviewed 05-18-15 revealed R #6 is at risk for Spontaneous Fractures. The goal of the care plan was to keep R #6 safe, comfortable and functional, without fractures over the next 92 days. Approaches included assisting R #6 carefully when providing care. Review of R #6's care plan for falls dated 02-23-15 and reviewed 02-24-15 and 05-27-15 revealed R #6 was at risk for falls due to falls on 02-01-15 and 05-25-15, a history of fractures and use of [MEDICAL CONDITION] medication. Review of facility's Incident/Accident Report Log for the period of 04-01-15 to 07-02-15 revealed one injury of unknown origin, which involved R #6 having experienced a fracture identified on 04-30-15. Review of facility's Provider Investigation Report (PIR) # 5 dated 05-01-15 revealed R #6's [DIAGNOSES REDACTED]. The PIR indicated R #6 required extensive assistance with functional ability, she was not independently ambulatory, nor did she have the capacity to make informed decisions. The PIR further indicated R #6 had a history of [REDACTED]. According to the PIR, R #6 expressed pain to Resident Care Specialist (RCS) A on 04-29-15 at 11:00 p.m. and was assessed to have a swollen left knee on 04-30-15 at 4:30 a.m. On 04-30-15 at approximately 6:00 p.m. according to the PIR, R #6 was diagnosed with [REDACTED]. The PIR stated R #6 did not suffer any fall and staff had no incidents with R #6. The PIR added that the only unusual event staff noticed was that family members visited R #6 on 04-29-15 and took R #6 around the facility via wheelchair, after which R #6 was put on bed. Attached to the PIR was documentation of the Assistant Director of Nurses' (ADON's) interview with RCS B dated 04-30-15 at 5:00 p.m., in which RCS B indicated she had transferred R #6 from wheelchair to bed using a gait belt, with no issues reported upon transfer. The PIR contained no review of R #6's care plans, assessments or other records. On 07-03-15 at 2:40 p.m., interview with Family Member (FM) Z and FM Y revealed they visited R #6 on the afternoon of 04-29-15, during which R #6 was seated in her wheelchair while the family wheeled her around the facility and front porch area. FM Z stated when the family left between 5:00 p.m. and 6:00 p.m. on 04-29-15, R #6 was in good spirits and had not complained of pain or discomfort. FM Z stated R #6 did not fall or bump her leg during their visit. FM Z stated when the family left the facility, a staff member (could not recall name) told them that someone would place R #6 back in bed after the family left. FM Z said the facility called on 04-30-15 and informed FM Z that R #6 had a fractured femur, and the facility did not know how the fracture occurred. FM Z and Y stated they were concerned there was no explanation for how R #6 acquired the fracture. During interview on 07-06-15 at 1:11 p.m. with the ADON, ADON said she believed pages were missing from the copy of the PIR provided to surveyor. At 1:19 p.m., the ADON provided additional pages missing from surveyor's copy of PIR (consisted of three pages of documented interviews). The ADON stated surveyor now had complete copy of facility's PIR # 5 related to R #6's fractured femur. Review of R #6's x-ray report dated 04-30-15 revealed she was diagnosed with [REDACTED]. Interview with RCS B on 07-06-15 at 1:34 p.m. revealed she worked from 2:00 p.m. to 10:00 p.m. on 04-29-15 and was assigned to care for R #6. RCS B stated she recalled R #6's family visited R #6 that afternoon, and R #6 was tired after the visit. RCS B said she transferred R #6 to bed the evening of 04-29-15, changed R #6's clothing, and R #6 was tranquil afterward. RCS B said no one assisted assisted her with R #6. RCS B said R #6 did not complain or cry when being transferred or changed. RCS B said she checked on R #6 before leaving that night, and R #6 was asleep. Interview with RCS A on 07-06-15 at 1:40 p.m. revealed she worked from 10:00 p.m. on 04-29-15 to 6:00 a.m. on 04-30-15. RCS A stated she checked on R #6 at approximately 11:00 p.m. on 04-29-15, and R #6 complained of pain to her left leg. RCS A said she reported this to nursing staff and asked if any incidents had occurred. RCS A said she was told nothing had occurred. RCS A said she and RCS C approached R #6 on 04-30-15 at 12:30 a.m. to change her. R #6 refused to allow staff to change her, and RCS A observed R #6's left knee to be swollen. RCS A said nursing staff assessed R #6, gave R #6 medication, and R #6 fell asleep. RCS A said at 4:30 a.m. on 04-30-15, R #6 stated it hurts referring to R #6's left knee. Interview with RCS C on 07-06-15 at 1:20 p.m. revealed RCS A asked RCS C to assist with changing R #6 on 04-30-15 after midnight, but when they pulled back the covers on R #6, they observed R #6's left knee was swollen and slightly red. RCS C said when she attempted to touch R #6, R #6 exclaimed loudly and expressed pain, so RCS A summoned a nurse to assess R #6. RCS C stated R #6 used to be able to stand and transfer with the use of a gait belt, but at the time of the incident on 04-30-15 R #6 required the assistance of two staff for transfers and changing because R #6 could be unpredictable and combative. RCS C stated this was why she was assisting RCS A. Interview with the ADON on 07-06-15 at 2:49 p.m. revealed the facility informed direct care staff (RCS) of residents' care plan information via Cardex (direct care reference sheet ). Each resident's Cardex sheet was kept in a binder at the nurses' station of each hallway for staff to use as a reference, and staff reviewed the Cardex of their assigned residents at the beginning of each shift. Review of R #6's Resident Care Cardex Worksheet (admitted [DATE]) located in the D-Hall Cardex binder revealed two hand-written entries under the section of Mobility, which also had checkmarks by the words transfer, assist, bed, chair, 1 person and 2 person. First, there was an entry in pen that read bed mobility and transfers with gait belt, which had a line drawn through it in pencil. In front of that entry was the date 04-30-15, written in pencil. A second entry, written entirely in pencil and dated 04-30-15 read, Hoyer (mechanical device to assist with transfers) 2 person + and was located below the first entry. Interview with the ADON on 07-06-15 at 3:57 p.m. revealed the first entry, which was written in pen and marked through with a pencil line, should have had D/C by it to indicate it was discontinued as of 04-30-15. The ADON said usually entries on the Cardex were written in pencil and erased when discontinued. The ADON said since the first entry was written with a pen, a line was drawn through and D/C should have been written by it to clarify the entry was no longer current. The ADON stated that as of 04-30-15, the Cardex directed staff to provide R #6 with the assistance of two persons and a Hoyer, based on the second entry dated 04-30-15. Review of Cardex with ADON on 07-06-15 at 5:05 p.m. revealed D/C written next to the 04-30-15 pen entry bed mobility and transfers with gait belt. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6's ability to transfer (how resident moves between surfaces, including to/from bed or wheelchair did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion on unit (movement between locations in room and adjacent corridor) did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) did not occur or family and/or non-facility staff provided care 100% of the time Review of R #6's Resident Transfer Evaluation dated 05-11-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, and was no longer able to sit on bedside without full back and head support. Caregivers had to perform 100% of the task of transferring. Review of Form 672 Resident Census and Conditions of Residents dated 07-01-15 revealed a census of 124 residents, 69 of whom required the assistance of one or more staff for transfers.

Based on observation, interview, and record review, the facility failed to implement policies and procedures prohibiting neglect for one of seven residents reviewed (R #6) who required the assistance of staff for positioning and transfers. Although R #6's care plans and assessments indicated the facility was to provide R #6 with the assistance of two persons for transfers, dressing, and toileting as of December 2014, R #6's direct care reference sheet instructed staff to use a gait belt to transfer R #6, with no mention of two persons. Staff performed a one person transfer and provided incontinent care with one person assistance. Shortly after this was provided, R #6 complained of pain, exhibited a swollen left knee, and was diagnosed with [REDACTED]. This failure to implement policies and procedures prohibiting neglect could affect the 69 residents of the facility who required staff assistance for transfers. The findings included: Review of R #6's face sheet dated 07-03-15 revealed R #6 was a [AGE] year old female. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6 could sometimes make herself understood by others (ability limited to making concrete requests) --R #6 could sometimes understand others (responds adequately to simple, direct communication only) --R #6 had impairment in range of motion in both lower extremities --R #6 required extensive assistance (resident involved, but staff provide weight-bearing support) from two or more persons for transfers, including to/from bed and wheelchair --R #6's locomotion on unit (movement between locations in room and adjacent corridor) resident involved in activity, staff provide weight-bearing support --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) resident involved in activity, staff provide weight-bearing support Review of R #6's Nursing Weekly/Monthly Summary dated February 2015 and April 2015 revealed: --R #6's mental status described as confused with short-term memory loss --R #6 was incontinent of bowel and bladder --R #6 required the assistance of two staff for transfers Review of R #6's Fall Risk Evaluations dated 12-05-14, 02-14-15, and 05-11-15 revealed R #6 was at high risk for falls. Review of R #6's Resident Transfer Evaluations dated 12-05-14 and 02-14-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, but could sit on her bedside with partial support from a rail or person. Review of R #6's Comprehensive Plan of Care for activities of daily living dated 12-23-14 and reviewed 02-24-15 and 05-18-15 revealed R #6 required extensive assistance of two plus staff for bed mobility, transfers, toileting, and dressing. Review of R #6's Comprehensive Plan of Care for [MEDICAL CONDITION] dated 02-24-15 and reviewed 05-18-15 revealed R #6 is at risk for Spontaneous Fractures. The goal of the care plan was to keep R #6 safe, comfortable and functional, without fractures over the next 92 days. Approaches included assisting R #6 carefully when providing care. Review of R #6's care plan for falls dated 02-23-15 and reviewed 02-24-15 and 05-27-15 revealed R #6 was at risk for falls due to falls on 02-01-15 and 05-25-15, a history of fractures and use of [MEDICAL CONDITION] medication. Review of facility's Incident/Accident Report Log for the period of 04-01-15 to 07-02-15 revealed one injury of unknown origin, which involved R #6 having experienced a fracture identified on 04-30-15. Review of facility's Provider Investigation Report (PIR) # 5 dated 05-01-15 revealed R #6's [DIAGNOSES REDACTED]. The PIR indicated R #6 required extensive assistance with functional ability, she was not independently ambulatory, nor did she have the capacity to make informed decisions. The PIR further indicated R #6 had a history of [REDACTED]. According to the PIR, R #6 expressed pain to Resident Care Specialist (RCS) A on 04-29-15 at 11:00 p.m. and was assessed to have a swollen left knee on 04-30-15 at 4:30 a.m. On 04-30-15 at approximately 6:00 p.m. according to the PIR, R #6 was diagnosed with [REDACTED]. The PIR stated R #6 did not suffer any fall and staff had no incidents with R #6. The PIR added that the only unusual event staff noticed was that family members visited R #6 on 04-29-15 and took R #6 around the facility via wheelchair, after which R #6 was put on bed. Attached to the PIR was documentation of the Assistant Director of Nurses' (ADON's) interview with RCS B dated 04-30-15 at 5:00 p.m., in which RCS B indicated she had transferred R #6 from wheelchair to bed using a gait belt, with no issues reported upon transfer. The PIR contained no review of R #6's care plans, assessments or other records. During interview on 07-06-15 at 1:11 p.m. with the ADON, ADON said she believed pages were missing from the copy of the PIR provided to surveyor. At 1:19 p.m., the ADON provided additional pages missing from surveyor's copy of PIR (consisted of three pages of documented interviews). The ADON stated surveyor now had complete copy of facility's PIR # 5 related to R #6's fractured femur. Review of R #6's x-ray report dated 04-30-15 revealed she was diagnosed with [REDACTED]. On 07-03-15 at 2:40 p.m., interview with Family Member (FM) Z and FM Y revealed they visited R #6 on the afternoon of 04-29-15, during which R #6 was seated in her wheelchair while the family wheeled her around the facility and front porch area. FM Z stated when the family left between 5:00 p.m. and 6:00 p.m. on 04-29-15, R #6 was in good spirits and had not complained of pain or discomfort. FM Z stated R #6 did not fall or bump her leg during their visit. FM Z stated when the family left the facility, a staff member (could not recall name) told them that someone would place R #6 back in bed after the family left. FM Z said the facility called on 04-30-15 and informed FM Z that R #6 had a fractured femur, and the facility did not know how the fracture occurred. FM Z and Y stated they were concerned there was no explanation for how R #6 acquired the fracture. Interview with RCS B on 07-06-15 at 1:34 p.m. revealed she worked from 2:00 p.m. to 10:00 p.m. on 04-29-15 and was assigned to care for R #6. RCS B stated she recalled R #6's family visited R #6 that afternoon, and R #6 was tired after the visit. RCS B said she transferred R #6 to bed the evening of 04-29-15, changed R #6's clothing, and R #6 was tranquil afterward. RCS B said no one assisted assisted her with R #6. RCS B said R #6 did not complain or cry when being transferred or changed. RCS B said she checked on R #6 before leaving that night, and R #6 was asleep. Interview with RCS A on 07-06-15 at 1:40 p.m. revealed she worked from 10:00 p.m. on 04-29-15 to 6:00 a.m. on 04-30-15. RCS A stated she checked on R #6 at approximately 11:00 p.m. on 04-29-15, and R #6 complained of pain to her left leg. RCS A said she reported this to nursing staff and asked if any incidents had occurred. RCS A said she was told nothing had occurred. RCS A said she and RCS C approached R #6 on 04-30-15 at 12:30 a.m. to change her. R #6 refused to allow staff to change her, and RCS A observed R #6's left knee to be swollen. RCS A said nursing staff assessed R #6, gave R #6 medication, and R #6 fell asleep. RCS A said at 4:30 a.m. on 04-30-15, R #6 stated it hurts referring to R #6's left knee. Interview with RCS C on 07-06-15 at 1:20 p.m. revealed RCS A asked RCS C to assist with changing R #6 on 04-30-15 after midnight, but when they pulled back the covers on R #6, they observed R #6's left knee was swollen and slightly red. RCS C said when she attempted to touch R #6, R #6 exclaimed loudly and expressed pain, so RCS A summoned a nurse to assess R #6. RCS C stated R #6 used to be able to stand and transfer with the use of a gait belt, but at the time of the incident on 04-30-15 R #6 required the assistance of two staff for transfers and changing because R #6 could be unpredictable and combative. RCS C stated this was why she was assisting RCS A. Interview with the ADON on 07-06-15 at 2:49 p.m. revealed the facility informed direct care staff (RCS) of residents' care plan information via Cardex (direct care reference sheet ). Each resident's Cardex sheet was kept in a binder at the nurses' station of each hallway for staff to use as a reference, and staff reviewed the Cardex of their assigned residents at the beginning of each shift. Review of R #6's Resident Care Cardex Worksheet (admitted [DATE]) located in the D-Hall Cardex binder revealed two hand-written entries under the section of Mobility, which also had checkmarks by the words transfer, assist, bed, chair, 1 person and 2 person. First, there was an entry in pen that read bed mobility and transfers with gait belt, which had a line drawn through it in pencil. In front of that entry was the date 04-30-15, written in pencil. A second entry, written entirely in pencil and dated 04-30-15 read, Hoyer (mechanical device to assist with transfers) 2 person + and was located below the first entry. Interview with the ADON on 07-06-15 at 3:57 p.m. revealed the first entry, which was written in pen and marked through with a pencil line, should have had D/C by it to indicate it was discontinued as of 04-30-15. The ADON said usually entries on the Cardex were written in pencil and erased when discontinued. The ADON said since the first entry was written with a pen, a line was drawn through and D/C should have been written by it to clarify the entry was no longer current. The ADON stated that as of 04-30-15, the Cardex directed staff to provide R #6 with the assistance of two persons and a Hoyer, based on the second entry dated 04-30-15. Review of Cardex with ADON on 07-06-15 at 5:05 p.m. revealed D/C written next to the 04-30-15 pen entry bed mobility and transfers with gait belt. Review of R #6's Minimum Data Set (MDS) Significant Change assessment dated [DATE] revealed the following: --R #6's ability to transfer (how resident moves between surfaces, including to/from bed or wheelchair did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion on unit (movement between locations in room and adjacent corridor) did not occur or family and/or non-facility staff provided care 100% of the time --R #6's locomotion off unit (how resident moves to and returns from off-unit locations) did not occur or family and/or non-facility staff provided care 100% of the time Review of R #6's Resident Transfer Evaluation dated 05-11-15 revealed R #6 was non-ambulatory, could not bear weight for ambulation, and was no longer able to sit on bedside without full back and head support. Caregivers had to perform 100% of the task of transferring. Review of facility's Abuse and Neglect Prohibition Policy (no date) revealed each resident had the right to be free from neglect. Neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The Abuse and Neglect Prohibition Policy Teaching Tool indicates on page 4 of 11, .even unintended lack of service that causes harm will be deemed neglect. Review of Form 672 Resident Census and Conditions of Residents dated 07-01-15 revealed a census of 124 residents, 69 of whom required the assistance of one or more staff for transfers.

Based on interview and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents and ensure safety for one Resident (R#1) of six residents reviewed for injuries, in that: R#1 required a mechanical lift for transfers according to her care plan. The facility did not ensure RCS/CNAs "A" and "B" used a mechanical lift when transferring R#1. RCS/CNAs "A" and "B" transferred R#1 without using a mechanical lift. R#1 was hospitalized with a proximal femur fracture after the transfer. R#1 remained in the hospital during this visit. This failure could affect 47 residents who are totally dependent of staff for transfers and place them at risk for injury/fracture that could cause injury. Findings were: R#1's Face Sheet dated 11/13/14 revealed a [AGE] year old female admitted on [DATE]. November 2014 physician's orders [REDACTED].), Senile Dementia Uncomplicated (occurring in older persons, usually over the age of 65), Anemia NOS, and Gastrointest Hemorr NOS (hemorrhage of gastrointestinal tract, unspecified). Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R#1: -had moderate difficulty in hearing, -had unclear speech, -sometimes understood (ability is limited to making concrete requests), -usually understands (misses some part/intent of message but comprehends most conversation), -had impaired vision, -required total dependence of two "plus" staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, -had no steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair), and, -had no Range of Motion (ROM) impairment of the lower extremity Care Plan-Transfers dated 11/06/14 revealed R#1: -had potential for injury. Impaired ability to self-transfer related to mental status, weakness, predisposing disease of Anemia and PVD (Peripheral Vascular Disease) -required use of mechanical lift (2 person assist required at all times) to/from toilet, chair, bed -approaches included to place call light within reach, encourage resident to obtain assistance for transfers, provide mechanical lift for transfers of full body lift to/from toilet, chair, bed, provide appropriate sling, educate resident/family to mechanical lift, and use calm, patient approach when using mechanical lift. Change of Condition form dated 11/12/14 revealed R#1 had change in skin; elevation (bump) and minor swelling to right thigh. Change of Condition form dated 11/12/14; under "Progress Note" revealed Resident Care Specialist-Certified Nurse Aide (RCS/CNA) reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Vital signs within limits. Unable to verbalize level of pain. Incident/Accident Report dated 11/12/14 revealed R#1 had a transfer injury. RCS/CNA reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Incident/Accident Report dated 11/12/14, under "Resident Outcome" revealed R#1 had a possible fracture to femur. Physician Telephone Order dated 11/12/14 revealed for R#1 to be transferred to emergency room (ER) for evaluation/treatment. Hospital's emergency documentation dated 11/13/14, under "History of Present Illness" revealed (R#1) "presents with hip injury. The onset was just prior to arrival. The course/duration of symptoms is constant. (R#1) was sent from nursing home according to the story they were transporting (R#1) and moving them her from bed to chair when they heard a pop." Hospital's emergency documentation dated 11/13/14, under "Medical Decision Making" revealed "history is not compatible with a fracture seen on (R#1) since patient has proximal spiral femur fracture more compatible with a fall or with a forceful twisting of the extremity." On 11/13/14 at 9:29 a.m., surveyor attempted to interview R#2, roommate of R#1, regarding R#1's incident. R#2 said she did not remember what happened to her roommate, R#1. On 11/13/14 at 9:56 a.m., Resident Care Specialist/Certified Nurse Aide (RCS/CNA) "A" said R#1 was a two person transfer using a mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" when transferring R#1 without the mechanical lift. RCS/CNA "A" said she did not use the mechanical lift because R#1 cried and moved slightly. RCS/CNA "A" said it was the first time she did not use the mechanical lift for R#1 and informed the charge nurse of her not using the mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" in getting R#1 up from the bed. RCS/CNA "A" said they sat R#1 up on the edge of bed, and held R#1 by her armpit while RCS/CNA "B" held other side of R#1. RCS/CNA "A" said R#1 was lifted up slowly and as they were turning R#1 to sit R#1 down the on Geri-chair she heard a pop sound. RCS/CNA "A" said R#1 did not fall on the floor. RCS/CNA "A" said she did not remember if R#1 hit herself with something when transferring R#1. RCS/CNA "A" said did not know how R#1 could have gotten the fracture. On 11/13/14 at 10:12 a.m., RCS/CNA "B" said she was assisting RCS/CNA "A" in dressing and changing R#1 and then sat R#1 up on the bed. RCS/CNA "B" said she and RCS/CNA "A" transferred R#1 by holding R#1 from each side when they heard the pop sound; then they sat R#1 on the Geri-chair and immediately notified the charge nurse. RCS/CNA "B" said R#1 required the use of mechanical lift for transfers. RCS/CNA "B" said she and RCS/CNA "A" "used bad judgment by doing a two person assist transfer, instead of using the mechanical lift." RCS/CNA "B" said R#1 made faces of pain when the mechanical lift was used. On 11/13/14 at 10:35 a.m., Licensed Vocational Nurse (LVN) "C" said he was notified by RCS/CNA "A" about the incident with R#1. LVN "C" said he was not present during the incident, however he was informed by RCS/CNA "A" and RCS/CNA "B" that when they were transferring R#1 from bed to Geri-chair RCS/CNA "A" and RCS/CNA "B" heard a snap sound. LVN "C" said R#1 required the use of a mechanical lift transfer and RCS/CNA "A" and RCS/CNA "B" were aware of R#1 needed to use of mechanical lift. LVN "C" said RCS/CNA "A" and RCS/CNA "B" were quiet when he questioned them regarding not using the mechanical lift for the transfer. On 11/13/14 at 11:56 a.m., LVN "D", of the hospital, said an orthopedic surgeon evaluated R#1 on 11/13/14 and R#1's Family Member/Responsible Party (FM/RP) "E" consented for surgery. LVN "D" said documentation from the surgeon was not available yet. On 11/13/14 at 12:02 p.m., FM/RP "E" said a facility nurse told him CNAs were transferring R#1 and did not use a mechanical lift when resident fell on the floor. FM/RP "E" said he did not know the name of the facility's nurse who informed him. FM/RP "E" said he thought that R#1 might have slipped and fell . FM/RP "E" said the doctor told him the fracture was related to a fall. On 11/13/14 at 12:07 p.m., surveyor attempted to interview R#1 at the hospital; however R#1 was not responding to surveyor when questions were asked. FM/RP "E" said R#1 did not talk. On 11/13/14 at 1:30 p.m., LVN "F" said she assessed R#1 and R#1 had elevation (bump) to the femur with mild swelling. LVN "F" said RCS/CNA "A" and RCS/CNA "B" informed her that they heard a pop sound when transferring R#1. LVN "F" said RCS/CNA "A" and RCS/CNA "B" did not mention if the resident had fallen. LVN "F" said R#1 required the use of a mechanical lift for transfers. LVN "F" said she asked RCS/CNA "A" and RCS/CNA "B" why the mechanical lift was not used for R#1, RCS/CNA "A" and RCS/CNA "B" did not respond. LVN "F" said CNAs were aware of resident's activities of daily living as a binder was located at nurse's station. On 11/13/14 at 2:37 p.m., the Director of Nurses (DON) said RCS/CNA "A" and RCS/CNA "B" were transferring R#1 from the bed to Geri-chair by a two man lift (two person assistance); instead of using a mechanical lift. The DON said R#1's fracture could be related to R#1's medical diagnoses. The DON said she believes if RCS/CNA "A" and RCS/CNA "B" would have used the mechanical lift, R#1 would not have the incident of the fracture. The DON said care plans needed to be followed by staff for the safety of the residents. The facility's Abuse & Neglect Prohibition dated June 2013, under "Definitions" revealed the following: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." The facility's Lift, Transfer, and Repositioning Policy dated 2010 revealed the following: "Direct care staff will be responsible for the following- a. Complying with this policy and the Lift and Transfer Guide b. Lifting and transferring residents in accordance with the residents' plans of care c. Using proper techniques when lifting and transferring residents d. Lifting and transferring residents with assistance of 2 staff members e. Using mechanical lifting device in accordance with manufacturer recommendations and instructions .... " During the exit conference, conducted on 11/13/14 at 2:50 p.m., the facility was given an opportunity to provide additional information. No additional information was provided. The facility's Resident and Census and Conditions of Residents form indicated a census of 47 residents.

Based on record review and interview, the facility failed to ensure services were provided according to the written care plan for one Resident (R#1) of six residents reviewed for plans of care, in that: R#1 required a mechanical lift for transfers according to her care plan. The facility did not ensure RCS/CNAs "A" and "B" used a mechanical lift when transferring R#1. RCS/CNAs "A" and "B" transferred R#1 without using a mechanical lift. R#1 was hospitalized with a proximal femur fracture after the transfer. R#1 remained in the hospital during this visit. This failure could affect 47 residents who are totally dependent of staff for transfers and place them at risk for injury/fracture that could cause injury. Findings were: R#1's Face Sheet dated 11/13/14 revealed a [AGE] year old female admitted on [DATE]. November 2014 physician's orders [REDACTED].), Senile Dementia Uncomplicated (occurring in older persons, usually over the age of 65), [MEDICAL CONDITION] NOS, and Gastrointest Hemorr NOS (hemorrhage of gastrointestinal tract, unspecified). Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R#1: -had moderate difficulty in hearing, -had unclear speech, -sometimes understood (ability is limited to making concrete requests), -usually understands (misses some part/intent of message but comprehends most conversation), -had impaired vision, -required total dependence of two "plus" staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, -had no steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair), and, -had no Range of Motion (ROM) impairment of the lower extremity Care Plan-Transfers dated 11/06/14 revealed R#1: -had potential for injury. Impaired ability to self-transfer related to mental status, weakness, predisposing disease of [MEDICAL CONDITION] and [MEDICAL CONDITIONS] -required use of mechanical lift (2 person assist required at all times) to/from toilet, chair, bed -approaches included to place call light within reach, encourage resident to obtain assistance for transfers, provide mechanical lift for transfers of full body lift to/from toilet, chair, bed, provide appropriate sling, educate resident/family to mechanical lift, and use calm, patient approach when using mechanical lift. Change of Condition form dated 11/12/14 revealed R#1 had change in skin; elevation (bump) and minor swelling to right thigh. Change of Condition form dated 11/12/14; under "Progress Note" revealed Resident Care Specialist-Certified Nurse Aide (RCS/CNA) reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Vital signs within limits. Unable to verbalize level of pain. Incident/Accident Report dated 11/12/14 revealed R#1 had a transfer injury. RCS/CNA reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Incident/Accident Report dated 11/12/14, under "Resident Outcome" revealed R#1 had a possible fracture to femur. Physician Telephone Order dated 11/12/14 revealed for R#1 to be transferred to emergency room (ER) for evaluation/treatment. Hospital's emergency documentation dated 11/13/14, under "History of Present Illness" revealed (R#1) "presents with hip injury. The onset was just prior to arrival. The course/duration of symptoms is constant. (R#1) was sent from nursing home according to the story they were transporting (R#1) and moving them her from bed to chair when they heard a pop." Hospital's emergency documentation dated 11/13/14, under "Medical Decision Making" revealed "history is not compatible with a fracture seen on (R#1) since patient has proximal spiral femur fracture more compatible with a fall or with a forceful twisting of the extremity." On 11/13/14 at 9:29 a.m., surveyor attempted to interview R#2, roommate of R#1, regarding R#1's incident. R#2 said she did not remember what happened to her roommate, R#1. On 11/13/14 at 9:56 a.m., Resident Care Specialist/Certified Nurse Aide (RCS/CNA) "A" said R#1 was a two person transfer using a mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" when transferring R#1 without the mechanical lift. RCS/CNA "A" said she did not use the mechanical lift because R#1 cried and moved slightly. RCS/CNA "A" said it was the first time she did not use the mechanical lift for R#1 and informed the charge nurse of her not using the mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" in getting R#1 up from the bed. RCS/CNA "A" said they sat R#1 up on the edge of bed, and held R#1 by her armpit while RCS/CNA "B" held other side of R#1. RCS/CNA "A" said R#1 was lifted up slowly and as they were turning R#1 to sit R#1 down the on Geri-chair she heard a pop sound. RCS/CNA "A" said R#1 did not fall on the floor. RCS/CNA "A" said she did not remember if R#1 hit herself with something when transferring R#1. RCS/CNA "A" said did not know how R#1 could have gotten the fracture. On 11/13/14 at 10:12 a.m., RCS/CNA "B" said she was assisting RCS/CNA "A" in dressing and changing R#1 and then sat R#1 up on the bed. RCS/CNA "B" said she and RCS/CNA "A" transferred R#1 by holding R#1 from each side when they heard the pop sound; then they sat R#1 on the Geri-chair and immediately notified the charge nurse. RCS/CNA "B" said R#1 required the use of mechanical lift for transfers. RCS/CNA "B" said she and RCS/CNA "A" "used bad judgment by doing a two person assist transfer, instead of using the mechanical lift." RCS/CNA "B" said R#1 made faces of pain when the mechanical lift was used. On 11/13/14 at 10:35 a.m., Licensed Vocational Nurse (LVN) "C" said he was notified by RCS/CNA "A" about the incident with R#1. LVN "C" said he was not present during the incident, however he was informed by RCS/CNA "A" and RCS/CNA "B" that when they were transferring R#1 from bed to Geri-chair RCS/CNA "A" and RCS/CNA "B" heard a snap sound. LVN "C" said R#1 required the use of a mechanical lift transfer and RCS/CNA "A" and RCS/CNA "B" were aware of R#1 needed to use of mechanical lift. LVN "C" said RCS/CNA "A" and RCS/CNA "B" were quiet when he questioned them regarding not using the mechanical lift for the transfer. On 11/13/14 at 11:56 a.m., LVN "D", of the hospital, said an orthopedic surgeon evaluated R#1 on 11/13/14 and R#1's Family Member/Responsible Party (FM/RP) "E" consented for surgery. LVN "D" said documentation from the surgeon was not available yet. On 11/13/14 at 12:02 p.m., FM/RP "E" said a facility nurse told him CNAs were transferring R#1 and did not use a mechanical lift when resident fell on the floor. FM/RP "E" said he did not know the name of the facility's nurse who informed him. FM/RP "E" said he thought that R#1 might have slipped and fell . FM/RP "E" said the doctor told him the fracture was related to a fall. On 11/13/14 at 12:07 p.m., surveyor attempted to interview R#1 at the hospital; however R#1 was not responding to surveyor when questions were asked. FM/RP "E" said R#1 did not talk. On 11/13/14 at 1:30 p.m., LVN "F" said she assessed R#1 and R#1 had elevation (bump) to the femur with mild swelling. LVN "F" said RCS/CNA "A" and RCS/CNA "B" informed her that they heard a pop sound when transferring R#1. LVN "F" said RCS/CNA "A" and RCS/CNA "B" did not mention if the resident had fallen. LVN "F" said R#1 required the use of a mechanical lift for transfers. LVN "F" said she asked RCS/CNA "A" and RCS/CNA "B" why the mechanical lift was not used for R#1, RCS/CNA "A" and RCS/CNA "B" did not respond. LVN "F" said CNAs were aware of resident's activities of daily living as a binder was located at nurse's station. On 11/13/14 at 2:37 p.m., the Director of Nurses (DON) said RCS/CNA "A" and RCS/CNA "B" were transferring R#1 from the bed to Geri-chair by a two man lift (two person assistance); instead of using a mechanical lift. The DON said R#1's fracture could be related to R#1's medical diagnoses. The DON said she believes if RCS/CNA "A" and RCS/CNA "B" would have used the mechanical lift, R#1 would not have the incident of the fracture. The DON said care plans needed to be followed by staff for the safety of the residents. The facility's Abuse & Neglect Prohibition dated June 2013, under "Definitions" revealed the following: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." The facility's Lift, Transfer, and Repositioning Policy dated 2010 revealed the following: "Direct care staff will be responsible for the following- a. Complying with this policy and the Lift and Transfer Guide b. Lifting and transferring residents in accordance with the residents' plans of care c. Using proper techniques when lifting and transferring residents d. Lifting and transferring residents with assistance of 2 staff members e. Using mechanical lifting device in accordance with manufacturer recommendations and instructions .... " During the exit conference, conducted on 11/13/14 at 2:50 p.m., the facility was given an opportunity to provide additional information. No additional information was provided. The facility's Resident and Census and Conditions of Residents form indicated a census of 47 residents.

Based on interview and record review, the facility failed to implement their written policies and procedures that prohibit abuse or neglect of residents, in that: R#1 required a mechanical lift for transfers according to her care plan. The facility did not ensure RCS/CNAs "A" and "B" used a mechanical lift when transferring R#1. RCS/CNAs "A" and "B" transferred R#1 without using a mechanical lift. R#1 was hospitalized with a proximal femur fracture after the transfer. R#1 remained in the hospital during this visit. This failure could affect 69 residents who required one or two person staff assistance and/or 47 residents who are totally dependent on staff for transfers at risk for abuse and neglect. Findings were: The facility's Abuse & Neglect Prohibition dated June 2013, under "Definitions" revealed the following: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." DADS Provider Letter #14-13 dated 08/19/14, Guidelines for Reporting Abuse, Neglect, Exploitation and other Incidents: -Neglect--- " The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. -The facility must determine if an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident. " R#1's Face Sheet dated 11/13/14 revealed a [AGE] year old female admitted on [DATE]. November 2014 physician's orders [REDACTED].), Senile Dementia Uncomplicated (occurring in older persons, usually over the age of 65), [MEDICAL CONDITION] NOS, and Gastrointest Hemorr NOS (hemorrhage of gastrointestinal tract, unspecified). Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R#1: -had moderate difficulty in hearing, -had unclear speech, -sometimes understood (ability is limited to making concrete requests), -usually understands (misses some part/intent of message but comprehends most conversation), -had impaired vision, -required total dependence of two "plus" staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, -had no steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair), and, -had no Range of Motion (ROM) impairment of the lower extremity Care Plan-Transfers dated 11/06/14 revealed R#1: -had potential for injury. Impaired ability to self-transfer related to mental status, weakness, predisposing disease of [MEDICAL CONDITION] and [MEDICAL CONDITIONS] -required use of mechanical lift (2 person assist required at all times) to/from toilet, chair, bed -approaches included to place call light within reach, encourage resident to obtain assistance for transfers, provide mechanical lift for transfers of full body lift to/from toilet, chair, bed, provide appropriate sling, educate resident/family to mechanical lift, and use calm, patient approach when using mechanical lift. Change of Condition form dated 11/12/14 revealed R#1 had change in skin; elevation (bump) and minor swelling to right thigh. Change of Condition form dated 11/12/14; under "Progress Note" revealed Resident Care Specialist-Certified Nurse Aide (RCS/CNA) reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Vital signs within limits. Unable to verbalize level of pain. Incident/Accident Report dated 11/12/14 revealed R#1 had a transfer injury. RCS/CNA reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Incident/Accident Report dated 11/12/14, under "Resident Outcome" revealed R#1 had a possible fracture to femur. Physician Telephone Order dated 11/12/14 revealed for R#1 to be transferred to emergency room (ER) for evaluation/treatment. Hospital's emergency documentation dated 11/13/14, under "History of Present Illness" revealed (R#1) "presents with hip injury. The onset was just prior to arrival. The course/duration of symptoms is constant. (R#1) was sent from nursing home according to the story they were transporting (R#1) and moving them her from bed to chair when they heard a pop." Hospital's emergency documentation dated 11/13/14, under "Medical Decision Making" revealed "history is not compatible with a fracture seen on (R#1) since patient has proximal spiral femur fracture more compatible with a fall or with a forceful twisting of the extremity." On 11/13/14 at 9:29 a.m., surveyor attempted to interview R#2, roommate of R#1, regarding R#1's incident. R#2 said she did not remember what happened to her roommate, R#1. On 11/13/14 at 9:56 a.m., Resident Care Specialist/Certified Nurse Aide (RCS/CNA) "A" said R#1 was a two person transfer using a mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" when transferring R#1 without the mechanical lift. RCS/CNA "A" said she did not use the mechanical lift because R#1 cried and moved slightly. RCS/CNA "A" said it was the first time she did not use the mechanical lift for R#1 and informed the charge nurse of her not using the mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" in getting R#1 up from the bed. RCS/CNA "A" said they sat R#1 up on the edge of bed, and held R#1 by her armpit while RCS/CNA "B" held other side of R#1. RCS/CNA "A" said R#1 was lifted up slowly and as they were turning R#1 to sit R#1 down the on Geri-chair she heard a pop sound. RCS/CNA "A" said R#1 did not fall on the floor. RCS/CNA "A" said she did not remember if R#1 hit herself with something when transferring R#1. RCS/CNA "A" said did not know how R#1 could have gotten the fracture. On 11/13/14 at 10:12 a.m., RCS/CNA "B" said she was assisting RCS/CNA "A" in dressing and changing R#1 and then sat R#1 up on the bed. RCS/CNA "B" said she and RCS/CNA "A" transferred R#1 by holding R#1 from each side when they heard the pop sound; then they sat R#1 on the Geri-chair and immediately notified the charge nurse. RCS/CNA "B" said R#1 required the use of mechanical lift for transfers. RCS/CNA "B" said she and RCS/CNA "A" "used bad judgment by doing a two person assist transfer, instead of using the mechanical lift." RCS/CNA "B" said R#1 made faces of pain when the mechanical lift was used. On 11/13/14 at 10:35 a.m., Licensed Vocational Nurse (LVN) "C" said he was notified by RCS/CNA "A" about the incident with R#1. LVN "C" said he was not present during the incident; however he was informed by RCS/CNA "A" and RCS/CNA "B" that when they were transferring R#1 from bed to Geri-chair RCS/CNA "A" and RCS/CNA "B" heard a snap sound. LVN "C" said R#1 required the use of a mechanical lift transfer and RCS/CNA "A" and RCS/CNA "B" were aware of R#1 needed to use of mechanical lift. LVN "C" said RCS/CNA "A" and RCS/CNA "B" were quiet when he questioned them regarding not using the mechanical lift for the transfer. On 11/13/14 at 11:56 a.m., LVN "D", of the hospital, said an orthopedic surgeon evaluated R#1 on 11/13/14 and R#1's Family Member/Responsible Party (FM/RP) "E" consented for surgery. LVN "D" said documentation from the surgeon was not available yet. On 11/13/14 at 12:02 p.m., Family Member/Responsible Party (FM/RP) "E" said a facility nurse told him CNAs were transferring R#1 and did not use a mechanical lift when resident fell on the floor. FM/RP "E" said he did not know the name of the facility's nurse who informed him. FM/RP "E" said he though that R#1 might have slipped and fell . FM/RP "E" said the doctor told him the fracture was related to a fall. On 11/13/14 at 12:07 p.m., surveyor attempted to interview R#1 at the hospital; however R#1 was not responding to surveyor when questions were asked. FM/RP "E" said R#1 did not talk. On 11/13/14 at 1:30 p.m., LVN "F" said she assessed R#1 and R#1 had elevation (bump) to the femur with mild swelling. LVN "F" said RCS/CNA "A" and RCS/CNA "B" informed her that they heard a pop sound when transferring R#1. LVN "F" said RCS/CNA "A" and RCS/CNA "B" did not mention if the resident had fallen. LVN "F" said R#1 required the use of a mechanical lift for transfers. LVN "F" said she asked RCS/CNA "A" and RCS/CNA "B" why the mechanical lift was not used for R#1, RCS/CNA "A" and RCS/CNA "B" did not respond. LVN "F" said CNAs were aware of resident's activities of daily living as a binder was located at nurse's station. On 11/13/14 at 2:37 p.m., the Director of Nurses (DON) said RCS/CNA "A" and RCS/CNA "B" were transferring R#1 from the bed to Geri-chair by a two man lift (two person assistance); instead of using a mechanical lift. The DON said R#1's fracture could be related to R#1's medical diagnoses. The DON said she believes if RCS/CNA "A" and RCS/CNA "B" would have used the mechanical lift, R#1 would not have the incident of the fracture. The DON said care plans needed to be followed by staff for the safety of the residents. The facility's Abuse & Neglect Prohibition dated June 2013, under "Definitions" revealed the following: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." The facility's Lift, Transfer, and Repositioning Policy dated 2010 revealed the following: "Direct care staff will be responsible for the following- a. Complying with this policy and the Lift and Transfer Guide b. Lifting and transferring residents in accordance with the residents' plans of care c. Using proper techniques when lifting and transferring residents d. Lifting and transferring residents with assistance of 2 staff members e. Using mechanical lifting device in accordance with manufacturer recommendations and instructions.... " During the exit conference, conducted on 11/13/14 at 2:50 p.m., the facility was given an opportunity to provide additional information. No additional information was provided. The facility's Resident and Census and Conditions of Residents form indicated a census of 130 residents.

Based on interview and record review, the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #1) of six Residents reviewed for injuries. R#1 required a mechanical lift for transfers according to her care plan. The facility did not ensure RCS/CNAs "A" and "B" used a mechanical lift when transferring R#1. RCS/CNAs "A" and "B" transferred R#1 without using a mechanical lift. R#1 was hospitalized with a proximal femur fracture after the transfer. R#1 remained in the hospital during this visit. This failure could affect 47 residents who are totally dependent of staff for transfers and place them at risk for injury/fracture that could cause injury. Findings were: R#1's Face Sheet dated 11/13/14 revealed a [AGE] year old female admitted on [DATE]. November 2014 physician's orders [REDACTED].), Senile Dementia Uncomplicated (occurring in older persons, usually over the age of 65), [MEDICAL CONDITION] NOS, and Gastrointest Hemorr NOS (hemorrhage of gastrointestinal tract, unspecified). Significant Change Minimum Data Set ((MDS) dated [DATE] revealed R#1: -had moderate difficulty in hearing, -had unclear speech, -sometimes understood (ability is limited to making concrete requests), -usually understands (misses some part/intent of message but comprehends most conversation), -had impaired vision, -required total dependence of two "plus" staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene, -had no steady, only able to stabilize with staff assistance for surface-to-surface transfer (transfer between bed and chair or wheelchair), and, -had no Range of Motion (ROM) impairment of the lower extremity Care Plan-Transfers dated 11/06/14 revealed R#1: -had potential for injury. Impaired ability to self-transfer related to mental status, weakness, predisposing disease of [MEDICAL CONDITION] and [MEDICAL CONDITIONS] -required use of mechanical lift (2 person assist required at all times) to/from toilet, chair, bed -approaches included to place call light within reach, encourage resident to obtain assistance for transfers, provide mechanical lift for transfers of full body lift to/from toilet, chair, bed, provide appropriate sling, educate resident/family to mechanical lift, and use calm, patient approach when using mechanical lift. Change of Condition form dated 11/12/14 revealed R#1 had change in skin; elevation (bump) and minor swelling to right thigh. Change of Condition form dated 11/12/14; under "Progress Note" revealed Resident Care Specialist-Certified Nurse Aide (RCS/CNA) reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Vital signs within limits. Unable to verbalize level of pain. Incident/Accident Report dated 11/12/14 revealed R#1 had a transfer injury. RCS/CNA reported upon transfer to Geri-chair, they heard a snap. Upon assessment elevation (bump) and minor swelling noted to anterior aspect of right thigh. Complaining of pain upon movement. Incident/Accident Report dated 11/12/14, under "Resident Outcome" revealed R#1 had a possible fracture to femur. Physician Telephone Order dated 11/12/14 revealed for R#1 to be transferred to emergency room (ER) for evaluation/treatment. Hospital's emergency documentation dated 11/13/14, under "History of Present Illness" revealed (R#1) "presents with hip injury. The onset was just prior to arrival. The course/duration of symptoms is constant. (R#1) was sent from nursing home according to the story they were transporting (R#1) and moving them her from bed to chair when they heard a pop." Hospital's emergency documentation dated 11/13/14, under "Medical Decision Making" revealed "history is not compatible with a fracture seen on (R#1) since patient has proximal spiral femur fracture more compatible with a fall or with a forceful twisting of the extremity." On 11/13/14 at 9:29 a.m., surveyor attempted to interview R#2, roommate of R#1, regarding R#1's incident. R#2 said she did not remember what happened to her roommate, R#1. On 11/13/14 at 9:56 a.m., Resident Care Specialist/Certified Nurse Aide (RCS/CNA) "A" said R#1 was a two person transfer using a mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" when transferring R#1 without the mechanical lift. RCS/CNA "A" said she did not use the mechanical lift because R#1 cried and moved slightly. RCS/CNA "A" said it was the first time she did not use the mechanical lift for R#1 and informed the charge nurse of her not using the mechanical lift. RCS/CNA "A" said she was assisted by RCS/CNA "B" in getting R#1 up from the bed. RCS/CNA "A" said they sat R#1 up on the edge of bed, and held R#1 by her armpit while RCS/CNA "B" held other side of R#1. RCS/CNA "A" said R#1 was lifted up slowly and as they were turning R#1 to sit R#1 down the on Geri-chair she heard a pop sound. RCS/CNA "A" said R#1 did not fall on the floor. RCS/CNA "A" said she did not remember if R#1 hit herself with something when transferring R#1. RCS/CNA "A" said did not know how R#1 could have gotten the fracture. On 11/13/14 at 10:12 a.m., RCS/CNA "B" said she was assisting RCS/CNA "A" in dressing and changing R#1 and then sat R#1 up on the bed. RCS/CNA "B" said she and RCS/CNA "A" transferred R#1 by holding R#1 from each side when they heard the pop sound; then they sat R#1 on the Geri-chair and immediately notified the charge nurse. RCS/CNA "B" said R#1 required the use of mechanical lift for transfers. RCS/CNA "B" said she and RCS/CNA "A" "used bad judgment by doing a two person assist transfer, instead of using the mechanical lift." RCS/CNA "B" said R#1 made faces of pain when the mechanical lift was used. On 11/13/14 at 10:35 a.m., Licensed Vocational Nurse (LVN) "C" said he was notified by RCS/CNA "A" about the incident with R#1. LVN "C" said he was not present during the incident, however he was informed by RCS/CNA "A" and RCS/CNA "B" that when they were transferring R#1 from bed to Geri-chair RCS/CNA "A" and RCS/CNA "B" heard a snap sound. LVN "C" said R#1 required the use of a mechanical lift transfer and RCS/CNA "A" and RCS/CNA "B" were aware of R#1 needed to use of mechanical lift. LVN "C" said RCS/CNA "A" and RCS/CNA "B" were quiet when he questioned them regarding not using the mechanical lift for the transfer. On 11/13/14 at 11:56 a.m., LVN "D", of the hospital, said an orthopedic surgeon evaluated R#1 on 11/13/14 and R#1's Family Member/Responsible Party (FM/RP) "E" consented for surgery. LVN "D" said documentation from the surgeon was not available yet. On 11/13/14 at 12:02 p.m., FM/RP "E" said a facility nurse told him CNAs were transferring R#1 and did not use a mechanical lift when resident fell on the floor. FM/RP "E" said he did not know the name of the facility's nurse who informed him. FM/RP "E" said he thought that R#1 might have slipped and fell . FM/RP "E" said the doctor told him the fracture was related to a fall. On 11/13/14 at 12:07 p.m., surveyor attempted to interview R#1 at the hospital; however R#1 was not responding to surveyor when questions were asked. FM/RP "E" said R#1 did not talk. On 11/13/14 at 1:30 p.m., LVN "F" said she assessed R#1 and R#1 had elevation (bump) to the femur with mild swelling. LVN "F" said RCS/CNA "A" and RCS/CNA "B" informed her that they heard a pop sound when transferring R#1. LVN "F" said RCS/CNA "A" and RCS/CNA "B" did not mention if the resident had fallen. LVN "F" said R#1 required the use of a mechanical lift for transfers. LVN "F" said she asked RCS/CNA "A" and RCS/CNA "B" why the mechanical lift was not used for R#1, RCS/CNA "A" and RCS/CNA "B" did not respond. LVN "F" said CNAs were aware of resident's activities of daily living as a binder was located at nurse's station. On 11/13/14 at 2:37 p.m., the Director of Nurses (DON) said RCS/CNA "A" and RCS/CNA "B" were transferring R#1 from the bed to Geri-chair by a two man lift (two person assistance); instead of using a mechanical lift. The DON said R#1's fracture could be related to R#1's medical diagnoses. The DON said she believes if RCS/CNA "A" and RCS/CNA "B" would have used the mechanical lift, R#1 would not have the incident of the fracture. The DON said care plans needed to be followed by staff for the safety of the residents. The facility's Abuse & Neglect Prohibition dated June 2013, under "Definitions" revealed the following: "Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect." The facility's Lift, Transfer, and Repositioning Policy dated 2010 revealed the following: "Direct care staff will be responsible for the following- a. Complying with this policy and the Lift and Transfer Guide b. Lifting and transferring residents in accordance with the residents' plans of care c. Using proper techniques when lifting and transferring residents d. Lifting and transferring residents with assistance of 2 staff members e. Using mechanical lifting device in accordance with manufacturer recommendations and instructions .... " During the exit conference, conducted on 11/13/14 at 2:50 p.m., the facility was given an opportunity to provide additional information. No additional information was provided. The facility's Resident and Census and Conditions of Residents form indicated a census of 47 residents.