Every finding on record at Lone Star Ranch Rehabilitation and Healthcare Cent

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 2 (Resident #40 and Resident #2) of 5 residents reviewed for infection control practices. The facility failed to ensure Resident #40 received proper or adequate incontinent care on 08/11/2026 at 8:22 AM. The facility failed to ensure Resident #2 received proper or adequate wound care on 08/11/2026 at 4:13 PM.These failures could place residents at risk for cross-contamination and infection due to inappropriate policies and precautions being used.The findings included:Record review of Resident #40's face sheet, reviewed 08/12/2026, revealed a [AGE] year-old female with an admission date of 07/08/2024. Pertinent diagnoses included Wedge Compression Fracture (spinal injury in which the front of a vertebra collapses, forming a wedge shape) and Inflammatory Polyneuropathy (a disease-causing inflammation in the nervous system)Record review of Resident #40's Quarterly MDS Assessment, dated 07/01/2026, revealed Resident #40 had a BIMS score of 15, which indicated intact cognition. The Quarterly MDS Assessment also revealed Resident #40 was frequently incontinent. Record review of Resident #40's Care Plan revealed Resident #40 had a focus for bowel incontinence (initiated 11/28/2025) and a focus for mixed bladder incontinence (initiated 07/17/2024). Interventions included provide peri-care (perineal region is the region surrounding the external genitalia and anus) after each incontinent episode. In an incontinent care observation on 08/08/2026 at 8:10 AM, CNA-E and the DON performed hand hygiene and donned (to put on) PPE. The DON and CNA-E were observed to pull down Resident #40's brief, and CNA-E proceeded to clean the front of Resident #40 while wiping resident with her right hand and keeping her left placed to pubic area to hold and maneuver Resident #40 while cleaning her. CNA-E went to perform hand hygiene with soap and water while the DON rolled resident to her left side. There was a strong smell of old urine, and Resident #40's bottom sheet was noted to be saturated wet with urine which had been there a while and left a large circle or ring on the sheet larger than where the resident's buttocks - torso area had been lying. CNA-E was observed to only lather and scrub her hands with soap for 3 seconds prior to rinsing and hurrying back to the bedside and donning new gloves. CNA-E continued to wipe Resident #40's backside and remove the completely saturated brief. The DON paused care, took off her contaminated gloves, started to put on clean gloves, then removed clean glove which was partially on and performed hand hygiene with ABHS x 3 seconds, then continued to put gloves back on. CNA-E (without removing contaminated gloves and performing hand hygiene) and the DON placed a clean brief on Resident #40, then placed Resident #40 back onto the urine-soaked sheet and covered her up. CNA-E and the DON removed contaminated gloves and took their trash out with bare hands after they had touched the outside of the bags with contaminated gloves. Attempted to interview Resident #40 on 08/011/2026 at 8:25 AM, she stated she was cold and in pain, and the staff here did not know how to take care of people, and she did not want to answer any more questions. Record review of Resident #2's face sheet, reviewed 08/12/2026, revealed a [AGE] year-old male with an initial admission date of 07/13/2024, and a current admission date of 05/19/2026. Pertinent diagnoses included Peripheral Vascular Disease (a slow and progressive disorder of the blood vessels, such as narrowing, blockage, or spasms in a blood vessel) and 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 #2's Quarterly MDS Assessment, dated 05/21/2026, revealed Resident #2 had a BIMS score of 06, which indicated severely impaired cognition. The Quarterly MDS Assessment also revealed Resident #2 had venous ulcers (wounds caused from damaged or obstructed veins) and/or arterial ulcers (wounds cause narrowed or blocked arteries) and an infection of the foot.Record review of Resident #2's Care Plan revealed Resident #2 had a wound to the right heel (initiated 05/22/2026). Interventions included cleanse right heel with wound cleanser, dry with gauze (a loosely woven fabric used for wounds), apply betadine moistened gauze (an antiseptic used to treat wounds) and cover with dry dressing daily. Another care plan focus revealed Resident had an arterial ulcer of the left heel (initiated 06/03/2025 and revised 05/22/2026). Interventions included cleanse wound with wound cleanser, apply Santyl (a dressing used to debride the wound, or removed dead tissue), calcium alginate (a highly absorbent dressing used for wounds with drainage), ABD pad (highly absorbent dressing), wrap with kerlix (a woven gauze in a roll to be unrolled around a wound) and secure with tape.Record review of Resident #2's physician order summary, reviewed 08/12/2026, revealed an order, started 08/06/2026, to cleanse right lateral heel wound with wound cleanser, dry with gauze, apply betadine, and cover with dry dressing one time a day and as needed. Another order, started 08/06/2026, to cleanse left heel wound with wound cleanser, apply Santyl, apply calcium alginate, apply ABD pad, wrap with kerlix, and secure with tape daily and as needed. In a wound care observation on 08/11/2026 at 4:15 PM, LVN-D was observed to clean Resident #2's bedside table prior to setting up her wound care field, performed hand hygiene, then continued to set up the wound care field without first donning gloves. After completing setup, LVN-D performed hand hygiene and started wound care. LVN-D did not put down a clean pad or barrier between Resident 2's heels and the dirty linens/pillow which his feet were resting on. After removing the dressing to the right heel, LVN-D performed hand hygiene with ABHS x 6 seconds before she donned new gloves and continued wound care. Once LVN-D had completed with the right heel, she sat Resident #2's foot back down on the dirty linens/pillow, and she started on the left heel. She removed and discarded the old dressing, and performed hand hygiene with ABHS x 8 seconds, donned new gloves and continued to cleanse the wound. There was contaminated, dirty, wound cleanser dripping from Resident #2's left heel onto the dirty linens/pillow which the feet were resting on. LVN-D performed hand hygiene again x 8 seconds with ABHS. She had difficulty getting new gloves on. By the time LVN-D had finished wound care on the left heel, the dressing on the right heel, which was resting on the dirty pillowcase had completely come untaped and was exposed to the dirty linens. LVN-D discarded trash and performed hand hygiene. LVN-D did not disinfect the table after wound care, nor did she put a clean pillowcase on Resident #2's pillow.In an interview on 08/11/2026 at 3:11 PM, CNA-E stated she should have removed her gloves, performed hand hygiene appropriately in which she scrubbed her hands for 20 seconds after touching anything dirty or contaminated and before going to a clean body part or area. She also stated she have brought in clean linens not left Resident #40 on soiled linens after performing incontinent care and putting a clean brief on her. She stated this increased the risk for infection and skin breakdown. In an interview on 08/11/2026 at 3:50 PM, the DON stated she should have done hand hygiene appropriately for 20 seconds while rubbing all surfaces of her hands after removing her soiled gloves and prior to putting on new gloves. She also stated she or CNA-E should have brought in or gone back to get clean linens for Resident #40 instead of leaving her on soiled linens after performing incontinent care and putting a clean brief on her. She stated this increased the risk for infection and skin breakdown. In an interview on 08/12/2026 at 2:56 PM, LVN-D stated for hand hygiene with ABHS, to apply enough hand sanitizer to cover all areas of the hands, then rub hands together for approximately 20 seconds. She stated she was not sure how long she performed hand hygiene because she was not counting. LVN-D stated she also should have applied a clean barrier under Resident #2's feet prior to wound care to avoid cross-contamination from the dirty pillowcase and Resident #2's open wounds and clean, dry dressings.In an interview on 08/12/2026 at 8:50 AM, the ICP, who was also the ADON, stated hand hygiene should be performed every time staff went from a dirty area of the body to a clean area of the body during incontinent care and wound care. She stated the hand hygiene procedure with water should include lathering and scrubbing wet hands for at least 20 seconds prior to rinsing and drying, and hand hygiene with ABHS should have taken around 20 seconds of rubbing hands together as well. The ICP stated dirty hands should not be put into clean gloves until hand hygiene had been performed. She also stated there should have been a clean barrier applied under Resident #2's feet during wound care, as well as a clean pillowcase applied to the pillow prior to setting Resident #2's feet back onto the pillow. She also stated Resident #40 should have had her bed cleaned and clean linens placed prior to placing her back down. She stated poor hand hygiene, poor incontinent care, and poor wound care could lead to cross contamination and infection. Record review of the facility's Infection Control Policy, dated January 2020 and reviewed January 2023, revealed Employee Training on Infection Control: Policy Statement: The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs. Policy Interpretation and Implementation: 3. Infection control training topics will include at least: A. Standard Precautions, including hand hygiene; D. Use of personal protective measures. Monitoring Compliance With Infection Control: Operational Strategies for Consideration: UTI's: Educate staff on criteria for urinary tract infections; Provide training on peri-care and catheter care.Record review of the facility's Handwashing / Hand Hygiene Policy, revised 04/16/2026, revealed Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. Indications for Hand Hygiene: 1. Hand hygiene is indicated: A. Immediately before touching a resident; B. Before performing an aseptic task; C. After contact with blood, body fluids, or contaminated surfaces; D. After touching a resident; E. After touching the residents' environment; F. Before moving from work on a soiled body site to a clean body site.; G. Immediately after glove removal. Procedure: Washing Hands: 1. Wet hand first with warm water. 2. Rub hands together vigorously for at least 20 seconds. 3. Rinse hands with water and dry.; Applying Alcohol Based Hand Rubs: 1. Apply generous amount of product to palm of hand and rub hands together. 2. Cover all surfaces of hands and fingers until hands are dry. 3. Rub hands together for a minimum of 20 seconds.Record review of the facility's Non-Sterile Dressing Change Skills Checklist, revised 03/05/2026, revealed Guideline: 4. Apply relevant PPE if applicable prior to entering room. Wash hands and put on gloves; 5. Set up a clean field. 6. Remove soiled dressing. 7. Remove gloves. 8. Wash hands (or hand sanitize) . 9. Cleanse wound. 10 Remove gloves. 11. Wash hands. 12. Apply treatment. 13. Apply cover dressing. 14. Remove gloves. 15. Wash hands. 16. Reposition patient. 17. Dispose of used items. Hand sanitize. Apply gloves. Disinfect the area where supplies were set up. Wash hands.:Record review of the CDC: Clean Hands: Clinical Safety: Hand Hygiene for Healthcare Workers, dated 02/27/2024, revealed When to use an alcohol-based hand sanitizer (ABHS): Unless hands are visibly soiled, ABHS is preferred over soap and water in most clinical situations because it: Is more effective at killing germs on hands than soap; Is easier to use when providing care, especially when moving from soiled to clean activities on the same patient or when moving between care of patients in shared rooms; Improves hand hygiene adherence. Know how to use alcohol-based hand sanitizer (ABHS): 1. Put product on hands and rub hands together. A. The efficacy (effectiveness) of ABHS depends on the volume applied to the hands. Use the right amount of ABHS product to clean your hands. 2. Cover all surfaces and rub until hands feel dry. A. This should take around 20 seconds.

Based on interviews and record reviews, the facility failed to ensure the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider and a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with the consent of the resident or the resident's representatives for one of three residents (Resident #1) reviewed for discharge. The facility failed to record the discharge in the resident's medical record. This failure could place the residents at risk of not ensuring residents receive safe and effective transition of care. Findings Include: Record review of Resident's #1's admission Record, dated [DATE], revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included dementia (decline in mental ability severe enough to interfere with daily life, affecting memory, communication, and problem-solving); hypertension (a chronic condition in which the force of blood against your artery wall is consistently too high); osteoporosis (a bone disease that causes bones to become weak, brittle, and highly susceptible to fractures). Record Review of Resident's #1's Comprehensive MDS, dated [DATE], revealed a BIMS Score of 12. Record Review of Resident's #1's Progress Note, dated [DATE], revealed, (Resident #1) was out on leave for 72 hours. Resident left with medications.Resident # 1 was accompanied by her children. Record Review of Resident's #1 Progress Note dated [DATE], revealed, RP was to let SW that family would pick up Resident this week to discharge to the city of Victoria. RP would let staff know what date for discharge and sign all paperwork. Family was to provide transportation. Record Review of Resident's #1's Request and Authorization for Release of Health Information form signed [DATE] authorized by RP, and Citation granting authority signed by SW, indicated authorization was for Facility A and revealed an expiration date of 30 days from the date the authorization was signed. Record Review of Resident's #1 Discharge MDS, dated [DATE], revealed an Unplanned Discharge Assessment, return not anticipated. In an interview on [DATE] at 5:17 p.m., the SW stated the resident's family lived in City A and was planning on transferring resident to Facility A located in City A. The SW stated resident's Family Member B had resided at Facility B and had recently expired. The Resident found it difficult to stay on at Facility B after Family Member B's passing. The SW stated Family the RP had planned on picking up resident from Facility B on a three-day pass to attend Family Member B's funeral services. The SW stated that the RP was to return to complete all discharge/transfer paperwork. The SW stated Resident did not return from three-day pass. The SW stated on [DATE] Resident's provider picked up resident's belongings from the facility. The SW stated on [DATE] she spoke to the RP who stated she would be in to sign discharge/transfer paperwork. The SW stated she called the RP on [DATE] and she never returned her call. The SW stated she figured resident was discharged and not coming back. The SW stated she was responsible for transferring the resident, setting up Home Health, DME and informing the RP to follow up with the PCP. She stated it was discussed during a facility morning meeting that the resident was not returning to Facility B, and the RP was not returning the facility's calls. The SW stated DON and ADON were aware resident #1 was not returning to the facility. In an interview on [DATE] at 5:13 p.m., the ADON stated resident #1 lived across the hall from Family Member B and she would visit him daily. She stated that when her Family Member B passed the RP took the Resident out on a pass for the funeral services and never returned her. She stated she received a call from the SW informing her the resident's provider had come to the facility and picked up the resident's belongings one or two days after she had left on her three-day pass. The SW informed the ADON she was not able to reach the RP via telephone and left several voicemails. The ADON stated the SW informed her the provider told her the RP would be returning to the facility to sign the transfer/discharge paperwork. She stated the RP never returned to sign the transfer/discharge paperwork; resident was discharged AMA by facility. The ADON stated no attempts were made to email or mail the RP discharge paperwork as per facility policy. The ADON stated as per facility policy the discharge should include a discharge summary, a Nurse's Note, transfer/discharge form, head to toe assessment and family/resident notification. She stated none of this had was done and she did not know why the family had not been notified of the discharge. In an interview on [DATE] at 5:45 p.m., the DON stated the resident's family had taken the resident home for a few days and was planning on returning her to the facility after the funeral services. The DON stated the RP called the facility and informed them the resident would not be returning to the facility. The ADON stated the RP had informed her that the resident would be moving to City A because she had family there. She stated that the SW had called the RP and received confirmation resident would not be returning to facility. She stated the resident's anticipated discharge had been discussed during her Care Plan meeting. The DON stated the facility stopped billing for services on [DATE]. The DON stated that the discharge process started on admission. She stated the facility policy indicated Discharge required a bases for discharge, the facility's attempt to meet the resident's needs, D/C summary and Nurse's Progress Note. She stated it is important to discuss D/C with resident because it includes discharge instructions and PCP follow ups. She did not know why the resident discharge was not done. Record Review of the facility policy's dated [DATE], titled Transfer or Discharge Documentation and Notice reflected: Policy Statement: When a resident is transferred or discharged 87details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provide. 4. When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: a. The basis for the transfer or discharge. b. The appropriate notice was provided to the residents and/or legal representative c. The date and time of the transfer or discharge d. The new location of the resident e. the mode of transportation f. a summary of the resident's overall medical, physical and mental condition g. disposition of personal effects a. disposition of medications; others as appropriate or as necessary; and the signature of the person recording the data in the medical record.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 resident's bathroom sink (Resident # 12 and #73) reviewed for the environment in that: The bathroom wall resident room for #12 and #73 was leaking water on to the bathroom floor. These failures could place Resident #12 and #73 at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings Include: A record review of Resident #12's Face Sheet 08/11/26 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #12s diagnoses included Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), heart failure the heart muscle is too weak and too stiff to pump enough oxygen-rich blood to meet your body's needs, non-traumatic brain destruction (happens from internal medical or biological factors rather than an outside physical force like a blow to the head) and Hypertension (a chronic condition where blood force against artery walls is too high. A record review of Resident #12s MDS ([NAME] Data Set) dated 06/18/26 revealed a BIMS (Brief Interview for Mental Status) score of 10 which indicates normal thinking and memory with little to no impairment. Resident #12 Functional Abilities revealed Resident #12's performance indicated the resident is independent with minimal assistance from staff for all ADL's (Activities of Daily Living). A record review of resident #12's care plan dated 05/26/26 revealed resident was cognitively impaired related to history and diagnosis of unspecified dementia with behavioral disturbances and had an ADL self-care performance deficit related to his history and diagnosis of Alzheimer's Disease. A record review of Resident #73 Face sheet dated 08/11/26 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #73's diagnoses include Alzheimer's Disease with late on set (a progressive disease that destroys memory and other important mental functions), non-Alzheimer's dementia(brain disorder causing a decline in thinking and daily functioning due to causes other than amyloid plaques and [NAME] tangles of Alzheimer's),anxiety disorder(a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation) and depression(Is a common and serious mental disorder that negatively affects how you feel, think, act, and perceive the world. A record review of Resident #73's MDS ([NAME] Data Set) dated 06/18/26 revealed a BIMS (Brief Interview for Mental Status) score of 3 which indicates severe cognitive impairment major difficulties with memory, attention, and knowing the correct time or date. Resident #73's Functional Abilities revealed Resident #73's performance indicated the resident is dependent on supervision assistance from staff for all ADL's (Activities of Daily Living). A record review of resident #73's care plan dated 05/26/26 revealed resident was cognitively impaired related to history and diagnosis of Alzheimer's disease and dementia with behavioral disturbances and had an ADL self-care performance deficit related to his history and diagnosis of Alzheimer's Disease. In observation and interview on 08/10/25 at 2:13 PM of Resident #12's bathroom the floor was wet with a blanket soaked with water on the floor against the wall. The state surveyor asked how long the floor had been wet Resident #12 refused to answer. In interview on 08/10/2026 at 2:30 PM with Resident #73 the state surveyor asked how long the floor had been wet and the wall leaking Resident #73 refused to answer. In an interview on 08/11/26 at 2:38 PM the Maintenance man stated the water heater was leaking in the mechanical room next door which was causing the wall to leak water on the next room of Resident #12 and #73. The MM stated the water heater must stay on so the locked unit could have hot water. The MM stated he was waiting for a part to arrive any day soon so that he may fix the water heater's leaking. The MM stated he and house keeping are monitoring the water leakage and kept the floor dry as possible. In a second interview on 08/12/2026 at 4:20PM with the MM he stated he had found a way to reroute the water leakage to the drain in the mechanical room so that no water can leak into the resident's bathroom next door. The MM stated he had been working on a way to prevent the water from leaking since 08/09/2026 when the leak had begun. The MM stated the residents were had no falls and did not prevent the residents from using the bathroom The MM stated the mechanical room and resident bathroom is checked every two hours by CNA'S, housekeeping, janitor and himself to ensure there is no leaking water. The MM stated all staff knew to report any issues with plumbing immediately by putting in a work order which he checks twice a day. The Policy and Procedures for Maintenance of facility equipment was not proved by facility.

Based on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Resident #10) reviewed for accuracy and completeness of clinical records.The facility failed to ensure RN A documented Resident #10's blood pressure on the eMAR before holding Resident #10's clonidine (blood pressure medication) on 08/08/26. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.The findings included:Record review of Resident #10's face sheet dated 08/12/26 revealed a [AGE] year-old male with an admission date of 02/16/17. The pertinent diagnosis included Essential Primary Hypertension (high blood pressure that does not have a single, known medical cause). Record review of Resident #10's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Record review of Resident #10's comprehensive care plan dated 08/12/26 revealed the focus The resident has hypertension initiated on 03/01/20. An intervention listed for the focus included Give anti hypertensive medications Clonidine and Lisinopril (blood pressure medication) as ordered. initiated on 04/15/21. Record review of Resident #10's order summary dated 08/12/26 revealed an active order for clonidine 0.1 mg Give 1 tablet by mouth every 4 hours as needed for [hypertension] related to ESSENTIAL PRIMARY HYPERTENSION for sbp greater than 160 or dbp greater than 90 initiated on 03/20/20. Record review of Resident #10's eMAR for August 2026 on 08/12/26 revealed clonidine had not been administered in the month of August. Record review of Resident #10's blood pressure history on 08/12/26 revealed his blood pressure was checked one time on 08/08/26 by MA B at 10:35 AM with the result of 162/81. During an interview with MA B at 11:27 AM on 08/12/26, MA B stated clonidine was a medication used to lower a resident's blood pressure. MA B stated she did not administer any PRN medications. MA B stated she notified the nurse any time a resident's blood pressure was different from their typical baseline. MA B stated she did not remember specifically notifying the nurse about Resident #10's blood pressure on 08/08/26, but with her measuring a 162/81 she would have. MA B stated based on the blood pressure she took Resident #10 should have received the clonidine. MA B stated it was important to give residents their blood pressure medication appropriately because an elevated blood pressure could lead to a heart attack. During an interview with RN A at 11:59 AM on 08/12/26, RN A stated nurses always give the PRN medications. RN A stated she remembered MA B telling her about Resident #10's blood pressure being elevated on 08/08/26. RN A stated she checked on Resident #10 after MA B told her about him and remeasured his blood pressure. RN A stated when she measured his blood pressure he was below the threshold to administer his clonidine. RN A stated she wrote his blood pressure down on her notepad but did not write it in the eMAR. RN A stated she no longer had the notepad where she wrote his blood pressure down and did not remember specifically what his blood pressure was. RN A stated it was important to document blood pressures so all staff were up to date on the status of the resident and for physicians to make changes to their care if necessary. During an interview with the DON at 4:26 PM on 08/12/26, the DON stated residents' blood pressures should be documented in the eMAR after they were taken. The DON stated RN A should have recorded the blood pressure she took of Resident #10 on 08/08/26 in the eMAR. The DON stated it was important to have a record of blood pressures to see any trends and for the physicians to make changes if necessary. Record review of the facility policy Medication Administration last revised 03/05/26 revealed the following: .Review allergies and relevant vital signs as indicated.Refused, withheld, or rescheduled medications are documented appropriately on the MAR

Based on observation, interviews and record review, the facility failed to ensure kitchen equipment was clean and in proper working condition and failed to ensure the storage of food was in accordance with professional standards for food service safety for 1 of 1-refrigerator (1 of 1 facility refrigerator) and 1 of 1 freezer (1 of 1 resident freezer reviewed for storage, preparation and sanitation . The facility failed to discard eroded non-stick pans and kept using them. The facility failed to ensure kitchen staff were wearing beard restraints while in the kitchen. The facility failed to ensure items in the refrigerators were labeled and dated. The facility failed to ensure items in the refrigerators we're fresh and mold free. The facility failed to ensure items in the refrigerators were properly sealed. The facility failed to ensure the sanitation and maintenance of kitchen equipment. These failures could place residents at risk of foodborne illnesses. The facility failed to ensure food items in the facility refrigerator were fresh and covered with mold.Observation and Initial tour of the kitchen on 08/10/26 at 10:15 a.m. revealed the staff was using scratched and dented pans for cooking, a dirty toaster, and a microwave that had a bulging damaged inside panel that was being used. Observation of the kitchen revealed a rack for storing clean containers had one shelf that contained a griddle that was dirty with food crumbs, the stove revealed the cook top was dirty with a black and brown substance along the black panel and between the cover/insert on the cooking surface. Observation of the oven revealed the oven door was caked with a thick black substance that covered the entire oven door and the oven itself had a thin black covering the bottom panel. Observation of a tray rack revealed a pan of corn bread uncovered that was cooling after baking. Observation of the refrigerator cornbread in a plastic storage bag unlabeled and unsealed, a bag of cooked chicken strips undated, a bag of whipped cream undated, a plastic bag of white cheese undated, and a container of strawberries that had no date and mold on them. In an interview on 08/11/2026 at 11:16 AM with the cook she stated all employees were responsible daily for making sure food in the refrigerator were labeled, covered or sealed correctly, and fruits and vegetables were to be fresh not covered with mold. The cook stated the strawberry containers not labeled and covered with mold must have overlooked by staff as the mold was at the bottom of the container. The cook stated the cooked corn bread, chicken strips that were left open must have recently been used and sealed closed correctly. The cook stated that all the equipment was to be cleaned daily so that it could be in proper working order. All dirty dishes, pots, and pans should not be place in an area with clean dishes as it could attract pest and clean dishes could be contaminated from the pest. The cook stated a new microwave was requested several times but had not received one. The cook stated all old and scratched pot and pan should not be used because scratches can hold bacteria and if metal comes of the pan it could be eaten and make the resident sick. The cook stated the cooked corn bread, chicken strips that were left open must have recently been used and sealed closed incorrectly. The last in-service storing food and cleaning equipment properly was about a month ago. The cook stated the cornbread was cooling and she forgot to cover it but stated all food cooked to serve for a meal must be covered until ready to serve so it is not exposed to the air and become contaminated. In an interview on 08/11/2026 AT 11:31 AM with DA E she stated that the refrigerator is cleaned out daily and those items that were not sealed correctly, unlabeled, and the strawberries that had mold must have been missed. DA E stated the all the equipment should be cleaned daily so that the epuipment was in good working condition and could not contaminate food that was prepared with the equipment. The DA stated not dirty dishes, pots, and pans should be stored with clean ones as they can contaminate the clean ones that can make the resident sick if used to serve or cook food. In an interview on 11/11/2026 at 2:30 PM with the DA-F stated he forgot to put on the beard restraint that day but normally puts it on everyday before entering the kitchen. DA F stated when he takes out food to cook on the alternative menu he makes sure what he opened and used is closed. DA stated all food stored in the dry storage, freezer, or refrigerator is to be labeled and dated with date entered or date expired. DA F stated all leftovers need to be stored for three days only and to thrown away if not used by the third day. DA F stated dirty dishes or equipment should never be placed next to clean dishes because they can be contaminated. In an interview 11/11/2026 3:02 PM with the DM she stated the pots and pans with scratched pans are not used much but will be thrown and will be asking for new replacements. The DM stated it was all of the kitchen staff responsibly to make sure all food placed in the dry pantry, refrigerator, and freezer should be labeled with date and sealed properly. The DM stated all food should be fresh and free of mold, the fruits and vegetables should have a date when placed in refrigerator and monitor daily so residents are not served expired food that can make them sick if eaten. The DM stated any left over foods can only be stored for three days and must be thrown away so it is not served to residents that is why all stored items must be dated. The DM stated all dirty dishes, pots, and pans are to remain separated so the the dirty dishes do not contaminate the clean ones. The DM stated she had request the a new microwave oven serval times because she was worried about using it while it had a bulging side panel inside the the microwave that looked like it was burnt. The DM stated no cooked food ready for serving should be left uncovered exposed to air as it can become contaminated. The DM stated all staff should wear appropriate clothes and shoes with hair restraints on and for male staff beard restraints. The DM stated she would be conducting a in-service on food storage, sanitation and maintenance of equipment, and proper attire for kitchen staff. In record review of the facility kitchen policy titled, Food Receiving and Storage Policy revised 03/05/2026 revealed The facility will ensure that all food received, stored, and maintained in the facility is handled safely, protected from contamination, and maintained at appropriate temperatures to endure food quality and resident safety. Food storage areas, refrigerators freezers, and dry storage rooms will be maintained in a sanitary condition and monitored to ensure compliance with safe food handing practices.2. All food must be dated upon delivery. All food must be dated upon delivery.Food removed from original packaging must be labeled with the product name and date.Prepared foods stored in refrigerators must include a use by date. Opened containers must be sealed or covered and dated . Expired foods must be immediately removed from storage areas. Bread products, beverages, and opened items must be dated when opened and used according to safe storage timelines. 3. Refrigerator and Freeze r StorageRefrigeration equipment will be maintained to protect food quality and prevent contamination. Additional Dry Storage Rules Opened foods must be tightly sealed and dated. In record review of the facility kitchen policy titled, Dietary Employee Dress Code Policy revised 03/05/2026 revealed All Employees will wear approved attire to preform their assigned duties. PROCEDURE All staff will have their hair off their shoulders, confined in a hairnet or cap-facial hair cover properly. According to the Food Code, Food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad. However, staff do not [NAME] to wear hairnets when distributing food to residents at the dining table(s) or when assisting residents to dine. All [NAME] and mustaches will be covered using appropriate coverings. In record review of the the facility kitchen policy titled, Sanitation Policy revised 03/05/2026 revealed Policy Statementl. The food service area shall be maintained in a clean and sanitary manner. 2. All kitchens, kitchen areas, and dining areas shall be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. 3. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be maintained in good repair.

Based on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 8 residents (Resident #38) reviewed for pharmacy services in that: The facility failed to ensure LVN C destroyed a tramadol (Schedule IV pain medication) tablet with no witnesses present at 9:00 PM on 08/11/26. This failure could place residents at risk of drug diversion.The findings included:Record review of Resident #38's face sheet dated 08/12/26 revealed a [AGE] year-old female with an admission date of 06/12/26. The pertinent diagnosis included Cerebral Infarction (blood clot or fatty plaque blocks an artery supplying blood to the brain). Record review of Resident #38's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated severe cognitive impairment. Record review of Resident #38's comprehensive care plan dated 08/12/26 revealed the focus The resident has chronic pain [related to] stroke initiated 08/10/26. An intervention listed for the focus included The resident prefers to have pain controlled by Tramadol initiated 08/10/26. Record review of Resident #38's order summary dated 08/12/26 revealed an active order for Tramadol 50 mg Give 1 tablet by mouth four times a day for moderate to severe pain. Record review of Resident #38's narcotic sheet for Tramadol 50 mg Tablets on 08/12/26 revealed LVN C signed one tablet out at 9:00 PM on 08/11/26 but did not administer it. LVN C wrote on the narcotic sheet for that date and time Refused medication - wasted. No other nurse signatures were on the narcotic sheet for the destruction of the tablet. During an interview with LVN C on 08/12/26 at 3:18 PM, LVN C stated she worked the 100 and 400 halls from 2:00 PM to 10:00 PM on 08/11/26. LVN C stated she remembered popping the tramadol for Resident #38 out of the blister pack at around 9:00 PM on 08/11/26. LVN C stated Resident #38 refused the tramadol that time because it had made her feel weird in the past. LVN C stated she put the tramadol tablet in the drug destruction bottle. LVN C stated she did not have any witnesses when she destroyed the tramadol. LVN C stated she knew she needed to have a witness, but she was in a rush and did not want to just set the tablet down. LVN C stated it was important to have a witness when destroying controlled medications to ensure no drug diversion was going on. During an interview with the DON on 08/12/26 at 4:26 PM, the DON stated tramadol was a controlled medication and required two licensed nurses to destroy it. The DON stated LVN C should have destroyed the tramadol with another nurse. The DON stated it required two nurses because controlled medications have a higher potential for abuse, so a witness was needed to ensure the drug was really destroyed and prevent drug diversion. Record review of the facility policy Medication Destruction Policy dated 03/05/26 revealed the following: .III. Controlled Substance Destruction (Schedule II-V)DON and Consultant Pharmacist oversee compliance.Partial doses or refused doses are destroyed immediately with two licensed nurse witnesses.Documentation is completed on the controlled substance accountability record.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 5 residents (Resident #6) reviewed for respiratory care.1. The facility failed to ensure Resident #6's continuous oxygen was administered on 08/11/2026 and 08/12/2026 as ordered by the physician.2. The facility failed to ensure Resident #6's oxygen saturation was assessed three times a day in July 2026 and August 2026. These failures could place residents at an increased risk of developing respiratory complications and a decreased quality of care.The findings included:Record review of Resident #6's face sheet, dated 08/12/2026, revealed a [AGE] year-old male with an admission date of 02/07/2013. Resident #6's pertinent diagnoses included Chronic Respiratory Failure with Hypoxia (happened when there was not enough oxygen in the blood) and Chronic Obstructive Pulmonary Disease (COPD - a progressive lung disease making it progressively difficult to breathe). Record review of Resident #6's Change of Condition MDS assessment, dated 05/21/2026, revealed a BIMS score of 10, which indicated moderately impaired cognition. Record review of Resident #6's active physician order summary, reviewed 08/11/2026, revealed an order, started 06/23/2026, for Oxygen at 2 liters per minute via nasal cannula continuously. May titrate (slowly increase the amount administered) up to 3 liters per minute to keep Oxygen saturations above 90%; and another order, started 06/23/2026, to check the Oxygen saturations three times a day. Record review of Resident #6's care plan, initiated 06/15/2026, revealed a care plan focus for shortness of breath related to COPD and Chronic Respiratory Failure. Interventions included oxygen at 2 Liters via nasal cannula for shortness of breath and COPD; Check oxygen saturation every shift. Record review of Resident #6's Oxygen saturation record revealed it was not checked three times per day, per the order, on the following dates:08/05/2026 - checked twice; 08/01/2026 - checked twice; 07/31/2026 - checked once; 07/30/2026 - checked once; 07/24/2026 - checked twice; 07/20/2026 - checked twice; 07/19/2026 - checked twice; 07/18/2026 - checked twice; 07/16/2026 - checked twice; 07/15/2026 - checked twice; 07/14/2026 - checked once; 07/09/2026 - checked twice; 07/03/2026 - checked twice; 07/02/2026 - checked twice.An observation on 08/11/2026 at 9:18 AM revealed Resident #6's oxygen concentrator (a medical device used to deliver oxygen to an individual) was against the wall, with no nasal cannula (tubing used to supply oxygen to an individual) connected, and the concentrator was not being utilized. Resident #6 had no type of Oxygen being administered during the observation. Attempted to interview Resident #6 on 08/11/2026 at 9:18 AM, but he had great difficulty with voicing or communicating answers to questions.In an interview on 08/12/2026 at 11:53 AM, RN-A stated it was the charge nurse's responsibility to have verified the oxygen order, set and adjusted the oxygen concentrator settings, placed the oxygen on the resident, and re-assessed to check if the settings were correct during resident rounds (assessing or checking in on residents to anticipate their needs and safety), as well as checked the residents oxygen saturation as ordered. She stated the nurses typically rounded at least every two hours on the residents. RN-A stated Resident #6 received oxygen as needed, which was why he did not have it on yesterday or today. She stated his order was for as needed oxygen, not continuous. After reviewing the order, she stated she had not realized the order was for continuous, and she would get it clarified and changed to as needed because Resident #6 did not need to be on continuous oxygen. RN-A stated oxygen was used for patients with respiratory issues, and if they were not getting enough oxygen, it could have caused increased respiratory issues, but no increased respiratory issued had been identified. In an interview on 08/13/2026 at 4:35 PM, the DON stated it was the charge nurse's responsibility to verify the oxygen order, adjust the oxygen concentrator settings as ordered or needed. The DON stated the charge nurse assessed the settings and oxygen placement on residents when the did their resident rounds. The DON stated Resident #6 was not on continuous oxygen because the order had been changed today (08/13/2026) to PRN. She stated the order was previously continuous, but he did not need it continuously, so they changed it to PRN. She stated if a resident actually needed oxygen continuously, and did not receive it, the resident could have had respiratory issues. Record review of the facility's Oxygen Administration and Safety Policy, revised 07/23/2025, revealed Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #3) reviewed for care plans. The facility failed to develop a care plan to address Resident #3's floor mats for fall prevention. This failure could place residents at an increased risk of needs going unmet or harm.The findings include:Record review of Resident #3's face sheet dated 08/12/26 revealed a [AGE] year-old female with an original admission date of 08/06/23 and a current admission date of 12/16/25. The pertinent diagnosis included Vascular Dementia (decline in thinking skills caused by reduced or blocked blood flow to the brain). Record review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 99 which indicated the interview could not be completed. Record review of Resident #3's comprehensive care plan dated 08/12/26 revealed the focus the resident is High risk for fall [related to] Confusion, Deconditioning, Incontinence, Poor communication/comprehension, and Psychoactive drug use, Unaware of safety needs initiated on 02/17/25. Interventions listed for the focus did not include any fall mats. During an observation at 1:23 PM on 08/12/26 of Resident #10's room, Resident #10 was laying in bed with a fall mat on each side of her bed. During an interview with the MDS nurse at 3:45 PM on 08/12/26, the MDS nurse stated it was her responsibility to ensure the care plan accurately reflected the care and current level of function of the resident. The MDS nurse stated fall mats should have been care planned for Resident #10. The MDS nurse stated the hospice nurse put fall mats in Resident #10's room and did not tell her. The MDS nurse stated the hospice nurse was supposed to tell her if they made any changes to her care so she could ensure the orders, consents, and care plans were updated accordingly. The MDS nurse stated it was important to ensure the care plan was accurate to ensure resident outcomes were high as possible and having an inaccurate care plan could put the resident in jeopardy. The MDS nurse stated she updated the care plan this afternoon for Resident #10 to include fall mats as soon as she was made aware of them. During an interview with the DON at 4:26 PM on 08/12/26, the DON stated fall mats should be care planned when they were in use. The DON stated it was important to care plan them to ensure continuity of care between the nursing staff. Record review of the facility's policy Care Plans, Comprehensive Person-Centered last reviewed 07/16/26 revealed the following: .The comprehensive, person-centered care plan will:Include measurable objectives and timeframes;Describe the services that re to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure all allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures for appropriate state agency for 2 of 5 residents (Resident #32 and Resident #61) reviewed for abuse, neglect, exploitation, and misappropriation.The facility failed to report to the appropriate state agency when Resident #32 was struck twice in the back by Resident #61 on 05/21/2026.This failure could result in an increased risk for not receiving a proper or thorough investigation and potential for further abuse. The findings included:1. Record review of Resident #32's face sheet, dated 08/12/2026, revealed a [AGE] year-old female with an admission date of 08/30/2022. Resident #32's pertinent diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning).Record review of Resident #32's care plan, initiated 09/27/2022, revealed Resident #32 had a mood problem related to mood disorder. Interventions included behavior health consults as needed and monitor and report mood patterns of depression, anxiety, and sadness.Record review of Resident #32's Annual MDS assessment, dated 06/07/2026, revealed a BIMS score of 12, which indicated moderately impaired cognition. Resident #32 had not exhibited behaviors including physical or verbal aggression toward others.2. Record review of Resident #61's face sheet, dated 08/12/2026, revealed a [AGE] year-old male who was originally admitted to the facility 12/21/2017, with a current admission date of 10/13/2025. Resident #61's pertinent diagnoses included Parkinson's Disease Without Dyskinesia (a progressive neurological disorder which primarily affected movement but did not involve involuntary movements) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning). Record review of Resident #61's Quarterly MDS assessment, dated 04/07/2026, revealed a BIMS score of 10, which indicated moderately impaired cognition. The Quarterly MDS assessment also revealed Resident #61 had not exhibited behaviors which included physical or verbal aggression toward others.Record review of LVN-D's witness statement, dated 05/21/2026, revealed LVN-D heard a commotion coming from the dining area, and she observed Resident #61 strike Resident #32 on the back of the head. Resident #32 turned around and swung back toward Resident #61, but she did not make contact. Resident #61 then swung two punches toward Resident #32, with one punch making contact to the back/shoulder area. Staff immediately intervened and separated the residents. An assessment was completed to the back, shoulders, neck, and head with no bruising, swelling, or visible injuries noted at this time.Record review of the facility's Incident and Accident Report revealed an incident dated 05/21/2026 for a Resident #61 for resident-to-resident incident.In an interview on 08/10/2026 at 4:20 PM, Resident #32 stated she recalled the incident, and Resident #61 hit her in the back of the head and the side of her neck. She stated she was not sure why he got upset or hit her, but she thought he was just crazy or confused. She stated she was not hurt, and the staff were in the dining room and assisted her. Resident #32 stated she had not had any further problems or issues with Resident #61 since then. Resident #32 denied being fearful or scared of being in the facility with the Resident #61. In an interview on 08/10/2026 at 5:25 PM, the Administrator stated she had only started in her position a couple of weeks ago, so she was not here when this incident occurred, and did not have any input regarding this incident. She also said the directive she had been given was the previous Administrator had reported an allegation the week prior and was under the assumption this incident had not needed to be reported and could be investigated while the previous incident was being investigated. In an interview on 08/12/2026 at 2:56 PM, LVN-D stated she was in the dining room assisting with passing breakfast trays on 05/21/2026, and she heard yelling. She stated she turned around just as Resident #61 hit Resident #32 in the back of the head. LVN-D stated no injuries to either resident were noted, and there had not been any further incidents with either resident since this time. She stated she was not sure what facilitated or instigated the incident. LVN-D stated she reported the incident to the Administrator and DON. In an interview on 08/13/2026 at 4:35 PM, the DON stated everyone was responsible for reporting abuse to the abuse coordinator, who was the Administrator. She stated the staff reported the incident between Resident #32 and Resident #61 immediately to the Administrator, but she was not sure why the Administrator had not reported the incident to the state. She stated residents had the right to be protected from abuse, which was why it was required to be reported within two hours to the state, and have it investigated. The DON stated she thought the previous Administrator had reported the incident, and he had not told her otherwise. Record review of the facility's Abuse Prohibition Policy, revised 02/26/2026, revealed Intent: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental, or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. 2. The facility will conduct an investigation of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of property for 1 of 5 residents (Resident #32 and Resident #61) reviewed for abuse, neglect, and exploitation.The facility failed to protect Resident #32's right to be free from physical abuse when Resident #61 hit Resident #32 on the back of the neck on 05/21/2026.This failure could place residents at risk of harm or injury.The findings included:1. Record review of Resident #32's face sheet, dated 08/12/2026, revealed a [AGE] year-old female with an admission date of 08/30/2022. Resident #32's pertinent diagnoses included Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning).Record review of Resident #32's care plan, initiated 09/27/2022, revealed Resident #32 had a mood problem related to mood disorder. Interventions included behavior health consults as needed and monitor and report mood patterns of depression, anxiety, and sadness.Record review of Resident #32's Annual MDS assessment, dated 06/07/2026, revealed a BIMS score of 12, which indicated moderately impaired cognition. Resident #32 had not exhibited behaviors including physical or verbal aggression toward others.2. Record review of Resident #61's face sheet, dated 08/12/2026, revealed a [AGE] year-old male who was originally admitted to the facility 12/21/2017, with a current admission date of 10/13/2025. Resident #61's pertinent diagnoses included Parkinson's Disease Without Dyskinesia (a progressive neurological disorder which primarily affected movement but did not involve involuntary movements) and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning). Record review of Resident #61's Quarterly MDS assessment, dated 04/07/2026, revealed a BIMS score of 10, which indicated moderately impaired cognition. The Quarterly MDS assessment also revealed Resident #61 had not exhibited behaviors which included physical or verbal aggression toward others.Record review of LVN-D's witness statement, dated 05/21/2026, revealed LVN-D heard a commotion coming from the dining area, and she observed Resident #61 strike Resident #32 on the back of the head. Resident #32 turned around and swung back toward Resident #61, but she did not make contact. Resident #61 then swung two punches toward Resident #32, with one punch making contact to the back/shoulder area. Staff immediately intervened and separated the residents. An assessment was completed to the back, shoulders, neck, and head with no bruising, swelling, or visible injuries noted at this time. In an interview on 08/10/2026 at 4:20 PM, Resident #32 stated she recalled the incident, and Resident #61 hit her in the back of the head and the side of her neck. She stated she was not sure why he got upset or hit her, but she thought he was just crazy or confused. She stated she was not hurt. Resident #32 stated she had not had any further problems or issues with Resident #61 since then. Resident #32 denied being fearful or scared of being in the facility with the Resident #61. In an interview on 08/10/2026 at 5:25 PM, the Administrator stated she had only started in her position a couple of weeks ago, so she was not at the facility when th3 incident occurred, and did not have any input regarding the incident which occurred between Resident #61 and Resident 32 on 05/21/2026. In an interview on 08/12/2026 at 2:56 PM, LVN-D stated she was in the dining room assisting with passing breakfast trays on 05/21/2026, and she heard yelling. She stated she turned around just as Resident #61 hit Resident #32 in the back of the head. LVN-D stated the residents were separated and assessed. No injuries to either resident were noted, and there had not been any further incidents with either resident since this time. She stated she was not sure what facilitated or instigated the incident. In an interview on 08/12/2026 at 3:15 PM, Resident #61 stated he recalled the incident. He stated Resident #32 was saying things to him, and she kept running her mouth, and he just got upset. Resident #61 stated he did not punch Resident #32, but he just slapped her in the back (he made an open-handed pushing motion). He stated Resident #32 did not hit him back, and he felt bad about hitting her. Resident #61 stated he knew he should not have done it, but he got upset. He also stated he saw Resident #32 all the time and had not had any issues with her. They had not had any further confrontations since. Resident #61 denied having previous incidents with Resident #32. Record review of the facility's Abuse Prohibition Policy, revised 05/07/2026, revealed Intent: Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. Policy: 1. The facility will prohibit neglect, mental, or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents.

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for one of one (wound care) carts observed for storage compliance. The facility failed to ensure the 400-hall wound care cart was left unlocked and unattended by LVN A. This failure could place residents at risk of access and ingestion of medications not intended for resident and drug diversion. Findings were: Observation on 5/28/26, at 10:45 a.m., the 400-hall wound care cart was unlocked parked outside of room [ROOM NUMBER]. The ADON locked the cart when walking by and stated it was the wound cart. During an interview on 5/28/26 at 12:15 p.m., LVN A verbalized she was performing wound care inside a room on the 400 hallway. LVN A stated she did access the wound cart after initially gathering supplies to get more gauze and thought she locked the cart. LVN A stated it is policy and procedure to lock all carts, including the wound care cart. LVN A stated a resident could have accessed the items in the cart, but there was only one resident on the hall and she was in the room with that resident. During an interview on 5/28/26 at 12:20 p.m., the DON stated it is the expectation of staff to lock medication and wound carts when unattended. The DON stated a resident could have ingested something from the cart and it was our responsibility to keep residents safe even if this was the only resident on the hall. During an interview on 5/28/26 at 1:30 p.m., the Administrator stated it was the expectation that staff assigned to a cart (wound care or medication cart) lock it when unattended and all staff can lock a cart if they see it unlocked. The Administrator stated it is the policy of the facility to keep all medication carts and wound care carts locked. The Administrator stated the staff member had been counseled and tomorrow there is an all staff meeting and this will be discussed at the meeting. Record review of a facility policy titled, Storage of Medication reviewed 6/24/2025, reflected 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Record review of a facility policy titled, Treatment cart set up reviewed January 2023, reflected in unnumbered bullet points carts are to be locked when not in use.

Based on interview and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #1's right to be free from physical abuse when Resident #2 hit Resident #1 on the right arm, twice, on 12/10/2025. This failure could place residents at risk for physical injury.The findings included: 1. Record review of Resident #1's face sheet, dated 12/10/2025, revealed a [AGE] year-old female with an original admission date of 02/14/2018, and a current admission date of 10/28/2025. Resident #1's diagnoses included Dementia (a condition which affects memory, thinking, and the ability to perform daily activities), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), and Cognitive Communication Deficit (difficulties in communication which arise from impaired cognitive processes, such as attention, memory, organization, and executive functioning). Record review of Resident #1's Quarterly MDS assessment, dated 10/21/2025, revealed a BIMS score of 02, which indicated severely impaired cognition. The Quarterly MDS assessment also revealed Resident #1 had Non-Traumatic Brain Dysfunction (brain injuries caused by internal factors rather than external trauma, such as lack of oxygen to the brain, which could lead to cognitive impairments, exposure to toxins, pressure from tumors, strokes), Alzheimer's Disease (a progressive disorder which was the most common cause of dementia, characterized by memory loss, cognitive decline, and behavioral changes), and Non-Alzheimer's Dementia (a condition which affects memory, thinking, and the ability to perform daily activities, not related to Alzheimer's Disease). The MDS also revealed Resident #1 had physical and verbal behavioral symptoms directed toward others 1-3 days per week but not daily. Record review of Resident #1's care plan, initiated 12/10/2025, revealed Resident #1 was hit by another resident. Interventions included Resident #1 was moved to safety, and a full body assessment was completed. Resident #1's care plan also revealed Resident #1 had an altercation with another resident on 04/30/2024 and 01/14/2025. Interventions included Resident #1 was removed from the situation, taken to relax, and labs were ordered. Record review of Resident #1's progress note, dated 12/10/2025, revealed LVN-B was at the nurses' station documenting when she heard a male resident yelling at someone. LVN-B got up and ran around the nurses' station and saw a male resident make contact twice with Resident #1 on her right arm, so she ran toward the residents. The residents were immediately separated, and a head-to-toe assessment was completed with no injuries, redness, or swelling noted. LVN-B then reported the incident to the Administrator, RP, the DON, and the doctor. Resident #1 did not show any signs of distress, and Resident #1 was unable to describe what had occurred. 2. Record review of Resident #2's face sheet, dated 12/10/2025, revealed a [AGE] year-old male with an original admission date of 06/13/2023, and a most recent admission date of 10/17/2025. Resident #2's diagnoses included Dementia, Schizoaffective Disorder (a mental health condition which was marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), Cognitive Communication Deficit, Anxiety (intense, excessive and persistent worry and fear about everyday situations), and Major Depressive Disorder (a persistent feeling of sadness and loss of interest). Record review of Resident #2's Quarterly MDS assessment, dated 10/29/2025, revealed a BIMS score of 00, which indicated severely impaired cognition. The Quarterly MDS assessment also revealed Resident #2 had Non-Traumatic Brain Dysfunction, Non-Alzheimer's Dementia, Schizophrenia (a serious mental health condition which affects how individuals think, feel, and behave), Anxiety, and Depression (a persistent feeling of sadness and loss of interest). The only documented behavior for Resident #2 on the Quarterly MDS assessment dated [DATE] was a behavior of wandering. Record review of Resident #2's care plan, initiated 03/20/2024 and revised on 12/10/2025, revealed Resident #2 had the potential to be physically aggressive related to Dementia and Depression. This care plan listed the following entries: 04/30/2024 - altercation with another resident and placed on one-to-one monitoring until psychological evaluation done; 08/17/2024 - hit another resident in the arm; 07/26/2025 - altercation with another resident; 09/29/2025 - altercation with another resident; 12/10/2025 - altercation with another resident. Interventions included Resident #2 placed on one-to-one monitoring on 12/10/2025; Administer medications as ordered; Analyze times of day, places, circumstances, triggers, and what de-escalated the behavior and document; Assess and anticipate Resident #2's needs, such as food, thirst, toileting needs, comfort level, body positioning, and pain. Resident #2 was removed from the situation and placed one to one after each incident, except 08/17/2025, in which the intervention included Resident #2 was redirected and kept safe. Record review of Resident #2's progress noted, dated 12/10/2025, revealed LVN-B heard Resident #2 yelling at someone, so she ran around the nurses' station and saw Resident #2 make contact twice with a female resident on her right arm, so she ran toward the residents. The residents were immediately separated, and a head-to-toe assessment was completed with no injuries noted. LVN-B then reported the incident to the Administrator, RP, the DON, and the doctor. Record review of progress notes also revealed multiple psych progress notes over the past two years. In an interview on 12/29/2025 at 10:10 AM LVN-B stated she was documenting at the nurses' station on 12/10/2025 (unsure of the exact time) when she heard Resident #2 yelling, so LVN-B ran around the nurses' station and saw Resident #2 hit Resident #1 twice in the right arm. LVN-B stated she was not sure who started it, or if anything happened prior to her witnessing Resident #2 hit Resident #1. She stated she and the CNA separated both residents, and skin assessments on were done on both residents. LVN-B stated neither resident had any injuries, redness, or bruising. LVN-B attempted to interview both residents after the incident, and neither recalled the incident. She stated Resident #2 was rambling about something which did not make any sense, and Resident #1 responded by saying something about those girls were fighting. LVN-B stated she had never seen Resident #1 be aggressive, other than not wanting others to touch her things. LVN-B also stated Resident #2 was confused and in his own little world all the time, and he did not like to be touched. She stated Resident #2 had multiple behavioral or aggressive outbursts over the past year or so, but he was currently out of the facility at a behavioral health hospital to be evaluated for his behaviors and for any needed medication adjustments, and she was not sure when Resident #2 would be returning. LVN-B stated they are in-serviced over abuse and neglect at least once per month, but usually multiple times a month. She stated the in-services had also included resident to resident aggression or conflict, and she knew in the event of resident-to-resident aggression, she would separate the residents, provide one-to-one monitoring for the aggressive residents. LVN-B would notify her the Administrator and DON regarding the incident, as well as notify the provider to obtain any needed orders. Then, she would notify the RP. In an interview on 12/29/2025 at 10:22 AM, the DON stated it was reported by LVN-B that she heard loud voices and ran down the hall where she saw Resident #2 making contact with Resident #1 on her arm. LVN-B separated the residents and placed Resident #2 on one-to-one monitoring. The DON stated both Resident #1 and Resident #2 reside in the memory care unit, but Resident #2 was currently at a behavioral health hospital. The DON stated Resident #2 had a history of aggression with other residents and had been sent to a behavioral health hospital previously, and he did good for a while, but then Resident #2 had episodes of aggression again. The DON stated the staff were hyper-vigilant in monitoring Resident #2 and anticipating his needs. The staff tried to get Resident #2 occupied with activities he might have enjoyed, such as music, but he rarely participated in activities. She also stated Resident #2 had multiple medication reviews and adjustments and saw psych services routinely. The DON stated the current steps were not working, and Resident #2 continued to have aggressive moments, so the facility was trying to figure out where to go from there. The facility discussed the issues with the family, and the family stated Resident #2 did well at the previous facility, but the previous facility did not have a memory unit or locked unit, which was one of the reasons he was transferred to a facility with a locked unit. The DON stated they have referred Resident #2 to many facilities, including an all-male facility, but the referrals were declined every time due to his aggressive behaviors, his wandering, and his background of being incarcerated. The DON stated they were still working on finding a facility which would be a good fit for Resident #2, but until it happened, Resident #2 would continue his stay at the behavioral health hospital, continue to have medication reviews, remain on the memory unit when he returned, and the staff would continue to keep a close eye on him, redirect him as needed, and try to anticipate his needs. In an interview on 12/29/2025 at 10:54 AM, the SS stated she followed up with both residents after the incident, and neither remembered the incident. The SS stated she sent a referral to the behavioral health hospital for Resident #2 because he usually did good, at least for a while, when he came back from behavioral health. The SS stated Resident #2 had been referred to the behavioral health hospital probably 3-4 times previously. She stated she had also tried to get him into an all-male facility, and other facilities, but none would accept him due to his history. The SS stated they (the facility) tried all the recommendations from the family and Ombudsman such as one-to-one monitoring, a locked unit, referrals to behavioral health, but none of the recommendations have worked. The SS stated she was still working on finding placement for Resident #2 in a facility where he might be a better fit. In an interview on 12/29/2025 at 1:11 PM, the Administrator stated LVN-B saw Resident #2 hit Resident #1 in the arm. He stated he was not sure what triggered Resident #2 prior to the incident. He also stated he was not sure what triggered Resident #2 prior to every aggressive outburst or behavior he had. The Administrator stated they have tried to figure out what triggered Resident #2, or what sets him off, but they could not determine any one thing which caused his aggressive outbursts. The Administrator stated Resident #2 was incarcerated previously, and he was not sure if he still had the mindset of being in prison since he was confused most of the time. The Administrator stated they have discussed progressive behaviors and outbursts with the family, as well as have tried to find placement in another facility, but the facility had no luck with finding anywhere to accept his referral. The Administrator stated they always followed any recommendations made by the Psych doctor, as well as his primary doctor, such as medication reviews, one-to-one monitoring with frequent or severe aggression, as well as educated staff to anticipate Resident #2's needs and assess for unmet needs. In an interview on 12/29/2025 at 2:31 PM, Resident #1 stated she lived in the facility so they would take care of her feet. She denied remembering any incident or altercation with any other residents. She denied experiencing any abuse by staff or residents. She was pleasantly confused. Record review of the facility's Abuse Prohibition Policy, revised 10/2022, revealed Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 treatment and medication carts (main treatment cart) reviewed for labeling and storage. The facility failed to ensure the main treatment cart belonging to RN-A was locked and secured. This failure could place the residents at risk of gaining access to unlocked medical supplies and medications which were not prescribed to them and could cause them harm.The findings included: Observation on 12/29/2025 at 8:19 AM revealed an unlocked treatment cart belonging to RN-A parked in the A Hall with no nurses or other staff around it. RN-A was in a room with a resident. There were residents noted to be ambulating in and down the halls. The main treatment cart lock was popped out, and all drawers were able to be opened and accessed. The main treatment cart was full of treatment supplies and treatment medications, to include scissors, needles, multiple containers of liquids, as well as a medication cup filled with a thick, white substance with a wooden spoon in it. Attempted to interview RN-A multiple times on 12/29/2025. She was performing treatments on residents at time the unlocked treatment cart was identified. RN-A left work early, as it was not her normal day or hours to work. Attempted to call RN-A multiple times on 12/29/2025 (called at 12:55 PM, texted at 12:56 PM, called at 5:01 PM) with no returned call or text from RN-A. In an interview on 12/29/2025 at 10:22 AM, the DON stated it was RN-A who worked on the main treatment cart today and did the resident treatments, and it was RN-A who left the main treatment cart unlocked. The DON stated all treatment carts and medication carts were to be locked for Resident safety if the nurse's step away from them. She stated if the carts were left unlocked residents could have gotten a hold of medications or supplies which could have caused them harm. She stated the last in-service for the nurses regarding medication carts was in November of 2024, so she went ahead and started an in-service today. In an interview on 12/29/2025 at 1:11 PM, the Administrator stated treatment and medication carts were supposed to be locked when not in use, and the nurses were responsible for their own medication and treatment carts. The cart was the responsibility of the nurse that was in control of it for that shift. He stated this was done for the residents' safety so they did not have access to medications or supplies which could harm them. The Administrator stated the DON had already started an in-service regarding this. Record review of the facility's Medication Storage Policy, dated 06/24/2025, revealed 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. 9. Unlocked medication carts are not left unattended.

Based on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #1 and Resident #2) of 2 residents reviewed for medical records.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #1's progress notes.LVN A failed to document a verbal and physical altercation on 10/08/25 between Resident #1 and Resident #2 in a timely manner in Resident #2's progress notes.LVN B failed to document injury assessments on Resident #1 in a timely manner.RN C failed to document injury assessments on Resident #1 in a timely manner. These failures could put residents at risk of improper care based on inaccurate or incomplete documentation.Record review of Resident #1's admission record reflected a [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included unspecified dementia with agitation (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with restless behaviors like pacing and rocking, as well as verbal or physical aggression like shouting or combativeness), mood disorder due to known physiological condition with depressive features (a mental health condition characterized by a disturbance in mood (like depression or mania) that is directly caused by a medical or physiological condition), and cognitive communication deficit (difficulty with communication).Record review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #1's progress notes reflected the following entries:Created date: 10/08/25 at 12:54 PM; Effective date: 10/08/25 at 12:50 PM by the MDS nurse, [PA-C] informed of incident with other resident and gave new order to increase Depakote 125mg PO TID. Order carried out and RP notified and agreed to medication increase. Floor nurse along with DON and Admin made aware of new order.Created date: 10/13/25 at 4:49 PM; Effective date: 10/08/25 at 4:46 PM by LVN A, CN was at nurses station and heard the resident in a verbal altercation with another resident in the hallway. CNA stated this resident was hit with a walker in the face by another resident passing him by. CNA separated both residents to de-escalate the situation. Resident stated, I don't know what happened, but he hit me. CN performed a head-to-toe assessment on the resident for any injuries. Resident had redness to the left eyebrow and under his left eye. Resident stated he had pain to the area. CN administered Tylenol to relieve the pain. RP, DON, ADMN and MD were notified.Created date: 10/15/25 at 4:05 PM; Effective date: 10/10/25 at 4:03 PM by LVN B, The resident with no noted injuries from altercation on 10/08/25, no bruising, nor redness noted to face nor upper body, the resident has no recollection of the incident.Created date: 10/16/25 at 5:24 AM; Effective date: 10/10/25 at 9:21 PM by RN C, No evidence of bruising or redness noted to face, or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Created date: 10/15/25 at 4:07 PM; Effective date: 10/11/25 at 4:00 PM by LVN B, The resident with no noted bruising nor redness to face nor upper body from altercation on 10/08/25, no c/o of pain voiced denies pain when asked. The resident does not remember anything about the altercation.Created date: 10/16/25 at 5:25 AM; Effective date: 10/11/25 at 8:15 PM by RN C, No evidence of bruising or redness noted to face or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Created date: 10/15/25 at 4:10 PM; Effective date: 10/12/25 at 1:07 PM by LVN B, The resident does not have any noted bruising nor redness to the face nor upper body from the altercation on 10/08/25, denies pain when asked, no c/o of pain voiced. the resident has no recollection of the altercation.Created date: 10/16/25 at 10:26 PM; Effective date: 10/12/25 at 10:30 PM by RN C, No evidence of bruising or redness noted to face or upper torso present from altercation on 10/08/25. No indication of pain. Continue plan of care.Record review of Resident #2's admission record reflected n [AGE] year-old male admitted to the facility on [DATE]. His relevant diagnoses included Alzheimer's disease with early onset (progressive brain disorder that slowly destroys memory and thinking skills) and unspecified dementia, unspecified severity, with other behavioral disturbance (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities with behavioral disturbances such as depression, agitation, and wandering).Record review of Resident #2's quarterly MDS dated [DATE] reflected a BIMS score of 4 which indicated severe cognitive impairment. Record review of Resident #2's progress notes reflected the following entry:Created date: 10/13/25 at 4:51 PM; Effective date: 10/08/25 at 4:50pm by LVN A, CN was at nurses station and heard the resident in a verbal altercation with another resident in the hallway. CNA stated this resident hit the other resident with a walker in the face as he passed the other resident. CNA separated both residents to de-escalate the situation. When asked what happened the resident stated, I am tired of him cussing at me (in spanish). CN performed a head-to-toe assessment on the resident for any injuries. No visible injuries or pain noted at this time. RP, DON, ADMN and MD were notified. CN call MD's office to request an order for a UA and labs. MD agreed STAT. Labs and urine have been collected. Pending results. Resident was placed on a 1:1 monitoring plan.In an interview on 11/26/25 at 3:25 PM, LVN B stated she was told in report about Resident #1 and Resident #2's altercation. LVN B stated, The nurse heard yelling, and she saw [Resident #2] hit [Resident #1] with his walker. [Resident #1] may have Tourette's because he will just be walking down the hall and say curse words. [Resident #2] is sensitive to other's words, so they keep [Resident #1] and [Resident #2] away from each other. LVN B stated she forgot to document the follow ups on 10/10/25, 10/11/25 and 10/12/25. She stated she was off on 10/13 and 10/14 and documented them on 10/15. LVN B stated she was advised the documentation was not done in morning report on 10/15/25. She stated she did the documentation and also told RN C that it needed to be done during report at shift change that evening. LVN B stated if something was not documented, it did not happen. She stated if things were not documented accurately and timely, it could lead to residents not receiving the care they needed. She stated documentation in-services were conducted at least every 3 months, and the last one was in October. She stated when that type of incident occurred, the nurse did a physical aggression-received report for the victim and physical aggression- initiated report in incident/ risk management reports which gave the steps to follow and progress notes were part of those steps. LVN B stated Resident #2 had not had any other incidents of physical aggression.In an interview on 11/26/25 at 4:18 PM, Resident #1 stated he felt safe in the facility and was not afraid of anyone. Resident #1 could not recall ever being hit by anyone or anything.In an interview on 11/26/25 at 4:24 PM, Resident #2 stated he did not remember hitting Resident #1 with his walker. He stated he was friends with Resident #1 and would never hit him. He stated he felt safe in the facility. In a telephone interview on 11/26/25 at 5:10 PM, LVN A stated she did not see the incident happen. She stated she heard something in the hallway, walked toward it, and asked the hospice CNA that was close by what happened. The hospice CNA told her Resident #1 and Resident #2 had a verbal altercation then Resident #2 picked up his walker and smacked Resident #1 in the face with it. LVN A stated she saw a red mark on Resident #1's face. LVN A stated she did put a progress note in, but she did not sign and lock it because she was told the DON needed to see it first. LVN A stated she was off from 10/10/25 to 10/12/25, and on 10/13/25, she went into her progress notes and signed/locked it so it would show up. She did not lock it on 10/08/25 because she was waiting on the DON to read it and approve it. LVN A stated there were no other issues between Resident #1 and Resident #2. She stated Resident #1 cursed and made inappropriate remarks all the time even with redirection. LVN A stated they automatically did an incident report that showed up in progress notes once it was copy/pasted at the end of the incident report. She stated it was important to document things when they happened so that details would not be forgotten and so that others knew what was going on with the resident. She stated she did not recall the last in-service for documentation.In a telephone interview on 11/26/25 at 5:43 PM, RN C stated she was told by the nurse she relieved (LVN B) to go back and make sure there was documentation of Resident #1's injury assessments from the altercation on 10/08/25. RN C stated she was told there was an altercation between Resident #1 and Resident #2, but was not aware Resident #1 had been hit since he did not have any injuries or any changes in behavior. Resident #1 and Resident #2 had not had any altercations prior to or since that incident and staff made sure they were apart. RN C stated it was important to document things so other staff were aware of what was going on with the resident and could provide appropriate care. In an interview on 11/26/25 at 6:05 PM the ADON stated it was important to document incidents accurately and timely to ensure the resident got the care/treatment necessary. The ADON stated when nurses were initially hired, she did a skills check off with them which included documentation. She stated nurse skills were also done annually and as needed. The ADON stated LVN A saved the initial progress note on 10/08/25 but she did not sign it, so it did not show up in the progress notes for that day. She stated annual evaluations and skills check offs were done quarterly. In an interview on 11/26/25 at 6:39 PM, the MDS nurse (who was acting DON) stated it was important to document things as they happened for the safety of the residents, to note interventions, and so other staff were aware of what was going on with the resident. She stated nurses had been educated and in-serviced that they were to document for 72 hours for any issues/incidents. The MDS nurse stated if things were not documented, the resident was at risk of not getting the care they needed. She stated nurses were in-serviced on documentation upon hire, annually, and as needed.Record review of the facility's Policy for Resident Incident and Visitor Accident Report dated 06/05/25 reflected in part: .3. Pertinent documentation must be completed:. d. Nurse Progress Notes. g. Follow up documentation every shift for 72 hours or more frequently if needed.

Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, and 2 of 2 nutrition rooms reviewed for storage, preparation, and sanitation. The facility failed to ensure the ice machine chute was clean. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the steam table wells were clean. The facility failed to ensure the underside of the shelf directly above the range was clean. The facility failed to ensure containers of spices were not left open to air. The facility failed to ensure items in the dry storage area were sealed properly. The facility failed to ensure items in the refrigerators were labeled and dated. The facility failed to ensure food in the walk-in freezer were sealed properly. The facility failed to ensure there were no personal items in the walk-in freezer. The facility failed to ensure the cleaning schedule was followed and monitored. The facility failed to ensure the dishwasher sanitation was correct. The facility failed to ensure all kitchen logs were recorded, maintained, and monitored. The facility failed to ensure items in the nutrition refrigerators were labeled, dated, and not expired. The facility failed to ensure there were no personal items in the nutrition rooms or refrigerators. These failures could place residents who received meals and/or snacks from the kitchen risk for food contamination and food borne illness. Findings included: During the initial tour and observation of the kitchen on 06/17/25 at 9:10 AM revealed the following: *chute inside the ice machine had a removable black-brown substance along the edge where the ice dumped out. *The juice gun inner nozzle had a thick red and a thick black substance stuck in the holes of the inner nozzle and black round spots around the threads where the outer nozzle connects with the inner nozzle. *Four of four steam table wells had a thick, yellowish substance that was flaking and floating in all four wells. The substance covered the bottoms and all sides of the wells. *The range top was covered in food particles and shiny with what appeared to be grease. *The underside of the shelf above the range, directly over cooking food, had a removable, gritty, brownish-red substance in clumps. *3 of 11, 15-ounce containers of spice were open to air. *an open and unsealed 35-ounce bag of cereal in the dry storage area. * 3, 6.4-ounce bags of powdered seasoning mix that was not sealed properly with one of the bags open inside the unsealed bag in the dry storage area. * a cut onion in the walk-in refrigerator in an unsealed, undated, and unlabeled bag. *3 undated and unlabeled trays of beverages in the walk-in refrigerator. * a beverage pitcher half full of a brown liquid that was undated and unlabeled. * an undated and unlabeled 16-ounce beverage cup from a local fast-food establishment on the shelf in the walk-in freezer. *a 9.84-pound box of frozen enchiladas that was open to air and had crystalized ice on the product in the walk-in freezer. *heavy ice build-up in the back left corner of the walk-in freezer. *an unsealed, undated, and unlabeled 1-gallon bag of an unidentifiable substance in the walk-in freezer. *The Low-Temp dishwasher chem strip read 10 ppm (parts per million) during the rinse cycle. *3 of three dumpsters had the lids open. 1 of the dumpsters' lids was broken. The open dumpsters could be seen through the windows of the main dining room. Observation of the B-wing nutrition room on 06/19/25 at 8:30 AM revealed the following: *1,16-ounce unopened bottle of water, *1,16-ounce half full bottle of water, *1 quart-size bag of green grapes, *1, 1-liter container of unknown food, *approximately 34 ice pops were unlabeled and undated, *1, 8-ounce, near empty container of sour cream and 1 large container of unknown food were labeled with a resident's name, but not the contents and not dated, and *1 opened 20-ounce container of strawberry jam had an expiration date of 04/08/25, was unlabeled and undated. Observation of the secure unit nutrition room on 06/19/25 at 8:40 AM revealed the following: *1, 16.9-ounce unopened bottle of water in the refrigerator that was unlabeled and undated. *a large purse in the nutrition room. During a return visit and observations of the kitchen on 06/19/25 at 8:50 AM revealed the following: *the chute inside the ice machine had the same removable black-brown substance along the edge where the ice dumped out and the filter had visible dust on it. *The juice gun inner nozzle had the same thick red and a thick black substance stuck in the holes of the inner nozzle. *The underside of the shelf above the range, directly over cooking food, had the same removable, gritty, brownish-red substance in clumps. *a 5-pound bag of opened brownie mix and a 10-pound package of dry pasta that were open and unsealed in the dry storage area. In an interview with DA 1 on 06/17/25 at 9:15 AM, he said the juice gun was cleaned every 4 days and they used it a lot. He detached the outer nozzle from the inner nozzle of the juice gun exposing clogged holes where the juice came through. He said he did not know what that was (clogging the holes). He said they were not dispensing any black drinks through the juice gun. He said the black substance was removable. He said the black substance might be mold. He said the drinks were getting cross-contaminated and could make residents sick. In an interview with the DW on 06/17/25 at 9:20 AM, she said the chem strip (sanitation level) for the dishwasher should be purple. She said she marked it in the log every day she worked before she started her shift-it was the first thing she did. When asked to see the log where she documented the sanitation level, she said, I didn't do it. I didn't test it (the sanitation level). She said she did not know what ppm's were or why it was important to maintain a specific level in the dishwasher rinse cycle. She demonstrated a chem strip test during the rinse cycle, the test strip color matched 10 ppm on the container of test strips. She said she was unaware of the large, printed instructions for using and reading chem strips that were on the front of the dishwasher. She said the process of washing dishes was to place dishes in a bin, run the bin through the dishwasher, let them air dry, then put them on the clean rack. She did not understand un-sanitized dishes and utensils should not be used for service. In an interview with the DS on 06/17/25 at 9:25 AM, she said the juice gun inner nozzle had mold on it. She said the juice gun was cleaned after each shift. She said the steam table wells had hard water staining them. At this time, the DS began to look for the cleaning schedules and temperature logs. She said she could not find the cleaning schedules. She said all food should be sealed, labeled, and dated. She said she did not know why the foods, spices, and beverages in the refrigerator, freezer, and dry storage room were not sealed, labeled, or dated. She said the chem strip for the dishwasher should be 100 ppm (parts per million). She said she had in-serviced staff regarding the above issues. She said personal items were never allowed in the kitchen or freezer. She would not say who the cup from a local fast-food establishment belonged to in the walk-in freezer. She said nothing when asked about the shelf over the range and the range being dirty. She said the dishwasher was the low temp kind. She said she was responsible for everything in the kitchen. Policies for dry storage, refrigerated foods, cleaning schedules, dishwasher sanitation logs, chem logs, in-services/trainings, and the RD were requested at this time. In an interview with the IADM, on 06/18/25 at 2:32 PM, she said it was important to have logs for the kitchen for infection control purposes as well as knowing if equipment was in working order and regulations required them. She said cleaning was really important for the kitchen because it was very susceptible to bacteria growth-the utensils and everything in the kitchen could harbor bacteria and make the residents sick if it was not being cleaned regularly and thoroughly. Kitchen policies, logbooks, cleaning schedules, in-services, and the RD were re-requested at this time. In an interview with ADON 1 on 06/19/25 at 8:40 AM, she said there were two nutrition rooms and they each had a designated refrigerator for the residents. She said all staff were responsible for labeling and dating everything in the nutrition refrigerators. In an interview with LVN A on 06/19/25 at 8:42 AM, he said the grapes and one of the bottles of water in the B wing nutrition refrigerator belonged to him. He said the nutrition room refrigerator was designated for the residents. He said everything in the nutrition refrigerator was supposed to be labeled with the resident's name, dated, and initialed by the person who received the item. He said the items required names and dates to make sure the food was still good. He said if staff did not know how old the food was, it could make the residents sick if consumed. He said food was good for 2 or 3 days. He said all staff were responsible for labeling and dating all food in the nutrition refrigerators to protect the residents. He said cross contamination would occur if mingling staff personal items with resident items. He said he had no excuse for not putting his personal items in the break room refrigerator where it belonged and for not labeling and dating them. In an interview with CNA B on 06/19/25 at 8:47 AM, she said the purse in the secure unit nutrition room belonged to her and she should not have left it there. She said she should have put her purse in the break room, which just outside the secure unit double doors. She said personal items inside the nutrition room could cause cross contamination to the residents and make them sick. She said she did not have an excuse as to why she had her purse in the nutrition room. She said everything in the nutrition room refrigerator should be labeled with the resident's names and dated. In an interview with DA 2, DS, and the cook on 06/19/25 at 9:35 AM, DA 2 said she did not notice the spices were open because she was not looking in that direction. She said she put the brownie mix in the dry storage area without properly sealing it and did not know why. She said she knew she should have put the brownie mix away properly, so it did not go bad. The cook said she put the cut onion in the walk-in Tuesday because she was in a rush. She said not storing foods and beverages properly could be very dangerous because food could grow mold and bacteria and could poison people. The DS and the cook said it was everyone's responsibility to keep the kitchen clean and safe. The DS said it was her ultimate responsibility to make sure the kitchen was operating as it should (meaning the logs were up to date, tasks were monitored, as well as the staff). The DS said the kitchen staff, usually herself, wiped down the ice machine inside and out every two weeks. She said the MS cleaned the filters and the inner workings every two weeks, so that was the schedule she followed for cleaning the ice machine and she did it when the MS was there, doing his thing. The DS said she could only find the daily cleaning schedules for June 2025. The DS said she did not know why the temperature logs were not consistent. She said she did not check them like she should have. She said she did not know if the temperatures got mixed up with the refrigerator or what but would have known had she been checking them. In an interview with the MS on 06/19/25 at 9:40 AM, he said he did not know when the ice machine was last cleaned but it was well over a month ago. He said he inspected the ice machine and did maintenance (cleaned the filter and inner workings around the motor) on it when the electronic reporting system popped up the task for it every 3 months. He said he defrosted the ice machine and wiped everything down. He said he ran a chemical through the system that cleaned the water pipes. He said he was the only one that cleaned the ice machine and was not sure if kitchen staff had anything to do with cleaning the ice machine. He said the discoloration on the ice chute was a build-up of dust. He said he did not know how dust could get inside the ice machine. He said the discoloration on the ice chute could be mold. He said he did not know the manufacturer's instructions or the facility policy for cleaning the ice machine. He said he did not check the logs in the kitchen. He said he was unaware of the ice build-up in the walk-in freezer. He said he was not responsible for the kitchen. During a phone interview with the Regional Lead Dietician on 06/20/25 at 3:30 pm, he said he visited the facility twice a month and once remotely. He said he had been going to the facility since November 2024. He said the DS reached out to him once a week or every other week for advice about food substitutions. He said his visits in April and May 2025 revealed some issues. He said he initiated in-services for sanitation in general including hairnets, hand washing, dry food boxes on the ground, logs were not filled out such as refrigerator, and freezer logs-there were several weeks not recorded in April or March 2025. He said he needed to hold people more accountable and had stressed to the DS that everything had to be clean all the time. He said there was an issue with kitchen employees having drinks in the kitchen. He said he told them they could not have personal drinks anywhere at any time inside the kitchen. He said, evidently there was no follow up after he left, and he needed to do more. He said there was lack of accountability. He said he also spoke to kitchen staff about having the dumpster lids closed. He said he was going to the facility next week to address the issues. He said he could not explain why the logs we not completed. Cleaning Policy requested. Record review of the facility's Daily kitchen 21-item cleaning checklists dated 06/01/25-06/14/25 revealed a total of 294 opportunities: Refrigerator, Freezer, Dry Storage, Counters, Steamtable, Mixer (crossed out-did not have one), Microwave, Toaster, Food Processor/Blender, Juice Machine, Coffee/Tea Urns, Slicer (crossed out-did not have one), Can Opener, Trash Cans, Steamer (crossed out-did not have one), Carts, Range/Grill, Oven, Pot & Pan Sink, Sinks, Dish machine, Ice Machine, Ice Scoop & Holder, and Floors. All tasks were checked as having been done. Record review of the facility's Freezer Temp Logs for 2025 revealed the following: January *the log for the month of January was missing. February *had no days recorded. March *walk-in freezer temps for morning and evening recorded for days 1-11 at 37-38 degrees F, *freezer temp log for the same time period was recorded at 32 F the morning of the 4th and 10th, all other days (from 1-11) were recorded at 35-37 F. There were no other days or evenings recorded. April *walk-in freezer temps were recorded 37F for the 1st-5th, and the 10th and 11th. No other days or evenings were recorded. * Freezer Temp Log was identical to April walk-in freezer temps. May * Freezer Temp Log was recorded for days 1-12, evenings 1-14 and the 29th and 30th. There were no temps recorded for the days of 13th-30th. 32 F or less was recorded 15 times out of 60 opportunities. The other temps recorded were 34F-37F. There was no May Walk-in Freezer Temp Log. June *Freezer Temp Log was missing the morning and evening of the 1st and 16th, and the evening of the 15th. All other temps logged were 10-13F. Record review of the facility's Refrigerator Temp Logs for 2025 revealed the following: January, March, and April *the logs were missing. February *had no days recorded. May *1st-12th days and evenings were recorded, and the evenings of the 13th, 14th, 29th, and 30th. All other days and evenings were blank. All temps were recorded as 32 F-41F. June *The log was missing the morning and evening of the 1st, 15th , and 16th. All other recordings ranged from 35 F-37 F. Record Review of the facility's Sink Temperature and Chemical logs for 2025 revealed the following: January *the log was missing. February *had no days recorded. March *days 1-11 had water temperatures ranging from 141-150F for breakfast and no sanitizer recorded. There were no temperature or sanitizer recorded for any days recorded for lunch. Days 1-15 had water temperature recorded that ranged from 147-152F. There were no days recorded for sanitizer. All other days were blank. April *days 1-5, 10, and 11 recorded at 150F for dinner only. There was no sanitizer recorded for any days or services in April. May *had temperatures recorded on days 1-13, 14 and 15, 29th and 30th. Temperature ranged from 122 F-130F for breakfast service, 125F-132F for lunch, and 120F-137F for dinner. Sanitizer was recorded as 160-180 ppm for days 1-13 for breakfast, 150-200 ppm for lunch, and 150-350 ppm for dinner service. June had no temperature or sanitizer recorded for days 1-16 breakfast and lunch services. Dinner service had temperatures recorded for 80 F-165 [NAME] days 1-13. There was no sanitizer recorded for dinner service on days 1-5. Days 6-13 had sanitizer recorded for dinner service as 100 ppm for each day. June *the 17th had water temperature recorded as 181 F and sanitizer as 100 ppm for breakfast service. Temperature for the 17th lunch service was 160F and 100 ppm sanitizer. There were no other dinner service recordings after the 15th of June. The 18th breakfast service recorded the water temperature at 125 F and sanitation at 000 ppm. Record Review of the facility's Dish Washer Temp and Chemical Log for 2025 revealed the following: January *the log was missing. February * there were no entries until days 11,12, and 13. Days 14,15, and 16 were blank. All recorded temperatures ranged between 135F and 152F. All sanitizer recordings were 100ppm for breakfast, lunch, and dinner services. March *the log was missing day 15 for all three services. All other temps ranged from 140F-160F. All sanitizer entries for all services were 100ppm. April *was missing days 7 and 8. All other temperatures were recorded ranging from 130F-172F for all services. All sanitizer entries for all services were 100ppm. May * was missing days 1, 2, 6, 28 lunch and dinner services, and the 29th had no entries. All other temperatures ranged from 140F-170F. All sanitizer entries for all services were 100ppm. June *the 17th and 18th were missing entries. The 17th had didn't use marked through the entire day. All other temps ranged from 140 F-172F. All sanitizer entries for all services were 100ppm. Record review of the facility's kitchen in-services revealed: Undated- No phones are to be out at all in kitchen during shift, Maintain professional behavior and respect co-workers, 04/15/25- Temp. Logs, Labeling, Cleaning Schedule. 05/09/25- Temp. Logs, Labeling, Cleaning Schedule. Record review of the ice machine task from the electronic reporting system revealed Instructions Ice Machines: Check filters (if present), clean coils, sanitize interior, delime as necessary. Marked done on-time by MS on June 13, 2025. Record review of the dish machine invoice dated 06/18/25 at 8:50 AM-9:50 AM revealed performed a check on dispenser to see if sanitizing solution was dispensing properly. Checked solution, shows the proper amount is being dispensed per test strip reading-solution testing between 50-100ppm. Record review of the facility policy dated 10/2022, titled, Food Receiving and Storage revealed under the policy statement: Foods shall be received and stored in a manner that complies with safe hood handling practices. 8. All foods stored in the refrigerator or freezer will be covered, labeled, and dated ( use by date). 9. Refrigerated foods must be stored below 41 F unless otherwise specified by law. 12. Functioning of the refrigerators and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. 14. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items .must be placed in the refrigerator located at the nurses' station and labeled with a use by date. b. All foods belonging to residents must be labeled with the resident's name, the item, and the use by date. c. Refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four hours. e. Other opened containers must be dated and sealed or covered during storage. f. Partially eaten food may not be kept in the refrigerator. Record review of the facility policy dated 10/2022, titled, Refrigerators and Freezers revealed the policy statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperature ranges are 35F to 40F for refrigerators and less than 0F for freezers. Record review of the facility policy revised 01/2024, titled, Sanitation revealed under policy statement: The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas, and dining areas shall be kept clean . 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair . 8. Dishwashing machines must be operated using the following specifications: Low-Temperature Dishwasher (Chemical Sanitation) a. Wash temperature (120F); b. Final rinse with 50 ppm chlorine for at least 10 seconds. 11. b. Fixed Equipment 2. Staff members will be trained in the cleaning and maintenance of all equipment. 3. Food contact equipment will be cleaned and sanitized after every use. 11. Ice machines will be drained, cleaned, and sanitized per manufacturer's instruction and facility policy. 16. The food services manager will be responsible for scheduling staff for regular cleaning of the kitchen. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the facility policy reviewed 01/2023, titled, Dry Storage revealed: 3. All items must be dated with the date that the food was delivered. 9. If an item is open, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If the food is directly in the bag, the bag must be sealed. 10. Lids on spices should be closed. Record review of the facility policy dated 04/2017, titled, Job Description-Dietary Manager revealed: under Supervisory Responsibilities Carries out supervisory responsibilities in accordance with the organizational policies and applicable laws .Ensures that food is received, stored, prepared, held, and served under sanitary conditions to prevent the transmission of food borne illness. Completes and maintains all food and nutrition services department records .Participates in long term care survey process. Instructs staff in matters of con disclosure. Always maintains presence while surveyors are on-site and timely collection of information required by the survey team. Demonstrates identified problems and undertakes corrective action while survey is in progress.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 (100-hall nurse cart) medication carts reviewed for medication storage. 1. The facility failed to write the open date on the vial of Resident #10's multidose Lantus insulin vial in the 100-hall nurse cart. 2. The facility failed to write the open date on the vial of Resident #133's multidose Lispro insulin vial in the 100-hall nurse cart. This deficient practice could place residents at risk of receiving expired insulin. The findings included: 1. Record review of Resident #10's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Pertinent diagnosis included Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to high blood sugar levels). Record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 (cognition intact). Further review revealed Resident #10 had received seven insulin injections in the past seven days. Record review of Resident #10's comprehensive care plan dated [DATE] revealed the focus The resident has Diabetes Mellitus initiated on [DATE]. An intervention listed for the focus stated [DATE] Lantus insulin added and will be administered per MD orders initiated on [DATE]. Record review of Resident #10's order summary revealed an active order dated [DATE] for Insulin Glargine Solution 100 UNIT/ML. Inject 55 unit subcutaneously at bedtime for diabetes related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. 2. Record review of Resident #133's face sheet dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Pertinent diagnosis included Type 2 Diabetes Mellitus. Record review of Resident #133's Comprehensive MDS assessment dated [DATE] revealed a BIMS score of 14 (cognition intact). Further review revealed Resident #133 had received seven insulin injections in the past seven days. Record review of Resident #133's comprehensive care plan had not been completed at the time of record review. Resident #133's baseline care plan indicated to administer medications as ordered by the physician. Record review of Resident #133's order summary revealed an active order dated [DATE] for Insulin Lispro Prot[[NAME]] & Lispro Subcutaneous Suspension (75-25) 100 UNIT/ML (Insulin Lispro Protamine & Lispro). Inject 150 unit subcutaneously two times a day for [diabetes mellitus] related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS. During an observation on [DATE] at 2:40 PM of the 100-hall nurse cart, this state surveyor found two opened, undated vials of insulin in the top drawer of the cart inside their original box. The label on the first vial stated it was Humalog (brand name for lispro) mix 75/25 and was for Resident #133. The label on the second vial stated it was Lantus and for Resident #10. Neither vial had an opened-on date written on the vial or box. In an interview with LVN D on [DATE] at 4:38 PM, LVN D stated she wrote the date an insulin vial was opened on the vial and its box as well. LVN D stated she was currently the nurse in charge of the 100-hall. LVN D stated she was unable to find any opened-on date on either of the two insulin vials or boxes found in the 100-hall nurse cart. LVN D stated she always checked the expiration date on an insulin vial before administering any insulin to a resident. LVN D stated it was important to write the opened-on date on insulin vials because they expire after only 28 days. LVN D stated administering expired insulin to a resident may not be as effective and lead to an elevated blood sugar level. In an interview with ADON 1 on [DATE] at 1:28 PM, ADON 1 stated nurses write the date an insulin vial was opened on the sticker attached to the insulin vial. ADON 1 stated nurses checked the expiration date on the vial before administering insulin to any resident. ADON 1 stated if expired insulin was administered to a resident, it may not be as effective leading to hyperglycemia (elevated blood sugar) or it could have an unpredictable effect. In an interview with the CCS on [DATE] at 2:02 PM, the CCS stated nurses wrote the date the insulin vial was opened on the sticker on the vial. The CCS stated nurses checked the expiration date on the insulin vial before administering it to a resident. The CCS stated if a nurse found an opened insulin vial that was not dated, they should inform the DON and then get a new vial if the insulin was determined to potentially be expired. The CCS stated expired insulin may not have the intended effect on a resident, leading to possible harm. Record review revealed the facility policy titled Medication Administration last reviewed [DATE] stated the following: .12. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Based on observations, interviews, and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41% based on 2 errors out of 27 opportunities, which involved 2 of 4 residents (Resident #45 and Resident #133) reviewed for medication errors. - LVN C failed to administer medication as ordered to Resident #45 by administering only one 400 mcg tablet of folic acid (Vitamin B-9, important in red blood cell formation and cell growth) instead of 800 mcg as ordered. - LVN C failed to administer medication as ordered to Resident #133 by holding one 12.5 mg tablet of hydrochlorothiazide (diuretic that lowers blood pressure as well as treat fluid retention) despite an active order to administer it. These failures could place residents receiving medication at risk of inadequate therapeutic outcomes. The findings included: 1. During an observation on 06/18/25 at 8:25 AM, LVN C prepared medications for Resident #45 during medication pass. LVN C only gathered one 400 mcg tablet of folic acid from the medication bottle. LVN C only administered one 400 mcg tablet of folic acid to Resident #45. This state surveyor asked LVN C if she was finished administering medications to Resident #45 and she stated she was finished. Record review of Resident #45's order summary revealed an active order dated 05/28/25 for Folic Acid Oral Capsule 0.8 MG (Folic Acid). Give 1 capsule via G tube one time a day for SUPPLEMENT related to ANEMIA, UNSPECIFIED. 2. During an observation on 06/18/25 at 8:34 AM, LVN C prepared medications for Resident #133 during medication pass. LVN C did not pop any hydrochlorothiazide tablets out of the blister pack to administer to Resident #133. LVN C did not administer any tablets of hydrochlorothiazide to Resident #133. This state surveyor asked LVN C if she finished administering medications to Resident #133 and she stated she was finished. Record review of Resident #133's order summary revealed an active order dated 06/10/25 for hydrochlorothiazide Oral Tablet 12.5 MG (Hydrochlorothiazide). Give 12.5 mg by mouth one time a day for hypertension [elevated blood pressure] related to ESSENTIAL (Primary) HYPERTENSION. In an interview with LVN C on 06/18/25 at 11:02 AM, LVN C stated Resident #45 had an active order for 800 mcg of folic acid 1 time per day. LVN C stated she administered 0.4 mg of folic acid to Resident #45 earlier that day. LVN C stated there were no 0.8 mg tablets in the nurse's cart. LVN C stated she made an error in only administering 1 400 mcg folic acid tablet to Resident #45. LVN C stated she chose to hold the hydrochlorothiazide for Resident #133 because her blood pressure was low. LVN C stated Resident #133 had three other blood pressure medications that were all held as well because Resident #133's blood pressure was below the threshold for administering them. LVN C stated the order for hydrochlorothiazide stated it was used to treat hypertension, so it should have had the same parameters on it as the other blood pressure medications. LVN C stated it was important for residents to receive medications as ordered so their symptoms and conditions did not worsen and harm the resident. In an interview with ADON 1 on 06/19/25 at 1:28 PM, ADON 1 stated before administering medication, nurses and med aides should compare what was written in the MAR to what was written on the blister pack to ensure there were no inconsistencies. ADON 1 stated LVN C should have given 800 mcg of folic acid to Resident #45 during medication pass. ADON 1 stated LVN C should have administered the hydrochlorothiazide to Resident #133 because the order was correct as written. ADON 1 stated the order did not have hold parameters because it was being used primarily to treat edema (excess fluid in the body tissues). ADON 1 stated the administration of incorrect doses of medications or holding medications inappropriately could lead to unnecessary changes in the treatment plans of residents leading to harm. In an interview with the CCS on 06/19/25 at 2:02 PM, the CCS stated if LVN C had questions about whether to administer the hydrochlorothiazide to Resident #133, she should have called the doctor to confirm the order. The CCS stated the order did not have hold parameters because it was being used primarily to treat edema. The CCS stated holding medications when they were supposed to be administered could harm the residents because it was not what the doctor ordered. The CCS stated errors in medication administration could lead to unnecessary changes to the treatment plan of residents. Record review revealed the facility policy titled Medication Administration last reviewed 07/08/24 stated the following: .4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interviews and record reviews, the facility failed to ensure the right to be free from abuse for two (Residents #2 and #3) of 4 residents reviewed for abuse. The facility failed to ensure Resident #2 was free from abuse. On 05/09/25, Resident #1 slapped Resident #2 in the face twice with an open hand because Resident #2 would not give Resident #1 her napkin. The facility failed to ensure Resident #3 was free from abuse. On 05/10/25, Resident #1 grabbed Resident #3 ' s arm and slapped it four times with an open hand, once with each word, while she said, I told you so. This failure could place residents at risk for abuse and psychological harm. Findings included: Record review of Resident #1's face sheet dated 06/27/22 with an original admitted [DATE] revealed a [AGE] year-old female with diagnoses including Alzheimer ' s, (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, Diabetes, high blood pressure, major depression, anxiety disorder, and abnormalities of gait and balance. Record review of Resident #1's quarterly MDS Assessment, dated 03/15/25, reflected a [AGE] year-old female who admitted on [DATE]. Her BIMS score of 03 indicated the resident had severe cognitive impairment with physical behavioral symptoms such as hitting or scratching occurring 1 to 3 days. She required supervision for oral hygiene and eating, moderate assistance with upper body dressing, and maximal assistance with toileting, showering, lower body dressing, footwear, and personal hygiene. She could walk, reposition herself, and transfer with supervision. She did not utilize a wheelchair or walker. She was frequently incontinent of bladder and bowel. She was taking an antidepressant and insulin. Record review of Resident #1's Care Plan dated 07/02/22, reflected Resident #1 had potential to be physically aggressive r/t Dementia, Depression, and Poor impulse control Date Initiated: 01/10/2023 Revision on: 01/10/2023. Resident #1 had a behavior problem r/t yelling, hits, throws things and uses abusive language due to Alzheimer's with poor cognition. RP often will refuse to allow treatment or medications for the behaviors. 05/05/25 altercation with Resident #2. 05/10/25 altercation with Resident #3 Date Initiated: 01/13/23 Revision on: 05/14/25. Resident #1 was placed on 1:1, psyche services contacted, and new orders for medication were received and implemented. 05/10/25 Removed from situation, placed on 1:1, new order for Depakote 125mg twice a day for mood stabilizer. Consent was obtained from the RP when she came in to visit the resident. Date Initiated: 05/10/25. 05/05/25 Resident removed from the situation. Placed on 1:1 observation, social worker trying to get the resident to a local Psych Hospital. Date Initiated: 05/06/25. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 01/13/23. Be conscious of resident position when in groups, activities, dining room to promote proper communication with others. Date Initiated: 07/10/22. The resident uses antidepressant medication (Prozac) r/t Depression Date Initiated: 07/10/22 Revision on: 10/31/22. She resided in the memory care locked unit. Record review of Resident #2's face sheet dated 04/18/25 with an original admitted [DATE] revealed a [AGE] year-old female with diagnoses including dementia (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), muscle wasting, anxiety disorder, depression, and abnormalities of gait and balance. Record Review of Resident #2's admission MDS Assessment, dated 05/01/25, reflected her BIMS score of 03 indicated the resident had severe cognitive impairment. She required supervision with eating, lower body dressing, personal and oral hygiene, toileting, transferring, and repositioning. She required moderate assistance with upper body dressing and footwear. She utilized a manual wheelchair and could propel herself. She was frequently incontinent of bladder and bowel. She took antianxiety and antidepressant medications. Resident #2's admission care plan dated 04/18/25 reflected Resident #2 was an elopement risk/wanderer r/t poor cognition and psychosis. Date Initiated: 04/18/2025 Revision on: 04/18/2025. She resided in the memory care locked unit. Record review of Resident #3's face sheet dated 06/19/23 revealed a [AGE] year-old female with diagnoses including dementia and early onset Alzheimer ' s (disease that results in loss of memory, language problem, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anxiety and mood disorders, major depression, and lack of coordination. Record Review of Resident #3's quarterly MDS Assessment, dated 02/06/25, reflected her BIMS score of 05 indicated the resident had severe cognitive impairment. She required set-up with eating. She required maximal assistance with oral hygiene. She was dependent for dressing, personal hygiene, and toileting. She was independent for walking, transferring, and repositioning. She did not utilize a wheelchair. She was frequently incontinent of bladder and bowel. She took antipsychotic, antianxiety, anticonvulsant (seizure), and antidepressant medications. Resident #3's care plan dated 04/18/25 reflected Resident #3 was on palliative care with hospice services due to end stage disease process of Alzheimer's. Expected physiological signs of weight loss, skin breakdown or pressure injury, dehydration, fecal impaction and gradual /rapid loss of the ability to move about or become bedfast is expected. Date Initiated: 07/02/23 Revision on: 07/22/23. Dignity will be maintained, and the resident will be kept comfortable and pain free with in one hour of intervention over the next review period Date Initiated: 07/02/2023 Target Date: 06/11/2025. I/my family, anticipate that I will remain LTC (Long Term Care) after respite stay is completed so that all of my needs can be met on a daily basis with safety. Date Initiated: 07/02/23 Revision on: 07/02/23. The resident is physically aggressive r/t dementia, depression, poor impulse control. Date Initiated: 07/22/23 Revision on: 07/22/2023. She resided in the memory care locked unit. Observation of Resident #1 in the memory unit on 05/13/25 at 2:30 pm revealed she was in the restroom. Upon leaving the restroom, she was ambulatory with a slow gait and could walk without assistive devices. She made her way with the hospitality aide at her side to one of the sofas in the memory care activity room. She sat down without difficulty or losing her balance. The hospitality aide sat down beside her. She was talkative with the hospitality aide while sitting on the couch. She was touching herself in between the legs and smiling. She was trying to take her pants down even though she just came out of the restroom. She told the hospitality aide she needed to use the restroom again for a bowel movement. She was saying she forgot toilet paper when she was sitting on the couch. In an interview with the hospitality aide, she said she was currently 1:1 with Resident #1 because she either fell recently or hit someone else. She said she had worked at the facility for 4 weeks and said Resident #1 did not hit others very often. In an interview with LVN A on 05/13/25 at 5:54 pm, she said she worked at the facility for 3 years and was familiar with all of the residents in the memory unit, as she only worked in the memory unit. She said Resident #1 got physical faster and would usually strike first. She said Resident #1 got agitated for no obvious reason-she saw her hitting a window with a belt one time. She said she was not at the facility during the incident between Resident #1 and Resident #3, but she heard Residents #1 and #3 were arguing and one hit the other and Resident #1 was put on 1:1 and she has stayed on 1:1 status ever since. She said the doctors were also making medication changes on Resident #1. In an interview with the SW on 05/14/25 at 9:30 am, she said she had worked at the facility since June 2025. She said on 05/10/25 she called the RP to discuss Resident #1's behavior. She said the local psychiatric hospital called the daughter to tell her they could meet Resident #1's needs and the RP told them her mother did not need psychiatric care, and she demanded to speak with the doctor's there. The SW said she received a phone call from the local psychiatric hospital and was told the RP would not let the intake specialist at the local psychiatric hospital get a word in to explain the procedures and the phone call ended there. She said the local psychiatric hospital called her (the SW) and told her they had been aggressively spoken to by the RP and the local psychiatric hospital closed out the referral. The SW said a meeting was held with the RP, ADM, DON, and RD. She said the RP told her she did not want Resident #1 to be on psychotropics because they would make her too sleepy. The SW said the RP told her she was going to see if the other nursing home in town would take her. The SW said the RP was able to get a referral yesterday (05/13/25) to transfer Resident #1 to the other nursing home in town. The SW said the Ombudsman would meet with the SW, RP, ADM, and DON on Friday, 05/16/25. Interview with LVN B on 05/14/25 at 1:43 pm, she said Resident #1's RP had not wanted her to be on any medications, and the facility was just recently able to try the medications (last 5 days ago). LVN B said she explained to the RP that it would take several days or even weeks for the medications to take effect. LVN B said the RP did not want Resident #1 to go to the local psychiatric hospital for evaluation and stabilization. LVN B said the facility told the RP if she did not allow them to try psyche or meds on Resident #1, they would have to transfer her due to not being able to meet her needs. She said the RP agreed this time. LVN B said the facility called the local psychiatric hospital back and they refused Resident #1 due to the way she treated them on the phone. She said she called the doctor and had to get consent for the medication Resident #1 needed. She said she called the RP to inform her and she gave consent. LVN B said Resident #1 was only on the Depakote for 3 days before Resident #1 slapped the arm of Resident #3. She said they were standing near each other when Resident #1 picked up Resident #3 ' s arm and said, I. Told. You. So., slapping lightly with each word as if she was reprimanding a child and was placed back on 1:1. She said she informed the RP and the RP told her she was scared Resident #1 would be thrown out (of the facility). LVN B said she called the doctor again and was placed on Zoloft and Trazodone. LVN B said Resident #1 remained on 1:1 until she was cleared by psyche. LVN B said the doctor saw Resident #1 in the facility on Sunday, 05/11/25 when he changed her meds. She said the RP came 2-3 times a week at lunch. She said staff in the memory unit got special training including the virtual dementia course. She said she told the RP about the course so she could try to better understand what Resident #1 was going through. She said Resident #3 did not seem to be effected or fearful and she did not recall the altercation at all. In an interview with the SW on 05/15/25 at 8:45 am, she said she reached out to a behavioral health hospital in the valley yesterday and they requested lab results for Resident #1, and she was still waiting for a call back at this time. In an interview with the DON on 05/15/25 at 1:00 pm, she said all staff received dementia training on computer based training and Virtual Dementia training. She said the families and community were also offered the virtual opportunity. She said the last virtual training was in November and done annually and as needed. She said Resident #1's RP had not done any of the dementia training that she knew of. The DON said everyone was invited to the dementia classes and courses via flyers, social media, and through their mass messaging for families. She said Resident #1 had a history of aggression. She said from Dec. 31, 2022, physical aggression was initiated by risk management (incidents & accidents). She said the facility was protecting other residents because they had Resident #1 on 1:1, doing/saying/watching to try to find a root cause, labs with urinalysis (UA), medication changes, and was currently trying to get her into a facility like a behavioral hospital to see if they could make medication changes or be able to help her with whatever therapy modalities they had such as group therapy. She said the facility may have found a place in the valley-they were waiting for a call back today. She said Resident #1 had been on 1:1 continuously since 05/05/25. The DON said the facility had Resident #1set up to transfer to the local behavioral hospital but they declined because her RP was hostile toward them. She said the RP came to the facility and met with the ADM, DON, SW and the RP 's SIL. She said during the meeting, the RP was reluctant and unsure and not understanding so she wanted to call the local behavioral hospital again, so they did and that was when the local behavioral hospital said they did not have a bed for Resident #1. The DON said the RP was upset at the news then agreed to let Resident #1 go somewhere and the meeting finished. She said encounters/incidents with Resident #1 started 10/2023 when she was yelling at another resident. She said the next encounters/incidents involving Resident #1's aggression was 12/3/0/24, 05/05/25 at 1:54 pm with Resident #2, and 05/10/25 with Resident #3. She said Residents #2 and #3 did not seem to be effected or fearful and neither recalled the altercations at all. In an interview with the ADM on 05/15/25 at 2:00 pm, he said he started working at the facility on 12/29/24. He said he first learned of Resident #1's aggression when she slapped Resident #2 in the face earlier this month. He said the 1:1 and in-services were immediate. He said the RP blocked the transfer to the local behavioral hospital because of her hostility towards them. He said he spoke to the RP and explained why the facility needed to get the help her mother needed that could not be attained at the facility. He mentioned the RP said I don ' t have time; I have a life when the facility asked if she or someone else could sit with Resident #1. He said the physician came in on Sunday 05/11/25 and met with him. He said the physician prescribed medication for insomnia and anxiety for Resident #1. He said he spoke with the RP Tuesday 05/13/25 and informed her of the 1:1 and she was upset and demanding to know how long she was going to be on the 1:1. The RP also told the other nursing home in town Resident #1 was on a 1:1 so they did not want to accept her and told the ADM he could lift the 1:1. He explained he could not for the safety of others. He said the facility was providing 1:1's and more education specific to the aggressors to keep others safe. He said he was interviewing the staff in the memory unit to make sure they knew who the abuse coordinator was, reporting immediately, and approved paid in-services utilizing videos on the company you tube page. He said he also discusses incidents in their daily morning meetings with the department heads. In an interview with the SW on 05/15/25 at 2:25 pm, she said the valley behavioral hospital was waiting for their clinical intake person to review the lab results for Resident #1 she sent this morning. She said she had not started a NOMOC because Resident #1 was LTC and she would be considered a transfer. She said if Resident #1 was denied at the valley behavioral hospital, the next behavioral hospital was near, and she would keep trying until she found a suitable fit for Resident #1. She said the RP told the other nursing home in town Resident #1 was a 1:1 and they declined. She said the RP wanted to speak with the Ombudsman face to face, and a meeting was set for 05/16/25 at 1:15 pm. In an interview with CNA C, LVN B, CNA D, and RN E on 05/15/25 at 2:45 pm, they all stated the Abuse Coordinator was the ADM. CNA C said she worked only in the memory unit and worked at the facility for [AGE] years. She said staff received in-services and seminars for training. She said they got the Virtual Dementia Training Annually. She said they also had courses on the electronic education courses such as abuse, transfers, infection control and more. She said some of the symptoms they were taught to look for if a resident was starting to become aggressive were pain, agitation, pacing. LVN B said if a staff member did not have dementia training, they had to take the all-day course. CNA D said staff they had to take the dementia course and testing for it. RN E said she was the instructor for the CNA ' s and hospitality aides at the facility. She said the courses included dementia, behavior managing, communication, falls, safety risks, sensory impairment, agitation, and being hypervigilant. They all said Residents #2 and #3 did not seem to be effected or fearful and neither did not recall the altercations at all. The RP was not available for interview after 3 good faith attempts to contact her. Record review of all staff in-service/training dated Record review of in-services: dated 05/05/25 All staff Abuse resident to resident. Record review of psychiatric physician note dated 05/08/25 revealed Resident #1 was released from 1:1 status. Record review of 15-minute monitoring of Resident #1 beginning 05/09/35 at 6:00 am through 05/11/25 at 12:00 pm. Record review of PIR (provider investigation report) dated 05/09/25 revealed Resident #2 was sitting in her wheelchair holding a napkin. Resident #1 attempted to grab the napkin to no avail resulting in Resident #1 slapping Resident #2. Head to toe assessments conducted on both residents. No physical or emotional distress noted to either resident. Residents were immediately separated to make sure residents were protected including if Resident #2 felt safe, increased supervision for Resident #1 by placing her on 1:1, immediate notification to physician and RP ' s and removal of alleged perpetrator. Family conference was held with Resident #1 ' s RP. In-service for Abuse and Neglect initiated for all staff. No malicious intent was determined by Resident #1. Residents did not recall the interaction. A referral was made to the local behavioral health hospital for Resident #1. He said because of the communication between the local behavioral health hospital and RP, they failed to secure a bed. He said Resident #1 ' s RP expressed she did not want Resident #1 on medications because she would fall. The facility suggested the RP come in and sit with her mom and she said, I have a life and I don't have time to sit 1:1. The ADM said another family member was also present during the conference and expressed the same concerns. He said when the doctor was on site, he gave new orders for Resident #1's anxiety and insomnia. The ADM said the RP finally gave verbal consent for med adjustment. He said Resident #1 would stay on 1:1 supervision. The ADM said, However, another altercation occurred with Resident #3 on 05/10/25. No injuries noted to either resident. He said the SW, himself, and the DON were still working with family for further review on what to do next about Resident #1' s aggressions. Record review of progress note by LVN B dated 05/10/25 at 7:03 pm: COMMUNICATION - with Physician, Situation: Resident #1 was in the activity room and was standing next to Resident #2. Resident #1 grabbed Resident #3 by the left arm and hit her three times and said I told you so in Spanish. LVN B assessed the resident, removed her from other residents, ensured her safety and notified RP, DON, ADMN, MD. New order has been obtained for on-on-one monitoring and has been initiated. Doctor has been contacted and gave a new order for Depakote 125mg BID for mood stabilizer. UA culture was also ordered to rule out UTI. Consent was obtained from RP. Record review of the facility policy titled, In-Service Training, Nurse Aid reviewed 12/09/24 4. Annual in-services: d. address the special needs of the residents, as determined by the facility assessment. e. include training that addresses the care of residents with cognitive impairment; and f. include training in dementia management and resident abuse prevention. 9. Required training topics for all staff (including nurse aides) include: c. abuse, neglect, and exploitation of residents; g. behavioral health. Record review of the facility policy titled, Abuse, Neglect, and Exploitation dated 08/15/22 defined abuse as the willful infliction of injury or intimidation. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on observation, interview and record review the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 4 medication carts observed for compliance. Medication cart #1 was left outside of room [ROOM NUMBER] unlocked and unattended by RN A. This failure could place residents at risk of access and ingestion of non-narcotic medications. This failure had the potential to affect 5 residents in this hall. Findings were: During an observation on 11/7/2024, at 8:39 a.m., Medication cart #1 unlocked on hall 400 without a supervised staff in view of the cart. The cart was unlocked for 5 minutes until RN A was questioned about the unlocked cart. During an interview on 11/7/2024 at 10:45 a.m., RN A verbalized the unlocked cart was her cart. She verbalized she must have forgot to lock the cart after giving her last medication. RN A stated it was proper process to lock the cart when the cart was not in view or when not being used. She also stated a resident could have accessed the medications in the drawers that were accessible. RN A stated all narcotics were locked in a double locked drawer and were not accessible. RN A stated she should have taken the medication cart back to the nurses station with her. During an interview on 11/7/2024 at 9:12 a.m., the Director of Nursing (DON) stated medication carts should be locked when licensed personnel walk away from the cart. The DON stated a resident could have opened the cart and taken a medication that was not theirs. All carts were to be within the line of sight of the staff member utilizing the cart or locked this prevents residents from obtaining access to improper medication. During an interview on 11/12/2024 at 2:50 p.m., the Administrator stated the expectation for all staff using medication carts was that they are locked when not in use and to follow the medication administration policy. The policy was in place to ensure the residents were kept safe. The unlocked cart could have allowed a resident access to the medications in the cart other than narcotics because they were locked in a drawer. A review of the Administering Medication policy dated 07/08/2024 number 19 revealed During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident ' s room, with open drawers facing inward, and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.

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 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to ensure dry goods were sealed 2. The facility failed to ensure dry goods were labeled and dated 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to refrain from having personal items in the prep areas 5. The facility failed to label and date items in the walk-in refrigerator 6. The facility failed to label and date items in the walk-in freezer 7. The facility failed to maintain temperature logs for refrigerators and the freezer 8. The facility failed to maintain temperature and sanitization logs for the 3-compartment sink 9. The facility failed to maintain proper lighting in the walk-in refrigerator 10. The facility failed to maintain the door latch in walk-in freezer These failures could place residents at risk of foodborne illnesses. Findings included: Observation and initial tour of the kitchen on [DATE] beginning at 9:20 AM revealed 1, partially full, 5-gallon bucket of rice was open to the air with a large scoop inside. There were 8, 16-oz. containers of spices open to the air. There was a bag of 6 slices of white bread with an expiration date of [DATE], and a bag of 8 hamburger buns with an expiration date of [DATE] in the dry storage area. 5 of 5 steam table wells were heavily crusted on the sides and bottoms with a flaking, yellow-whitish substance. There were no covers on the plate warmers. The light in the walk-in refrigerator was very dim. The latch on the walk-in freezer did not lock and there was ice build-up on the wall. There was a large purse with personal items visible inside it on a prep table. There was an opened, unlabeled, and undated 16-oz. bottle of water on a beverage cart with resident's beverages. There was a set of keys on a lanyard, a personal phone, a plastic file of papers, an ink pen, and other papers on a different prep table (the beverage prep table). There was a purple personal cup of ice with no lid on the shelf in the dry storage room. The light in the walk-in refrigerator was very dim. In the walk-in refrigerator, there was an unlabeled, undated 5-pound bag of shredded cheese open to the air, 4 uncovered, unlabeled, and undated cups of desserts on a tray of 13 other desserts, all unlabeled and undated, and 40 cups of beverages unlabeled and undated. In the walk-in freezer, there was a 2-gallon bag of cinnamon rolls, a 2-gallon bag of enchiladas, a 10-pound bag of breaded fish, a 10-pound bag of tamales, and a 10-pound bag of breaded chicken breasts all open to the air, unlabeled and undated. In an interview with the FSM on [DATE] beginning at 9:30 AM, he stated the bucket of rice should have been covered at all times and the scoop should not have been in there. The FSM stated the spices should have been closed because particles could fall into them and that would be cross contamination. The FSM stated the bread and buns were expired and should have been thrown out. The FSM stated the steam table wells were cleaned nightly and the pans were new; they should be shiny. The FSM stated the particles floating in the steam table wells could contaminate the food and make residents sick. The FSM stated the cleaning log had been filled out as if the steam table had been cleaned daily, but the steam table wells did not look like they had been cleaned very recently, if at all. The FSM stated he did not know why there were no plate covers on the plates in the plate warmer. The FSM stated the plates would lose their heat, and the plates could get contaminated from particles in the air dropping on them, causing cross contamination and make residents sick. The FSM stated he was unaware the freezer latch had been broken and without a good seal on the door, the food inside could become damaged. The FSM stated he had not noticed the ice on the wall of the walk-in freezer. The FSM stated he was aware of the dim light in the walk-in refrigerator but did not know how to change the bulb, did not pursue how to, nor follow up. Further, the light in the walk-in refrigerator had been dim like that for weeks. The FSM stated the purse belonged to one of the dietary aids and should not have been on the prep table because of cross contamination. The FSM stated the water bottle belonged to one of the dietary aids and should not have been on the beverage cart with the resident's beverages because of cross contamination The FSM stated the set of keys on a lanyard belonged to him and they should have been on a hook on the wall because of cross contamination. The FSM stated the personal phone on the beverage prep table should not have been there because of cross contamination. The FSM stated the file of papers, an ink pen, and other papers on the beverage prep table should not have been there because of cross contamination. The FSM stated the purple personal cup of ice with no lid on the shelf in the dry storage room should not have been there because of cross contamination and it could have spilled, creating more cross contamination. The FSM stated the items in the walk-in refrigerator and freezer should all have been sealed, labeled, and always dated. The FSM stated the uncovered, undated, and unlabeled cups of desserts in the walk-in refrigerator were from yesterday. The FSM stated the items in the walk-in freezer that were open to the air were at risk for becoming freezer burned and should have been thrown out because they were no longer good and if it were used, it would taste bad and possibly make the residents sick. In an interview with DA-A on [DATE] at 9:35 AM, she stated the water bottle on the beverage cart was hers, and it was her personal phone on the beverage prep table, she said they should not have been there because cross contamination could occur and make the residents sick. DA-A stated she did not know why she put her personal belongings on the beverage prep table, and guessed it was ok because the other items were on the table. In an interview with DA-B, on [DATE] at 9:40 AM, she stated the purse and purple cup on the prep table belonged to her, and they should not have been there. DA-B stated her personal purple cup of ice was on the shelf in the dry storage room because she moved it from the prep table, and it should not have been there either because cross contamination could occur and make the residents sick. DA-B stated the cup should have always had a lid on it because it could have spilled and contaminated the prep table and/or items in the dry storage room. DA-B stated she did not sanitize the prep table after removing her personal belongings from it. DA-B stated all stored items, whether in dry storage or the refrigerator or freezer, should always be labeled, dated, and sealed. DA-B stated she was unaware of the unlabeled, undated, and open to the air items in the dry storage, the refrigerator, or the freezer. DA-B stated she was always having to clean extra water out of the milk refrigerator and did not know what was causing it, nor told anyone about it-she just did it. Record review of the cleaning log dated [DATE] documented the steam table wells had been cleaned daily from [DATE]-[DATE]. Observation in the kitchen on [DATE] at 12:05 PM revealed in the walk-in refrigerator, 6 trays (20 cups per tray) of desserts and beverages all unlabeled and undated, the same items seen on day 1 ([DATE]) that were open to the air, now including 2, 2-gallon bags of salad that had a thick-like brown liquid inside the bag. The milk refrigerator had 24 1-gallon containers of milk inside. In an interview with the FSM on [DATE] at 12:10 PM, he stated he was responsible for checking the walk-ins and he did not do it today. The FSM stated the milk refrigerator was not holding temperature and they were having to wipe up condensation off the floor because of it. The FSM stated he was not sure why the milk refrigerator was not working properly. The FSM stated he did not know if he was responsible for the milk refrigerator and had mentioned it to the maintenance supervisor. Observation and record review in the kitchen on [DATE] at 11:00 AM, revealed a personal phone on a prep table next to a container of pureed yellow food. There was no temperature log for the milk refrigerator or the 3-compartment sink sanitation and temperature. In an interview with the FSM on [DATE] at 11:13 AM, he stated he did not have any temperature logs for the walk-ins, the milk refrigerator, or 3-compartment sink. The FSM stated he did not know he was supposed to have logbooks for temperatures and had no way of knowing if the equipment was operating within parameters. The FSM stated he had not informed the ADM about the milk refrigerator or the plate warmer covers. The FSM stated he had contacted the company to replace the milk refrigerator several times but they would not replace it and he stated he did not have a copy of the contract. The FSM stated there was a risk of slip/fall accidents due to the condensation on the floor. The FSM stated he was not aware of his responsibilities as a food service manager. The FSM stated he was not aware of the facility policies regarding the kitchen but was aware there were policies. In an interview with Cook-A on [DATE] at 11:15 AM, she stated it was her phone on the prep table, she needed to use the restroom, so she just set her phone down on the prep table, indicating she was using her phone in the work area of the kitchen. Cook-A stated she was sorry and could have easily dropped her phone in her pocket instead of putting it on the prep table and did not know why she did not. Cook-A stated she knew better and putting personal items on the prep tables was a source of cross contamination. Return trip to the kitchen and interview with the ADM on [DATE] at 1:20 PM, revealed the steam table wells now had a black substance on the bottoms along with a flaking, yellow-whitish substance. There was an 80-oz. partially full bag of instant dry milk and a 5-pound box of breading that were unlabeled, undated, and unsealed in the dry storage room. In an interview with the ADM on [DATE] at 1:27 PM, she stated she was unaware of the milk refrigerator malfunctioning and did not know there had been no temperature or sanitization logs. The ADM stated she was unaware of the dim light in the walk-in refrigerator or the broken walk-in freezer latch. The ADM stated the MS was out, but he could be reached via phone. In an interview with DA-B on [DATE] at 1:30 PM, she stated she had been a kitchen worker for years and knew there was supposed to be temperature logs for all the refrigerators, the freezer, and the 3-compartment sink. DA-B stated she told the FSM about not having logs 6 months ago, but he did not do anything about it. DA-B stated she did not notify anyone else because it was the FSM's responsibility. In a phone interview with LSC, ADM, and the MS on [DATE] at 3:17 PM, the MS stated the milk cooler was rented and it was the FSM's responsibility to replace. The MS stated he replaced the bulb in the walk-in refrigerator with the only bulb he could find. LSC asked the MS if he looked online or contacted the manufacturer for the bulb and the MS stated he did not. LSC asked the MS if he was aware of the broken latch on the walk-in freezer and the MS stated he noticed it a couple of weeks ago when he was working on the freezer fan. The MS stated he knocked ice off the latch but needed to go back and check the latching mechanism to see if it needed a part or if it was just coated with ice. Record review of the FSM's certification revealed a certificate of completion for an 8-hour course dated [DATE] titled Food Safety Management Principles. Record review of the RD's certification revealed a licensed dietician with an expiration date of [DATE]. Record review of the facility's undated position description for dietary department director revealed the FSM was to report to the ADM and/or the RD. The job summary revealed, This position will provide management for the facility dietary department, ensuring quality food. It will report directly to the facility administrator and/or the dietician. It will direct and assist the preparation and serving of regular meals and therapeutic diets, order food and dietary supplies, maintain area and equipment in sanitary condition. This individual will assume administrative authority, responsibility, and accountability of managing the dietary department. Job Responsibilities: .directs and manages all facility dietary functions and personnel, develops job descriptions, cleaning schedules, and other dietary management tools, assures that proper storage is available, and that handling of food and supplies complies with federal guidelines. Position Qualifications: .Minimum 5 years dietary experience in long term care or hospital setting, strong organizational skills with attention to detail, ability to manage and maintain a safe and operating kitchen . Record review of In-services: [DATE]-Care and Services-employees cannot refuse reasonable requests from residents, [DATE]-Dress code, Fostering Mutual Respect and Professionalism. Record review of the facility's policy titled Food Preparation and Service dated ,d+[DATE] documented under Policy Statement, Food and nutrition employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area 4. Appropriate measures are used to prevent cross contamination. Food Preparation, Cooking, and Holding Time/Temperatures 1. The danger zone for food temperatures is between 41 F and 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Record review of the facility's policy titled Refrigerators and Freezers dated ,d+[DATE] documented under Policy Statement, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. 1. Acceptable temperature ranges are 35 F to 40 F for refrigerators and less than 0 F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials, and action taken. 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. 6. Information regarding acceptable storage periods for perishable foods will be kept in the supervisor's office. A condensed version will be posted by each refrigerator and freezer for reference. 7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be comp let ed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes. 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition. fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. Record review of the facility's police titled, Food Receiving and Storage dated ,d+[DATE] documented under Policy Statement, Foods shall be received and stored in a manner that complies with safe food handling practices. Under policy interpretation and implementation: 7. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by date). 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (' use by date). 9. Refrigerated foods must be stored below 41 F unless otherwise specified by law. 11. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. 14. Food items and snacks kept . must be maintained as indicated below: a. All food items to be kept below 41 F must be placed in the refrigerator . and labeled with a use by date. e. Refrigerators must have working thermometers and be monitored for temperature according to late-specific guidelines. d. Beverages must be dated when opened and discarded after twenty-four (24 ) hours. e. Other opened containers must be dated and sealed or covered during storage. f. Partially eaten food may not be kept in the refrigerator. Record review of the facility's police titled, Sanitization revised Jan. 2024 documented under Policy Statement, The food service area shall be maintained in a clean and sanitary manner. Under Policy interpretation and implementation: 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 9. Manual washing and sanitizing will employ a three-step process for washing, rinsing and sanitizing: a. Scrape food particles and wash using hot water and detergent b. Rinse with hot water to remove soap residue; and c. Sanitize with hot water or chemical sanitizing solution. 12. Kitchen waste that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. 16. The Food Services Manager will be responsible for scheduling staff' for regular cleaning of the kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment .

Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R#2) reviewed for accidents. The facility failed to provide R #2 with adequate supervision, resulting in falls on 08/13/23 and 08/17/23. This failure could lead to the injury of residents that are at risk of falls. The findings included: Record review of R #2 's file reflected a [AGE] year-old female, with an original admitted [DATE]. Her diagnoses included: unspecified fracture of upper end of left humerus (upper arm bone), muscle wasting and atrophy, other lack of coordination, cognitive communication deficit (difficulties with thinking and how someone uses language), dysphagia (swallowing difficulties), cerebral infarction (stroke), anxiety disorder, and other specified depressive episodes. Record review of R #2's MDS assessment dated [DATE] reflected R#2 had a BIMS score of 12 (moderate cognitive impairment) and required extensive assistance for bed mobility, transfer, locomotion on/off unit (how resident moves between locations), dressing, eating, toilet use, and personal hygiene. MDS reflected R #2 uses a mobility device: wheelchair. Record review of R #2's Care Plan dated 08/22/23 reflected Focus: R #2 has limited physical mobility due to weakness and left humerus fracture. Date initiated: 08/22/23 Interventions included: Physical therapy and occupational therapy referrals as ordered, pro re nata (PRN) (as needed). Focus: The resident has had an actual fall with serious injury due to poor balance, psychoactive drug use, and unsteady gait. Date Initiated: 08/22/23 Interventions included: On 08/16/23: floor mattress next to bed while in bed for safety On 08/17/23: R #2 will be taken to bed after meals and shower, not left alone in wheelchair, bed in lowest position, call light within reach, fall mats beside bed, sent to emergency room for evaluation and treatment. - Continue interventions on the at-risk plan. - Monitor/document /report PRN for 72 hours to doctor for signs and symptoms: pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, and agitation. - Pharmacy consult to evaluate medications. - Physical therapy consult for strength and mobility. Focus: The resident is high risk for falls due to confusion, gait/balance problems, incontinence, psychoactive drug use, and unaware of safety needs. Date Initiated: 08/22/23 Interventions included: - Follow facility fall protocol. - Physical therapy evaluate and treat as ordered or PRN. Record review of Hospital records dated 08/13/23 at 3:20 PM reflected right arm x-ray with no fracture noted. Record reflected a head computer tomography (CT) (medical imaging technique used to obtain detailed internal images of the body) scan was done with a right frontal scalp hematoma noted. Record reflected CT of facial bones with no fracture. Record reflected a CT of the cervical spine with no fracture. Record review of X-Ray from mobile x-ray imaging date of exam: 08/17/23 reflected left shoulder, left humerus, left elbow, left forearm, left wrist, and left-hand x-rays complete. Findings: There is an acute displaced left humeral neck fracture with angulation (normal axis of the bone has been altered). No dislocation is identified. Mild degenerative changes are present. Impression: Acute displaced left humeral neck fracture. Electronically signed on: 08/17/23 at 11:01 PM. Record review of Hospital records dated 08/17/23. Patient visit information: altered mental status and shoulder fracture (left). Shoulder fracture received on 08/18/23 at 1:14 AM. Left shoulder fracture requires immobilization with arm sling, and orthopedic referral. 95 % of the case was treated non-surgically. The patient can follow up with orthopedic referral as an outpatient. The treatment is shoulder immobilization and analgesics. Education was provided for shoulder fracture. Record review of R #2's file reflected progress notes: On 08/11/23 at 11:08 PM, written by: LVN A. Resident arrived at facility via facility transportation van, resident was transferred from another facility to this at 3:00 PM. Resident is at facility for long term care. Resident was in good spirits; resident was noted with discoloration on left hand and bruising on bilateral upper extremities. Resident denied any pain to the area. Resident is incontinent of both bowel/bladder, full code, 1-person physical assist, alert and oriented X 3. Resident has a diet of NAS (low sodium diet), Pureed texture, Nectar thickened, and needs assistance with feedings. Resident's family was present during resident's admission and had no verbal concerns. Notified NP on resident's arrival and to verify medications, there were no verbal concerns made. On 08/13/23 at 3:36 PM, written by: LVN A. Housekeeper notified nurse that resident was on the floor in the hallway. Upon assessment resident was laying on the right side, with her right arm tucked under. Resident was wearing socks, floor was dry, and clutter free. Head-To-Toe Assessment was done. Neuro checks in place. Resident was assessed for pain. Resident is alert and oriented to person, place, and time. Hematoma (bump) to the head noted on resident's right temporal, PERRLA (pupils equal, round, reactive to light and accommodation) noted. NP notified, emergency contact notified, DON notified, EMS notified for transportation, RN from Hospital was notified on resident's situation and transportation. On 08/13/23 at 5:51 PM, written by: LVN A. RN from Hospital called to give report regarding to resident. Resident has negative CT scans with a hematoma on the scalp and negative x-ray on the right upper extremity. RN stated there were no new orders and resident is going to be transferred back to facility. At 5:40 PM resident arrived at facility via stretcher, resident is in good spirits and denies any pain. PERRLA noted. Notified emergency contact about resident's arrival, no verbal concerns were made. Notified NP, no verbal concerns were made. On 08/14/23 at 10:31 AM, written by: Social Worker (SW). Care plan meeting was held, in attendance was SW, Business office manager (BOM), activities director, responsible party (RP), and RP's family member. BOM discussed insurance authorization that is going on. BOM explained how the insurance covers therapy. DON discussed the possibility of needing psych services. RP wants resident going to dining room and will need help feeding. Director of Rehab (DOR) explained the therapy services. RP stated plan is to stay long term. DON explained that resident will stay full code (intercede if a resident's heart stops beating or if the resident stops breathing) until power of attorney (POA) is filled out and do not resuscitate (DNR) order can be signed. On 08/16/23 at 11:58 AM, written by: MDS Coordinator. late entry: Resident stated that she wanted to get up from bed and go to the bathroom, let resident know that she cannot get up on her own. Resident attempted to stand up on her own and fell on her knees on the side mat that is next to her bed that is in the lowest position. The room was clutter free. Notified CNA to help assist resident back to bed. Performed head-to-toe assessment, no bruising or active bleeding was noted. Resident denied any pain. Neuros have been placed. Notified ADON, NP, and Emergency contact. On 08/17/23 at 12:39 PM, written by: LVN B. Communication with physician: Resident had a fall in the hallway in front of the shower room. Resident was sitting down on her bottom. Resident denied hitting her head. Resident stated that she had pain to her left shoulder area. No distress noted. Resident noted with bruising and skin tear to left elbow. Bruising with skin tear measuring at 3 x 1.5 centimeters. Head to toe and skin assessment done. Encouraged resident to not try and stand or walk alone. Skin tear cleansed with saline, pat dried with gauze, applied marathon (liquid skin protectant) to stop bleeding and secured with dressing. On 08/17/23 at 1:34 PM, written by: LVN B. Resident had a fall and landed on her left elbow area. Resident noted with bruising and skin tear to left elbow. Resident reported pain and was given PRN medication for pain. PCP contacted and received orders for x-ray on left shoulder, elbow, and wrist. X-ray company called for x-rays and will call back with estimated time for arrival. RP aware of situation. On 08/17/23 at 10:35 PM, written by: LVN B. X-ray company here to perform x-rays. Pending results. On 08/17/23 at 11:45 PM, written by: LVN C. NP updated with x-ray results. Order send resident to ER for evaluation/treatment. EMS transported resident to ER. RPs updated. Questions answered. DON informed. Report called to staff at ER. On 08/18/23 at 2:25 PM, written by: LVN A. Resident arrived from ER from Hospital at 2:00 PM, resident arrived via stretcher. Resident is alert and oriented X 3. Notified NP and RP. Faxed over discharged papers to NP. No verbal concerns were made. Record review of the Facility Investigation Report dated 08/13/23 reflected a fall with injury. Incident location: hallway. Person preparing report: LVN A. Nursing description: Housekeeper notified nurse that R #2 was on the floor in the hallway. Upon assessment, R #2 was lying on the right side, with her arm tucked under. R #2 was wearing socks, floor was dry, and clutter free. R #2 unable to give description. Immediate action taken: Head-to-toe assessment was done. Neuro checks in place. R #2 was assessed for pain. R #2 was alert and oriented X3. Hematoma to the head noted on R #2's right temporal. NP and RP notified. DON notified. EMS notified for transportation. RN from hospital notified on R #2's situation. R #2 was taken to the hospital. Injuries observed: hematoma to top of scalp. Level of pain: 6. Mental status: oriented to person, situation, and place. No injuries observed post incident. Predisposing situation factors: admitted within last 72 hours. Witnesses listed as Housekeeper and R #8. DON, FM, and MD notified. Notes: R #2 anxious and RP revealed R #2 was on medication for anxiety and hallucinations. NP to be in on 08/15/23 to evaluate and adjust medications as needed. R #2 to be put in bed after each meal within a timely manner. Fall mat to be placed at bedside when R #2 is in bed. Call light within reach. RP and MD aware. Full body assessment completed. Neuros in place. Incident witness: R #8. Dated 08/13/23. Statement: R #8 stated that she saw R #2 trying to get out of wheelchair and then fell on the ground. Incident witness: Housekeeper. Dated on 08/13/23. Who took statement: LVN A. Statement: Housekeeper was in hallway cleaning when she heard R #8 say someone fell , then notified nurse. Record review of Provider Investigation dated 08/28/23 reflected date and time reported to HHSC on 08/18/23 at 8:55 AM. Incident category: other, fall with injury. Incident date and time on 08/17/23 at 12:05 PM. R #2 required no special supervision, was not able to ambulate independently, was not interviewable, and did not have the capacity to make informed decisions. Provider response: Head-to-toe assessment, MD notified, RP notified, orders obtained for x-ray to left shoulder, R #2 sent to the hospital to confirm fracture. Investigation Summary: R #2 had an unwitnessed fall in the hallway in front of the shower room at approximately 12:05 PM. R #2 was found by the CNA sitting on her bottom. R #2 stated she was trying to walk. The hallway was free from clutter and of spills leading to the fall. The nurse was notified, and a head-to-toe assessment completed. R #2 was noted with bruising and a skin tear to her left elbow with complaints of pain to her left shoulder. RP notified, MD notified, and orders obtained for an x-ray. At approximately 10:35 PM, X-ray on Wheels arrived at the facility and performed x-rays to left shoulder, humerus, elbow, forearm, wrist, and hand. At approximately 1:45 AM results showed an acute displaced left humeral neck fracture. R #2 sent to ER for confirmation and returned to the facility on [DATE] at 2:25 AM with confirmation of left humeral neck fracture. Orders to follow up with ortho. Peer to peer surveys with 15 employees show no signs of neglect. Life satisfaction rounds with 9 random residents show no signs or trends of neglect. Facility concluded the resident's fall was not due to neglect or abuse and fracture was a result of the fall. Neglect/Abuse unsubstantiated. Investigation findings: Unconfirmed. Provider action taken post-investigation: In-services on fall prevention with 18 staff. R #2 pending referral from insurance for an ortho follow up. Facility to continue all previous fall interventions. Interventions: bed in lowest position, fall mats, R #2 to be placed in bed after meals and showers. Therapy to evaluate and treat. Psych evaluation for anxiety concerns. Witness statement dated 08/18/23 reflected LS was walking through the dining hall. LS saw R #2 on the floor and reported it to the cafeteria aide. She reported it to AD. LS saw a CNA and she attended to R #2. A nurse went to R #2. Signed. Record review of the in-service record dated 08/18/23 for Topics: abuse and neglect, fall prevention, and plan of care (POC). Record review of the Policy: Resident Incident and Visitor Accident Report Policy (revised 07/23/18) Resident Incidents/Accidents: -If staff witness an incident/accident, staff must: immediately summon help, do not move the resident until he/she has been assessed by a licensed nurse, and do not leave the resident unattended. -Licensed nurse must: examine the resident and obtain vital signs, if the resident hit his/her head or if the incident is unwitnessed initiate neurological checks, conduct further assessment as warranted, render appropriate treatment, notify the physician, family, legal representative, and notify the administrator/designee and/or DON/designee. In an interview with R #2 on 09/07/2023 at 11:30 AM. R #2 said her arm is in a sling because it is broken. R #2 said she cannot be walking because she loses her balance. R #2 said she has fallen several times. R #2 said when she falls, the staff always respond. R #2 said the staff help her up. R #2 said she does not remember how many times she has fallen. R #2 said it seems like a lot. R #2 said she does not remember when R #2 fell . R #2 said she does not know until when she needs to wear the sling. R #2 said she fell out of bed. R #2 said she fell out of her wheelchair. R #2 said she was in the hallway. R #2 said she fell out of bed. R #2 said she is pretty sure the nurse checked her. R #2 started mumbling random words and was speaking nonsensically. R #2 said she can eat. R #2 said somebody feeds her. R #2 said the staff feed her. R #2 said somebody stays with her to eat. R #2 said her son said she can stay here. R #2 said random words. R #2 said they wrote the sign for her. R #2 said her purse was in the restroom. R #2 was confused. R #2 said she can have things like she wants. R #2 said she does not know if she has lost weight. R #2 said she gets hungry and receives enough food here. R #2 said she did have bruising to her face. R #2 said the bruising was from a fall before she came here to this facility. R #2 said she does not remember where she fell but it was not here. R #2 said the nurses give her medications with thick water. R #2 said she needs that kind of water. R #2 said she does not know why. R #2 said she takes pain medication and other medications, but she does not know the names of the medications. R #2 started mumbling random words again. R #2 was speaking nonsensically. This investigator attempted to redirect R #2 to answer questions. R #2 continue to speak about random topics. Observation on 09/07/23 at 11:45 AM. R #2 was lying in with the bed in lowest position. R #2 had a thick mattress next to her bed. The call light was within reach and the room had a homelike environment with personal photos and decor. R #2 was observed with purplish bruising, mainly to the right side of R #2's face and arms. R #2 was observed to be wearing a sling on her left shoulder. R #2 was observed moving her right arm. The room was clean and free of odors. R #2 had good personal hygiene and was not in distress. In an interview with CNA B on 09/07/23 at 2:30 PM. CNA B said on 08/17/23, R #2 fell during CNA B's shift. CNA B said she did not see R #2 fall. CNA B said somebody said R #2 was on the ground. CNA B said she does not remember who said R #2 was on the ground. CNA B said she went to tell the nurse. CNA B said she went to tell the morning nurse, but she does not remember which nurse it was. CNA B said the nurse went to check on R #2. CNA B said she does not remember if R #2 said what happened. CNA B said R #2 was on the ground in front of the shower area. CNA B said the nurse went to assess R #2, but CNA B did not stay there. CNA B said R #2 was sitting in her wheelchair, she assumes because she was up to go to dining. CNA B said she did not put R #2 in her wheelchair that day. CNA B said she did not know who put her in the wheelchair. CNA B said R #2 did not require any special supervision. CNA B said she does not remember if R #2 was sent to the hospital. CNA B said she was informed about the fracture the next day. CNA B said R #2 had a sling on her left shoulder. CNA B said she thinks R #2 already had the bruising to her face before her fall on 08/17/23. CNA B said R #2 had fallen on her face. CNA B said she was informed that R #2 had fallen. CNA B said after those two times, R #2 never fell off the wheelchair again because they were instructed to not get her up that frequently. CNA B said they get her up into her wheelchair for meals and they cannot leave her alone in the wheelchair. CNA B said R #2 also has a mattress next to her bed now. CNA B said they try to explain to R #2 that she cannot get up, but she does not understand sometimes and will still try. In an interview with LVN A on 09/07/23 at 3:40 PM. LVN A said she worked on 08/13/23 when R #2 fell off her wheelchair. LVN A said when she was notified by the housekeeper that R #2 had fallen. LVN A said when she arrived to the tv room, R #2 was on the floor. LVN A said she saw R #2 had a hematoma (bump) to the right side of her forehead. LVN A said R #2 had fallen on R #2's right side. LVN A said she assumed this because of the bump, not because anyone told her this. LVN A said it was at around 2 PM because it was almost time for shift report. LVN A said R #2 could not tell LVN A what happened. LVN A said she notified the doctor and the doctor ordered x-rays to make sure there was nothing broken and because she had the hematoma. LVN A said she notified the family, and they had no concerns. LVN A said the ambulance arrived sometime after and transported R #2 to the hospital. LVN A said R #2 came back to the facility. LVN A said R #2 did not have any other injuries besides the hematoma. LVN A said R #2 did have bruising around the hematoma. LVN A said she had bruising on the right side of her face, but nothing else, no fractures. LVN A said the bruising was a result of this fall. LVN A said she had not seen bruising to R #2's face before this fall. LVN A said when R #2 was first admitted she was very anxious. LVN A said R #2's medications were reviewed and adjusted. LVN A said she is not sure exactly when the medications were adjusted. LVN A said R #2 is doing much better now. LVN A said R #2 also has the fall mattress next to her bed and she has not fallen off her wheelchair anymore because she cannot be left alone in the wheelchair after the fall on 08/17/23 when R #2 sustained the fracture. In an interview with Laundry Staff (LS) on 09/07/23 at 4:00 PM. LS said she clocked out to go to lunch at around 12:30 PM, and on the way to the break room, LS turned towards the nurse's station. LS said she saw R #2 on the floor in the hallway in front of the shower area. LS said she turned and called the other staff, AD, that was coming from the other hall. LS said LS walked towards R #2. LS said R #2 was not yelling or calling out for help. LS said R #2 was not saying anything. LS said LS told CNA B. LS said CNA B went to call LVN B. LS said once CNA B came back and stayed with R #2, LS went to the break room. LS said nobody else had seen R #2 on the floor before LS saw her. LS said when LS saw R #2, nobody had witnessed R #2 fall because nobody was assisting R #2 yet. LS said R #2 was not bleeding and she did not see any injuries on R #2. LS said she assumed R #2 fell . LS said she did not see R #2 fall. LS said nobody had witnessed R #2 fall. LS said she did not see any scratches or other injuries to R #2, but she did not move R #2. LS said she was not sure on which side R #2 was on. LS said she thinks R #2 was sent to the hospital to get checked. In an interview with Housekeeper on 09/07/23 at 4:20 PM. Housekeeper said she recalls working when R #2 had a fall in the tv room on 08/13/23. Housekeeper said she was talking to RN A down the hallway. Housekeeper said they heard a thump, so she and RN A went down the hallway to the tv room. Housekeeper said R #2 was on the floor. Housekeeper said R #2 fell face forward off the chair. Housekeeper said she does not know if R #2 was trying to get up to walk or how she fell as Housekeeper did not witness the fall. Housekeeper said when she saw R #2 in the tv room a little while before the fall, R #2 was just sitting there in the tv room and R #2 was fine. Housekeeper said R #2 did not say anything and did not mention what happened. Housekeeper said RN A called out for the nurse who was working on R #2's hall that day. Housekeeper said she did not recall who that other nurse was. Housekeeper said the nurses assessed and took care of R #2, so Housekeeper continued with her tasks. Housekeeper said she was not sure if R #2 was sent to the hospital or what happened after that. In an interview with DON on 09/07/23 at 5:00 PM. DON said R #2 fell on [DATE] and then on 08/17/23. DON said both times were off the wheelchair. DON said it took them some time to realize that R #2 was at risk for falls. DON said the team was told by the family that R #2 would be fine in a wheelchair and did not mention R #2 would fall off the wheelchair. DON said after the falls, the team realized R #2 was at risk for falls. DON said if they knew R #2 was at risk for falls, then they would have implemented something sooner. DON said the family told the team that if R #2 was in her wheelchair, that R #2 would not fall. DON said when she was first admitted , R #2 was very erratic and high anxiety. DON said R #2 needed the medications for her anxiety. DON said after the first fall, the bedside fall mats were put in place, and they also put R #2's bed in the lowest position, even though the first fall was not in R #2's room. DON said R #2 was referred to psych services and had R #2's medications reviewed. DON said R #2 was put back on some of the medication that the hospital had discontinued. DON said after the second fall they implemented the mattress which is what R #2 has now, which is a mattress that is at the same level as R #2's bed. DON said the second fall off the wheelchair was in the hallway. DON said R #2 moves around a lot. DON said after the second fall, R #2 wears a sling since R #2's left shoulder is fractured. DON said R #2 takes off the sling. DON said now they do not get R #2 up as often as per the family's request, to prevent falls. DON said R #2 rolls around in bed but since she has that mattress, R #2 does not fall. DON said R #2 had a bump on her head resulting from the fall on 08/13/23. DON said R #2 was admitted with bruising to her face. DON said the bruising had healed a little, but then R #2 fell on [DATE] and the bruising got worse. DON said R #2 still has some bruising, mainly on the right side. DON said R #2 had bruising on her body too. DON said R #2 had the bedside fall mats and R #2 was falling on those too. DON said they decided to put the mattress, which is still considered a fall mat, but it is higher. DON said R #2 can move around more especially when R #2 gets anxious, R #2 will be moving around a lot. In an interview with AD on 09/08/23 at 11:30 AM. AD said she recalls working when R #2 fell on [DATE]. AD said one of the laundry workers made her aware that R #2 was on the floor. AD said she did not see R #2 fall. AD said she asked R #2 what happened, and R #2 said she was trying to scoot up out of the chair and fell off the chair. AD said after the nurse arrived, AD left the area. AD said R #2 was admitted into the facility with bruising to her face and body, so R #2 already had bruising before this fall. AD said the nursing staff did inform everybody that R #2 had a fracture to her left shoulder. AD said R #2 tends to try to do things by herself even though she is not able to anymore. AD said R #2 does not understand that she cannot get up and walk. In an interview with FM on 09/08/23 at 11:42 AM. FM said he was concerned about R #2 falling at the facility. FM said on 08/13/23, R #2 fell and hurt her head. FM said on 08/17/23, R #2 fell again and fractured her left shoulder. FM said for the first fall, R #2 wanted to get up and walk, and R #2 fell on her face. FM said the second fall, R #2 fell off the wheelchair. FM said R #2 was in the hallway and again she tried to get up to walk and fell . FM said after the first fall, he does not think much was done to prevent another fall. FM said the family wanted more interventions in place. FM said after the fall on 08/17/23, the family asked that R #2 is not put in the wheelchair as much because R #2 fell off the wheelchair on 08/17/23. In an interview with LVN B on 09/08/23 at 11:45 AM. LVN B said she recalls working on 08/17/23 when R #2 fell . LVN B said she does not remember who, but one of the CNAs or staff informed her that R #2 was on the floor in the hallway. LVN B said R #2 was lying on her side. LVN B said R #2 had told LVN B that R #2 was not in pain and that R #2 had not hit her head. LVN B said R #2 did not tell her what happened or how she ended up on the floor. LVN B said when she asked R #2 what happened, R #2 said the little girl. LVN B said R #2 will be in and out of reality at times. LVN B said the doctor said to monitor R #2 for any changes. LVN B said she and another staff assisted R #2 up into the wheelchair. LVN B said she kept R #2 sitting in the wheelchair, but she put her right next to LVN B in the nurse's station, so she could monitor her. LVN B said R #2 kept tugging at R #2's arm. LVN B said she asked R #2 if she was in pain, but R #2 continued to say no. LVN B said about an hour later, R #2 said yes that she was in pain. LVN B said she informed the doctor and the doctor ordered x-ray. LVN B said the mobile x-ray company arrived and did the x-rays. LVN B said R #2 did have a fracture to her left shoulder. LVN B said the doctor ordered for R #2 to be sent out to the hospital to confirm the fracture. LVN B said her shift ended and the next shift sent her out to the hospital. LVN B said the next day she came into work and was informed during report that R #2 did have a fracture to her left shoulder. LVN B said R #2 was wearing a sling on her left shoulder. LVN B said when there is a fall, the nurse notifies the DON and the Administrator, and they are made aware of the fracture or injury. LVN B said after the fall on 08/17/23, the staff were told to not leave R #2 alone in the wheelchair. LVN B said R #2 is also fed in her room to lessen the falls. LVN B said the interventions have been working as R #2 has not had any more falls off the wheelchair. In an interview with Administrator on 09/08/23 at 1:45 PM. Administrator said R #2 has had several falls since her admission. Administrator said she was not sure exactly how many falls R #2 has had. Administrator said after the first fall, they put fall mats into place in R #2's room. Administrator said R #2 was referred to therapy services but the facility was having an issue with the insurance authorization. Administrator said R #2 was referred to psych services because R #2 was very anxious which is why R #2 was trying to get out of the wheelchair. Administrator said the NP did a medication review and adjustment to control R #2's anxiety and because R #2 was hallucinating. Administrator said she does not think R #2 had injuries from the first fall. Administrator said R #2 had come to the facility bruised up from previous falls at the other facility. Administrator said R #2 already had that bruising to her face. Administrator said after the fall on 08/17/23, R #2 had the fracture to her left shoulder. Administrator said she does not really know what happened. Administrator said when she spoke to R #2 after the second fall, R #2 was just rambling and saying random sentences. Administrator said R #2 said her arm hurt. Administrator said R #2 did not tell Administrator that R #2 fell off the wheelchair. Administrator said staff followed the proper protocol for the falls/incidents. Administrator said the staff notified the nurse, the nurse assessed R #2, and the nurse notified the doctor and family. Administrator said upon admission, R #2 was already at fall risk from report from the other facility. Administrator said that is why R #2's bed was lowered to the lowest position since admission. In an interview with FM on 09/18/23 at 9:00 AM. FM said things have been going much better. FM said R #2 has not had any more falls. FM said R #2 has not been injured anymore which was their biggest concern. In an interview with R #2 on 09/18/23 at 10:00 AM. R #2 said she was doing well. R #2 said she had eaten breakfast. R #2 said it was good. R #2 said everything was fine. R #2 was asked other questions however R #2 continued to say everything was fine. Observation on 09/18/23 at 10:10 AM. R #2 was lying in with the bed in lowest position. R #2 had a thick mattress next to her bed. The call light was within reach and the room had a homelike environment with personal photos and decor. R #2 was observed to be wearing a sling on her left shoulder. R #2's bruising on face was almost gone. The room was clean and free of odors. R #2 had good personal hygiene and was not in distress. In an interview with MDS Coordinator (MDSC) on 09/18/23 at 11:40 AM. MDSC said R #2 thinks she can still walk but she cannot. MDSC said R #2 cannot ambulate because of R #2's cognition. MDSC said R #2 did use the wheelchair and R #2 could self-propel the wheelchair with her feet and grab the hallway rail and pull herself. MDSC said R #2 was still using the wheelchair after 8/13/23 and still uses the wheelchair now. MDSC said they did not put any assistive devices on R #2's wheelchair because the issue was not R #2's wheelchair. MDSC said the issue was that R #2 did not understand that R #2 cannot get up to walk. MDSC said between R #2's psychosis, dementia, and stroke, R #2 just does not comprehend. MDSC said R #2's medications were adjusted. MDSC said on 08/16/23 they implemented the floor mattress next to the bed after the 08/13/23 fall. MDSC said that is when R #2's medications were also referred to be reviewed. MDSC said on 08/17/23 they implemented for R #2 to be taken to bed after meals and shower, bed in lowest position, floor bed mats at bedside, and emergency room (ER) for evaluation. MDSC said 08/13/23 was a weekend so once they were back, the team evaluated and implemented interventions. MDSC said the dates on the care plan would be the dates those interventions were implemented. MDSC said the team put an intervention in place that R #2 cannot be left alone in her wheelchair anymore. MDSC said that was after the second fall off her wheelchair on 08/17/23. MDSC said on 8/16/23, R #2 had a fall in her room where R #2 fell to her knees on the bedside mat. MDSC said the floor mattress was implemented after that as the care plan notes on 08/16/23. MDSC said the floor mattress was for the 08/16/23 fall, not for the one on 08/13/23. MDSC said on 08/13/23, R #2 was sent to the ER. MDSC said R #2 returned from the hospital on 08/13/23. MDSC sai

Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 5 residents reviewed for supervision. The facility did not implement interventions to prevent Resident #1 from eloping from the facility. Resident #1 exited the facility undetected and was missing 2.5 hours before the facility initiated a search and located Resident#1 two miles from the facility. This failure resulted in an identification of a past non-compliance Immediate Jeopardy at 1:00 p.m. on 10/07/22. The noncompliance was identified as PNC. The IJ began on 08/20/22 and ended on 08/24/22. The facility had corrected the noncompliance before the survey began. This failure could place the residents with exit seeking behaviors at risk for injury or death. Findings included: Record review of Resident #1's face sheet, dated 12/22/21, revealed he was admitted on [DATE] with medical diagnoses of dementia, depression, mood disorder, [CONDITION(S)], malnutrition, diabetes, high cholesterol, obesity, communication deficit, muscle wasting, abnormalities of gait and mobility, and lack of coordination. Record review of Resident #1's MDS assessment revealed his BIMS score was 5, indicative of severe cognitive impairment, and he was ambulatory. Record review of Resident #1's care plan, created on 12/31/21 (revised 08/20/22), indicated: Resident #1 had been evaluated as a wandering risk related to decreased safety awareness, confusion, wandering behaviors and had been placed in the secure unit for his safety. Interventions documented: 08/20/22 Elopement - call performed, complete blood count, comprehensive metabolic panel, in-service with staff for 3 days, frequent rounds done with the resident, and signs placed on all exit doors to not allow the residents to leave the facility for safety. Check location frequently. Encourage resident to participate in activities of preference. Record review of Resident #1's care plan, dated 08/20/22, documented focus of Resident #1 eloped from the secure unit on 08/20/22 - Upon safe return to the facility, he did not exhibit any negative effects, and had no signs or symptoms of dehydration, heat exhaustion, or fatigue. On 08/23/22, daily monitoring revealed no abnormalities noted during 72 hours post incident. Interventions included: assess/record/report to MD risk factors for potential elopement such as wander, consistently communicate with all staff of Resident #1's elopement behaviors so they too can observe and redirect. Staff were to check for Resident #1's location frequently to ensure he was secure in his community. Record review of Resident #1's Elopement Risk Assessment/ Wander Data Collection completed on 12/22/21 indicated that Resident #1 was cognitively impaired with poor decision-making skills, wandered at home or in the previous living settings, and at high risk for wandering. Record review of Resident #1's Elopement Risk Assessment/ Wander Data Collection completed on 08/20/22 indicated that Resident #1 was cognitively impaired with poor decision-making skills, wandered at home or in the previous living settings, and at high risk for wandering. Record review of a progress note, documented by LVN A, on 08/20/22 at 7:42 PM documented Resident eloped from the facility staff members were searching inside the facility, managers were searching outside the facility resident was found by the maintenance Director. Responsible Party was notified Head to toe assessment was done no injuries were noted. lips moist, good skin turgor. Vitals Blood pressure 130/64, respirations 18, Pulse 85, temperature 97.9 degrees Fahrenheit, Oxygen at 98% at room air. Resident was showered and offered his supper. Record review of the facility's incident report for Resident #1's elopement, dated 08/20/22, documented: writer [LVN A] was in the dining room with the residents while the [CNA B] was passing out the hall trays and she asked writer where [Resident #1] was because he was not in his room. Writer [LVN A] went to search for resident in his bathroom, closet and asked [CNA B] to help account for the residents. Another resident in the unit was having a birthday party and the family of that resident was not aware that this resident resided in the secure unit and allowed [Resident #1] out of the unit. Elopement was called and staff searched the building. Managers searched outside of the facility and resident was found by Maintenance Director. [Resident #1] informed staff that he left to collect cans, denies pain with no signs or symptoms of pain noted. No dehydration signs or symptoms. An interview with the DON and ADM on 09/07/22 at 3:04 pm revealed there had been a large gathering for one of the other residents and family in the lobby on 08/20/22 in the afternoon, and there were a lot of people going in and out the front doors, as well as the memory care unit. So they speculated Resident #1 slipped out of the secured unit with one of them. They explained this resident had a history of wandering. They said the facility did not use wander guards and the only monitoring, besides physically watching them, was the alarms on the doors that were activated by the push bar that had to be pressed for the door to open. They said an elopement risk assessment was done at admission on every resident and those at risk would have it care-planned. They ADM revealed residents should be checked by staff at least every two hours and as needed. An interview with the MS on 09/08/22 at 12:00 p.m. revealed he received an alert on his phone around 5 pm on 8/20/22 about an elopement at the facility and that the resident had already been missing for 2-3 hours. He said he arrived at the facility around 5:15 pm and immediately drove through the neighborhood around the facility where he found Resident #1 sitting on a bench in front of a saddle shop around 5:35 pm. He described the shop as being a little over 2 miles from the facility and it probably would have taken Resident #1 a couple of hours to walk that far. He said Resident #1 would have had to cross multiple streets and intersections, including a highway, to get to the saddle shop. He said they (the facility) got lucky nothing happened to Resident #1. He said when he found Resident #1, he was a little out of breath and hot, but said he was ok. He also had an old-looking plastic bag he had collected 4 empty beer cans in. Resident #1 told the MS that he was collecting cans to raise money for cigarettes. He said Resident #1 was dressed in black sweatpants, a long-sleeved western shirt, a long-sleeved black hoodie with the hood up, sneakers, and a ball cap. The MS said Resident #1 told him he was going home. He said he waited for the AD to arrive, and she took Resident #1 back to the facility in her vehicle. He said he personally put keys (10 in total) for the door alarms on each of the 4 charge nurse key rings, administration had one, and housekeeping had 5. He said he did not know how many keys were left of the 10, but he knew housekeeping had one and that was who turned off the alarm that day. He said another resident from the memory care had a party outside the memory care unit, there was a lot of in & out, and Resident #1 must have followed someone out of the locked unit. An interview with LVN A on 09/08/22 at 3:00 pm revealed she was the nurse on the secure unit during the incident on 8/20/22. She said she saw Resident #1 go into his room at 2:30 pm. She said RN A mentioned she saw someone in the parking lot that matched Resident #1's description at 2:45 pm but by the time they looked out into the parking lot, there was no one in sight. She said a room-to-room check and headcount wasn't initiated until around 5:00 PM when food trays were being passed and she discovered Resident #1 was missing. She said she did not know why a headcount was not done sooner. At 5:20 pm, she announced an elopement alert (code white) over the intercom. She said the MS found the resident, and the AD returned him at 5:36 pm via her vehicle. She said she assessed Resident #1 and found no distress and normal vital signs. She said he was bathed and offered supper. She said she knew Resident #1 was at risk for elopement. She said that was one of the reasons why he was in the secured unit. She said they get training on it (elopement) every year. She could not say why Resident #1 was not being monitored more closely. She revealed residents were to be checked on every 2 hours and as needed, but Resident #1 had not been seen since 2:30 pm. She stated, it was important to monitor residents in the secured unit more often to prevent elopement and to make sure they are safe. An interview with CNA B on 09/08/22 at 3:20 pm revealed she was the CNA on the secure unit during the incident on 08/20/22. She said she saw Resident #1 in his room on the secured unit at 2:30 pm. She said she didn't see him again, as she was assisting other residents in the living room of the secured unit until around 4 pm. She said she knew he was at risk for elopement because she worked in the secured unit frequently and it's documented in his care plan. She said they got trained on it (elopement) every year and recently, right after the incident on 8/20/22. She could not say why she was not monitoring Resident #1 more closely. She stated it was important to monitor the residents in the secure unit at least every 2 hours and prn, because they are confused and could leave the facility like Resident #1 did. She revealed Resident #1 is alert and likes his privacy and can get agitated at times when bothered during naps or when he does not want to be bothered. So they will give him time to himself, but they are checking on him more often. An interview with RN A on 09/21/22 at 11:28 AM revealed she was working the day of 08/20/22 as an RN supervisor for the facility. She revealed she works as RN supervisor during the weekend and was not familiar with all the residents in the facility. She stated, around 2:45 PM, the alarm went off, she went to the door that was alarming and looked out the windows and noted a man walking with a mask through the parking lot but there are people who use the parking lot to walk to the apartments in the back of the facility, and she didn't recognize the man. She went to the locked unit to tell the staff about the man walking outside of the facility. LVN A and RN A went to look out the windows but didn't see anyone during that time. She stated, no one knew Resident #1 was not in the secured unit until LVN A alerted her around 5:15 PM. She stated, LVN A called elopement and told staff Resident #1 was missing and that it was probably the resident who she saw outside of the facility. Record review of the facility in-service dated 08/20/22 documented: Elopement topic. -When a door alarm sounds, staff shall respond immediately and determine the cause of the alarm. - Staff member responding to the alarm shall check the outside of the building to determine if a resident has left the building. -If no apparent cause is determined for the alarm, the charge nurse shall immediately initiate an accounting of the whereabouts of all the residents at risk for elopement. Observation of the secured unit on 09/21/22 revealed the exit and entrance doors had signs stating, Please make sure doors close behind you when entering. And Dear Families/Visitors, please exercise caution when exiting our facility to ensure that our residents do not leave behind you. Record review of the facility's Wanderer Management, Monitoring System and Resident Elopement protocol, dated 10/08/20, documented: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. -Record review revealed on 08/20/22, One to one education provided to staff working during the time of incident. and Disciplinary write up for RN A about response to door alarms. -Record review and observation on 10/07/22 revealed on 08/20/22, POD checked all doors and alarms of the facility were working properly. -Record review revealed all staff working were educated and in-serviced on 8/20/22 for Door Alarms, how to identify residents at risk for elopement, how to supervise, monitor, and redirect residents, Elopement, when a resident is found, post elopement, and an elopement book. -Observation and record review revealed on 8/20/22 Signs posted at the entrance and exit of the secured unit stating, please make sure doors close behind you when entering and please exercise caution when exiting our facility to ensure that our residents do not leave behind you. - Record review of updated care plan dated 8/20/22 documented: I have been evaluated as a wandering risk related to specify: (decreased safety awareness, confusion, wandering behavior, and has been placed in the secure unit for his safety) . Interventions included: Check my location frequently, encourage me to participate in activities of my preference, engage me in diversional activities when indicated, observe me for signs and symptoms of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness, report increased behaviors to nurses for further interventions, provide me with re-orientation as needed, resident will be accounted for during functions within the unit. - Record review of Resident #1's Elopement Risk Assessment/ Wander Data Collection completed on 8/20/22 indicated that Resident #1 was cognitively impaired with poor decision-making skills, wandered at home or in the previous living settings, and at high risk for wandering. -Record review revealed on 8/20/22 Elopement risk binder was checked to ensure it was up to date. (Picture of Resident #1 was in the binder). -Record review on 8/22/22, facility added pre and posttest for Elopement wandering test to new employee orientation packet and all staff were oriented to the elopement wandering test for employee files. -Record review on 8/24/22 facility started Mock Elopement drill 1-2 a week for 4 weeks and monthly to monitor response time and actions taken by staff. Due to the above failure, the facility Administrator was notified of the past non-compliance IJ on 10/07/22 at 1:00 p.m.

Based on observation, interview, and record review, the facility failed to ensure four Residents (R#7, R #26, R #66 and R#56) of 22 residents reviewed for pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. 1) R#7 developed avoidable ulcers (one stage III pressure ulcer, four Stage II pressure ulcers, an unstageable pressure injury, and a deep tissue injury). The facility failed to provide timely off-loading of pressure areas and repositioning in accordance with the care plan. The facility also failed to know and implement manufacturer's recommendations for R#7's specialty mattress. 2.) The facility did not provide R #26, who was identified at risk for pressure ulcer development, with timely off-loading or repositioning, allowing her to have continuous pressure to her buttocks/sacrum/coccyx. R #26 had constant pressure to her buttocks for over seven hours and was not checked or changed for incontinence for over five hours. Staff did not apply skin barrier cream on R #26 after incontinent care was provided, to protect the skin from irritation and breakdown, as indicated in her care plan. 3.) The facility did not provide R #66, who was identified at high risk for pressure ulcer development, with timely off-loading or repositioning, allowing her to have continuous pressure to her buttocks/sacrum/coccyx. R #26 had constant pressure to her buttocks for over seven hours and was not checked or changed for incontinence for over five hours. 4.)The facility failed to accurately identify and document R#56's Left and right buttock facility acquired pressure ulcer & staged and documented the ulcer as an unstageable despite the description of an ulcer meeting a stage 2. The Facility staff failed to document and report the stage of the wound accurately, the wound care treatment may not be appropriate for the wound. -Registered Nurse (RN) J failed to follow R#56's physician orders [REDACTED].#56's pressure ulcer wound care. These failures had the potential to affect residents by placing them at risk for infection and the development and worsening of pressure ulcers. The findings included: R#7 Record review of R#7's (MONTH) 2019 Physician order [REDACTED]. R#7's [DIAGNOSES REDACTED]. Record review of R#7's Significant change in status MDS assessment dated [DATE] revealed R#7: -had adequate hearing; -had unclear speech; -had impaired vision; -was usually understood by others; -was able to understand others; -had severe cognitive impairment; -required assistance from one staff with bed mobility, transfers, locomotion on unit, locomotion off unit, dressing, toilet use, personal hygiene, and bathing; -was not steady, only able to stabilize with staff assistance when moving from seated to standing position and surface-to-surface transfer; -had an upper extremity and lower extremity functional limitation in range of motion; -was always incontinent of the bladder and bowel; -was at risk of developing pressure ulcer/injury; and -did not have any pressure ulcer/injury during the time of this assessment. Record review of R#7's Care Plan revealed a Category titled: Pressure Ulcer, I am at risk for pressure ulcers due to diabetes mellitus, decreased mobility and incontinent of bowel and bladder which had the following Approaches: -Administer my insulin per order. Start Date: 12/19/2018. -Apply my ammonium [MEDICATION NAME] 12% lotion to my bilateral extremities to aid in skin elasticity. Start Date: 12/19/2018. -Avoid shearing my skin when transferring and positioning. Start Date: 12/19/2018. -Conduct a systematic skin inspection weekly. Pay particular attention to the bony prominences. Start Date: 12/19/2018. -Keep clean and dry as possible. Minimize skin exposure to moisture. Start Date: 12/19/2018. -Keep linens clean, dry, and wrinkle free. Start Date: 12/19/2018. -Maintain the head of the bed at the lowest degree of elevation possible. Start Date: 12/19/2018. -Make sure that you are floating my heels while in bed. Start Date: 12/19/2018. -Monitor and report labs as needed. Start Date: 12/19/2018. -Provide incontinence care after each incontinent episode. Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin; avoid friction to skin. Start Date: 12/19/2018. -Report any signs of skin breakdown (sore, tender, red, or broken areas). Start Date: 12/19/2018. -Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity. Start Date: 12/19/2018. -Use moisture barrier product to perineal area. Start Date: 12/19/2018. -Use pressure relieving mattress to my bed to aid in my skin integrity. Start Date: 12/19/2018. -Use pressure relieving pad to wheelchair. Start Date: 12/19/2018. Record review of R#7's Weekly Skin Assessment revealed on 02/20/19, R#7 had redness to his right bottom. Record review of R#7's clinical record revealed R#7 was hosptalized on [DATE] due to a productive cough, rales to the bilateral lungs, and a temperature of 101.3 F. R#7 was readmitted to the facility on [DATE]. Record review of R#7's Progress Notes, dated 03/17/19, revealed on 03/16/19, R#7 returned from the hospital with a deep tissue injury to the left heel. The deep tissue injury was described as now open, with no drainage from the wound. Record review of R#7's care plan, dated 03/17/19, revealed the following Plan of Approach relating to this pressure injury, -Weekly head to toe assessment by licensed nurse. -CNA (certified nurse aide) to check skin with shower and notify nurse or issue/concerns. -TX (treatment) as ordered. -Dietician consult as indicated. -Supplements as ordered -Licensed nurse to notify family and discuss treatment plan and interventions. -Licensed nurse to educate CNA on treatment plan. -Monitor for pain, give med per order, monitor for effectiveness. -Keep MD and RP informed of resident's progress. -Other individualized interventions, monitor healing, reposition frequently and float heels. Record review of R#7's Wound Evaluation Flow Sheets revealed: -On 03/18/19, R#7 had an unstageable pressure injury to the left heel measuring 4.5 x 3.5 x <0.1. -On 03/20/19, R#7 was found with a deep tissue injury to the right lateral heel measuring 3.8 x 2.5. Record review of R#7's care plan, dated 03/20/19, revealed no differences from the 03/17/19 care plan. Record review of R#7's Wound Evaluation Flow Sheets revealed: -On 03/25/19, R#7 had an unstageable pressure injury to the left heel which measured 6 x 5x <0.1. The deep tissue injury to the right lateral heel measured 4 x 2.5 x <0.1. -On 03/26/19, R#7 was found with a Stage II to the right buttocks measuring 4.6 x 1.1 x <0.1. Record review of R#7's care plan, dated 03/26/19, revealed no changes from the 03/17/19 and 03/20/19 care plans except: Other individualized interventions, monitor until resolved, pressure relieving mattress and reposition frequently. Review of R#7's, Clinical Conditions Predicting High Risk Pressure Injury Development, dated 03/26/19, revealed R#7 was at high risk for pressure injury development. The surveyor conducted the following observations of R#7: -On 03/24/19 at 1:48 p.m., R#7 was observed laying on his back while in bed. -Observation of R#7 on 03/25/19 at 5:58 a.m. revealed he was laying in bed, on his back, with a pillow under each arm, and the head of bed elevated. R#7 had his eyes closed and did not awaken to verbal stimuli. -Observation of R#7 on 03/25/19 at 6:18 a.m., this surveyor accompanied Certified Nurse Aide (CNA) AY into R#7's room. R#7's brief was wet. R#7 had perineal, buttocks, and upper inner thigh redness, CNA AY applied a white cream that was in a small medicine cup, to the reddened area and said, I don't know what the cream is called but we get it from the nurse, it is for his redness. I think he gets it put on every time we change him. -On 03/25/19 at 8:06 a.m., R#7 was observed laying on his back while in bed. -On 03/25/19 at 11:31 a.m., R#7 was observed laying on his back while in bed. -On 03/25/19 at 1:13 p.m., R#7 was observed laying on his back while in bed. -On 03/25/19 at 2:57 p.m., R#7 was observed laying on his back while in bed. -On 03/26/19 at 8:46 a.m., R#7 was observed laying on his back while in bed. -On 03/26/19 at 10:46 a.m., R#7 was observed laying on his back while in bed. -On 03/26/19 at 12:22 p.m., R#7 was observed laying on his back while in bed. -On 03/27/19 at 8:32 a.m., R#7 was observed laying on his back while in bed. -On 03/27/19 at 11:09 a.m., R#7 was observed laying on his back while in bed. On 03/27/19 at 8:32 a.m., surveyor attempted to interview R#7. R#7 had limited communication and could answer some questions by nodding or moving his head from side to side. The surveyor asked R#7 if staff repositioned him in bed and moved him from one side to another throughout the day. R#7 did not respond to the question asked. On 03/27/19 at 1:18 p.m. the surveyor interviewed CNA AX and CNA BX about R#7. They said it depended on how R#7 was feeling as to whether or not he let them reposition him while in bed. They said R#7 preferred to be either facing the window or the door. In an interview on 03/27/19 at 9:23 a.m., RN K said, (R#7) came from the hospital with a DTI and it opened so then it became an unstageable. He has an unstageable to his left heel. Treatment is cleaning with normal saline, pat dry with gauze, apply collagen, wrap with kerlix and tape. He has an in-house acquired DTI to the right heel. He has his Stage 2 to his left buttock that is new as of yesterday. He has ongoing moisture associated damage to his buttocks, we are putting zinc twice a day and as needed for now. Observation of R#7 on 03/27/19 at 9:27 a.m., revealed R#7 was lying in bed, on his back, with a pillow under his calves, offloading his feet off the bed. R#7 had a dressing on his left foot that was dry and intact. There was a fitted sheet and a draw sheet folded in fours over the mattress that R#7 was lying on and R#7 had a brief on. Record review of the manufacturer's instructions for Air Immersion Mattress (AIM) Hybrid auto, self-inflating, pressure relief system revealed, Linens, Too many linens between the AIM Hybrid and the individual will compromise the product's skin protection characteristics. Please use as few linens and incontinent pads as possible. On 03/27/19 at 9:38 a.m., Registered Nurse (RN) K gathered all supplies for wound care. RN K washed her hands, donned gloves, and cut off R#7's left foot dressing. R#7's exposed wound on the left heel had purple/maroon discoloration. Within the purple discoloration was an area of approximately 40% black soft tissue and 10% yellow tissue. There was <5% area of red tissue that slowly seeped blood. RN K cleaned the wound with normal saline soaked gauze. RN K measured the wound as, Open area is 2.2 X 3.0 centimeters and the entire area including the DTI is 4.0 X 7.0 centimeters. RN K applied a collagen dressing and wrapped with kerlix dressing and secured with tape. At 9:54 a.m., RN K removed R#7's sock, exposing an area of purple and maroon discolored tissue on R#7's right heel. RN K measured the wound at 3.4 X 2.9 centimeters. RN K applied skin prep over the wound, allowed it to dry, and re-applied R#7's sock. At 10:12 a.m., RN K opened R#7's brief, exposing a reddened perineal area. R#7 was turned to his right-side, exposing his buttocks having redness, wet, and a little soft, whitish, wrinkled looking skin with an open area to R#7's right buttock. RN K measured the wound on R#7's right buttock, which she identified as a Stage 2 pressure ulcer, as 4.4 X 1.0 centimeters. R#7 was lying on a folded top sheet that was wrinkled. R#7's back and buttocks had marks matching the wrinkles of the sheet. RN K stated there were new pressure injuries R#7 did not have yesterday. RN K said the new pressure injuries observed on R#7 were: -Left buttock: 2.0 X 0.7 centimeters, open, red superficial, appears moisture associated, a Stage 2 pressure injury. -Left buttock, located near coccyx, 1.0 X 1.0 centimeters, red small open area superficial, Stage 2. -Center line 1.0 X 0.4 centimeters, Open, normal skin color. I would say it was a Stage 2 as well. RN K did not attempt to measure the depth of the wound that had obvious depth. -Middle, coccyx 0.4 X 0.4 X 0.1 centimeters, Open, red center, a Stage 2. After RN K gathered supplies from her medication cart, she applied zinc oxide with a wooden applicator to R#7's entire bilateral buttocks, including open wounds and perineum. RN K, with the help of a CNA BQ, placed a clean yellow brief on R#7 and placed a pillow behind R#7's right upper to mid back. When R#7 rested on the pillow, the pillow flattened. R#7's pelvis and buttocks remained resting on the bed. R#7 remained laying on a wrinkled top sheet. In an interview on 03/27/19 at 10:42 a.m., RN K revealed she had just finished her wound care orientation last week. RN K said she had wound care orientation for one week. RN K said her protocol was to get assistance from the Director of Nursing (DON), the other wound care nurse, and the District Director of Clinical Services (DDCS). When RN K was asked if the amount of linen and the use of a brief could contribute to moisture and minimize the air flow of the mattress, RN K responded I guess it could, I'm not sure. RN K said she was going to get with the DON and the DDCS to assist her in identifying the locations of the wounds. RN K showed the surveyor her wound care book that had sheets titled, Educational Updates/Characteristics of Pressure Ulcers, Staging Tips, that she said she referred to for staging and treatments. RN K said, The nurse holds the zinc in the medication cart because this zinc has a higher zinc concentration than the house barrier cream and the nurse has to administer it. On 03/27/19 at 3:48 p.m., the DDCS and RN K provided the surveyor with R#7's wound sheets. The DDCS said she re-assessed the wounds and provided the surveyor with the updated measurements of each wound. The DDCS explained that since the Center Coccyx wound's depth extended to the subcutaneous tissue, being more extensive than the superficial layer, she staged the wound at a Stage 3. On 03/27/19 R#7 was found with: -Stage II to the left medial buttocks measuring 2 x 0.7 x <0.1; -Stage II to the left superior buttocks measuring 1 x 1 x <0.1; -Stage II to the sacral crease measuring 1 x 0.4 x <0.1; and -Stage III to the center coccyx measuring 0.4 x 0.4 x 0.3. In an interview with the Director of Nursing (DON) on 03/28/19 at 1:33 p.m., she said (R#7) had one DTI on the left heel that he came with from the hospital. He developed another DTI on the right heel. The DON said that, overnight, R#7 developed an additional four wounds. She said they were off-loading R#7's heels and they placed on an AIMS mattress on his bed on 03/27/19, in the afternoon. The DON said R#7's AIM air mattress did not require any special linen and did not require limited linen. After the DON reviewed the manufacturer's recommendations for the AIMs mattress, she said, I guess, this does say to limit the linens. When asked if R#7 had five to six layers of linen between him and the mattress, the DON said, It is safer to have a draw sheet, we are not going to pull the resident by their limbs, I don't think the draw sheet caused his skin breakdown. I think it is better for him to have the draw sheet. I believe it is necessary for him to have a brief for his incontinence. When asked if R#7 having a fitted sheet, a draw sheet that was folded in four/causing four layers and wearing a brief would cause moisture and heat to R#7's buttocks, the DON replied, No, not necessarily. When asked if moisture and heat would cause skin breakdown, DON replied, Yes, it could. The DON said their current interventions for R#7 were offloading, repositioning every two hours and rounding on him every hour. The surveyor explained the surveyor conducted observations of R#7 over a two-day period and R#7 was observed lying on his back the entire time. The DON reviewed her documentation of staff checking on R#7 every hour on 03/26/19. After reviewing the log for that day, the DON said R#7 was on his back a lot on this day. The DON said staff were supposed to do a check and change and reposition R#7 every two hours. The DON was informed of the positioning R#7 was placed in after wound care on 03/27/19 and informed that the pillow that was placed behind his right back had flattened when R#7's) back rested on it, causing R#7's back and buttocks not to be offloaded. The DON said, I guess the staff didn't notice that, I don't know, I can't tell you, I was not there, but staff should have gotten more pillows and made sure he was offloaded. The DON said RN K was their new Treatment Nurse and she just started last week. The DON said RN K did not have a wound care certification, but she had some background in wounds, she did not know how much. The DON said RN K would receive additional training after the inspection process. When asked if training had been conducted with staff regarding R#7's skin care, the DON stated, Not documented sit down training, but we have been telling staff when to reposition him and change him in passing. The DON said the DDCS was at the facility once a week and was always available to them if they had any questions. The DON said R#7 had declined a lot as far as his health. R#7 used to yell and got combative, but he was not combative anymore. The DON said they also received a recommendation from the dietician for [MEDICATION NAME] twice a day to promote wound healing. They also ordered labs and just got those results in about 15 minutes ago. The DON said R#7's physician ordered zinc for his maceration and redness to his peri-area. The DON said to treat maceration, they usually get an order for [REDACTED]. The DON said staff were told as soon as R#7 was incontinent, they needed to change him or R#7 would tell them by pointing that he needed changing. R #26: R #26's Face Sheet dated 03/25/19 documented a [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #26's Clinical Conditions Predicting High Risk for Pressure Injury Development dated 10/09/18 documented a score of 14 - Moderate Risk. R #26's comprehensive Care Plan dated 04/25/18 documented (R #26 is at risk for pressure ulcers related to dementia, decreased mobility and incontinence of bowel and bladder .Approaches: (R #26) will be provided with incontinence care after each episode of incontinence .Will be repositioned at least every two hours; Will have moisture barrier product used to perineal area at all incontinence episodes; Will be kept as clean and dry as possible. Her skin will be kept from exposure to moisture as much as possible . Urinary Incontinence: (R #26) has functional urinary incontinence related to Alzheimer's/Dementia. Approach: (R #26) will be provided with incontinence care after each incontinent episode; (R #26) will have adequate bowel elimination; (R #26) will have moisture barrier applied to skin. R #26's Nursing Assistant Care Plan dated 05/30/18 revealed it documented Positioning: Assist positioning X1 at least every ___ hours. Skin Intact: NO, Apply house barrier cream to coccyx every shift .Elimination: Bladder: Incontinent, assist X1; Bowel: Incontinent, assist X1 . This plan did not specify how often R #26 should be repositioned or checked/provided incontinent care. R #26's Clinical Conditions Predicting High Risk for Pressure Injury Development dated 01/07/19 documented a score of 14 - Moderate Risk. R #26's Quarterly Minimum (MDS) data set [DATE] documented R #26: -rarely/never made self understood or understood others; -had severely impaired cognition for daily decision making -was totally dependent with one staff person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene -was always incontinent of bowel and bladder -was at risk for developing pressure ulcers. R #26 did not have any pressure ulcers. Observation of R #26 on 03/25/19 at 06:05 AM revealed she was laying in bed, on her back with her eyes closed. R #26 did not use any offloading devices. Observation of R #26 on 03/25/19 at 07:11 AM revealed she was laying in bed, on her back with her eyes closed. R #26 did not have any offloading devices used. Observation of R #26 on 03/25/19 at 07:50 AM revealed she continued to lay in bed, on her back, with her eyes closed. No offloading devices were used. Observation of R #26 on 03/25/19 at 7:48 AM revealed CNAs BB and BC entered R #26's room and provided R #26 with incontinent care, dressed her, and transfered her to her wheelchair. Observation of R #26 on 03/25/19 at 08:16 AM revealed she was provided incontinent care, dressed, and transfered to a sitting position in her customized wheelchair and escorted to the dining room. The CNAs did not apply any barrier cream on R #26's skin after providing incontinent care. At 8:05 AM, R #26 was escorted to the dining room and left at the dining room table. Interview with CNA BC on 03/25/19 at 8:07 AM revealed she said We (the CNAs) usually put our house skin barrier on her but I did not have any on me when I changed her. CNA BC said the barrier cream was used to protect the resident's skin to prevent breakdown. Continuous observation of R #26 on 03/25/19 at 09:30 AM revealed, after being fed breakfast, R #26 was escorted to the Day Room and positioned in front of the television. At 10:21 AM, R #26 remained in the Day Room awake, staring out the window. At 10:28 AM, R #26 was escorted to the dining room by the Activity Director and positioned at a dining room table. As of 11:27 AM, R #26 remained sitting in her wheelchair in the dining room. Continued observation of R #26 on 03/25/19 at 01:02 PM revealed she remained sitting in her wheelchair, in the dining room, being fed by staff. Simultaneous interview with CNA CS, CNA BB, CNA BG, and CNA BX, on 03/25/19 at 01:18 PM revealed they had not provided R #26 with incontinent care or repositioned R #26 since she got out of bed at approximately 08:00 AM. Each staff said R #26 was dependent on staff for repositioning and incontinent care. When asked how they were aware of every incontinent episode R #26 had, CNA CS said There is no way of knowing beacuse she is incontinent and can't tell us. We just check incontinent residents every two hours. All the other CNAs said they agreed with CNA CS's answer. Observation of R #26 on 03/25/19 at 01:52 PM revealed R #26 continued to sit in her wheelchair in the hallway outside of her room. As of 01:52 PM, R #26 was left on her back with continuous pressure on her buttocks/sacrum/coccyx for over seven hours and was not checked or changed for incontinence for over five hours. Interview with the Director of Nurses (DON), with the presence of the District Director of Clinical Services (DDCS) on 03/26/19 at 03:05 PM revealed the DON stated dependent resident should be repositioned and checked/changed at least every two hours. The DON said the importance of repositioning and keeping residents clean and dry is to Decrease the risk of skin breakdown. 3.) R #66 R #66's Face Sheet dated 03/25/19 documented an [AGE] year-old female admitted on [DATE] with the [DIAGNOSES REDACTED]. R #66's Clinical Conditions Predicting High Risk for Pressure Injury Development dated 11/23/18 documented a score of 10 - High Risk. R #66's Nursing Assistant Care Plan dated 07/24/18 revealed it documented Positioning: Assist positioning X2 at least every ___ hours. Skin Intact: Yes, Apply house barrier cream to coccyx every shift .Elimination: Bladder: Incontinent, assist X1; Bowel: Incontinent, assist X1 . The plan did not specify how often R #26 should be repositioned or checked/provided incontinent care. R #66's Clinical Conditions Predicting High Risk for Pressure Injury Development dated 02/04/19 documented a score of 10 - High Risk. R #66's Quarterly Minimum (MDS) data set [DATE] documented R #66: -rarely/never made self understood or understood others; -had severely impaired cognition for daily decision making -was totally dependent with one staff person physical assist for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene -was always incontinent of bowel and bladder -was at risk for developing pressure ulcers. R #66 did not have any pressure ulcers. R #66's Care Plan dated 03/25/19 documented I have alteration in bowel elimination and urinary incontinence related to: Immobility, Lack of voluntary sphincter control, and inability to perceive bowel cues/dementia .Approaches: Provide me with incontinent care/peri-care each incontinent episode; Apply moisture barrier to skin; Check for incontinence PRN (as needed) . -I am at risk for pressure ulcers related to decreased mobility, incontinence, and history of breakdown .Approaches: Provide incontinence care after each incontinent episode; Use moisture barrier product to perineal area every shift and PRN R #66's care plan did not include any interventions for off-loading/repositioning and did not specifically define checking for incontinence and after each incontinent episode for R #26 was was not able to alert staff of her incontinence. Observation of R #66 on 03/25/19 at 06:05 AM revealed she was laying in bed, on her back with her eyes closed. R #66's feet were elevated off the bed by the use of pillows beneath her lower legs. Observation of R #66 on 03/25/19 at 07:11 AM revealed she was laying in bed, on her back with her eyes closed. R #66's feet were elevated off the bed by the use of pillows beneath her lower legs. Observation of R #66 on 03/25/19 at 07:50 AM revealed she continued to lay in bed, on her back, with her eyes closed. Her feet remained elevated on a pillow. Observation of R #66 on 03/25/19 at 08:16 AM revealed she was sitting in her Geriatric chair and was being escorted out of her room to the dining room. Continuous observation of R #66 on 03/25/19 beginning at 09:18 AM revealed after she was fed her breaakfast, R #66 was escorted to the Day Room. R #66 was reclined back in her Geriatric chair and R #66 closed her eyes. At 10:21 AM, R #26 remained in the Day Room asleep sitting in her Geriatric chair in a reclined position. At 10:24 AM, R #66 was escorted to the dining room and positioned at a dining table. As of 11:27 AM, R #66 continued to sit in her Geriatric chair in the dining room. Continued observation of R #66 on 03/25/19 at 01:02 PM revealed she remained sitting in her wheelchair, in the dining room, being fed by staff. Interview with CNA AS, CNA BB, CNA BG, and CNA BC on 03/25/19 at 01:18 PM revealed they each stated they did not get R #66 out of bed. Each staff said they had not provided R #66 with incontinent care or repositioning since she was assisted out of bed. Staff said the only other person that might have provided care was CNA BX. Each staff said R #66 was dependent on staff for repositioning and incontinent care and was not able to alert staff of when she needed to bed changed. Interview with CNA BX on 03/25/19 at 01:21 PM revealed he stated he arrived at the facility just after 08:00 AM this morning and he got R #66 out of bed at approximately 08:10 AM. CNA BX stated he provided R #66 with incontinent care before getting her out of bed. CNA said he had not provided R #66 with any incontinent care or repositioning since then. Observation of R #66 on 03/25/19 at 01:31 PM revealed CNA BC escorted R #66 to her room. CNAs BC and BX gathered the mechanical lift and supplies. Both staff entered R #66's room, sanitized hands, and donned gloves. Staff used the mechanical lift to transfer R #66 out of her Geriatric chair to her bed. Staff removed R #66's soiled brief and cleaned R #66 of incontinent urine and feces. R #66's coccyx area was reddened but blanchable. R #66's bilateral buttocks had various lines throughout embedded into her skin from the brief. As of 1:31 PM. R #66 was left with constant pressure on her buttocks/sacrum/coccyx for over seven hours and without a brief check or change for over five hours. Interview with CNAs BC and BX on 03/25/19 at 01:41 PM revealed they both said R #66 required a brief check and change, if needed, at least every two hours and was dependent on staff to provide the care. Both staff said leaving a resident in one position for more than two hours and in a soiled brief could cause the resident to acquire a pressure ulcer. Interview with the DON on 03/25/19 at 02:06 PM revealed she was made aware of R #66's observations. The DON said both residents were dependent on staff for all care. The DON said she needed to check each residents care plan but they should be repositioned and a brief check at least every two hours. The DON said if R #66 were left in the same position and unclean for a long period of time, that could increase their risk of skin breakdown. Interview with the DON, with the presence of the DDCS on 03/26/19 03:05 PM revealed they confirmed R #66's care plan had not been updated or revised. The DON explained that the purpose of the care plans was to have a written instruction on how to provide individualized care for the resident and so that all staff have access to it to provide the care. Referencing R #66's care plan, when asked how staff determined an instruction of as needed or after each incontinent episode was specific instructions for R #66's care, the DDCS stated It could be more specific, it should state to provide the care every two hours. Both staff agreed R #66's care plan should specifically address her off-loading and repositioning needs. The DON said the importance of repositioning and keeping residents clean and dry is to Decrease the risk of skin breakdown. R#56 - R #56's face sheet revealed a [AGE] year old female who was admitted on [DATE] had a [DIAGNOSES REDACTED]. (disorder of the central nervous system that affects movement, often including tremors), Type 2 Diabetes Mellitus (chronic condition that affects the way the body processes blood sugar), Hypertension (condition in which the force of the blood against the artery walls is too high), Chronic Pai[DIAGNOSES REDACTED] (Persistent pain that lasts weeks to years), and Neuromuscular dysfunction of the Bladder (flaccid (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for two residents (R#49 and R#84) of 22 residents reviewed for accidents, in that: The facility did not provide the type and amount of supervision necessary to prevent R#49 from falling four times in two months. R#49's last fall resulted in a fracture to her neck. The facility failed to ensure the fall mat was placed on the floor at the bedside while Resident #84 was in bed. These failures could place residents at risk for severe injury. The findings were: Record review of R#49's (MONTH) 2019 Physician order [REDACTED]. R#49's [DIAGNOSES REDACTED]. Record review of R#49's Significant change in status assessment, dated 02/04/19, revealed R#49: -had minimal difficulty hearing; -had clear speech; -was able to make herself understood; -was able to understand others; -had impaired vision; -had moderate cognitive impairment; -required assistance from one staff with bed mobility, transfers, dressing, toilet use and bathing; -was not steady, only able to stabilize with staff assistance when moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; -utilized a manual wheelchair; -was always continent of bowel and bladder; -had a fall in the last month prior to admission/entry or reentry; -had a fall in the last 2-6 months prior to admission/entry or reentry; and -had two falls with no injury and one fall with a major injury. Record review of the Event Reports relating to R#49's falls revealed R#49 fell on [DATE], 01/07/19, 01/11/19, and 01/21/19. -12/31/18, Fall without injury. R#49 stated that she was trying to transfer herself from her bed to her wheelchair, she missed her wheelchair and slipped to the floor. It was noted at time of the fall the resident did not have the wheels locked on her wheelchair prior to attempted transfer. The facility-initiated neuro checks, a rehab evaluation was requested and R#49 was educated on the importance of locking the wheels on her wheelchair prior to any attempted transfer. -01/07/19, Fall without injury. Resident stated she was trying to transfer herself from the toilet to her wheelchair and slid off the toilet instead landing on her bottom. The facility instructed and reminded R#49 to call for assistance with transfers and R#49's toilet seat was checked. The facility added the intervention of, Remind/encourage to use call light for assistance to R#49's care plan after this fall. -01/11/19, Witnessed fall in the dining room without injury. R#49 fell asleep in her wheelchair while in the dining room and fell forward. The facility determined R#49 had some medication increases for her behavior which caused increased drowsiness. -01/21/19, Unwitnessed fall with C2 fracture. R#49 said she had gotten out of her wheelchair to move another resident's wheelchair that was left in front of the toilet and when she did that she fell on to her right side. R#49 was taken to the emergency room for evaluation of complaints of pain to her right hip, knees, head, and neck. The facility instructed the staff to never obstruct the path to the toilet of the adjoining bathroom especially if one of the residents self-toilets. R#49 returned to the facility with a neck brace in place. The facility added the following interventions to R#49's Care Plan after this fall: Instruct resident to ensure wheelchair wheels are locked; Med review and adjustment; Resident returned with clavicle collar in place, check every 15 minutes to ensure it is in place and (R#49) does not remove it herself. Review of R#49's Care Plan revealed the following areas relating to falls: -Problem, I am at risk for falls due to history of falls, [MEDICAL CONDITION] med use and the use of my w/c (wheelchair), walker for mobility. Approach Start Date: 02/04/19. Bed in low position with floor mat. Encourage participation in activities of choice and/or exercise program. Encourage/assist with rest periods during the day. Encourage/remind to use assistive device walker and w/c with all ambulation. Have my Medical Doctor and pharmacy to review my meds at least quarterly or as needed if fall happens. Lock all moveable equipment before transferring me. Place items that I commonly use within reach. Provide adequate lighting. Refer to Formal Therapy as needed. Remind me to change positions slowly to avoid dizziness/orthostatic [MEDICAL CONDITION]. Remind/encourage to use call light for assistance. Transfer with assist x 1. -Problem: (R#49) is to wear a cervical collar at all times following a cervical fracture she sustained. Approach Start Date: 03/25/19, Staff will ensure (R#49) has her cervical collar on at all times by assessing placement every 15 minutes. Staff will educate (R#49) on the importance of compliance with regards to keeping her cervical collar on at all times. Staff will be attentive and understanding of (R#49's) concerns and emotional aspects of having to wear a cervical collar. On 03/25/19 at 2:52 p.m., surveyor interviewed R#49 about her recent fall on 01/21/19. R#49 said she was trying to move a wheelchair that was in front of the commode when she fell on her right side. She said she got a neck fracture and has had to wear a neck brace for the past five weeks. She said she went to the doctor yesterday and was told she needed to wear the neck brace an additional five weeks. R#49 said the neck brace bothered her and she could not wait to take it off. On 03/27/19 at 1:27 p.m., surveyor observed R#49 sitting on the commode in her restroom, asleep. The light to the restroom was off. The light was motion sensored. The surveyor observed Assistant Director of Nurses (ADON) M walk by. Surveyor informed ADON M that R#49 was observed asleep sitting on the commode. ADON M walked into the restroom and the light turned on. Right when the light turned on, R#49 woke up and asked for wipes. ADON M said R#49 stayed up all night coloring and fell asleep easily during the day because of it. On 03/29/19 at 9:18 a.m., during an interview, the surveyor asked R#49 if staff had implemented any interventions to prevent her from falling again. R#49 said she used to have a fall mat at bedside, but did not have it anymore. The surveyor asked R#49 if her care needs had changed since her neck fracture. R#49 said two staff now help her after she uses the commode and before one staff would help her. R#49 said she used her call light more often to ask staff for assistance. The surveyor did not observe a fall mat at bedside in R#49's room. On 03/29/19 at 9:41 a.m., during an interview with Certified Nurse Aide (CNA) AY, the surveyor asked if R#49's care needs had changed since her neck fracture. CNA AY said two staff now helped R#49 after she used the restroom and R#49 asked staff for help more often. CNA AY said, to his knowledge, no new interventions had been put into place after R#49's falls. On 03/29/19 at 10:13 a.m., during an interview with CNA BR, the surveyor asked if R#49's care needs had changed since her neck fracture. CNA BR said R#49 used her call light more to ask for assistance from staff. She said two staff assisted R#49 with toileting and before one staff would help her. The surveyor asked what interventions have been put into place after R#49's falls. CNA BR said R#49's bed must now be low, and she was supposed to have a fall mat at bedside. The surveyor asked CNA BR to show her the fall mat at bedside because the surveyor could not locate it. CNA BR and the surveyor entered R#49's room. CNA BR could not locate the fall mat. CNA BR said she would inform the nurse and said she did not know where R#49's fall mat went to. On 03/29/19 at 11:27 a.m., during an interview with LVN Y, the surveyor asked if R#49's care needs had changed since her neck fracture. LVN Y said R#49 required more help from staffs after she used the restroom. She said two staff assisted her and before one staff would assist her. LVN Y said they had also been educating R#49 on using the call light whenever she needed assistance. On 03/29/19 at 12:58 p.m., during an interview with CNA AQ, the surveyor asked what interventions had been put into place after R#49's falls. CNA AQ said they encouraged R#49 to use her call light when she needed assistance and placed her bed in a low position with a mat at bedside. On 03/29/19 at 1:14 p.m., the surveyor interviewed the Director of Nursing (DON) about R#49's multiple falls and fall with major injury. The DON said, on 01/21/19, R#49 told them she was in the bathroom when she noticed a wheelchair in front of the commode. She got up from her wheelchair and in the process of moving the wheelchair in front of the commode out of the way, she fell on her right side. The DON said during their investigation into the incident, they were unsure if the wheelchair was in front of the commode or up against the wall. The DON said R#49 was sent to the hospital and was diagnosed with [REDACTED]. The DON said after R#49 returned to the facility, they implemented checking on her every 15 minutes to ensure she did not remove the neck brace. The surveyor asked what interventions were put into place after R#49's falls, prior to her fall with major injury. The DON said they attempted a toileting schedule, but R#49 refused the program. The DON said R#49 was also referred to therapy. The surveyor asked about the intervention of supervision and explained this intervention was not found on the care plan and staff interviewed did not voice this as a current intervention. The DON said staff had been supervising R#49. The surveyor asked for documentation of this and the DON did not provide any documentation showing R#49 is being supervised by staff. Review of the facility's policy titled, Falls- Evaluation and Prevention with a revision date of 09/2014, revealed, Policy, It is the policy of this home to evaluate residents for their fall risk and develop interventions for prevention. Definition, A fall is a defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. A near fall is a sudden loss of balance that does not result in a fall or other injury. This can include a person who slips, stumbles or trips but is able to regain control prior to falling. An unwitnessed fall occurs when a resident is found on the floor and neither the resident nor anyone else knows how he or she got there. Procedure, Upon Admission, the nursing staff/interdisciplinary team should determine if a resident is at risk for falls and develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible and avoid any injury related to falls. The staff should not utilize a restraint to prevent falls unless they receive written documentation to support the use of the restraint. A restraint should be the last intervention implemented by the staff. The care plan should only specify a few interventions at a time so that the staff can determine what intervention is not successful and needs to be changed. -R#84: Review of Resident #84's face sheet revealed R#84 was a [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]., or fear that are strong enough to interfere with one's daily activities), and [MEDICATION NAME] Degeneration (eye disease that causes vision loss). Resident #84's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 4 (severe cognitive impairment), required extensive assistance with one person-physical assist with bed mobility, transferring, toileting, dressing, personal hygiene, physical help in part of bathing activity, was frequently incontinent of the bladder & bowel, and has had one fall prior to assessment. Review of R#84's Nursing Assistant Care Plan dated 05/30/18 revealed no care planning of R#84's fall interventions nor behavior interventions. Review of R#84's care plans dated 11/06/16 revealed, Category Falls: R#84 is at risk for falls due to medication side effects & weakness. Goal: R#84 will not fall over the next review period. Approach: Assessment & treatment for [REDACTED]. If R#84 becomes upset at staff, R#84 will attempt to place self on floor. R#84 will be monitored for behaviors when R#84 wants attention or to be sent to emergency room . Staff will intervene to keep R#84 safe. Review of R#84's Care plan dated 1/21/19 revealed, Problem/Need: Potential for injury: Falls. Interventions: Provide me with a low bed. Keep the bed in the low position whenever R#84 in be Place fall mats on floor at my bedside. Review of R#84's Fall Risk Assessment Form dated 1/21/19 revealed a score of 22 with instructions indicating A score of 10 or more indicates HIGH RISK FOR FALLS. Patient has been informed about fall risk assessment results & safety/fall prevent recommendations: Yes. Observation on 03/29/19 at 11:14 AM of R#84 lying in her bed on her back leaning to the left and bed was in lowest position. R#84's fall mat is folded and not laid out on right side of bed and R#84's wheelchair was placed in front of floor mat that was folded and up against the wall. CNA (Certified Nursing Assistant) AS walked in R#84's room and when asked if R#84's floor mat should be laid out when R#84 is in bed, CNA AS replied, She flips it over and hates it. When asked again if R#84's floor mat should be laid out when R#84 is in bed, CNA AS replied, Yes it's supposed to be laid out when she is in bed. Surveyor asked if CNA AS was an LVN (Licensed Vocational Nurse), CNA AS replied, I'm a CNA. CNA AS did not lay out R#84's floor mat prior to leaving R# 84's room. Review of the Facility's Incident book documented the following for R#84 by date, time, type of occurrence, nature of injury, location of incident, root cause, action taken, reported to HHS (Health & Human Services): Friday (MONTH) 11, 2019 at 11:30 AM unwitnessed fall without injury in rest room. Resident # 84 was using the restroom prior to the fall & she stated she was just trying to go to bed. She was not wearing her non-slip shoes but her bed was to the lowest position & locked & non slip adhesive tape was in place at the time of the fall. Initiated neuro checks; Reminded Resident # 84 to utilize the call bell system when she needs to go to the bathroom; rehab evaluation requested. Monday (MONTH) 21, 2019 at 5:45 AM fall without injury in restroom. Resident # 84 stated she got out of bed to get a pair of paints out of her closet when she felt weak & sat on the floor. Always keep residents in bed in low position while she is in it and the fall mats at her bedside. Interview on 3/29/19 at 2:55 PM with the DON (Director of Nursing) stated, The floor mats are to help prevent her from having injury. I don't know who put the floor mats there. When Surveyor explained to the DON her observations, the DON asked Who was it? Surveyor replied she could not answer that. The DON stated, What's wrong with these people! Review of the facility's policy titled Falls - Evaluation & Prevention, dated 01/2008 & revised on 09/2014 revealed: . It is the policy of this home to evaluate residents for their fall risk & develop interventions for prevention. Procedure: Upon Admission, the nursing staff/interdisciplinary care team should determine if a resident is at risk for falls & develop appropriate interventions based on the evaluation. The goal is to prevent falls if possible & avoid any injury related to falls . Education of Staff Related to Fall Prevention: Providing a safe environment for residents Cause & risk factors for falls as well as the interventions to manage risk .

Based on observation, interview and record review the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for one (Resident #5) of 5 residents reviewed for quality of care in that: Facility staff failed to monitor and supervise, an NPO (nothing by mouth) resident, to keep the resident from obtaining food and beverages that the resident was unable to consume due to medical diagnoses, thus resulting in the resident aspirating and being sent to the local Acute Care Hospital where the resident was diagnosed with [REDACTED].>Additionally, the facility Director of Nursing was aware that the resident required more supervision than the facility was able to provide but the resident was not discharged to a facility that would be able to provide the supervision needed to keep the resident safe. This failure affected one (R#5) resident and placed 18 other residents at risk who resided on the Special Needs Unit (SNU). Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/18/18 R #5's medical record was reviewed. Review of the medical record revealed an Admission Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed R #5 as having an Intellectual Disability and a Brief Interview for Mental Status (BIMS) score of 14. Additionally, facility staff assessed R #5 as requiring a mechanically altered diet. Staff did not assess R#5 as having any behaviors. Review of R#5's comprehensive care plan dated 03/19/18, revealed no documentation or care plan regarding R#5's behaviors of taking food and beverages to consume that belonged to other residents, taking food out of the trash cans, getting un-thickened beverages (such as coffee, water, milk) from the dining room, nurses' station or found in the hall. Review of R#5's Care Conference Report revealed the following entries: a. 06/6/18: .Resident is NPO due to failed swallow study. Staff is having difficulty keeping patient away from drink and food as he will often dig through the trash and eat what he finds. Will also take cups off the table and trays after other residents have finished them. Resident misses eating food and drinking water and coffee. When he takes something he should not he is instantly apologetic but will continue taking and consuming what he shouldn't. b. 06/11/18: . He is NPO. He is not very cooperative with the exercises and therefore still with issues swallowing. Continues to grab food and drink from wherever he can find them. Continues with pneumonia. Has issues with impulse control and is often caught with food and drink that he is not safe to drink. c. 08/8/18: Res (resident) is NPO . Res is very non compliant with NPO status and is often taking fluids and food from nurse station. Res often develops PNA (pneumonia) D/T (due to) this. Review of the medical record revealed an Against Medical Advise (sic) Related to Swallowing/Eating/Fluid Restrictions form dated 06/18/18. The form indicated that R#5 would be at risk for choking/coughing and Aspiration Pneumonia. The form indicated that the facility and its representatives were to Allow pt (patient) to have thicken liquid trials and puree consistency with SLP (Speech Language Pathologist) only. The form was signed by R#5's mother, who according to the form was R#5's Power of Attorney. No documentation could be found to show that R#5's mother was R#5's Power of Attorney. On 09/19/18 at 4:45 PM, the facility Director of Nursing (DON) was interviewed. The DON stated that R#5 was responsible for making his own decisions but that his mother helped him with medical decisions. The DON stated that R#5's mother was not his Power of Attorney. Review of R#5's Progress Notes revealed the following entries: a. 07/6/18: Res caught coming out of DR (dining room) (after) dinner. When questioned, Res breath smelt of coffee. Res reminded that he is not supposed to be eating or drinking anything. And that he will fail swallow study test if he keeps trying to sneak food. Res said he was sorry and that he won't do it again. b. 07/9/18: Res con't (continues) to be non-compliant (with) NPO diet. Had swallow study test done. Res stated he failed. Res was caught during diner (with) a cup he got from nurse's station trying to sneak it into his room when DON (name) caught him. c. 07/27/18: Res wanders through unit. Constant supervision needed, non-compliant (with) NPO status. A cup of water was found on bedside table in res room. d. 08/11/18: Resident caught eating out of tray of other resident. e. 08/14/18: Res cont to be non-compliant. Res drinking thin liquids when nurse walked away from dining room. f. 08/27/18: Res cont (with) non-compliance, was caught trying to get into nurse's cart while nurse walked away. g. 09/8/18: Res caught drinking thin coffee in dining area. h. 09/15/18: Resident noted shaking uncontrollably. Skin hot to touch. Temp. (temperature) was 104.1 AX (axillary). Resident noted (with) crackles and congested cough. Resident's abdomen was firm and distended. Urine in toilet noted (with) dark color and foul odor. Resident medicated (with) Tylenol 650 mg (milligrams) via [DEVICE] (gastrostomy). 6 AM bolus held D/T resident's cough and congestion. Resident was noted (with) hallucinations and confusion. Wet cold compresses applied to forehead, abdomen and axillas. SN (skilled nurse) called residents mother (name) to inform her that resident was being sent to the ER (emergency room ) via ambulance D/T high fever and cough and congestion. Review of the Acute Care Hospital Admission paperwork for R#5 revealed the following entry: Assessment and Plan Hospital Course, (MONTH) 15, (YEAR): Patient admitted today. [AGE] years old male with past medical history of [REDACTED]. The patient is managed with a PEG (Percutaneous Endoscopic Gastrostomy) tube feedings, as per the ED (Emergency Department) physician he was eating 'regular food from the resident's (sic) at the nursing home and aspirated again.' Assessment and Plan Problems: (1) Recurrent aspiration pneumonia Status: Acute . On 09/18/18 at 10:45 AM and 2:20 PM and 09/19/18 at 10:30 AM, observations, of the Special Needs Unit (SNU) where R#5 resided while at the facility, revealed one Licensed Nurse and two Certified Nursing Assistants (CNAs) to deliver care and monitor/supervise 18 special needs residents. One CNA was observed to facilitate a scheduled activity while trying to monitor residents in the Activity room while the other CNA was observed to try and provide Activities of Daily Living (ADLs) to residents while monitoring residents for falls and behaviors. On 09/18/18 at 11:00 AM, the facility SNU dining room was observed. Observations revealed a stack of clear plastic cups by the sink. All SNU residents had access to the cups and sink to obtain water. Multiple observations on 09/18/18 at 10:45 AM, 11:30 AM, and 12:30 PM and 09/19/18 at 10:30 AM, were made of the medication cart being left unattended with water and Med Pass formula on the top the cart. Residents were observed wandering up and down the hall and had access to the nurse medication cart. On 09/18/18 at 4:30 PM, observations revealed that all resident rooms on the unit had a mug of water on their bedside table. Residents were again observed wandering up and down the hall and in and out of the activity room while one CNA facilitated an activity and the other CNA was observed to be providing showers or assisting residents with ADLs. On 09/19/18 at 11:20 AM, an observation of the nurse's station revealed a snack size package of M&Ms candy left unattended. On 09/18/18 at 11:20 AM, Licensed Vocational Nurse (LVN) A was interviewed. LVN A stated that R#5 helps himself to stuff. LVN A stated that staff try their best to monitor R#5 but could not always stop him. LVN A further stated that R#5 was, very sneaky and would take off his shoes to sneak around. LVN A stated that R#5 was non-complaint with his diet. LVN A stated that she did not feel the SNU had adequate staff to monitor the residents sufficiently. On 09/18/18 at 10:55 AM, Certified Nursing Assistant (CNA) D was interviewed. CNA D stated that it would be helpful to have additional staff to watch special needs residents. CNA D stated that it was a safety issue to monitor all of the residents with just the two staff members. On 09/18/18 at 2:20 PM, LVN B was interviewed. LVN B stated that she did not feel the SNU had enough staff to monitor the residents sufficiently. LVN B stated that R#5 was non-compliant with his diet and could be very sneaky. LVN B stated that staff did their best to monitor R#5 but caught R#5 with food and coffee all of the time. On 09/18/18 at 2:30 PM, CNA E was interviewed. CNA E stated that the staff did the best they could with monitoring the residents but she felt that the SNU could use more staff. On 09/19/18 at 12:20 PM, the facility DON was interviewed. The DON stated that R#5 was NPO on admission and was admitted to the facility to receive increased supervision because he had been consuming coffee at a different facility and the other facility was not able to monitor/supervise him to prevent the behavior. The DON stated that other residents have alerted staff to R#5 having food and beverages so the staff could intervene. The DON stated that the resident would yell out, Hey, (R#5) has food he is not supposed to have. The DON stated that R#5 had to be monitored constantly. The DON further stated that the staff were doing the best that they could but that the facility did not do One on One care. The DON stated that the staff attempted to educate R#5 that he could not have food and beverage items but that R#5 forgot right after he was educated. On 09/19/18 at 12:30 PM, the facility Licensed Baccalaureate Social Worker (LBSW) was interviewed. The LBSW stated that she had not been involved in the planning of care on how to deal with R#5's behaviors regarding consuming food and beverages he was not supposed to have. On 09/19/18 at 3:17 PM, LVN C was interviewed. LVN C stated that she was the nurse providing cares to R#5 on the morning he was sent to the hospital. LVN C stated that when she went in to give R#5 medication, that R#5 was shaking uncontrollably and was not in his right mind. LVN 3 stated that R#5 was confused, not able to converse well and was hallucinating. LVN C stated that she knew R#5 did not feel well because R#5 was moaning and in pain. LVN C stated that R#5 was very hot to the touch and had a fever of 104.1, had a cough and was congested. LVN C stated that she provided care and called 911 to send R#5 to the local hospital. The facility's LVN A, provided the census of 18 for the Special Needs locked Unit on 09/18/18.

Based on observation, interview and record review, the facility failed to provide treatment and care to five (R#4, R#10, R#44, R#73, and R #86) of 19 Residents reviewed for quality of care, that was in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. The facility did not notify R#73's physician and Responsible Party (RP) when there were significant changes in her wounds. The facility delayed in rescheduling an appointment with a Cardiologist for about one month (that was ordered by R#73's physician). When R#73 saw the cardiologist, he sent her immediately to the emergency room . R#73 was admitted to the hospital and had an amputation of the left leg above the knee. The facility did not notify R#73's physician or RP when the wound on the middle toe of R#73's left foot deteriorated, spreading to other toes, and eventually became gangrenous. The facility failed to consistently identify the correct location of R#73's wound in their assessments/documentation, making it difficult to track the wound progress. The facility did not refer R#4 to a rheumatologist as ordered by her physician. The facility did not provide Nepro, a supplement for persons on [MEDICAL TREATMENT], according to R#10's Physician Order. The facility did not provide adequate meal time nutrition for R#10 when he went to [MEDICAL TREATMENT]. The facility did not follow up on a timely basis on a Physician order [REDACTED]. LVN TX did not provide R #86 with wound care of her diabetic ulcer as per her physician's orders [REDACTED]. These failures could place 13 residents identified with wounds at risk for deterioration of a wound, loss of a limb or death; two residents who went to [MEDICAL TREATMENT] at risk of decreased quality of care; and 96 residents who may be at risk of decreased quality of care if they were not referred for treatments or specialists as per physician's orders [REDACTED]. The findings were: Resident #73 Review of Face Sheet undated revealed R#73 was admitted to the facility on [DATE] and readmitted on [DATE]. R#73's [DIAGNOSES REDACTED].; [MEDICAL CONDITION]; Unspecified mood (affective) disorder; [MEDICAL CONDITION]; and Hypertension. R#73 was [AGE] years old. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#73 had a Brief Interview for Mental Status (BIMS) score of 00, indicating she had severe cognitive impairment. R#73 required extensive assistance with the help of one person to move about in bed; was totally dependent on the help of one person to be transferred in and out of bed and chair; did not walk and had to be assisted with moving her wheelchair; and was totally dependent on others for help with dressing, bathing, eating and toileting. R#73 was always incontinent of bowel and bladder. Review of Physicians Orders for 02/01/18 to 03/31/18 revealed R#73 had orders which included [MEDICATION NAME], to be administered 100 unit/mL (milliliter), per sliding scale, subcutaneous, before meals and at bedtime, 6:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. for diabetes; [MEDICATION NAME] 100 unit/mL, 25 units, subcutaneous once daily at 8:00 a.m. for diabetes; and [MEDICATION NAME] 325 mg Q6h PRN (every six hours as needed) for pain or fever. No more than four grams of [MEDICATION NAME] from all sources could be given within a 24 hour period. R#73 was to have a pain assessment each shift, and a pressure reduction mattress. Review of Physician Telephone Order dated 12/29/17 to discontinue wound treatment to R#73's left third toe due to the area being healed. Review of R#73's Care Plan dated 02/02/17 and updated 01/16/18 revealed: -R#73 was at risk for pressure ulcers. Approaches started 01/15/18 included turning and repositioning her at least every two hours; performing a daily skin inspection with all bony prominences being observed very carefully; keeping bony prominences from coming in direct contact with one another with the use of wedges and pillows; keeping her skin as dry as possible. On 04/05/18 this care plan problem was updated with Cont (continue) P[NAME] (plan of care) and review 07/05/18. On 04/06/18, the pressure ulcer care plan problem was updated with Cleanse second toe with NS (normal saline), pat dry, cover with ABD pad and wrap (with) kerlix QD (daily) & PRN. Cleanse L (left) 4th toe (with) NS, pat dry, apply gauze between 4th and 5th toes, cover (with) ABD pad & wrap (with) kerlix QD & PRN. This was the only documentation of wound care found in the care plan. -R#73 had difficulty focusing attention and was easily distracted, out of touch, and had difficulty following what was said. Approaches began on 01/15/18 included assessing her for pain. -R#73 was at high risk for skin breakdown related to her diabetes and bowel and bladder incontinence. Approaches dated 01/15/18 and updated 04/05/18 did not list anything related to the infection of R#73's toes on her left foot or how to prevent skin breakdown specific to her feet. R#73 had previously had skin breakdown on her toes which was resolved on 12/29/17. -R#73 was at risk for falls due to her cognitive deficits and poor safety awareness, weakness and [MEDICAL CONDITION] medication use; approaches begun on 01/15/18 and updated 04/05/18 included keeping her bed in the low position whenever in bed. Review of physician progress notes [REDACTED].#73 had [DIAGNOSES REDACTED]. There was no documentation regarding observation of any wounds or concerns regarding R#73's left foot. Review of Progress Notes revealed: 02/10/18 (2:00): CNA reported to (this nurse-unable to read signature) R#73 had dried blood on her sock to the left foot. No active bleeding found or open areas. Dried blood around coarse toenail found to second toe; noted bruising to second toe of left foot, dark purple in color. Bruising covers toe 3 cm length X 2 cm width. Noted with redness traveling from bruised area to left side of foot; warm to touch; pain upon touch-was determined through R#73 pulling back foot slightly and facial grimacing and mumbling. Tylenol 325 two tabs administered for pain. Cleansed second left toe with normal saline and gauze; pat dried with gauze, left open to air. Foot elevated with pillow. Physician informed/faxed. Due to history of Diabetes and [MEDICAL CONDITION], takes ASA, requesting LLE (left lower extremity) Doppler venous/arterial (?) X-ray of left foot/toes? ABT (antibiotic) therapy? AM (morning) nurse to follow up phone call for orders; will continue to monitor. 02/10/18 (12:30 pm.): Called on call physician; informed of R#73's left second digit on left foot. Gave order for Keflex 500 mg tid (three times daily) X five days for infected left foot and Xray to left foot two views. 02/10/18 (1:00 p.m.): Called portable xray company to take xrays of R#73's left foot. Will be at facility sometime today. Notified RP by leaving message due to no answer. These Progress Notes document concerns found on the second toe of the left foot. Review of Radiology report dated 02/10/18 revealed R#73 had modest [MEDICAL CONDITION] joint disease. There was no fracture, dislocation, or soft tissue swelling. No osteo[DIAGNOSES REDACTED] was seen. The bones appeared diffusely demineralized. Peripheral [MEDICAL CONDITION] disease was noted along with heel spurs. The report concluded that R#73 had modest [MEDICAL CONDITION] joint disease; otherwise, no fracture of dislocation seen. Review of Progress Notes continued: 02/11/18 (8:00 a.m.): Initial dose of Keflex 500 mg tid given at this time. Left toe and foot with increased redness. Second digit on left foot continued with dark purple color. complained of pain when touched. Again, these progress notes document wound to second digit on left foot. Review of Skin Assessment Flow sheet for non-pressure injury conditions (skin assessment) with date of onset of 02/11/18, revealed R#73 had a skin risk score of 14, and the physician and RP were notified. The third toe on the left foot was infected with purple discoloration. Description of skin alteration: 3.5 cm. length X 1.5 cm width. Treatment was to monitor. These progress notes documented wound to third toe of left foot. Review of Progress Notes continued: 02/12/18 (12:00 p.m.): Called R#73's physician, Physician Z, to inform of R#73's right foot noted with more redness. Physician Z gave order to send to emergency room to evaluate and treat. These Progress Notes documented wound to right foot. 02/12/18 (1:00 p.m.) Ambulance arrived to transport R#73 to the hospital. 02/12/18 (5:00 p.m.) R#73 arrived back from the hospital with new order for [MEDICATION NAME] HCl 300 mg (milligram) TID X seven days for infection. Discontinued Keflex 500 mg TID X 5 days for infection. Need to follow up with PCP (Physician AZ) in a couple of days. Will continue to monitor. (8:30 p.m.) Called RP (Responsible Party) to notify of new medication; RP did not answer. 02/15/18 (1:00 a.m.) Received response from fax- left foot-xray-LLE arterial performed on 02/10/18; [MEDICATION NAME] 300 mg TID X ten days. R#73 currently on [MEDICATION NAME] 300 mg TID X seven days received at ER visit on 02/12/18. No side effects or A/R (adverse reaction) to [MEDICATION NAME]. LLE arterial Doppler to be set at hospital radiology department (no record of arterial Doppler having been performed until 04/05/18). Left foot continued with redness and warm to touch; no drainage with dark color discoloration to second toe of left foot; elevated with pillow. Will continue to monitor. Follow up appointment with PCP to be set up. 02/17/18 (1:00 p.m.) Physician AZ at facility to do rounds. No new orders received. Continue on [MEDICATION NAME] 300 mg TID X ten days for left foot infection. 02/18/18 (9:50 p.m.) R#73 continued on [MEDICATION NAME] 300 mg TID for left foot infection. Redness and deterioration noted to second left toe. Will continue to monitor. 02/19/18 (9:45 p.m.): R#73 received last dose of [MEDICATION NAME] therapy. No complaint of pain or discomfort. These progress notes documented wound on second toe of left foot. Review of Skin Assessment Flow Sheet-Non-Pressure injury condition dated 02/21/18 revealed Dry scabbed area to left third toe, 3.5 cm length X 1.2 cm width with no depth. There was no treatment change. Review of Skin assessment dated [DATE] revealed the left third toe was noted to have necrotic tissue and sloughing, and R#73 was positive for [MEDICAL CONDITION]. The size was noted to be 4.0 cm. length X 1.5 cm width. This Skin Assessment documented wound on left third toe. Review of Progress Notes continued: 03/01/18 (11:00 a.m.): Received order from Physician AZ to do a wound culture to third toe on left foot and start [MEDICATION NAME] 150 mg TID X seven days for toe infection. RP made aware of new orders. 03/02/18 (8:00 a.m.) Initial dose of [MEDICATION NAME] 150 mg TID X seven days for left toe infection. 03/06/18 (11:15 a.m.) : Continue on antibiotic [MEDICATION NAME] 150 mg PO TID X seven days for toe infection. No side effects or adverse reaction noted .Toe continues with necrotic area . (unable to read much of the note and nurse initials are illegible). Review of Lab report of wound culture done on 03/02/18 at 8:08 a.m. revealed R#73 had [DIAGNOSES REDACTED]. The wound culture report was received by the facility on 03/06/18 at 4:50 p.m. Review of Progress Notes continued: 03/06/18 (5:00 p.m.) This nurse (initials appear to be AZ but employee list has no one with those initials) received culture results for wound infection to left second digit. Results showed three organisms-Pseudomonas Aeruginosa, Staph Aureus and yeast. On call service for Physician AZ notified. R#73 was afebrile and had no complaints of pain. Pending Physician AZ call back. (5:30 p.m.): Physician AZ called back and [MEDICATION NAME] mg BID (twice daily) X ten days, [MEDICATION NAME] 500 mg BID X ten days, [MEDICATION NAME] 100 mg single dose; discontinue (d/c) [MEDICATION NAME] 150 mg TID X seven days. Initial dose of [MEDICATION NAME] given; pending initial dose [MEDICATION NAME] arrived from pharmacy. (9:30 p.m.) RP notified of wound culture results and medication changes. These Progress Notes documented wound on left second digit. Skin assessment dated [DATE] revealed R#73 had dry eschar/necrotic tissue to her left third toe; dry dressing in place. The size was 3.5 cm length X 1.5 cm width, and zero depth. This Skin Assessment documented wound to left third toe. Review of Progress Notes continued: 03/08/18 (9:00 p.m.): RP was called and made aware of appointment with Cardiologist on 03/12/18 at 11:45 p.m. (?). 03/09/18 (9:00 p.m.) R#73 continued on antibiotic [MEDICATION NAME] mg BID X ten days and [MEDICATION NAME] 500 mg Bid X ten days for foot infection. No S/S (signs or symptoms) of pain or discomfort. No side effects or adverse reactions to medication noted. 03/11/18 (9:40 a.m.) continue on antibiotic therapy. R#73 continued with redness to the left foot; no drainage or odor noted. (10:20 p.m.): Antibiotic Cipro/[MEDICATION NAME] continues due to left second digit. R#73 would grimace when LLE was moved. No other complaints of pain otherwise. Dressing noted as clean, dry and intact. Will monitor. 03/12/18 (2:00 a.m.) Left foot second toe infection-dressing intact, no drainage through dressing; no side effects or adverse reaction to antibiotics. Appointment with Cardiologist to be rescheduled per RP request, unable to make appointment with R#73. AM (morning) nurse to reschedule. These Progress Notes documented wound to left second toe and left foot second digit. Review of Skin Assessment Flow Sheet dated 03/13/18 revealed R#73's third toe ulcer had increased in size and continued with dry eschar. The size of the wound was not 4.0 length X 2.0 cm in width, with no depth. This Skin Assessment documented wound to third toe. Review of Progress Notes continued: 03/14/18 (9:45 p.m.) R#73 continued [MEDICATION NAME] for infection to wound on left foot second toe. Continued with daily wound care. Denied pain, no symptoms of pain noted. 03/16/18 (4:00 p.m.) Noted during dressing change to left toe new area with pressure left inner heel. Need to float heels. Left second toe with dark area noted to top. Noted maceration. Dressing change per treatment nurse. 03/17/18 (2:00 p.m.) R#73 noted with cough/congestion. Afebrile. Will continue to monitor. (9:00 p.m.) R#73 noted in bed at this time; dressing to left foot with minimum serosanguinous drainage. Grimacing/guarding noted. PRN (as needed) Tylenol administered, no foul odor noted to left second digit. status [REDACTED]. Will monitor. 03/18/18 (9:00 p.m.) This nurse (unable to read initials) provided wound care. Wound bed with necrotic tissue. Wound edges noted with red wound bed. Minimal serosanguinous drainage noted. No foul odor, redness or inflammation present. Medication PRN for pain. 03/20/18 (10:55 a.m.) R#73's RP arrived at facility; nurse called Cardiologist to reschedule R#73's appointment that was cancelled by RP last week due to her not being able to go because of a family emergency. An appointment with the Cardiologist was rescheduled for 03/28/18 at 1:00 p.m. These Progress Notes documented wound to left foot second toe or left second digit. Review of Skin Assessment Flow Sheet dated 03/21/18 revealed R#73's left toe wound had not changed and the area was stable. Measurement continued to be 4.0 cm length and 2.0 cm width, with no depth. Review of Progress Notes continued: 03/23/18 (2:00 p.m.) R#73 noted with yellowish drainage .MD faxed; pending response. (new note for 03/23/18 with no time noted) R#73 noted with a 3.5 cm X .3 cm X .1 cm abrasion with two other small abrasions to right shin. No drainage or bleeding or warmth to touch. Redness noted around abrasion. R#73 denied any pain or discomfort. Abrasion cleansed, RP and MD notified. 03/25/18 (2:00 p.m.) Physician AZ at facility doing rounds with no new orders. Review of physician progress notes [REDACTED].#73 had hypertension, Diabetes; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; overactive bladder; and depression. There was no mention of R#73's wound on her left foot. Review of Nutrition assessment dated [DATE] revealed R#73 weighed 126 pounds, which was 126% of her ideal body weight. R#73 was at nutritional risk and risk for dehydration secondary to her [DIAGNOSES REDACTED]. A routine snack at night was being offered but no supplements were noted for help with wound healing. Review of Skin Assessment Flow Sheet dated 03/27/18 revealed R#73 had dry eschar, with measurements decreased to 3.0 cm length X 1.3 cm width, X zero depth. The left inner toe had a purple area noted .5 cm X .5 cm. Review of Nurse's notes revealed no documentation dated 03/28/18 regarding whether R#73 kept the Cardiologist appointment or whether it was rescheduled and why it might have been rescheduled. On 04/08/18, nurse's notes documented that the appointment was missed on 03/28/18; no reason given (see notes dated 04/06/18 and 04/08/18). Review of Progress Notes continued: 04/02/18 (10:00 p.m.) R#73's wound to left second digit toe had necrotic tissue. Serosanguinous drainage yellowish with foul odor. Left lower (unable to read) was also warm to touch. The fourth digit left foot had redness, notified MD via fax. Waiting for response. Will continue to monitor. Bed in lowest position, call light within reach. 04/03/18 (2:00 p.m.) Late entry for 04/02/18 at 8:00 p.m. R#73 had bruise to left lower leg. Notified RP. RP said R#73's leg was under her wheelchair's foot rest instead of on top of it, and caused her leg to press against it, which led to the bruise. Continue to monitor. 04/03/18 (5:50 p.m.) New order for LLE arterial doppler, wound culture. [MEDICATION NAME] 300 mg TID X ten days. Notified RP. Schedule arterial doppler for 04/04/18. These Progress Notes documented wound to left second digit. Review of Skin Assessment Flow Sheet dated 04/03/18 revealed R#73 had dry eschar to the left third toe and fourth toe had purple area increasing in size to 1.3 cm X 1.3 cm. The dimensions of the wound on the left third toe was 3.5 cm. X 1.5 cm, with zero depth. This Skin Assessment documented wound to left third toe and fourth toe. Review of R#73's Quarterly Pain assessment dated [DATE] revealed R#73 did not have pain; expressed pain through facial expressions and protective body movements; was not able to verbalize whether she had pain; had symptoms of pain with any physical activity change; medications or treatments in the last five days had eased her pain completely; and a pain level of one was R#73's acceptable level of comfort. Review of Progress Notes continued: 04/04/18 (8:00 p.m.) Collected wound culture. R#73 tolerated well. Sample was in hall Z refrigerator. Will continue to monitor. 04/05/18 (3:30 p.m.) Wound care was done, little drainage on fifth toe, mild odor. (5:00 p.m.) Arterial doppler performed, R#73 was laid back in bed. (Late entry 3:30 p.m.) Daily wound care provided at this time. Necrotic areas noted to second digit, fourth/fifth digit. Second digit measured 3.9 X 2.4 X .1 cm. Yellow slough noted at 3:00. Minimal drainage noted. Necrotic areas to fourth and fifth digit with no drainage. R#73 grimacing and guarding during care. PRN pain medication. Continue with [MEDICATION NAME] 300 mg TID for wound infection. Minimal foul odor noted during wound care. R#73 tolerated antibiotic well. Will continue to monitor. (late entry 5:00 p.m.) Mobile xray to perform arterial doppler to LLE. R#73 tolerated procedure well. Pedal pulse weak. No cyanosis noted. Warm to touch. Pending doppler results. These Progress Notes documented wound to second digit, fourth/fifth digit. No mention is noted of wound to third toe. Review of Ultrasound Report of duplex lower extremity arterial unilateral , left extremity, dated 04/05/18, revealed R#73 had moderate [MEDICAL CONDITION] changes. Review of Physician's Telephone Orders dated 04/06/18 revealed: 1. Clarification order for 02/27/18: Cleanse left third toe with NS (normal saline), pat dry, cover with abd (large gauze) pad and wrap with Kerlix QD (daily) until all resolved. 2. Clarification order for 03/22/18: Cleanse left fourth toe with NS, pat dry, apply gauze between fourth and fifth toes, cover with abd pad, wrap with Kerlix QD until resolved. Surveyor noted that this is the first time orders for wound care were found in R#73's clinical record. This Physician Telephone Order documented wound to left third, fourth and fifth toe. Review of Progress Notes continued: 04/06/18 (11:10 a.m.) Called RP to make her aware that R#73's appointment with Cardiologist was rescheduled for (MONTH) 11, (YEAR) at 11:45 a.m. Also advised RP that R#73's arterial doppler was positive for [MEDICAL CONDITION]. R#73 continued on antibiotic therapy for infection to toes of left foot. Continued with redness to left foot, no grimacing or pain noted to face. Will continue to monitor. (10:00 p.m.) R#73 continued on antibiotics for infection of left toes. No adverse effects noticed at this time. Tolerating well. No complaints of pain. Will continue to monitor. (11:45 p.m.) On [MEDICATION NAME] therapy for infected second digit of left foot. Starting to have possible reaction to the medication. Noted red splotchy rash on right side and buttocks. Will continue to monitor. 04/07/18 (10:00 a.m.) R#73 noted with rash to peri-area and buttocks; no itching noted. (10:15 a.m.) Called Physician AZ to inform of R#73's status. Pending MD call back. (3:30 p.m.) Physician AZ called back with new order for Keflex 500 mg BID X ten days for infection to the left foot toes fourth and second digits. [MEDICATION NAME] cream BID until rash resolved; [MEDICATION NAME] 180 mg X ten days; and [MEDICATION NAME] 150 mg BID X ten days for allergic reaction. Discontinue [MEDICATION NAME] due to allergic reaction. (Late entry) Notified RP. (7:00 p.m.) Administered Keflex from house kit; no adverse affects at this time. Will continue to monitor. 04/08/18 (10:00 p.m.) R#73's fifth toes to the left foot has developed a black spot on the inner side near the fourth toe. Size .5 X .3 cm. R#73 missed her appointment with Cardiologist on 03/28/18. Need to reschedule. Will continue to monitor. These notes documented wounds to the fourth and second digits and fifth toe. Review of Skin Assessment Flow sheet dated 04/11/18 revealed R#73 was discharged to the hospital on [DATE]. Review of Hospital History and Physical dated 04/11/18 revealed R#73 was admitted to the hospital with [REDACTED].#73 had been on antibiotics in the nursing facility and started to develop necrosis and there was admitted to the hospital for further evaluation and treatment. The Assessment and Plan revealed R#73 had gangrene of the left second toe with necrosis; and R#73 had a cardiology consult with a Cardiologist. An operation was done on 04/16/18 due to R#73 having gangrene and osteo[DIAGNOSES REDACTED] of the left lower extremity. A left above the knee amputation was indicated due to severe stenosis of the distal femoral artery. These hospital notes documented gangreen to the left second toe with necrosis. Review of Physicians Telephone orders dated 04/19/18 revealed R#73 was readmitted to the nursing facility with orders to continue with all previous nursing home medication, treatment and labs; discontinue [MEDICATION NAME] and Levimer insulin; and start [MEDICATION NAME] per moderate sliding scale before breakfast and at night. Next Progress Notes continued: 04/19/18 (11:00 a.m.) readmitted from the hospital. Sleeping, aroused easily. Dressing to left AKA (above knee amputation) dry and intact. No distress noted. Review of R#73's Comprehensive Pain Assessment completed at 5:30 p.m. on 04/19/18, after R#73 returned to the facility following the amputation of her left lower extremity, revealed R#73 occasionally moaned or groaned indicating she might have pain; would tense and call out don't touch when moving limb; and had moderate pain in the last five days. R#73 expressed pain with facial expressions and protective body movements. Review of Progress Notes Continued: 04/20/18 (12:00 p.m.) Received new order from Physician AZ for R#73's continued pain. Tylenol #3 q6h (every six hours) prn (as needed); faxed to pharmacy; pending arrival. (Late entry for 04/19/18, 3:50 p.m.) R#73 had two red areas to right toes third digit, .2 X .2; and second at outer area .1 X .1. Notified wound care nurse. D/C IV (intravenous) feeding on right hand. Will continue to monitor. R#73 tolerated well. In an interview at 8:04 a.m. on 04/25/18, R#73's RP wanted to speak to surveyors who were in the process of doing a recertification of the facility. The RP expressed concerns that the facility was slow to respond to changes in the wound on R#73's left foot, which led to the amputation of the leg above the knee. The RP said she thought possibly the amputation would not have been as severe if the facility had responded to the wound care and notification of the physician on a timely basis. The RP said R#73 was on three different antibiotics and she had an allergic reaction to the third one. In the interview at 8:04 a.m. on 04/25/18, the RP said she was never told how bad R#73's wounds were to R#73's left foot, and she said she was just informed that it was bad by some of the nurses. When Physician AZ decided to send R#73 to a cardiologist, the RP said she could not keep the first appointment and wanted to be present for the cardiologist appointment. The RP said she called the nursing facility on the day that the appointment was rescheduled to, but she was told R#73 was down for another rescheduled appointment. The RP said the facility van was being worked on and was not available. The RP said the facility was not aggressively attempting to reschedule R#73's appointment with the Cardiologist. The RP said another week or so went by and it got to the point that the RP offered to take R#73 to the Cardiologist in her own car. The RP said someone from the nursing facility helped load R#73 into her vehicle so she could take her to the Cardiologist appointment on 04/11/18. In the interview at 8:04 a.m. on 04/25/18, the RP said when they got to the Cardiologist, he unwrapped R#73's wound and said her toes had gangrene and she needed to go immediately to the hospital. The RP said the sores on R#73's toes smelled very bad. R#73 had osteomyeliltis and infection had spread all the way to her knee. R#73 had the amputation of her lower left leg on 04/16/18 and did very well with the surgery. The RP said she asked the facility when was the last time Physician AZ saw R#73's left foot before she went to the hospital for the amputation, but no one gave her the answer. The RP said she had difficulty finding out when Physician AZ was going to be visiting R#73 so she could be there to meet with him. The RP said she was told by different staff members that he came on weekends only, or came during the week only. The RP said she was told by someone, she could not recall who, that Physician AZ was in R#73's wing of the building and thought Physician AZ looked at R#73's foot. The RP said she asked the nurses how they were documenting in R#73's chart so that Physician AZ would know he needed to look at R#73's foot, but did not get a straight answer. The RP said she felt there was no aggressiveness on the facility's part to bring attention to R#73's changing wound on her foot. The RP said she was advised that several different nurses did wound care at the facility. The RP said she had spoken with the charge nurses about her concerns, but had not expressed her concerns to the Administrator or Director of Nurses (DON) and would like to talk with the DON. At 8:41 a.m. on 04/25/18, a meeting was held with the RP and DON in the presence of surveyors. The RP advised the DON that she was never shown R#73's foot and she took the word of the nurses regarding the condition of R#73's foot. The nurses described R#73's foot as bad or very bad. The RP said she was unable to keep one of the appointments with the Cardiologist, but after this, the Cardiologist appointments were delayed because the facility van was being worked on or the facility did not remember to reschedule the appointment. The RP said she finally took R#73 to the Cardiologist herself on 04/11/18, and when the Cardiologist opened the dressing on R#73's left foot, there was a foul smell and R#73's entire digit was covered in gangrene. The RP said gangrene had started to form between two of R#73's toes and she had not been advised that the infection was spreading to other parts of R#73's foot or that it was gangrenous. The RP told the DON that she received copies of R#73's records from the facility and there was no description of the severity of R#73's foot. The RP said it was upsetting that the Cardiologist appointment was delayed and Physician AZ had not seen her foot when he made rounds. In the meeting on 04/25/18 at 8:41 a.m., the DON said she was aware of the concern regarding R#73's foot but she could not say definitely that Physician AZ saw R#73's foot because he usually came in after hours. The DON reviewed physician progress notes [REDACTED].#73's wound in his notes. The DON said the facility had a wound care nurse, Licensed Vocational Nurse (LVN) TX. LVN TX worked all week, was also a scheduler. LVN TX sometimes covered the weekends as well. Other nurses may do wound care on the weekend; usually the weekend supervising RN did the wound care. The DON said the eschar on R#73's foot got very thick on her toe and could have been unstageable. R#73 would kick off her shoe because it was painful. R#73's foot would turn really red at times. The DON said if the nurses were having a problem with a resident, they would approach the physician and tell the physician that he needed to see the resident. The DON said the wound care nurse would be expected to report a problem to a charge nurse. The DON said everyone was worried about R#73's toe and knew it was getting worse. The RP said she talked with one of the MDS nurses instead of the DON about her concerns because she knew that nurse. After the RP left, at 9:15 a.m. on 04/25/18, the surveyors continued meeting with the DON regarding R#73's left foot wound. LVN TX was called into the meeting. The DON said things could have been done differently to communicate with Physician AZ to be sure he saw R#73's foot wound. LVN TX reviewed the wound care for R#73 and answered the following questions: Surveyor: What does infected toe mean? LVN TX: the discoloration and swelling of the toe meant infection. DON: there should be a description of the toe. Surveyor: Would infected toe be valid? DON: No. LVN TX: Findings were also documented in the nurses' notes what the findings were. There's limited space on that note (Skin Assessment Note). On 02/11/18 when it was brought to my attention, I read the nurse's note dated 02/10/18. The charge nurse looks at the wound and she (LVN TX) just does the wound care charting weekly. The two to ten nurse was with her most of the time. If she (charge nurse) noticed a change she would document and notify the doctor. I usually asked the charge nurse to go with me when doing wound care. Surveyor: On 02/21, she has a dry scab area to the left toe; on 02/28, it says it's grown in size and it says left third toe noted with necrotic tissue and sloughing. How much necrotic and sloughing and where? LVN TX: (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their policy and procedures that prohibited neglect of one Resident (R#73) of 19 residents reviewed for abuse, neglect and exploitation. The facility did not provide timely consultation with R#73's physician of significant changes in the wound of her left lower extremity. R#73 required an amputation of the left leg above the knee. The facility failed to consistently identify the correct location of R#73's wound in their assessments/documentation, making it difficult to track the wound progress. This failure could affect 13 residents who had wounds by causing further decline in their physical condition. The findings were: Review of facility abuse/neglect policy, entitled Reportable Events Policy, effective 01/2008, revised 01/20/18 revealed: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Neglect as defined in 42 CFR 483.5-The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Face Sheet undated revealed R#73 was admitted to the facility on [DATE] and readmitted on [DATE]. R#73's [DIAGNOSES REDACTED].; [MEDICAL CONDITION]; Unspecified mood (affective) disorder; [MEDICAL CONDITION]; and Hypertension. R#73 was [AGE] years old. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#73 had a Brief Interview for Mental Status (BIMS) score of 00, indicating she had severe cognitive impairment. R#73 required extensive assistance with the help of one person to move about in bed; was totally dependent on the help of one person to be transferred in and out of bed and chair; did not walk and had to be assisted with moving her wheelchair; and was totally dependent on others for help with dressing, bathing, eating and toileting. R#73 was always incontinent of bowel and bladder. Review of Physicians Orders for 02/01/18 to 03/31/18 revealed R#73 had orders which included [MEDICATION NAME], to be administered 100 unit/mL (milliliter), per sliding scale, subcutaneous, before meals and at bedtime, 6:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. for diabetes; [MEDICATION NAME] 100 unit/mL, 25 units, subcutaneous once daily at 8:00 a.m. for diabetes; and [MEDICATION NAME] 325 mg Q6h PRN (every six hours as needed) for pain or fever. No more than four grams of [MEDICATION NAME] from all sources could be given within a 24 hour period. R#73 was to have a pain assessment each shift, and a pressure reduction mattress. Review of Physician Telephone Order dated 12/29/17 to discontinue wound treatment to R#73's left third toe due to the area being healed. Review of R#73's Care Plan dated 02/02/17 and updated 01/16/18 revealed: -R#73 was at risk for pressure ulcers. Approaches started 01/15/18 included turning and repositioning her at least every two hours; performing a daily skin inspection with all bony prominences being observed very carefully; keeping bony prominences from coming in direct contact with one another with the use of wedges and pillows; keeping her skin as dry as possible. On 04/05/18 this care plan problem was updated with Cont (continue) P[NAME] (plan of care) and review 07/05/18. On 04/06/18, the pressure ulcer care plan problem was updated with Cleanse second toe with NS (normal saline), pat dry, cover with ABD pad and wrap (with) kerlix QD (daily) & PRN. Cleanse L (left) 4th toe (with) NS, pat dry, apply gauze between 4th and 5th toes, cover (with) ABD pad & wrap (with) kerlix QD & PRN. This was the only documentation of wound care found in the care plan. -R#73 had difficulty focusing attention and was easily distracted, out of touch, and had difficulty following what was said. Approaches began on 01/15/18 included assessing her for pain. -R#73 was at high risk for skin breakdown related to her diabetes and bowel and bladder incontinence. Approaches dated 01/15/18 and updated 04/05/18 did not list anything related to the infection of R#73's toes on her left foot or how to prevent skin breakdown specific to her feet. R#73 had previously had skin breakdown on her toes which was resolved on 12/29/17. -R#73 was at risk for falls due to her cognitive deficits and poor safety awareness, weakness and [MEDICAL CONDITION] medication use; approaches begun on 01/15/18 and updated 04/05/18 included keeping her bed in the low position whenever in bed. Review of physician progress notes [REDACTED].#73 had [DIAGNOSES REDACTED]. There was no documentation regarding observation of any wounds or concerns regarding R#73's left foot. Review of Progress Notes revealed: 02/10/18 (2:00): CNA reported to (this nurse-unable to read signature) R#73 had dried blood on her sock to the left foot. No active bleeding found or open areas. Dried blood around coarse toenail found to second toe; noted bruising to second toe of left foot, dark purple in color. Bruising covers toe 3 cm length X 2 cm width. Noted with redness traveling from bruised area to left side of foot; warm to touch; pain upon touch-was determined through R#73 pulling back foot slightly and facial grimacing and mumbling. Tylenol 325 two tabs administered for pain. Cleansed second left toe with normal saline and gauze; pat dried with gauze, left open to air. Foot elevated with pillow. Physician informed/faxed. Due to history of Diabetes and [MEDICAL CONDITION], takes ASA, requesting LLE (left lower extremity) Doppler venous/arterial (?) X-ray of left foot/toes? ABT (antibiotic) therapy? AM (morning) nurse to follow up phone call for orders; will continue to monitor. 02/10/18 (12:30 pm.): Called on call physician; informed of R#73's left second digit on left foot. Gave order for Keflex 500 mg tid (three times daily) X five days for infected left foot and Xray to left foot two views. 02/10/18 (1:00 p.m.): Called portable xray company to take xrays of R#73's left foot. Will be at facility sometime today. Notified RP by leaving message due to no answer. These Progress Notes document concerns found on the second toe of the left foot. Review of Radiology report dated 02/10/18 revealed R#73 had modest [MEDICAL CONDITION] joint disease. There was no fracture, dislocation, or soft tissue swelling. No osteo[DIAGNOSES REDACTED] was seen. The bones appeared diffusely demineralized. Peripheral [MEDICAL CONDITION] disease was noted along with heel spurs. The report concluded that R#73 had modest [MEDICAL CONDITION] joint disease; otherwise, no fracture of dislocation seen. Review of Progress Notes continued: 02/11/18 (8:00 a.m.): Initial dose of Keflex 500 mg tid given at this time. Left toe and foot with increased redness. Second digit on left foot continued with dark purple color. complained of pain when touched. Again, these progress notes document wound to second digit on left foot. Review of Skin Assessment Flow sheet for non-pressure injury conditions (skin assessment) with date of onset of 02/11/18, revealed R#73 had a skin risk score of 14, and the physician and RP were notified. The third toe on the left foot was infected with purple discoloration. Description of skin alteration: 3.5 cm. length X 1.5 cm width. Treatment was to monitor. These progress notes documented wound to third toe of left foot. Review of Progress Notes continued: 02/12/18 (12:00 p.m.): Called R#73's physician, Physician Z, to inform of R#73's right foot noted with more redness. Physician Z gave order to send to emergency room to evaluate and treat. These Progress Notes documented wound to right foot. 02/12/18 (1:00 p.m.) Ambulance arrived to transport R#73 to the hospital. 02/12/18 (5:00 p.m.) R#73 arrived back from the hospital with new order for [MEDICATION NAME] HCl 300 mg (milligram) TID X seven days for infection. Discontinued Keflex 500 mg TID X 5 days for infection. Need to follow up with PCP (Physician AZ) in a couple of days. Will continue to monitor. (8:30 p.m.) Called RP (Responsible Party) to notify of new medication; RP did not answer. 02/15/18 (1:00 a.m.) Received response from fax- left foot-xray-LLE arterial performed on 02/10/18; [MEDICATION NAME] 300 mg TID X ten days. R#73 currently on [MEDICATION NAME] 300 mg TID X seven days received at ER visit on 02/12/18. No side effects or A/R (adverse reaction) to [MEDICATION NAME]. LLE arterial doppler to be set at hospital radiology department (no record of arterial doppler having been performed until 04/05/18). Left foot continued with redness and warm to touch; no drainage with dark color discoloration to second toe of left foot; elevated with pillow. Will continue to monitor. Follow up appointment with PCP to be set up. 02/17/18 (1:00 p.m.) Physician AZ at facility to do rounds. No new orders received. Continue on [MEDICATION NAME] 300 mg TID X ten days for left foot infection. 02/18/18 (9:50 p.m.) R#73 continued on [MEDICATION NAME] 300 mg TID for left foot infection. Redness and deterioration noted to second left toe. Will continue to monitor. 02/19/18 (9:45 p.m.): R#73 received last dose of [MEDICATION NAME] therapy. No complaint of pain or discomfort. These progress notes documented wound on second toe of left foot. Review of Skin Assessment Flow Sheet-Non-Pressure injury condition dated 02/21/18 revealed Dry scabbed area to left third toe, 3.5 cm length X 1.2 cm width with no depth. There was no treatment change. Review of Skin assessment dated [DATE] revealed the left third toe was noted to have necrotic tissue and sloughing, and R#73 was positive for [MEDICAL CONDITION]. The size was noted to be 4.0 cm. length X 1.5 cm width. This Skin Assessment documented wound on left third toe. Review of Progress Notes continued: 03/01/18 (11:00 a.m.): Received order from Physician AZ to do a wound culture to third toe on left foot and start [MEDICATION NAME] 150 mg TID X seven days for toe infection. RP made aware of new orders. 03/02/18 (8:00 a.m.) Initial dose of [MEDICATION NAME] 150 mg TID X seven days for left toe infection. 03/06/18 (11:15 a.m.) : Continue on antibiotic [MEDICATION NAME] 150 mg PO TID X seven days for toe infection. No side effects or adverse reaction noted .Toe continues with necrotic area . (unable to read much of the note and nurse initials are illegible). Review of Lab report of wound culture done on 03/02/18 at 8:08 a.m. revealed R#73 had [DIAGNOSES REDACTED]. The wound culture report was received by the facility on 03/06/18 at 4:50 p.m. Review of Progress Notes continued: 03/06/18 (5:00 p.m.) This nurse (initials appear to be AZ but employee list has no one with those initials) received culture results for wound infection to left second digit. Results showed three organisms-Pseudomonas Aeruginosa, Staph Aureus and yeast. On call service for Physician AZ notified. R#73 was afebrile and had no complaints of pain. Pending Physician AZ call back. (5:30 p.m.): Physician AZ called back and [MEDICATION NAME] mg BID (twice daily) X ten days, [MEDICATION NAME] 500 mg BID X ten days, [MEDICATION NAME] 100 mg single dose; discontinue (d/c) [MEDICATION NAME] 150 mg TID X seven days. Initial dose of [MEDICATION NAME] given; pending initial dose [MEDICATION NAME] arrived from pharmacy. (9:30 p.m.) RP notified of wound culture results and medication changes. These Progress Notes documented wound on left second digit. Skin assessment dated [DATE] revealed R#73 had dry eschar/necrotic tissue to her left third toe; dry dressing in place. The size was 3.5 cm length X 1.5 cm width, and zero depth. This Skin Assessment documented wound to left third toe. Review of Progress Notes continued: 03/08/18 (9:00 p.m.): RP was called and made aware of appointment with Cardiologist on 03/12/18 at 11:45 p.m. (?). 03/09/18 (9:00 p.m.) R#73 continued on antibiotic [MEDICATION NAME] mg BID X ten days and [MEDICATION NAME] 500 mg Bid X ten days for foot infection. No S/S (signs or symptoms) of pain or discomfort. No side effects or adverse reactions to medication noted. 03/11/18 (9:40 a.m.) continue on antibiotic therapy. R#73 continued with redness to the left foot; no drainage or odor noted. (10:20 p.m.): Antibiotic Cipro/[MEDICATION NAME] continues due to left second digit. R#73 would grimace when LLE was moved. No other complaints of pain otherwise. Dressing noted as clean, dry and intact. Will monitor. 03/12/18 (2:00 a.m.) Left foot second toe infection-dressing intact, no drainage through dressing; no side effects or adverse reaction to antibiotics. Appointment with Cardiologist to be rescheduled per RP request, unable to make appointment with R#73. AM (morning) nurse to reschedule. These Progress Notes documented wound to left second toe and left foot second digit. Review of Skin Assessment Flow Sheet dated 03/13/18 revealed R#73's third toe ulcer had increased in size and continued with dry eschar. The size of the wound was not 4.0 length X 2.0 cm in width, with no depth. This Skin Assessment documented wound to third toe. Review of Progress Notes continued: 03/14/18 (9:45 p.m.) R#73 continued [MEDICATION NAME] for infection to wound on left foot second toe. Continued with daily wound care. Denied pain, no symptoms of pain noted. 03/16/18 (4:00 p.m.) Noted during dressing change to left toe new area with pressure left inner heel. Need to float heels. Left second toe with dark area noted to top. Noted maceration. Dressing change per treatment nurse. 03/17/18 (2:00 p.m.) R#73 noted with cough/congestion. Afebrile. Will continue to monitor. (9:00 p.m.) R#73 noted in bed at this time; dressing to left foot with minimum serosanguinous drainage. Grimacing/guarding noted. PRN (as needed) Tylenol administered, no foul odor noted to left second digit. status [REDACTED]. Will monitor. 03/18/18 (9:00 p.m.) This nurse (unable to read initials) provided wound care. Wound bed with necrotic tissue. Wound edges noted with red wound bed. Minimal serosanguinous drainage noted. No foul odor, redness or inflammation present. Medication PRN for pain. 03/20/18 (10:55 a.m.) R#73's RP arrived at facility; nurse called Cardiologist to reschedule R#73's appointment that was cancelled by RP last week due to her not being able to go because of a family emergency. An appointment with the Cardiologist was rescheduled for 03/28/18 at 1:00 p.m. These Progress Notes documented wound to left foot second toe or left second digit. Review of Skin Assessment Flow Sheet dated 03/21/18 revealed R#73's left toe wound had not changed and the area was stable. Measurement continued to be 4.0 cm length and 2.0 cm width, with no depth. Review of Progress Notes continued: 03/23/18 (2:00 p.m.) R#73 noted with yellowish drainage .MD faxed; pending response. (new note for 03/23/18 with no time noted) R#73 noted with a 3.5 cm X .3 cm X .1 cm abrasion with two other small abrasions to right shin. No drainage or bleeding or warmth to touch. Redness noted around abrasion. R#73 denied any pain or discomfort. Abrasion cleansed, RP and MD notified. 03/25/18 (2:00 p.m.) Physician AZ at facility doing rounds with no new orders. Review of physician progress notes [REDACTED].#73 had hypertension, Diabetes; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; overactive bladder; and depression. There was no mention of R#73's wound on her left foot. Review of Nutrition assessment dated [DATE] revealed R#73 weighed 126 pounds, which was 126% of her ideal body weight. R#73 was at nutritional risk and risk for dehydration secondary to her [DIAGNOSES REDACTED]. A routine snack at night was being offered but no supplements were noted for help with wound healing. Review of Skin Assessment Flow Sheet dated 03/27/18 revealed R#73 had dry eschar, with measurements decreased to 3.0 cm length X 1.3 cm width, X zero depth. The left inner toe had a purple area noted .5 cm X .5 cm. Review of Nurse's notes revealed no documentation dated 03/28/18 regarding whether R#73 kept the Cardiologist appointment or whether it was rescheduled and why it might have been rescheduled. On 04/08/18, nurse's notes documented that the appointment was missed on 03/28/18; no reason given (see notes dated 04/06/18 and 04/08/18). Review of Progress Notes continued: 04/02/18 (10:00 p.m.) R#73's wound to left second digit toe had necrotic tissue. Serosanguinous drainage yellowish with foul odor. Left lower (unable to read) was also warm to touch. The fourth digit left foot had redness, notified MD via fax. Waiting for response. Will continue to monitor. Bed in lowest position, call light within reach. 04/03/18 (2:00 p.m.) Late entry for 04/02/18 at 8:00 p.m. R#73 had bruise to left lower leg. Notified RP. RP said R#73's leg was under her wheelchair's foot rest instead of on top of it, and caused her leg to press against it, which led to the bruise. Continue to monitor. 04/03/18 (5:50 p.m.) New order for LLE arterial doppler, wound culture. [MEDICATION NAME] 300 mg TID X ten days. Notified RP. Schedule arterial doppler for 04/04/18. These Progress Notes documented wound to left second digit. Review of Skin Assessment Flow Sheet dated 04/03/18 revealed R#73 had dry eschar to the left third toe and fourth toe had purple area increasing in size to 1.3 cm X 1.3 cm. The dimensions of the wound on the left third toe was 3.5 cm. X 1.5 cm, with zero depth. This Skin Assessment documented wound to left third toe and fourth toe. Review of R#73's Quarterly Pain assessment dated [DATE] revealed R#73 did not have pain; expressed pain through facial expressions and protective body movements; was not able to verbalize whether she had pain; had symptoms of pain with any physical activity change; medications or treatments in the last five days had eased her pain completely; and a pain level of one was R#73's acceptable level of comfort. Review of Progress Notes continued: 04/04/18 (8:00 p.m.) Collected wound culture. R#73 tolerated well. Sample was in hall Z refrigerator. Will continue to monitor. 04/05/18 (3:30 p.m.) Wound care was done, little drainage on fifth toe, mild odor. (5:00 p.m.) Arterial doppler performed, R#73 was laid back in bed. (Late entry 3:30 p.m.) Daily wound care provided at this time. Necrotic areas noted to second digit, fourth/fifth digit. Second digit measured 3.9 X 2.4 X .1 cm. Yellow slough noted at 3:00. Minimal drainage noted. Necrotic areas to fourth and fifth digit with no drainage. R#73 grimacing and guarding during care. PRN pain medication. Continue with [MEDICATION NAME] 300 mg TID for wound infection. Minimal foul odor noted during wound care. R#73 tolerated antibiotic well. Will continue to monitor. (late entry 5:00 p.m.) Mobile xray to perform arterial doppler to LLE. R#73 tolerated procedure well. Pedal pulse weak. No cyanosis noted. Warm to touch. Pending doppler results. These Progress Notes documented wound to second digit, fourth/fifth digit. No mention is noted of wound to third toe. Review of Ultrasound Report of duplex lower extremity arterial unilateral , left extremity, dated 04/05/18, revealed R#73 had moderate [MEDICAL CONDITION] changes. Review of Physician's Telephone Orders dated 04/06/18 revealed: 1. Clarification order for 02/27/18: Cleanse left third toe with NS (normal saline), pat dry, cover with abd (large gauze) pad and wrap with Kerlix QD (daily) until all resolved. 2. Clarification order for 03/22/18: Cleanse left fourth toe with NS, pat dry, apply gauze between fourth and fifth toes, cover with abd pad, wrap with Kerlix QD until resolved. Surveyor noted that this is the first time orders for wound care were found in R#73's clinical record. This Physician Telephone Order documented wound to left third, fourth and fifth toe. Review of Progress Notes continued: 04/06/18 (11:10 a.m.) Called RP to make her aware that R#73's appointment with Cardiologist was rescheduled for (MONTH) 11, (YEAR) at 11:45 a.m. Also advised RP that R#73's arterial doppler was positive for [MEDICAL CONDITION]. R#73 continued on antibiotic therapy for infection to toes of left foot. Continued with redness to left foot, no grimacing or pain noted to face. Will continue to monitor. (10:00 p.m.) R#73 continued on antibiotics for infection of left toes. No adverse effects noticed at this time. Tolerating well. No complaints of pain. Will continue to monitor. (11:45 p.m.) On [MEDICATION NAME] therapy for infected second digit of left foot. Starting to have possible reaction to the medication. Noted red splotchy rash on right side and buttocks. Will continue to monitor. 04/07/18 (10:00 a.m.) R#73 noted with rash to peri-area and buttocks; no itching noted. (10:15 a.m.) Called Physician AZ to inform of R#73's status. Pending MD call back. (3:30 p.m.) Physician AZ called back with new order for Keflex 500 mg BID X ten days for infection to the left foot toes fourth and second digits. [MEDICATION NAME] cream BID until rash resolved; [MEDICATION NAME] 180 mg X ten days; and [MEDICATION NAME] 150 mg BID X ten days for allergic reaction. Discontinue [MEDICATION NAME] due to allergic reaction. (Late entry) Notified RP. (7:00 p.m.) Administered Keflex from house kit; no adverse affects at this time. Will continue to monitor. 04/08/18 (10:00 p.m.) R#73's fifth toes to the left foot has developed a black spot on the inner side near the fourth toe. Size .5 X .3 cm. R#73 missed her appointment with Cardiologist on 03/28/18. Need to reschedule. Will continue to monitor. These notes documented wounds to the fourth and second digits and fifth toe. Review of Skin Assessment Flow sheet dated 04/11/18 revealed R#73 was discharged to the hospital on [DATE]. Review of Hospital History and Physical dated 04/11/18 revealed R#73 was admitted to the hospital with [REDACTED].#73 had been on antibiotics in the nursing facility and started to develop necrosis and there was admitted to the hospital for further evaluation and treatment. The Assessment and Plan revealed R#73 had gangrene of the left second toe with necrosis; and R#73 had a cardiology consult with a Cardiologist. An operation was done on 04/16/18 due to R#73 having gangrene and osteo[DIAGNOSES REDACTED] of the left lower extremity. A left above the knee amputation was indicated due to severe stenosis of the distal femoral artery. These hospital notes documented gangreen to the left second toe with necrosis. Review of Physicians Telephone orders dated 04/19/18 revealed R#73 was readmitted to the nursing facility with orders to continue with all previous nursing home medication, treatment and labs; discontinue [MEDICATION NAME] and Levimer insulin; and start [MEDICATION NAME] per moderate sliding scale before breakfast and at night. Next Progress Notes continued: 04/19/18 (11:00 a.m.) readmitted from the hospital. Sleeping, aroused easily. Dressing to left AKA (above knee amputation) dry and intact. No distress noted. Review of R#73's Comprehensive Pain Assessment completed at 5:30 p.m. on 04/19/18, after R#73 returned to the facility following the amputation of her left lower extremity, revealed R#73 occasionally moaned or groaned indicating she might have pain; would tense and call out don't touch when moving limb; and had moderate pain in the last five days. R#73 expressed pain with facial expressions and protective body movements. Review of Progress Notes Continued: 04/20/18 (12:00 p.m.) Received new order from Physician AZ for R#73's continued pain. Tylenol #3 q6h (every six hours) prn (as needed); faxed to pharmacy; pending arrival. (Late entry for 04/19/18, 3:50 p.m.) R#73 had two red areas to right toes third digit, .2 X .2; and second at outer area .1 X .1. Notified wound care nurse. D/C IV (intravenous) feeding on right hand. Will continue to monitor. R#73 tolerated well. In an interview at 8:04 a.m. on 04/25/18, R#73's RP wanted to speak to surveyors who were in the process of doing a recertification of the facility. The RP expressed concerns that the facility was slow to respond to changes in the wound on R#73's left foot, which led to the amputation of the leg above the knee. The RP said she thought possibly the amputation would not have been as severe if the facility had responded to the wound care and notification of the physician on a timely basis. The RP said R#73 was on three different antibiotics and she had an allergic reaction to the third one. In the interview at 8:04 a.m. on 04/25/18, the RP said she was never told how bad R#73's wounds were to R#73's left foot, and she said she was just informed that it was bad by some of the nurses. When Physician AZ decided to send R#73 to a cardiologist, the RP said she could not keep the first appointment and wanted to be present for the cardiologist appointment. The RP said she called the nursing facility on the day that the appointment was rescheduled to, but she was told R#73 was down for another rescheduled appointment. The RP said the facility van was being worked on and was not available. The RP said the facility was not aggressively attempting to reschedule R#73's appointment with the Cardiologist. The RP said another week or so went by and it got to the point that the RP offered to take R#73 to the Cardiologist in her own car. The RP said someone from the nursing facility helped load R#73 into her vehicle so she could take her to the Cardiologist appointment on 04/11/18. In the interview at 8:04 a.m. on 04/25/18, the RP said when they got to the Cardiologist, he unwrapped R#73's wound and said her toes had gangrene and she needed to go immediately to the hospital. The RP said the sores on R#73's toes smelled very bad. R#73 had osteomyeliltis and infection had spread all the way to her knee. R#73 had the amputation of her lower left leg on 04/16/18 and did very well with the surgery. The RP said she asked the facility when was the last time Physician AZ saw R#73's left foot before she went to the hospital for the amputation, but no one gave her the answer. The RP said she had difficulty finding out when Physician AZ was going to be visiting R#73 so she could be there to meet with him. The RP said she was told by different staff members that he came on weekends only, or came during the week only. The RP said she was told by someone, she could not recall who, that Physician AZ was in R#73's wing of the building and thought Physician AZ looked at R#73's foot. The RP said she asked the nurses how they were documenting in R#73's chart so that Physician AZ would know he needed to look at R#73's foot, but did not get a straight answer. The RP said she felt there was no aggressiveness on the facility's part to bring attention to R#73's changing wound on her foot. The RP said she was advised that several different nurses did wound care at the facility. The RP said she had spoken with the charge nurses about her concerns, but had not expressed her concerns to the Administrator or Director of Nurses (DON) and would like to talk with the DON. At 8:41 a.m. on 04/25/18, a meeting was held with the RP and DON in the presence of surveyors. The RP advised the DON that she was never shown R#73's foot and she took the word of the nurses regarding the condition of R#73's foot. The nurses described R#73's foot as bad or very bad. The RP said she was unable to keep one of the appointments with the Cardiologist, but after this, the Cardiologist appointments were delayed because the facility van was being worked on or the facility did not remember to reschedule the appointment. The RP said she finally took R#73 to the Cardiologist herself on 04/11/18, and when the Cardiologist opened the dressing on R#73's left foot, there was a foul smell and R#73's entire digit was covered in gangrene. The RP said gangrene had started to form between two of R#73's toes and she had not been advised that the infection was spreading to other parts of R#73's foot or that it was gangrenous. The RP told the DON that she received copies of R#73's records from the facility and there was no description of the severity of R#73's foot. The RP said it was upsetting that the Cardiologist appointment was delayed and Physician AZ had not seen her foot when he made rounds. In the meeting on 04/25/18 at 8:41 a.m., the DON said she was aware of the concern regarding R#73's foot but she could not say definitely that Physician AZ saw R#73's foot because he usually came in after hours. The DON reviewed physician progress notes [REDACTED].#73's wound in his notes. The DON said the facility had a wound care nurse, Licensed Vocational Nurse (LVN) TX. LVN TX worked all week, was also a scheduler. LVN TX sometimes covered the weekends as well. Other nurses may do wound care on the weekend; usually the weekend supervising RN did the wound care. The DON said the eschar on R#73's foot got very thick on her toe and could have been unstageable. R#73 would kick off her shoe because it was painful. R#73's foot would turn really red at times. The DON said if the nurses were having a problem with a resident, they would approach the physician and tell the physician that he needed to see the resident. The DON said the wound care nurse would be expected to report a problem to a charge nurse. The DON said everyone was worried about R#73's toe and knew it was getting worse. The RP said she talked with one of the MDS nurses instead of the DON about her concerns because she knew that nurse. After the RP left, at 9:15 a.m. on 04/25/18, the surveyors continued meeting with the DON regarding R#73's left foot wound. LVN TX was called into the meeting. The DON said things could have been done differently to communicate with Physician AZ to be sure he saw R#73's foot wound. LVN TX reviewed the wound care for R#73 and answered the following questions: Surveyor: What does infected toe mean? LVN TX: the discoloration and swelling of the toe meant infection. DON: there should be a description of the toe. Surveyor: Would infected toe be valid? DON: No. LVN TX: Findings were also documented in the nurses' notes what the findings were. There's limited space on that note (Skin Assessment Note). On 02/11/18 when it was brought to my attention, I read the nurse's note dated 02/10/18. The charge nurse looks at the wound and she (LVN TX) just does the wound care charting weekly. The two to ten nurse was with her most of the time. If she (charge nurse) noticed a change she would document and notify the doctor. I usually asked the charge nurse to go with me when doing wound care. Surveyor: On 02/21, she has a dry scab area to the left toe; on 02/28, it says it's grown in size and it says left third toe noted with necrotic tissue and sloughing. How much necrotic and sloughing and where? LVN TX: On 02/28 I was not here that week, it was a different nurse. Measurements on top of the box-that's what the eschar measured. When I came back there was no slough or drainage, it was just a dry area. They wrote an order for [REDACTED]. Surveyor: Did (Physician AZ) ever come in with you when you did wound care? LVN TX: No. Surveyor: Did (Physician AZ) ever approach you and ask to see it? LVN TX: No. On 03/27/18, it looked like the wound started showing some signs of left fourth inner toe spreading discoloration to that toe from the middle toe. I call (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide care and services to prevent neglect of one Resident (R#73) of 19 residents reviewed for abuse, neglect and exploitation. The facility did not provide timely consultation with R#73's physician of significant changes in the wound of her left lower extremity. R#73 required an amputation of the left leg above the knee. The facility failed to consistently identify the correct location of R#73's wound in their assessments/documentation, making it difficult to track the wound progress. This failure could affect 13 residents who had wounds by causing further decline in their physical condition. The findings were: Review of facility abuse/neglect policy, entitled Reportable Events Policy, effective 01/2008, revised 01/20/18 revealed: It is the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Neglect as defined in 42 CFR 483.5-The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of Face Sheet undated revealed R#73 was admitted to the facility on [DATE] and readmitted on [DATE]. R#73's [DIAGNOSES REDACTED].; [MEDICAL CONDITION]; Unspecified mood (affective) disorder; [MEDICAL CONDITION]; and Hypertension. R#73 was [AGE] years old. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#73 had a Brief Interview for Mental Status (BIMS) score of 00, indicating she had severe cognitive impairment. R#73 required extensive assistance with the help of one person to move about in bed; was totally dependent on the help of one person to be transferred in and out of bed and chair; did not walk and had to be assisted with moving her wheelchair; and was totally dependent on others for help with dressing, bathing, eating and toileting. R#73 was always incontinent of bowel and bladder. Review of Physicians Orders for 02/01/18 to 03/31/18 revealed R#73 had orders which included [MEDICATION NAME], to be administered 100 unit/mL (milliliter), per sliding scale, subcutaneous, before meals and at bedtime, 6:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. for diabetes; [MEDICATION NAME] 100 unit/mL, 25 units, subcutaneous once daily at 8:00 a.m. for diabetes; and [MEDICATION NAME] 325 mg Q6h PRN (every six hours as needed) for pain or fever. No more than four grams of [MEDICATION NAME] from all sources could be given within a 24 hour period. R#73 was to have a pain assessment each shift, and a pressure reduction mattress. Review of Physician Telephone Order dated 12/29/17 to discontinue wound treatment to R#73's left third toe due to the area being healed. Review of R#73's Care Plan dated 02/02/17 and updated 01/16/18 revealed: -R#73 was at risk for pressure ulcers. Approaches started 01/15/18 included turning and repositioning her at least every two hours; performing a daily skin inspection with all bony prominences being observed very carefully; keeping bony prominences from coming in direct contact with one another with the use of wedges and pillows; keeping her skin as dry as possible. On 04/05/18 this care plan problem was updated with Cont (continue) P[NAME] (plan of care) and review 07/05/18. On 04/06/18, the pressure ulcer care plan problem was updated with Cleanse second toe with NS (normal saline), pat dry, cover with ABD pad and wrap (with) kerlix QD (daily) & PRN. Cleanse L (left) 4th toe (with) NS, pat dry, apply gauze between 4th and 5th toes, cover (with) ABD pad & wrap (with) kerlix QD & PRN. This was the only documentation of wound care found in the care plan. -R#73 had difficulty focusing attention and was easily distracted, out of touch, and had difficulty following what was said. Approaches began on 01/15/18 included assessing her for pain. -R#73 was at high risk for skin breakdown related to her diabetes and bowel and bladder incontinence. Approaches dated 01/15/18 and updated 04/05/18 did not list anything related to the infection of R#73's toes on her left foot or how to prevent skin breakdown specific to her feet. R#73 had previously had skin breakdown on her toes which was resolved on 12/29/17. -R#73 was at risk for falls due to her cognitive deficits and poor safety awareness, weakness and [MEDICAL CONDITION] medication use; approaches begun on 01/15/18 and updated 04/05/18 included keeping her bed in the low position whenever in bed. Review of physician progress notes [REDACTED].#73 had [DIAGNOSES REDACTED]. There was no documentation regarding observation of any wounds or concerns regarding R#73's left foot. Review of Progress Notes revealed: 02/10/18 (2:00): CNA reported to (this nurse-unable to read signature) R#73 had dried blood on her sock to the left foot. No active bleeding found or open areas. Dried blood around coarse toenail found to second toe; noted bruising to second toe of left foot, dark purple in color. Bruising covers toe 3 cm length X 2 cm width. Noted with redness traveling from bruised area to left side of foot; warm to touch; pain upon touch-was determined through R#73 pulling back foot slightly and facial grimacing and mumbling. Tylenol 325 two tabs administered for pain. Cleansed second left toe with normal saline and gauze; pat dried with gauze, left open to air. Foot elevated with pillow. Physician informed/faxed. Due to history of Diabetes and [MEDICAL CONDITION], takes ASA, requesting LLE (left lower extremity) Doppler venous/arterial (?) X-ray of left foot/toes? ABT (antibiotic) therapy? AM (morning) nurse to follow up phone call for orders; will continue to monitor. 02/10/18 (12:30 pm.): Called on call physician; informed of R#73's left second digit on left foot. Gave order for Keflex 500 mg tid (three times daily) X five days for infected left foot and Xray to left foot two views. 02/10/18 (1:00 p.m.): Called portable xray company to take xrays of R#73's left foot. Will be at facility sometime today. Notified RP by leaving message due to no answer. These Progress Notes document concerns found on the second toe of the left foot. Review of Radiology report dated 02/10/18 revealed R#73 had modest [MEDICAL CONDITION] joint disease. There was no fracture, dislocation, or soft tissue swelling. No osteo[DIAGNOSES REDACTED] was seen. The bones appeared diffusely demineralized. Peripheral [MEDICAL CONDITION] disease was noted along with heel spurs. The report concluded that R#73 had modest [MEDICAL CONDITION] joint disease; otherwise, no fracture of dislocation seen. Review of Progress Notes continued: 02/11/18 (8:00 a.m.): Initial dose of Keflex 500 mg tid given at this time. Left toe and foot with increased redness. Second digit on left foot continued with dark purple color. complained of pain when touched. Again, these progress notes document wound to second digit on left foot. Review of Skin Assessment Flow sheet for non-pressure injury conditions (skin assessment) with date of onset of 02/11/18, revealed R#73 had a skin risk score of 14, and the physician and RP were notified. The third toe on the left foot was infected with purple discoloration. Description of skin alteration: 3.5 cm. length X 1.5 cm width. Treatment was to monitor. These progress notes documented wound to third toe of left foot. Review of Progress Notes continued: 02/12/18 (12:00 p.m.): Called R#73's physician, Physician Z, to inform of R#73's right foot noted with more redness. Physician Z gave order to send to emergency room to evaluate and treat. These Progress Notes documented wound to right foot. 02/12/18 (1:00 p.m.) Ambulance arrived to transport R#73 to the hospital. 02/12/18 (5:00 p.m.) R#73 arrived back from the hospital with new order for [MEDICATION NAME] HCl 300 mg (milligram) TID X seven days for infection. Discontinued Keflex 500 mg TID X 5 days for infection. Need to follow up with PCP (Physician AZ) in a couple of days. Will continue to monitor. (8:30 p.m.) Called RP (Responsible Party) to notify of new medication; RP did not answer. 02/15/18 (1:00 a.m.) Received response from fax- left foot-xray-LLE arterial performed on 02/10/18; [MEDICATION NAME] 300 mg TID X ten days. R#73 currently on [MEDICATION NAME] 300 mg TID X seven days received at ER visit on 02/12/18. No side effects or A/R (adverse reaction) to [MEDICATION NAME]. LLE arterial doppler to be set at hospital radiology department (no record of arterial doppler having been performed until 04/05/18). Left foot continued with redness and warm to touch; no drainage with dark color discoloration to second toe of left foot; elevated with pillow. Will continue to monitor. Follow up appointment with PCP to be set up. 02/17/18 (1:00 p.m.) Physician AZ at facility to do rounds. No new orders received. Continue on [MEDICATION NAME] 300 mg TID X ten days for left foot infection. 02/18/18 (9:50 p.m.) R#73 continued on [MEDICATION NAME] 300 mg TID for left foot infection. Redness and deterioration noted to second left toe. Will continue to monitor. 02/19/18 (9:45 p.m.): R#73 received last dose of [MEDICATION NAME] therapy. No complaint of pain or discomfort. These progress notes documented wound on second toe of left foot. Review of Skin Assessment Flow Sheet-Non-Pressure injury condition dated 02/21/18 revealed Dry scabbed area to left third toe, 3.5 cm length X 1.2 cm width with no depth. There was no treatment change. Review of Skin assessment dated [DATE] revealed the left third toe was noted to have necrotic tissue and sloughing, and R#73 was positive for [MEDICAL CONDITION]. The size was noted to be 4.0 cm. length X 1.5 cm width. This Skin Assessment documented wound on left third toe. Review of Progress Notes continued: 03/01/18 (11:00 a.m.): Received order from Physician AZ to do a wound culture to third toe on left foot and start [MEDICATION NAME] 150 mg TID X seven days for toe infection. RP made aware of new orders. 03/02/18 (8:00 a.m.) Initial dose of [MEDICATION NAME] 150 mg TID X seven days for left toe infection. 03/06/18 (11:15 a.m.) : Continue on antibiotic [MEDICATION NAME] 150 mg PO TID X seven days for toe infection. No side effects or adverse reaction noted .Toe continues with necrotic area . (unable to read much of the note and nurse initials are illegible). Review of Lab report of wound culture done on 03/02/18 at 8:08 a.m. revealed R#73 had [DIAGNOSES REDACTED]. The wound culture report was received by the facility on 03/06/18 at 4:50 p.m. Review of Progress Notes continued: 03/06/18 (5:00 p.m.) This nurse (initials appear to be AZ but employee list has no one with those initials) received culture results for wound infection to left second digit. Results showed three organisms-Pseudomonas Aeruginosa, Staph Aureus and yeast. On call service for Physician AZ notified. R#73 was afebrile and had no complaints of pain. Pending Physician AZ call back. (5:30 p.m.): Physician AZ called back and [MEDICATION NAME] mg BID (twice daily) X ten days, [MEDICATION NAME] 500 mg BID X ten days, [MEDICATION NAME] 100 mg single dose; discontinue (d/c) [MEDICATION NAME] 150 mg TID X seven days. Initial dose of [MEDICATION NAME] given; pending initial dose [MEDICATION NAME] arrived from pharmacy. (9:30 p.m.) RP notified of wound culture results and medication changes. These Progress Notes documented wound on left second digit. Skin assessment dated [DATE] revealed R#73 had dry eschar/necrotic tissue to her left third toe; dry dressing in place. The size was 3.5 cm length X 1.5 cm width, and zero depth. This Skin Assessment documented wound to left third toe. Review of Progress Notes continued: 03/08/18 (9:00 p.m.): RP was called and made aware of appointment with Cardiologist on 03/12/18 at 11:45 p.m. (?). 03/09/18 (9:00 p.m.) R#73 continued on antibiotic [MEDICATION NAME] mg BID X ten days and [MEDICATION NAME] 500 mg Bid X ten days for foot infection. No S/S (signs or symptoms) of pain or discomfort. No side effects or adverse reactions to medication noted. 03/11/18 (9:40 a.m.) continue on antibiotic therapy. R#73 continued with redness to the left foot; no drainage or odor noted. (10:20 p.m.): Antibiotic Cipro/[MEDICATION NAME] continues due to left second digit. R#73 would grimace when LLE was moved. No other complaints of pain otherwise. Dressing noted as clean, dry and intact. Will monitor. 03/12/18 (2:00 a.m.) Left foot second toe infection-dressing intact, no drainage through dressing; no side effects or adverse reaction to antibiotics. Appointment with Cardiologist to be rescheduled per RP request, unable to make appointment with R#73. AM (morning) nurse to reschedule. These Progress Notes documented wound to left second toe and left foot second digit. Review of Skin Assessment Flow Sheet dated 03/13/18 revealed R#73's third toe ulcer had increased in size and continued with dry eschar. The size of the wound was not 4.0 length X 2.0 cm in width, with no depth. This Skin Assessment documented wound to third toe. Review of Progress Notes continued: 03/14/18 (9:45 p.m.) R#73 continued [MEDICATION NAME] for infection to wound on left foot second toe. Continued with daily wound care. Denied pain, no symptoms of pain noted. 03/16/18 (4:00 p.m.) Noted during dressing change to left toe new area with pressure left inner heel. Need to float heels. Left second toe with dark area noted to top. Noted maceration. Dressing change per treatment nurse. 03/17/18 (2:00 p.m.) R#73 noted with cough/congestion. Afebrile. Will continue to monitor. (9:00 p.m.) R#73 noted in bed at this time; dressing to left foot with minimum serosanguinous drainage. Grimacing/guarding noted. PRN (as needed) Tylenol administered, no foul odor noted to left second digit. status [REDACTED]. Will monitor. 03/18/18 (9:00 p.m.) This nurse (unable to read initials) provided wound care. Wound bed with necrotic tissue. Wound edges noted with red wound bed. Minimal serosanguinous drainage noted. No foul odor, redness or inflammation present. Medication PRN for pain. 03/20/18 (10:55 a.m.) R#73's RP arrived at facility; nurse called Cardiologist to reschedule R#73's appointment that was cancelled by RP last week due to her not being able to go because of a family emergency. An appointment with the Cardiologist was rescheduled for 03/28/18 at 1:00 p.m. These Progress Notes documented wound to left foot second toe or left second digit. Review of Skin Assessment Flow Sheet dated 03/21/18 revealed R#73's left toe wound had not changed and the area was stable. Measurement continued to be 4.0 cm length and 2.0 cm width, with no depth. Review of Progress Notes continued: 03/23/18 (2:00 p.m.) R#73 noted with yellowish drainage .MD faxed; pending response. (new note for 03/23/18 with no time noted) R#73 noted with a 3.5 cm X .3 cm X .1 cm abrasion with two other small abrasions to right shin. No drainage or bleeding or warmth to touch. Redness noted around abrasion. R#73 denied any pain or discomfort. Abrasion cleansed, RP and MD notified. 03/25/18 (2:00 p.m.) Physician AZ at facility doing rounds with no new orders. Review of physician progress notes [REDACTED].#73 had hypertension, Diabetes; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; overactive bladder; and depression. There was no mention of R#73's wound on her left foot. Review of Nutrition assessment dated [DATE] revealed R#73 weighed 126 pounds, which was 126% of her ideal body weight. R#73 was at nutritional risk and risk for dehydration secondary to her [DIAGNOSES REDACTED]. A routine snack at night was being offered but no supplements were noted for help with wound healing. Review of Skin Assessment Flow Sheet dated 03/27/18 revealed R#73 had dry eschar, with measurements decreased to 3.0 cm length X 1.3 cm width, X zero depth. The left inner toe had a purple area noted .5 cm X .5 cm. Review of Nurse's notes revealed no documentation dated 03/28/18 regarding whether R#73 kept the Cardiologist appointment or whether it was rescheduled and why it might have been rescheduled. On 04/08/18, nurse's notes documented that the appointment was missed on 03/28/18; no reason given (see notes dated 04/06/18 and 04/08/18). Review of Progress Notes continued: 04/02/18 (10:00 p.m.) R#73's wound to left second digit toe had necrotic tissue. Serosanguinous drainage yellowish with foul odor. Left lower (unable to read) was also warm to touch. The fourth digit left foot had redness, notified MD via fax. Waiting for response. Will continue to monitor. Bed in lowest position, call light within reach. 04/03/18 (2:00 p.m.) Late entry for 04/02/18 at 8:00 p.m. R#73 had bruise to left lower leg. Notified RP. RP said R#73's leg was under her wheelchair's foot rest instead of on top of it, and caused her leg to press against it, which led to the bruise. Continue to monitor. 04/03/18 (5:50 p.m.) New order for LLE arterial doppler, wound culture. [MEDICATION NAME] 300 mg TID X ten days. Notified RP. Schedule arterial doppler for 04/04/18. These Progress Notes documented wound to left second digit. Review of Skin Assessment Flow Sheet dated 04/03/18 revealed R#73 had dry eschar to the left third toe and fourth toe had purple area increasing in size to 1.3 cm X 1.3 cm. The dimensions of the wound on the left third toe was 3.5 cm. X 1.5 cm, with zero depth. This Skin Assessment documented wound to left third toe and fourth toe. Review of R#73's Quarterly Pain assessment dated [DATE] revealed R#73 did not have pain; expressed pain through facial expressions and protective body movements; was not able to verbalize whether she had pain; had symptoms of pain with any physical activity change; medications or treatments in the last five days had eased her pain completely; and a pain level of one was R#73's acceptable level of comfort. Review of Progress Notes continued: 04/04/18 (8:00 p.m.) Collected wound culture. R#73 tolerated well. Sample was in hall Z refrigerator. Will continue to monitor. 04/05/18 (3:30 p.m.) Wound care was done, little drainage on fifth toe, mild odor. (5:00 p.m.) Arterial doppler performed, R#73 was laid back in bed. (Late entry 3:30 p.m.) Daily wound care provided at this time. Necrotic areas noted to second digit, fourth/fifth digit. Second digit measured 3.9 X 2.4 X .1 cm. Yellow slough noted at 3:00. Minimal drainage noted. Necrotic areas to fourth and fifth digit with no drainage. R#73 grimacing and guarding during care. PRN pain medication. Continue with [MEDICATION NAME] 300 mg TID for wound infection. Minimal foul odor noted during wound care. R#73 tolerated antibiotic well. Will continue to monitor. (late entry 5:00 p.m.) Mobile xray to perform arterial doppler to LLE. R#73 tolerated procedure well. Pedal pulse weak. No cyanosis noted. Warm to touch. Pending doppler results. These Progress Notes documented wound to second digit, fourth/fifth digit. No mention is noted of wound to third toe. Review of Ultrasound Report of duplex lower extremity arterial unilateral , left extremity, dated 04/05/18, revealed R#73 had moderate [MEDICAL CONDITION] changes. Review of Physician's Telephone Orders dated 04/06/18 revealed: 1. Clarification order for 02/27/18: Cleanse left third toe with NS (normal saline), pat dry, cover with abd (large gauze) pad and wrap with Kerlix QD (daily) until all resolved. 2. Clarification order for 03/22/18: Cleanse left fourth toe with NS, pat dry, apply gauze between fourth and fifth toes, cover with abd pad, wrap with Kerlix QD until resolved. Surveyor noted that this is the first time orders for wound care were found in R#73's clinical record. This Physician Telephone Order documented wound to left third, fourth and fifth toe. Review of Progress Notes continued: 04/06/18 (11:10 a.m.) Called RP to make her aware that R#73's appointment with Cardiologist was rescheduled for (MONTH) 11, (YEAR) at 11:45 a.m. Also advised RP that R#73's arterial doppler was positive for [MEDICAL CONDITION]. R#73 continued on antibiotic therapy for infection to toes of left foot. Continued with redness to left foot, no grimacing or pain noted to face. Will continue to monitor. (10:00 p.m.) R#73 continued on antibiotics for infection of left toes. No adverse effects noticed at this time. Tolerating well. No complaints of pain. Will continue to monitor. (11:45 p.m.) On [MEDICATION NAME] therapy for infected second digit of left foot. Starting to have possible reaction to the medication. Noted red splotchy rash on right side and buttocks. Will continue to monitor. 04/07/18 (10:00 a.m.) R#73 noted with rash to peri-area and buttocks; no itching noted. (10:15 a.m.) Called Physician AZ to inform of R#73's status. Pending MD call back. (3:30 p.m.) Physician AZ called back with new order for Keflex 500 mg BID X ten days for infection to the left foot toes fourth and second digits. [MEDICATION NAME] cream BID until rash resolved; [MEDICATION NAME] 180 mg X ten days; and [MEDICATION NAME] 150 mg BID X ten days for allergic reaction. Discontinue [MEDICATION NAME] due to allergic reaction. (Late entry) Notified RP. (7:00 p.m.) Administered Keflex from house kit; no adverse affects at this time. Will continue to monitor. 04/08/18 (10:00 p.m.) R#73's fifth toes to the left foot has developed a black spot on the inner side near the fourth toe. Size .5 X .3 cm. R#73 missed her appointment with Cardiologist on 03/28/18. Need to reschedule. Will continue to monitor. These notes documented wounds to the fourth and second digits and fifth toe. Review of Skin Assessment Flow sheet dated 04/11/18 revealed R#73 was discharged to the hospital on [DATE]. Review of Hospital History and Physical dated 04/11/18 revealed R#73 was admitted to the hospital with [REDACTED].#73 had been on antibiotics in the nursing facility and started to develop necrosis and there was admitted to the hospital for further evaluation and treatment. The Assessment and Plan revealed R#73 had gangrene of the left second toe with necrosis; and R#73 had a cardiology consult with a Cardiologist. An operation was done on 04/16/18 due to R#73 having gangrene and osteo[DIAGNOSES REDACTED] of the left lower extremity. A left above the knee amputation was indicated due to severe stenosis of the distal femoral artery. These hospital notes documented gangreen to the left second toe with necrosis. Review of Physicians Telephone orders dated 04/19/18 revealed R#73 was readmitted to the nursing facility with orders to continue with all previous nursing home medication, treatment and labs; discontinue [MEDICATION NAME] and Levimer insulin; and start [MEDICATION NAME] per moderate sliding scale before breakfast and at night. Next Progress Notes continued: 04/19/18 (11:00 a.m.) readmitted from the hospital. Sleeping, aroused easily. Dressing to left AKA (above knee amputation) dry and intact. No distress noted. Review of R#73's Comprehensive Pain Assessment completed at 5:30 p.m. on 04/19/18, after R#73 returned to the facility following the amputation of her left lower extremity, revealed R#73 occasionally moaned or groaned indicating she might have pain; would tense and call out don't touch when moving limb; and had moderate pain in the last five days. R#73 expressed pain with facial expressions and protective body movements. Review of Progress Notes Continued: 04/20/18 (12:00 p.m.) Received new order from Physician AZ for R#73's continued pain. Tylenol #3 q6h (every six hours) prn (as needed); faxed to pharmacy; pending arrival. (Late entry for 04/19/18, 3:50 p.m.) R#73 had two red areas to right toes third digit, .2 X .2; and second at outer area .1 X .1. Notified wound care nurse. D/C IV (intravenous) feeding on right hand. Will continue to monitor. R#73 tolerated well. In an interview at 8:04 a.m. on 04/25/18, R#73's RP wanted to speak to surveyors who were in the process of doing a recertification of the facility. The RP expressed concerns that the facility was slow to respond to changes in the wound on R#73's left foot, which led to the amputation of the leg above the knee. The RP said she thought possibly the amputation would not have been as severe if the facility had responded to the wound care and notification of the physician on a timely basis. The RP said R#73 was on three different antibiotics and she had an allergic reaction to the third one. In the interview at 8:04 a.m. on 04/25/18, the RP said she was never told how bad R#73's wounds were to R#73's left foot, and she said she was just informed that it was bad by some of the nurses. When Physician AZ decided to send R#73 to a cardiologist, the RP said she could not keep the first appointment and wanted to be present for the cardiologist appointment. The RP said she called the nursing facility on the day that the appointment was rescheduled to, but she was told R#73 was down for another rescheduled appointment. The RP said the facility van was being worked on and was not available. The RP said the facility was not aggressively attempting to reschedule R#73's appointment with the Cardiologist. The RP said another week or so went by and it got to the point that the RP offered to take R#73 to the Cardiologist in her own car. The RP said someone from the nursing facility helped load R#73 into her vehicle so she could take her to the Cardiologist appointment on 04/11/18. In the interview at 8:04 a.m. on 04/25/18, the RP said when they got to the Cardiologist, he unwrapped R#73's wound and said her toes had gangrene and she needed to go immediately to the hospital. The RP said the sores on R#73's toes smelled very bad. R#73 had osteomyeliltis and infection had spread all the way to her knee. R#73 had the amputation of her lower left leg on 04/16/18 and did very well with the surgery. The RP said she asked the facility when was the last time Physician AZ saw R#73's left foot before she went to the hospital for the amputation, but no one gave her the answer. The RP said she had difficulty finding out when Physician AZ was going to be visiting R#73 so she could be there to meet with him. The RP said she was told by different staff members that he came on weekends only, or came during the week only. The RP said she was told by someone, she could not recall who, that Physician AZ was in R#73's wing of the building and thought Physician AZ looked at R#73's foot. The RP said she asked the nurses how they were documenting in R#73's chart so that Physician AZ would know he needed to look at R#73's foot, but did not get a straight answer. The RP said she felt there was no aggressiveness on the facility's part to bring attention to R#73's changing wound on her foot. The RP said she was advised that several different nurses did wound care at the facility. The RP said she had spoken with the charge nurses about her concerns, but had not expressed her concerns to the Administrator or Director of Nurses (DON) and would like to talk with the DON. At 8:41 a.m. on 04/25/18, a meeting was held with the RP and DON in the presence of surveyors. The RP advised the DON that she was never shown R#73's foot and she took the word of the nurses regarding the condition of R#73's foot. The nurses described R#73's foot as bad or very bad. The RP said she was unable to keep one of the appointments with the Cardiologist, but after this, the Cardiologist appointments were delayed because the facility van was being worked on or the facility did not remember to reschedule the appointment. The RP said she finally took R#73 to the Cardiologist herself on 04/11/18, and when the Cardiologist opened the dressing on R#73's left foot, there was a foul smell and R#73's entire digit was covered in gangrene. The RP said gangrene had started to form between two of R#73's toes and she had not been advised that the infection was spreading to other parts of R#73's foot or that it was gangrenous. The RP told the DON that she received copies of R#73's records from the facility and there was no description of the severity of R#73's foot. The RP said it was upsetting that the Cardiologist appointment was delayed and Physician AZ had not seen her foot when he made rounds. In the meeting on 04/25/18 at 8:41 a.m., the DON said she was aware of the concern regarding R#73's foot but she could not say definitely that Physician AZ saw R#73's foot because he usually came in after hours. The DON reviewed physician progress notes [REDACTED].#73's wound in his notes. The DON said the facility had a wound care nurse, Licensed Vocational Nurse (LVN) TX. LVN TX worked all week, was also a scheduler. LVN TX sometimes covered the weekends as well. Other nurses may do wound care on the weekend; usually the weekend supervising RN did the wound care. The DON said the eschar on R#73's foot got very thick on her toe and could have been unstageable. R#73 would kick off her shoe because it was painful. R#73's foot would turn really red at times. The DON said if the nurses were having a problem with a resident, they would approach the physician and tell the physician that he needed to see the resident. The DON said the wound care nurse would be expected to report a problem to a charge nurse. The DON said everyone was worried about R#73's toe and knew it was getting worse. The RP said she talked with one of the MDS nurses instead of the DON about her concerns because she knew that nurse. After the RP left, at 9:15 a.m. on 04/25/18, the surveyors continued meeting with the DON regarding R#73's left foot wound. LVN TX was called into the meeting. The DON said things could have been done differently to communicate with Physician AZ to be sure he saw R#73's foot wound. LVN TX reviewed the wound care for R#73 and answered the following questions: Surveyor: What does infected toe mean? LVN TX: the discoloration and swelling of the toe meant infection. DON: there should be a description of the toe. Surveyor: Would infected toe be valid? DON: No. LVN TX: Findings were also documented in the nurses' notes what the findings were. There's limited space on that note (Skin Assessment Note). On 02/11/18 when it was brought to my attention, I read the nurse's note dated 02/10/18. The charge nurse looks at the wound and she (LVN TX) just does the wound care charting weekly. The two to ten nurse was with her most of the time. If she (charge nurse) noticed a change she would document and notify the doctor. I usually asked the charge nurse to go with me when doing wound care. Surveyor: On 02/21, she has a dry scab area to the left toe; on 02/28, it says it's grown in size and it says left third toe noted with necrotic tissue and sloughing. How much necrotic and sloughing and where? LVN TX: On 02/28 I was not here that week, it was a different nurse. Measurements on top of the box-that's what the eschar measured. When I came back there was no slough or drainage, it was just a dry area. They wrote an order for [REDACTED]. Surveyor: Did (Physician AZ) ever come in with you when you did wound care? LVN TX: No. Surveyor: Did (Physician AZ) ever approach you and ask to see it? LVN TX: No. On 03/27/18, it looked like the wound started showing some signs of left fourth inner toe spreading discoloration to that toe from the middle toe. I called the charge nur (TRUNCATED)

Based on observation, interview and record review, the facility failed to notify the physician and the Responsible Party (RP) of significant changes in the physical status of one Resident (R#73) of 19 Residents reviewed for significant changes in physical, mental or psychosocial status. The facility did not notify R#73's physician or RP when the wound on the middle toe of R#73's left foot deteriorated, spreading to other toes, and eventually became gangrenous. R#73 had an amputation of the left leg above the knee. This failure could affect 13 residents who were receiving wound care by not cconsulting the physician or responsible partypotentially causing their wounds to worsen due to delay in intervention by the physician; and could cause responsible parties to not be involved in assisting residents to make decisions regarding their health status. The findings were: Review of Face Sheet undated revealed R#73 was admitted to the facility on [DATE] and readmitted on [DATE]. R#73's [DIAGNOSES REDACTED].; [MEDICAL CONDITION]; Unspecified mood (affective) disorder; [MEDICAL CONDITION]; and Hypertension. R#73 was [AGE] years old. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#73 had a Brief Interview for Mental Status (BIMS) score of 00, indicating she had severe cognitive impairment. R#73 required extensive assistance with the help of one person to move about in bed; was totally dependent on the help of one person to be transferred in and out of bed and chair; did not walk and had to be assisted with moving her wheelchair; and was totally dependent on others for help with dressing, bathing, eating and toileting. R#73 was always incontinent of bowel and bladder. Review of Physicians Orders for 02/01/18 to 03/31/18 revealed R#73 had orders which included [MEDICATION NAME], to be administered 100 unit/mL (milliliter), per sliding scale, subcutaneous, before meals and at bedtime, 6:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. for diabetes; [MEDICATION NAME] 100 unit/mL, 25 units, subcutaneous once daily at 8:00 a.m. for diabetes; and [MEDICATION NAME] 325 mg Q6h PRN (every six hours as needed) for pain or fever. No more than four grams of [MEDICATION NAME] from all sources could be given within a 24 hour period. R#73 was to have a pain assessment each shift, and a pressure reduction mattress. Review of Physician Telephone Order dated 12/29/17 to discontinue wound treatment to R#73's left third toe due to the area being healed. Review of R#73's Care Plan dated 02/02/17 and updated 01/16/18 revealed: -R#73 was at risk for pressure ulcers. Approaches started 01/15/18 included turning and repositioning her at least every two hours; performing a daily skin inspection with all bony prominences being observed very carefully; keeping bony prominences from coming in direct contact with one another with the use of wedges and pillows; keeping her skin as dry as possible. On 04/05/18 this care plan problem was updated with Cont (continue) P[NAME] (plan of care) and review 07/05/18. On 04/06/18, the pressure ulcer care plan problem was updated with Cleanse second toe with NS (normal saline), pat dry, cover with ABD pad and wrap (with) kerlix QD (daily) & PRN. Cleanse L (left) 4th toe (with) NS, pat dry, apply gauze between 4th and 5th toes, cover (with) ABD pad & wrap (with) kerlix QD & PRN. This was the only documentation of wound care found in the care plan. -R#73 had difficulty focusing attention and was easily distracted, out of touch, and had difficulty following what was said. Approaches began on 01/15/18 included assessing her for pain. -R#73 was at high risk for skin breakdown related to her diabetes and bowel and bladder incontinence. Approaches dated 01/15/18 and updated 04/05/18 did not list anything related to the infection of R#73's toes on her left foot or how to prevent skin breakdown specific to her feet. R#73 had previously had skin breakdown on her toes which was resolved on 12/29/17. -R#73 was at risk for falls due to her cognitive deficits and poor safety awareness, weakness and [MEDICAL CONDITION] medication use; approaches begun on 01/15/18 and updated 04/05/18 included keeping her bed in the low position whenever in bed. Review of physician progress notes [REDACTED].#73 had [DIAGNOSES REDACTED]. There was no documentation regarding observation of any wounds or concerns regarding R#73's left foot. Review of Progress Notes revealed: 02/10/18 (2:00): CNA reported to (this nurse-unable to read signature) R#73 had dried blood on her sock to the left foot. No active bleeding found or open areas. Dried blood around coarse toenail found to second toe; noted bruising to second toe of left foot, dark purple in color. Bruising covers toe 3 cm length X 2 cm width. Noted with redness traveling from bruised area to left side of foot; warm to touch; pain upon touch-was determined through R#73 pulling back foot slightly and facial grimacing and mumbling. Tylenol 325 two tabs administered for pain. Cleansed second left toe with normal saline and gauze; pat dried with gauze, left open to air. Foot elevated with pillow. Physician informed/faxed. Due to history of Diabetes and [MEDICAL CONDITION], takes ASA, requesting LLE (left lower extremity) Doppler venous/arterial (?) X-ray of left foot/toes? ABT (antibiotic) therapy? AM (morning) nurse to follow up phone call for orders; will continue to monitor. 02/10/18 (12:30 pm.): Called on call physician; informed of R#73's left second digit on left foot. Gave order for Keflex 500 mg tid (three times daily) X five days for infected left foot and Xray to left foot two views. 02/10/18 (1:00 p.m.): Called portable xray company to take xrays of R#73's left foot. Will be at facility sometime today. Notified RP by leaving message due to no answer. These Progress Notes document concerns found on the second toe of the left foot. Review of Radiology report dated 02/10/18 revealed R#73 had modest [MEDICAL CONDITION] joint disease. There was no fracture, dislocation, or soft tissue swelling. No osteo[DIAGNOSES REDACTED] was seen. The bones appeared diffusely demineralized. Peripheral [MEDICAL CONDITION] disease was noted along with heel spurs. The report concluded that R#73 had modest [MEDICAL CONDITION] joint disease; otherwise, no fracture of dislocation seen. Review of Progress Notes continued: 02/11/18 (8:00 a.m.): Initial dose of Keflex 500 mg tid given at this time. Left toe and foot with increased redness. Second digit on left foot continued with dark purple color. complained of pain when touched. Again, these progress notes document wound to second digit on left foot. Review of Skin Assessment Flow sheet for non-pressure injury conditions (skin assessment) with date of onset of 02/11/18, revealed R#73 had a skin risk score of 14, and the physician and RP were notified. The third toe on the left foot was infected with purple discoloration. Description of skin alteration: 3.5 cm. length X 1.5 cm width. Treatment was to monitor. These progress notes documented wound to third toe of left foot. Review of Progress Notes continued: 02/12/18 (12:00 p.m.): Called R#73's physician, Physician Z, to inform of R#73's right foot noted with more redness. Physician Z gave order to send to emergency room to evaluate and treat. These Progress Notes documented wound to right foot. 02/12/18 (1:00 p.m.) Ambulance arrived to transport R#73 to the hospital. 02/12/18 (5:00 p.m.) R#73 arrived back from the hospital with new order for [MEDICATION NAME] HCl 300 mg (milligram) TID X seven days for infection. Discontinued Keflex 500 mg TID X 5 days for infection. Need to follow up with PCP (Physician AZ) in a couple of days. Will continue to monitor. (8:30 p.m.) Called RP (Responsible Party) to notify of new medication; RP did not answer. 02/15/18 (1:00 a.m.) Received response from fax- left foot-xray-LLE arterial performed on 02/10/18; [MEDICATION NAME] 300 mg TID X ten days. R#73 currently on [MEDICATION NAME] 300 mg TID X seven days received at ER visit on 02/12/18. No side effects or A/R (adverse reaction) to [MEDICATION NAME]. LLE arterial doppler to be set at hospital radiology department (no record of arterial doppler having been performed until 04/05/18). Left foot continued with redness and warm to touch; no drainage with dark color discoloration to second toe of left foot; elevated with pillow. Will continue to monitor. Follow up appointment with PCP to be set up. 02/17/18 (1:00 p.m.) Physician AZ at facility to do rounds. No new orders received. Continue on [MEDICATION NAME] 300 mg TID X ten days for left foot infection. 02/18/18 (9:50 p.m.) R#73 continued on [MEDICATION NAME] 300 mg TID for left foot infection. Redness and deterioration noted to second left toe. Will continue to monitor. 02/19/18 (9:45 p.m.): R#73 received last dose of [MEDICATION NAME] therapy. No complaint of pain or discomfort. These progress notes documented wound on second toe of left foot. Review of Skin Assessment Flow Sheet-Non-Pressure injury condition dated 02/21/18 revealed Dry scabbed area to left third toe, 3.5 cm length X 1.2 cm width with no depth. There was no treatment change. Review of Skin assessment dated [DATE] revealed the left third toe was noted to have necrotic tissue and sloughing, and R#73 was positive for [MEDICAL CONDITION]. The size was noted to be 4.0 cm. length X 1.5 cm width. This Skin Assessment documented wound on left third toe. Review of Progress Notes continued: 03/01/18 (11:00 a.m.): Received order from Physician AZ to do a wound culture to third toe on left foot and start [MEDICATION NAME] 150 mg TID X seven days for toe infection. RP made aware of new orders. 03/02/18 (8:00 a.m.) Initial dose of [MEDICATION NAME] 150 mg TID X seven days for left toe infection. 03/06/18 (11:15 a.m.) : Continue on antibiotic [MEDICATION NAME] 150 mg PO TID X seven days for toe infection. No side effects or adverse reaction noted .Toe continues with necrotic area . (unable to read much of the note and nurse initials are illegible). Review of Lab report of wound culture done on 03/02/18 at 8:08 a.m. revealed R#73 had [DIAGNOSES REDACTED]. The wound culture report was received by the facility on 03/06/18 at 4:50 p.m. Review of Progress Notes continued: 03/06/18 (5:00 p.m.) This nurse (initials appear to be AZ but employee list has no one with those initials) received culture results for wound infection to left second digit. Results showed three organisms-Pseudomonas Aeruginosa, Staph Aureus and yeast. On call service for Physician AZ notified. R#73 was afebrile and had no complaints of pain. Pending Physician AZ call back. (5:30 p.m.): Physician AZ called back and [MEDICATION NAME] mg BID (twice daily) X ten days, [MEDICATION NAME] 500 mg BID X ten days, [MEDICATION NAME] 100 mg single dose; discontinue (d/c) [MEDICATION NAME] 150 mg TID X seven days. Initial dose of [MEDICATION NAME] given; pending initial dose [MEDICATION NAME] arrived from pharmacy. (9:30 p.m.) RP notified of wound culture results and medication changes. These Progress Notes documented wound on left second digit. Skin assessment dated [DATE] revealed R#73 had dry eschar/necrotic tissue to her left third toe; dry dressing in place. The size was 3.5 cm length X 1.5 cm width, and zero depth. This Skin Assessment documented wound to left third toe. Review of Progress Notes continued: 03/08/18 (9:00 p.m.): RP was called and made aware of appointment with Cardiologist on 03/12/18 at 11:45 p.m. (?). 03/09/18 (9:00 p.m.) R#73 continued on antibiotic [MEDICATION NAME] mg BID X ten days and [MEDICATION NAME] 500 mg Bid X ten days for foot infection. No S/S (signs or symptoms) of pain or discomfort. No side effects or adverse reactions to medication noted. 03/11/18 (9:40 a.m.) continue on antibiotic therapy. R#73 continued with redness to the left foot; no drainage or odor noted. (10:20 p.m.): Antibiotic Cipro/[MEDICATION NAME] continues due to left second digit. R#73 would grimace when LLE was moved. No other complaints of pain otherwise. Dressing noted as clean, dry and intact. Will monitor. 03/12/18 (2:00 a.m.) Left foot second toe infection-dressing intact, no drainage through dressing; no side effects or adverse reaction to antibiotics. Appointment with Cardiologist to be rescheduled per RP request, unable to make appointment with R#73. AM (morning) nurse to reschedule. These Progress Notes documented wound to left second toe and left foot second digit. Review of Skin Assessment Flow Sheet dated 03/13/18 revealed R#73's third toe ulcer had increased in size and continued with dry eschar. The size of the wound was not 4.0 length X 2.0 cm in width, with no depth. This Skin Assessment documented wound to third toe. Review of Progress Notes continued: 03/14/18 (9:45 p.m.) R#73 continued [MEDICATION NAME] for infection to wound on left foot second toe. Continued with daily wound care. Denied pain, no symptoms of pain noted. 03/16/18 (4:00 p.m.) Noted during dressing change to left toe new area with pressure left inner heel. Need to float heels. Left second toe with dark area noted to top. Noted maceration. Dressing change per treatment nurse. 03/17/18 (2:00 p.m.) R#73 noted with cough/congestion. Afebrile. Will continue to monitor. (9:00 p.m.) R#73 noted in bed at this time; dressing to left foot with minimum serosanguinous drainage. Grimacing/guarding noted. PRN (as needed) Tylenol administered, no foul odor noted to left second digit. status [REDACTED]. Will monitor. 03/18/18 (9:00 p.m.) This nurse (unable to read initials) provided wound care. Wound bed with necrotic tissue. Wound edges noted with red wound bed. Minimal serosanguinous drainage noted. No foul odor, redness or inflammation present. Medication PRN for pain. 03/20/18 (10:55 a.m.) R#73's RP arrived at facility; nurse called Cardiologist to reschedule R#73's appointment that was cancelled by RP last week due to her not being able to go because of a family emergency. An appointment with the Cardiologist was rescheduled for 03/28/18 at 1:00 p.m. These Progress Notes documented wound to left foot second toe or left second digit. Review of Skin Assessment Flow Sheet dated 03/21/18 revealed R#73's left toe wound had not changed and the area was stable. Measurement continued to be 4.0 cm length and 2.0 cm width, with no depth. Review of Progress Notes continued: 03/23/18 (2:00 p.m.) R#73 noted with yellowish drainage .MD faxed; pending response. (new note for 03/23/18 with no time noted) R#73 noted with a 3.5 cm X .3 cm X .1 cm abrasion with two other small abrasions to right shin. No drainage or bleeding or warmth to touch. Redness noted around abrasion. R#73 denied any pain or discomfort. Abrasion cleansed, RP and MD notified. 03/25/18 (2:00 p.m.) Physician AZ at facility doing rounds with no new orders. Review of physician progress notes [REDACTED].#73 had hypertension, Diabetes; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION]; overactive bladder; and depression. There was no mention of R#73's wound on her left foot. Review of Nutrition assessment dated [DATE] revealed R#73 weighed 126 pounds, which was 126% of her ideal body weight. R#73 was at nutritional risk and risk for dehydration secondary to her [DIAGNOSES REDACTED]. A routine snack at night was being offered but no supplements were noted for help with wound healing. Review of Skin Assessment Flow Sheet dated 03/27/18 revealed R#73 had dry eschar, with measurements decreased to 3.0 cm length X 1.3 cm width, X zero depth. The left inner toe had a purple area noted .5 cm X .5 cm. Review of Nurse's notes revealed no documentation dated 03/28/18 regarding whether R#73 kept the Cardiologist appointment or whether it was rescheduled and why it might have been rescheduled. On 04/08/18, nurse's notes documented that the appointment was missed on 03/28/18; no reason given (see notes dated 04/06/18 and 04/08/18). Review of Progress Notes continued: 04/02/18 (10:00 p.m.) R#73's wound to left second digit toe had necrotic tissue. Serosanguinous drainage yellowish with foul odor. Left lower (unable to read) was also warm to touch. The fourth digit left foot had redness, notified MD via fax. Waiting for response. Will continue to monitor. Bed in lowest position, call light within reach. 04/03/18 (2:00 p.m.) Late entry for 04/02/18 at 8:00 p.m. R#73 had bruise to left lower leg. Notified RP. RP said R#73's leg was under her wheelchair's foot rest instead of on top of it, and caused her leg to press against it, which led to the bruise. Continue to monitor. 04/03/18 (5:50 p.m.) New order for LLE arterial doppler, wound culture. [MEDICATION NAME] 300 mg TID X ten days. Notified RP. Schedule arterial doppler for 04/04/18. These Progress Notes documented wound to left second digit. Review of Skin Assessment Flow Sheet dated 04/03/18 revealed R#73 had dry eschar to the left third toe and fourth toe had purple area increasing in size to 1.3 cm X 1.3 cm. The dimensions of the wound on the left third toe was 3.5 cm. X 1.5 cm, with zero depth. This Skin Assessment documented wound to left third toe and fourth toe. Review of R#73's Quarterly Pain assessment dated [DATE] revealed R#73 did not have pain; expressed pain through facial expressions and protective body movements; was not able to verbalize whether she had pain; had symptoms of pain with any physical activity change; medications or treatments in the last five days had eased her pain completely; and a pain level of one was R#73's acceptable level of comfort. Review of Progress Notes continued: 04/04/18 (8:00 p.m.) Collected wound culture. R#73 tolerated well. Sample was in hall Z refrigerator. Will continue to monitor. 04/05/18 (3:30 p.m.) Wound care was done, little drainage on fifth toe, mild odor. (5:00 p.m.) Arterial doppler performed, R#73 was laid back in bed. (Late entry 3:30 p.m.) Daily wound care provided at this time. Necrotic areas noted to second digit, fourth/fifth digit. Second digit measured 3.9 X 2.4 X .1 cm. Yellow slough noted at 3:00. Minimal drainage noted. Necrotic areas to fourth and fifth digit with no drainage. R#73 grimacing and guarding during care. PRN pain medication. Continue with [MEDICATION NAME] 300 mg TID for wound infection. Minimal foul odor noted during wound care. R#73 tolerated antibiotic well. Will continue to monitor. (late entry 5:00 p.m.) Mobile xray to perform arterial doppler to LLE. R#73 tolerated procedure well. Pedal pulse weak. No cyanosis noted. Warm to touch. Pending doppler results. These Progress Notes documented wound to second digit, fourth/fifth digit. No mention is noted of wound to third toe. Review of Ultrasound Report of duplex lower extremity arterial unilateral , left extremity, dated 04/05/18, revealed R#73 had moderate [MEDICAL CONDITION] changes. Review of Physician's Telephone Orders dated 04/06/18 revealed: 1. Clarification order for 02/27/18: Cleanse left third toe with NS (normal saline), pat dry, cover with abd (large gauze) pad and wrap with Kerlix QD (daily) until all resolved. 2. Clarification order for 03/22/18: Cleanse left fourth toe with NS, pat dry, apply gauze between fourth and fifth toes, cover with abd pad, wrap with Kerlix QD until resolved. Surveyor noted that this is the first time orders for wound care were found in R#73's clinical record. This Physician Telephone Order documented wound to left third, fourth and fifth toe. Review of Progress Notes continued: 04/06/18 (11:10 a.m.) Called RP to make her aware that R#73's appointment with Cardiologist was rescheduled for (MONTH) 11, (YEAR) at 11:45 a.m. Also advised RP that R#73's arterial doppler was positive for [MEDICAL CONDITION]. R#73 continued on antibiotic therapy for infection to toes of left foot. Continued with redness to left foot, no grimacing or pain noted to face. Will continue to monitor. (10:00 p.m.) R#73 continued on antibiotics for infection of left toes. No adverse effects noticed at this time. Tolerating well. No complaints of pain. Will continue to monitor. (11:45 p.m.) On [MEDICATION NAME] therapy for infected second digit of left foot. Starting to have possible reaction to the medication. Noted red splotchy rash on right side and buttocks. Will continue to monitor. 04/07/18 (10:00 a.m.) R#73 noted with rash to peri-area and buttocks; no itching noted. (10:15 a.m.) Called Physician AZ to inform of R#73's status. Pending MD call back. (3:30 p.m.) Physician AZ called back with new order for Keflex 500 mg BID X ten days for infection to the left foot toes fourth and second digits. [MEDICATION NAME] cream BID until rash resolved; [MEDICATION NAME] 180 mg X ten days; and [MEDICATION NAME] 150 mg BID X ten days for allergic reaction. Discontinue [MEDICATION NAME] due to allergic reaction. (Late entry) Notified RP. (7:00 p.m.) Administered Keflex from house kit; no adverse affects at this time. Will continue to monitor. 04/08/18 (10:00 p.m.) R#73's fifth toes to the left foot has developed a black spot on the inner side near the fourth toe. Size .5 X .3 cm. R#73 missed her appointment with Cardiologist on 03/28/18. Need to reschedule. Will continue to monitor. These notes documented wounds to the fourth and second digits and fifth toe. Review of Skin Assessment Flow sheet dated 04/11/18 revealed R#73 was discharged to the hospital on [DATE]. Review of Hospital History and Physical dated 04/11/18 revealed R#73 was admitted to the hospital with [REDACTED].#73 had been on antibiotics in the nursing facility and started to develop necrosis and there was admitted to the hospital for further evaluation and treatment. The Assessment and Plan revealed R#73 had gangrene of the left second toe with necrosis; and R#73 had a cardiology consult with a Cardiologist. An operation was done on 04/16/18 due to R#73 having gangrene and osteo[DIAGNOSES REDACTED] of the left lower extremity. A left above the knee amputation was indicated due to severe stenosis of the distal femoral artery. These hospital notes documented gangreen to the left second toe with necrosis. Review of Physicians Telephone orders dated 04/19/18 revealed R#73 was readmitted to the nursing facility with orders to continue with all previous nursing home medication, treatment and labs; discontinue [MEDICATION NAME] and Levimer insulin; and start [MEDICATION NAME] per moderate sliding scale before breakfast and at night. Next Progress Notes continued: 04/19/18 (11:00 a.m.) readmitted from the hospital. Sleeping, aroused easily. Dressing to left AKA (above knee amputation) dry and intact. No distress noted. Review of R#73's Comprehensive Pain Assessment completed at 5:30 p.m. on 04/19/18, after R#73 returned to the facility following the amputation of her left lower extremity, revealed R#73 occasionally moaned or groaned indicating she might have pain; would tense and call out don't touch when moving limb; and had moderate pain in the last five days. R#73 expressed pain with facial expressions and protective body movements. Review of Progress Notes Continued: 04/20/18 (12:00 p.m.) Received new order from Physician AZ for R#73's continued pain. Tylenol #3 q6h (every six hours) prn (as needed); faxed to pharmacy; pending arrival. (Late entry for 04/19/18, 3:50 p.m.) R#73 had two red areas to right toes third digit, .2 X .2; and second at outer area .1 X .1. Notified wound care nurse. D/C IV (intravenous) feeding on right hand. Will continue to monitor. R#73 tolerated well. In an interview at 8:04 a.m. on 04/25/18, R#73's RP wanted to speak to surveyors who were in the process of doing a recertification of the facility. The RP expressed concerns that the facility was slow to respond to changes in the wound on R#73's left foot, which led to the amputation of the leg above the knee. The RP said she thought possibly the amputation would not have been as severe if the facility had responded to the wound care and notification of the physician on a timely basis. The RP said R#73 was on three different antibiotics and she had an allergic reaction to the third one. In the interview at 8:04 a.m. on 04/25/18, the RP said she was never told how bad R#73's wounds were to R#73's left foot, and she said she was just informed that it was bad by some of the nurses. When Physician AZ decided to send R#73 to a cardiologist, the RP said she could not keep the first appointment and wanted to be present for the cardiologist appointment. The RP said she called the nursing facility on the day that the appointment was rescheduled to, but she was told R#73 was down for another rescheduled appointment. The RP said the facility van was being worked on and was not available. The RP said the facility was not aggressively attempting to reschedule R#73's appointment with the Cardiologist. The RP said another week or so went by and it got to the point that the RP offered to take R#73 to the Cardiologist in her own car. The RP said someone from the nursing facility helped load R#73 into her vehicle so she could take her to the Cardiologist appointment on 04/11/18. In the interview at 8:04 a.m. on 04/25/18, the RP said when they got to the Cardiologist, he unwrapped R#73's wound and said her toes had gangrene and she needed to go immediately to the hospital. The RP said the sores on R#73's toes smelled very bad. R#73 had osteomyeliltis and infection had spread all the way to her knee. R#73 had the amputation of her lower left leg on 04/16/18 and did very well with the surgery. The RP said she asked the facility when was the last time Physician AZ saw R#73's left foot before she went to the hospital for the amputation, but no one gave her the answer. The RP said she had difficulty finding out when Physician AZ was going to be visiting R#73 so she could be there to meet with him. The RP said she was told by different staff members that he came on weekends only, or came during the week only. The RP said she was told by someone, she could not recall who, that Physician AZ was in R#73's wing of the building and thought Physician AZ looked at R#73's foot. The RP said she asked the nurses how they were documenting in R#73's chart so that Physician AZ would know he needed to look at R#73's foot, but did not get a straight answer. The RP said she felt there was no aggressiveness on the facility's part to bring attention to R#73's changing wound on her foot. The RP said she was advised that several different nurses did wound care at the facility. The RP said she had spoken with the charge nurses about her concerns, but had not expressed her concerns to the Administrator or Director of Nurses (DON) and would like to talk with the DON. At 8:41 a.m. on 04/25/18, a meeting was held with the RP and DON in the presence of surveyors. The RP advised the DON that she was never shown R#73's foot and she took the word of the nurses regarding the condition of R#73's foot. The nurses described R#73's foot as bad or very bad. The RP said she was unable to keep one of the appointments with the Cardiologist, but after this, the Cardiologist appointments were delayed because the facility van was being worked on or the facility did not remember to reschedule the appointment. The RP said she finally took R#73 to the Cardiologist herself on 04/11/18, and when the Cardiologist opened the dressing on R#73's left foot, there was a foul smell and R#73's entire digit was covered in gangrene. The RP said gangrene had started to form between two of R#73's toes and she had not been advised that the infection was spreading to other parts of R#73's foot or that it was gangrenous. The RP told the DON that she received copies of R#73's records from the facility and there was no description of the severity of R#73's foot. The RP said it was upsetting that the Cardiologist appointment was delayed and Physician AZ had not seen her foot when he made rounds. In the meeting on 04/25/18 at 8:41 a.m., the DON said she was aware of the concern regarding R#73's foot but she could not say definitely that Physician AZ saw R#73's foot because he usually came in after hours. The DON reviewed physician progress notes [REDACTED].#73's wound in his notes. The DON said the facility had a wound care nurse, Licensed Vocational Nurse (LVN) TX. LVN TX worked all week, was also a scheduler. LVN TX sometimes covered the weekends as well. Other nurses may do wound care on the weekend; usually the weekend supervising RN did the wound care. The DON said the eschar on R#73's foot got very thick on her toe and could have been unstageable. R#73 would kick off her shoe because it was painful. R#73's foot would turn really red at times. The DON said if the nurses were having a problem with a resident, they would approach the physician and tell the physician that he needed to see the resident. The DON said the wound care nurse would be expected to report a problem to a charge nurse. The DON said everyone was worried about R#73's toe and knew it was getting worse. The RP said she talked with one of the MDS nurses instead of the DON about her concerns because she knew that nurse. After the RP left, at 9:15 a.m. on 04/25/18, the surveyors continued meeting with the DON regarding R#73's left foot wound. LVN TX was called into the meeting. The DON said things could have been done differently to communicate with Physician AZ to be sure he saw R#73's foot wound. LVN TX reviewed the wound care for R#73 and answered the following questions: Surveyor: What does infected toe mean? LVN TX: the discoloration and swelling of the toe meant infection. DON: there should be a description of the toe. Surveyor: Would infected toe be valid? DON: No. LVN TX: Findings were also documented in the nurses' notes what the findings were. There's limited space on that note (Skin Assessment Note). On 02/11/18 when it was brought to my attention, I read the nurse's note dated 02/10/18. The charge nurse looks at the wound and she (LVN TX) just does the wound care charting weekly. The two to ten nurse was with her most of the time. If she (charge nurse) noticed a change she would document and notify the doctor. I usually asked the charge nurse to go with me when doing wound care. Surveyor: On 02/21, she has a dry scab area to the left toe; on 02/28, it says it's grown in size and it says left third toe noted with necrotic tissue and sloughing. How much necrotic and sloughing and where? LVN TX: On 02/28 I was not here that week, it was a different nurse. Measurements on top of the box-that's what the eschar measured. When I came back there was no slough or drainage, it was just a dry area. They wrote an order for [REDACTED]. Surveyor: Did (Physician AZ) ever come in with you when you did wound care? LVN TX: No. Surveyor: Did (Physician AZ) ever approach you and ask to see it? LVN TX: No. On 03/27/18, it looked like the wound started showing some signs of left fourth inner toe spreading discoloration to that toe from the middle toe. I called the charge nurse, LVN S, into the room to see the wound; she voiced she would notify the doctor. On 04/02, LVN S documented changes in the wound, leaking serosanguinous and foul odor. Left lower leg warm to touch. On communication note to dr. He responded. DON: It doesn't say she notified the RP (looking at the note). Surveyor: Why did it take from 03/27 to 04/02 to send the communication note to the dr? DON: Can't answer why. Should have notified the physician before 04/02. Consequences for the reside (TRUNCATED)

Based on observation, interview and record review, the facility failed to implement their written policy and procedures to prevent neglect for 2 Residents (R#3 and R#8) of 20 residents who were reviewed for neglect. The facility failed to: --to properly conduct a skin assessment for R#8 when he vocalized pain and discomfort during care and --ensure R#3 physician's orders [REDACTED]. These failures could affect 1 resident who had orders to receive Vitamin B-12 IM and 1 resident whose skin assessment was not conducted, placing 29 residents at risk for risk for moderate to severe pain, and neglect. Findings: Review of the facility's Policy and Procedure on Abuse-Reportable Events, effective date 02/2008, revised date 05/2014. Policy: It is the policy of this fhome to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or my be adversely affected by abuse or neglect caused by another person. Definitions: Abuse: Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R #8: R #8's undated Face Sheet documented an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Admission/Re-Admission Data Summary dated 05/15/17 documented Skin Condition: Superficial irritation to coccyx 10 X 12 centimeters, surgical site to area below left knee 25 centimeters long closed with 31 staples, and surgical site to area below right knee 24 centimeters long closed with 27 staples. Incontinent of bladder and bowel, pads, briefs used. R #8's Weekly Skin assessment dated [DATE] documented See Admission Assessment. R #8's Start-Up Orders dated 05/15/17 documented Cleanse superficial irritation to coccyx with normal saline and 4X4 gauze, apply A & D Ointment q (every) shift and per each incontinent episode. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/15/17 documented by Licensed Vocational Nurse B revealed Skin Risk Score 15- High Risk. Care Plan/Goal: Will resolve without complications. Location: Peri Area and buttocks and scrotum. Description: Rash/redness. R #8's May 2017 Medication Administration Record [REDACTED]. The MAR/TAR documented an assessment of pain on 05/01/17 on each shift and on 05/02/17 only the 6:00 a.m.-2:00 p.m. shift was assessed and documented. There was no documentation providing evidence that R #8's pain was assessed from 05/02/17 beginning at 2:01 p.m. thru 05/26/17. R #8's attached Pain Management Flowsheet dated May 2017 revealed no entries were documented on the form. The facility's A-D Wing Shower Sheets dated 05/16/17, 05/18/17, 05/20/17, 05/23/17 revealed R #8's scheduled shower days were Tuesday, Thursday, and Saturday. The attached Nursing Assistant Daily Body Observation Form dated 05/18/17 revealed Guidelines: Complete during shower or bath for each resident scheduled. Mark on the diagram the location of the skin problem with an X. Check the box indicating the type of problem or write in the space provided. Inform the charge nurse of the skin problem. The charge nurse must sign the form after they review the information. The form should be turned into the DON/designee on a daily basis. If the skin problem appears serious, immediately notify the charge nurse. The form was labeled with R #8's name however, the form was not completed and no reviewer signature was present. The other Shower Sheets and attached Nursing Assistant Daily Body Observation Forms for the rest of the dates above did not include a Nursing Assistant Daily Body Observation Form for R #8. R #8's Weekly Skin assessment dated [DATE] revealed an X on the front lower genital area and the buttocks of the body figure indicating the site of skin impairment however, there was no description of the type of skin impairment. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/19/17 documented by LVN B revealed Noted with redness/rash to peri area and buttocks. R #8's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #8 had unclear speech, rarely/never made self understood, and sometimes understood others. R #8 had short and long-term memory problems and had severely impaired daily decision making skills. R #8 was totally dependent on one to two person physical assistance for bed mobility, transfers, dressing, bathing, and personal hygiene. R #8 was always incontinent of bladder and bowel. R #8's staff assessment for pain indicated non-verbal sounds and facial expressions as indicators of pain observed. R #8 was determined at risk for pressure ulcers with no current pressure ulcers. R #8's skin condition assessment did not indicate any skin problems. R #8's Care Plan dated 05/23/17 documented: -Pain, due to recent surgical procedures (R #8) will require use of [MEDICATION NAME] pain medication .(R #8) will be monitored for effective pain relief as evidenced by no facial grimacing, no vocalization of pain. No yelling out when he is moved . -Due to recent bilateral BKA ([MEDICAL CONDITION]) (R #8) is unable to move about independently and cannot bear weight. (R #8) is unable to move or shift in his bed due to poor cognition and he requires two people to help with any transfer or change in body position He requires one person total assist for bathing due to his poor cognition . -(R #8) has bladder and bowel incontinence related to dementia and decreased sensation .(R #8) will have incontinent care after each incontinent episode (R #8) will have moisture barrier to skin with each incontinence care . -(R #8) has difficulty making self understood related to his advancing dementia .(R #8) will be observed for non-verbal signs of distress: guarding, moaning, restless, grimacing, fidgeting .(R #8's) needs will be anticipated by staff due to his inability to communicate . -I am at risk for pressure ulcer related to decreased mobility, incontinence of bladder and bowel .Avoid sharing my skin during positioning, transferring, and turning. Keep clean and dry as possible. Minimize skin exposure to moisture. Provide incontinent care after each incontinent episode. Avoid hot water and use mild cleansing agent that minimizes irritation and dryness of the skin, avoid friction to skin. Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity. Use moisture barrier product to perineal area . Observation of R #8 on 05/23/17 at 9:50 a.m. revealed R #8 was reclined back in his Geriatric (Geri) chair positioned in front of the A-Unit nurses station. R #8 was restless and uneasy, displaying facial grimacing, as he unsuccessfully attempted to raise and reposition his buttocks off the chair. R #8 continuously yelled out Me duele la cola, Aye Aye Aye Aye (My butt hurts, ouch ouch ouch). Two nurses were observed to sit at the nurse's station, directly across from R #8 but did not address or intervene to assess R #8. At 9:56 a.m., CNA E approached R #8 as R #8 again said Me duele la cola; CNA E told R #8 Okay, we are going to give you a shower. CNA E escorted R #8 into the shower room and began to undress him with the assistance of CNA F. CNA E and CNA F assisted to transfer R #8 to the shower bed and immediately after R #8's buttocks touch the shower bed, he began to yell out Aye Aye Aye, me duele la cola, dios mio (my god). Both CNAs ignored R #8's verbalization of pain and continued to provide R #8 a shower. R #8's inner groin and scrotum were raw and chaffed, beef red in color, and with multiple areas of denuding. As CNA F positioned the shower head toward R #8's genital area, R #8 yelled out Aye, Aye, Aye dios mio as the water fell on his genitals and groin. CNA F lathered a washcloth with soap and cleansed R #8's groin areas and genitals using rough long downward [MEDICAL CONDITION]. R #8 yelled while clinching his eyes shut and said Aye, aye, aye ya no, me dule dios mio (ouch, ouch, ouch, no more, it hurts, my god). CNAs E and F told R #8 they were sorry but they needed to clean him and continued to repeat the process. CNA E and F turned R #8 to his right side and again R #8 yelled out Aye, Aye, Aye. R #8's buttocks, anus, and upper thighs were beef red, chaffed, and had multiple area of denuding. CNA F again lathered a washcloth with soap and water and began to scrub R #8's perineum and buttocks then rinsed them with water. The entire time of cleansing and rinsing, R #8 yelled out loud Aye, Aye, me duele ya, ya, ya, dios mio. Upon drying R #8, CNAs E and F used the towel to wipe, using downward long stokes, R #8's inner groin areas, scrotum, and buttocks; the entire time R #8 was screaming. A 10:21 a.m., CNA F applied Dermaseptin (skin barrier protectant) cream on R #8's reddened, chaffed, denuded areas on his inner groins, scrotum, and buttocks and then applied a clean brief; R #8 yelled throughout the application saying no, no, ya, no (no more). CNA E explained R #8 was going to be dressed and prepared to go to his doctor's appointment scheduled for noon time. Observation of R #8 on 05/23/17 from 11:40 a.m. to 12:00 p.m. revealed R #8 was transferred to the Emergency Medical Service (EMS) stretcher with the assistance of two male paramedics and LVN A. LVN A said R #8 was going to a doctor's appointment and anticipated his return to the facility in approximately three hours. LVN A said she did not check or change R #8's brief prior to him leaving the facility and did not know when his brief was last changed. Interview with CNAs E and F on 05/23/17 at 1:55 p.m. revealed both staff denied checking or changing R #8's brief prior to his departure of the facility for his appointment. Neither CNAs were aware of what time R #8 left for his appointment. CNAs E and F said R #8 required a check, change, and reposition every two hours. CNA F said R #8's brief was due to be checked and changed at approximately 12:30- 12:45 p.m. CNAs E and F stated they did not inform the nurse of R #8's yelling or reddened skin. CNAs E and F said they did not know how long R #8 had his groin and perineum reddened and chaffed. CNAs E and F said R #8's reddened areas appeared to be hurting him upon touched when asked if they thought R #8 was having pain at any time throughout the shower. On 05/23/17 at 3:50 p.m., observation revealed R #8 was taken to his room via stretcher by two EMS employees and transfered back to bed. Surveyor requested CNA R to check R #8 for incontinence. CNA R removed R #8's brief and said, he is soaked. CNA R said she would have to get the assistance of another aide to change R #8's brief. CNA R left the room and returned with CNA S. CNAs R and S removed R #8's urine soaked brief and and placed a clean brief on R #8 without providing incontinent care. On 05/23/17 at 4:05 p.m., interview with CNA R said she and CNA S should have washed the urine off R #8's skin, but CNA R said that CNA S had already starting appling R #8's diaper before she had a chance to provide incontinent care. CNA R said R #8 could develop a rash or skin irritation if he was not provided incontinent care with brief change. Observation of R #8 on 05/24/17 at 10:55 a.m. revealed CNAs F and J were preparing to provide R #8 with incontinent care. R #8 was lying in bed, on his back. CNA F opened R #8's soiled brief and positioned her left hand on R #8's pubic region, lifting his skin taut then with a disposable cleansing wipe, wiped his left inner groin area using a long downward stoke. R #8 began to scream Aye, Aye, Aye Jesus Christ Aye, Aye, Aye, Ya as he tensed his body tight, and shook his pelvic region. CNA F wiped R #8's right inner groin and scrotum and again R #8 began to yell loudly. R #8 was turned to his right side and again CNA F wiped R #8's perineum, anus, and buttocks using long downward [MEDICAL CONDITION] causing R #8 to yell saying Aye, Aye, Aye, ya no. CNA J tells CNA F to call the nurse because He is raw and it's hurting him. CNA F applied Dermaseptin cream on R #8's perineum and buttocks and again, R #8 began to yell. The surveyor asked R #8 three times while he received incontinent care if he was in pain however, R #8 did not provide a verbal response however, he displayed facial grimacing and yelled out symptoms of pain. Interview with LVN A on 05/24/17 at 11:13 a.m. revealed she was not aware of R #8 having any skin issues other than his surgical incisions. LVN A said she had not been informed by any CNAs of R #8 having any altered skin impairments. LVN A said if there were any skin issues then staff would report them to the treatment nurse. LVN A said the CNAs completed a Nursing Assistant Daily Body Observation Form for every resident bather/showered and turned in to her or who ever the charge nurse was. LVN B stated she was responsible for reviewing the forms within her shift. LVN B said she had not seen any form for R #8 that indicated any skin impairments. Interview with LVN B on 05/24/17 at 11:20 a.m. revealed LVN B identified herself as the Treatment Nurse. LVN B said she last assessed R #8 on 05/19/17 after his return from the hospital on [DATE]. LVN B said on 05/19/17, R #8 had redness to his buttocks. LVN B said the reddened area was tender to touch as evidenced by R #8 saying aye' when the area was touched. LVN B stated R #8's reddened areas were not chaffed or denuded at that time and denied redness to his inner groins. LVN B said she had not been informed of R #8's reddened areas worsening. LVN B said she would not know unless she was informed or when she assessed him during his weekly skin assessment. LVN B said any nurse could assess and inform the physician of any skin issues. LVN B said R #8 currently had A & D ointment ordered for his skin irritation to his buttocks. This surveyor informed LVN B of R #8's skin impairment to his perineum and buttocks. The surveyor informed LVN B of observation of staff applying Dermaseptin to R #8's redness; LVN B said They should be using A & D. Upon the surveyor's request, LVN B entered R #8's room and searched the room for A & D ointment. After LVN B looked in R #8's top dresser drawer, there were two tubes of ProCare A & D ointments. LVN B showed the surveyor the tubes and said this is what the physician ordered. During this time CNAs F and J were assisting in repositioning R #8 and when asked by the surveyor if they had used this cream on R #8, both CNAs said No. Both CNAs denied being informed they were to use the A & D ointment on R #8. LVN B explained the A & D ointment was a petroleum based product used as a skin barrier/protectant and the Dermaseptin was not a petroleum based skin protectant. LVN B said I will call the doctor to change the order to Dermaseptin since that's what is being used. *LVN B did not assess R #8's skin at any time prior to calling R #8's physician. R #8's Physician's Telephone Orders dated 05/24/17 documented D/C (discontinue order to apply A & D ointment to scrotum and resident buttocks. N.O. (new order): Apply Dermaseptin Barrier Cream to peri area, scrotum, and buttocks after each incontinent episode. Interview with the Director of Nurses (DON) on 05/24/17 at 11:47 a.m. revealed she was made aware of observations of R #8. The DON said she was not aware of R #8 having any skin impairment. The DON stated the CNAs should have immediately contacted R #8's nurse when they saw his skin red and irritated then gently pat the area for cleaning, instead of wiping or rubbing it, which causes skin irritation and discomfort. The DON stated the facility procedure for monitoring each resident's skin was the CNAs documented any skin impairments observed during showers on the Nursing Assistant Daily Body Observation Form then give the form to the charge nurse for review. The DON stated the Charge Nurse was responsible to review the forms and follow-up on any concerns. The DON said she expected each nurse to conduct a head to toe assessment of their assigned resident at least once her shift. The DON said if the skin concern was a pressure ulcer or a complicated wound then the nurse was to inform the Treatment Nurse. The DON stated CNAs and nurses were responsible for on-going identification and assessment of each resident's pain. The DON said if R #8 was yelling and saying no or stop, then CNAs should have stopped manipulating the area of pain and immediately contacted R #8's nurse. The DON said in R #8's situation, There was a breakdown in communication and the resident suffered and was not getting treatment or appropriate treatment. The DON said staff should have been using the treatment ordered by R #8's physician. The DON said the negative effect of this situation was that R #8 endured pain and could develop behavioral issues due to not wanting a shower because he would relate personal care and showers to pain that could lead to inaccurate [DIAGNOSES REDACTED]. Further interview with the DON on 05/24/17 at 3:26 p.m. revealed the surveyor informed the DON of LVN B receiving a change of treatment order from A & D ointment to the Dermseptin cream. The surveyor again informed the DON of observations of staff already using the Dermaseptin cream and asked the DON how long a treatment was used before a nurse would question the effectiveness of the treatment. The DON stated treatments should be monitored daily and after 4-5 days, if no change or improvement was noted then the nurse was responsible for informing the physician of the status of the treatment. The surveyor accompanied the DON into R #8's room, at the surveyor's request. The DON assessed R #8's perineal and buttocks. The DON stated Oh my, if I had that irritation, I would be screaming in pain too. The DON gently palpated R #8's inner right groin and R #8 yelled saying Aye, Aye, Aye and then moaned loudly. The DON asked R #8 if he had pain but there was no return verbal response from R #8. The DON said R #8 definitely had pain to the reddened areas on his perineum, buttocks, anus, and posterior upper thighs upon touch. The DON asked CNA K, whom was assisting the DON to turn R #8, how long R #8 was reddened. CNA K stated R #8 had been like this since he came in. The DON stated R #8's physician would be called and informed that the treatment he initially ordered had not been carried through since staff had been using the Dermaseptin instead of the A & D ointment and if a change of treatment is recommended since the Dermaseptin had not been effective, as well as the pain R #8 endured upon manipulation to those areas. The DON said R #8 should be assessed for pain daily, every shift. After informed of R #8's pain assessment section on the TAR being blank, the DON said all she could conclude was that the assessments were not done if it was not documented. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/24/17 documented by the DON revealed Incontinence Associated [MEDICAL CONDITION] Goal: Resolve without further skin involvement and resident discomfort. Location: Peri Area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Treatment Change: Dermaseptin Ointment after each incontinent episode. Assess q day. Evaluation Results: Incontinence Associated [MEDICAL CONDITION]. [DIAGNOSES REDACTED] with partial thickness erosions and [MEDICAL CONDITION] with deep pink to purple in color areas: Peri area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Areas are painful to touch, warm to touch with some weepy serous exudate present. The facility's Pain Management Policy and Procedure dated 11/2013 documented It is the policyof this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life,,,The home recognizes that a response to pain is subjective and individual .The home will treat the resident under the premise that pain is present whenever the resident says that it is. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities . R#3 Review of R#3's Face Sheet undated revealed R#3 was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. R#3 had [DIAGNOSES REDACTED]. Review of R#3's Physician Telephone Order dated 03/06/17 revealed an order for [REDACTED]. Review of R#3's March 2017 Medication Administration Review (MAR) revealed an order for [REDACTED]. Further review revealed R#3 was administered Vitamin B-12 1000 mg on 03/07/17, 03/14/17, and 03/21/17. Review of R#3's Physician Telephone Order dated 03/26/17 revealed an order for [REDACTED]. Review of R#3's Physician Telephone Order dated 04/08/17 revealed R#3 was readmitted to the facility. Review of R#3's Start Up Orders dated 04/08/17 revealed R#3 had a Physician order [REDACTED].#3 received a Vitamin B-12 IM on 04/17/17 and 04/24/17. Review of R #3's laboratory results dated [DATE] R #3's Hemoglobin was 11.6 (low) and Hematocrit was 33.0 (low) and MCV was 87 (Range: 80-97) Review of R#3's May 2017 MAR indicated [REDACTED]. During an interview on 05/23/17 at 4:01 p.m. the Director of Nurses (DON) reviewed R#3's April 2017 Start Up orders and May 2017 MARs for R#3 to receive Vitamin B-12 IM once a week. The DON stated R#3 received a Vitamin B-12 IM on 04/17/17 and 04/24/17. The DON reviewed R#3's May 2017 MARs, and further stated the order was not transcribed into the May 2017 MARS. The DON stated according to the Physician order [REDACTED].#3 should have received Vitamin B-12 IM weekly and had missed 4 doses of Vitamin B-12 IMs. The DON stated she did not know why R#3 had missed the Vitamin B-12 IM as the Assistant DON (ADON) transcribed all the new orders and the DON did not know why the new order was not listed in R#3's May MARs. The DON stated this was a medication error. During an interview on 05/23/17 at 4:40 p.m. accompanied with the DON and LVN M, LVN M opened the medication cart and we observed two sealed individual Vitamin B-12 vials ordered for R#3 as of 04/09/17. LVN M reviewed R#3's May 2017 MARs that was kept on the medication cart for administering of medications and stated R#3 did not have an order for [REDACTED]. Review of R#3's Physician Telephone Order dated 05/23/17 revealed a clarification order for B-12 1000 mg IM Q month (every 24th). During an interview on 05/24/17 at 9:47 a.m. the ADON stated she got clarification orders yesterday (05/23/17) after surveyor had spoken to the DON. The ADON stated R#3's order for B-12 IM was changed to once a month on the 24th. The ADON stated she was responsible for transcribing all Physician order [REDACTED].#3's May 2017 MARs. The ADON stated she thought she had overlooked R#3's B-12 IM physician order. During a telephone interview on 05/25/17 at 11:00 a.m. R#3's Physician stated R#3 was a new patient and had an order to receive B-12 IM injections. R#3's Physician stated the facility had not informed her and therefore was unaware that R#3 had missed 4 doses of B-12 IM as ordered upon R#3's readmission on 04/08/17. R#3's Physician was asked what adverse effects could R#3 have if R#3 did not receive B-12 as ordered, R#3's Physician stated she could become Anemic. R#3's Physician stated R#3 now had a new order dated 05/23/17, for B 12 IM to be administered 1 X month on the 24th. During an interview on 05/25/17 at 12:00 p.m. the ADON stated she could not explain why R#3's Physician order [REDACTED]. The ADON stated she thought she overlooked R#3's B-12 order. The ADON was asked what adverse effect could R#3 have if not following a physician order [REDACTED].#3's Dx of [MEDICAL CONDITIONS] meant but was unable to explain what it was. The ADON stated she did not give medications. The ADON stated she forgot what [MEDICAL CONDITIONS] was and thought it would cause weakness, loss of appetite, and thought it may decrease the blood cell count. During an interview on 05/26/17 at 10: 37 a.m. the Corporate Registered Nurse (CRN) stated R#3 did not have a Dx of [MEDICAL CONDITIONS] as indicated on R#3's Physician Telephone order (TO) dated 03/06/17. The CRN further stated the writing on the TO had two different hand writings and she did not know who had written in R#3's Dx of [MEDICAL CONDITIONS]. CRN further stated that a nurse could not diagnose a resident and again stated R#3 did not have a Dx of [MEDICAL CONDITIONS]. The CRN stated R#3 had an order for [REDACTED].#3 received two B-12 IM prior to her hospitalization and two more after her return. The CRN stated the new orders superseded the old orders and the new Orders did not indicate R#3 had a Dx of [MEDICAL CONDITIONS]. R#3's readmission orders [REDACTED]. The CRN was informed R#3 had missed 4, B-12 IM's in May 2017 as the order was not transcribed to reflect on R#3's May 2017 MARs. The CRN stated she was aware the facility had a system failure but did not agree that R#3 had a Dx of [MEDICAL CONDITIONS]. During an interview on 05/26/17 at 11:52 a.m. LVN L stated she was the person responsible for writing in R#3's Dx of [MEDICAL CONDITIONS]. LVN L stated she clarified the Telephone order dated 03/06/17 with the DON because the telephone order did not have a Dx for the B-12 order and she was trained that each order must have a Dx. LVN L stated the DON was in agreement that R#3's B-12 IM order was for Dx of [MEDICAL CONDITIONS]. According to NIH https://www.nhlbi.nih.gov/health/health-topics/topics/[MEDICAL CONDITION]/signs referenced on 06/08/17 revealed A lack of vitamin B12 (vitamin B12 deficiency) causes the signs and symptoms of [MEDICAL CONDITIONS]. Without enough vitamin B12, your body can't make enough healthy red blood cells, which causes [MEDICAL CONDITION]. Some of the signs and symptoms of [MEDICAL CONDITIONS] apply to all types of [MEDICAL CONDITION]. Other signs and symptoms are specific to a lack of vitamin B12. Signs and Symptoms of [MEDICAL CONDITION] The most common symptom of all types of [MEDICAL CONDITION] is fatigue (tiredness). Fatigue occurs because your body doesn ' t have enough red blood cells to carry oxygen to its various parts. A low red blood cell count also can cause shortness of breath, dizziness, headache, coldness in your hands and feet, pale or yellowish skin, and chest pain. A lack of red blood cells also means that your heart has to work harder to move oxygen-rich blood through your body. This can lead to irregular heartbeats called arrhythmias (ah-RITH-me-ahs), heart murmur, an enlarged heart, or even heart failure. Signs and Symptoms of Vitamin B12 Deficiency Vitamin B12 deficiency may lead to nerve damage. This can cause tingling and numbness in your hands and feet, muscle weakness, and loss of reflexes. You also may feel unsteady, lose your balance, and have trouble walking. Vitamin B12 deficiency can cause weakened bones and may lead to [MEDICAL CONDITION]. Severe vitamin B12 deficiency can cause neurological problems, such as confusion, dementia, depression, and memory loss. Other symptoms of vitamin B12 deficiency involve the digestive tract. These symptoms include nausea (feeling sick to your stomach) and vomiting, heartburn, abdominal bloating and gas, constipation or diarrhea, loss of appetite, and weight loss. An enlarged liver is another symptom . Complete Blood Count Often, the first test used to diagnose many types of [MEDICAL CONDITION] is a complete blood count (CBC). This test measures many parts of your blood. For this test, a small amount of blood is drawn from a vein (usually in your arm) using a needle. A CBC checks your hemoglobin (HEE-muh-glow-bin) and hematocrit (hee-MAT-oh-crit) levels. Hemoglobin is an iron-rich protein that helps red blood cells carry oxygen from the lungs to the rest of the body. Hematocrit is a measure of how much space red blood cells take up in your blood. A low level of hemoglobin or hematocrit is a sign of [MEDICAL CONDITION]. The normal range of these levels may be lower in certain racial and ethnic populations. Your doctor can explain your test results to you. The CBC also checks the number of red blood cells, white blood cells, and platelets (PLATE-lets) in your blood. Abnormal results may be a sign of [MEDICAL CONDITION], another blood disorder, an infection, or another condition. Finally, the CBC looks at mean corpuscular (kor-PUS-kyu-lar) volume (MCV). MCV is a measure of the average size of your red blood cells. MCV can be a clue as to what's causing your [MEDICAL CONDITION]. In [MEDICAL CONDITIONS], the red blood cells tend to be larger than normal. Specific Types of Treatment . [MEDICAL CONDITIONS] usually is easy to treat with vitamin B12 shots or pills. If you have severe [MEDICAL CONDITIONS], your doctor may recommend shots first. Shots usually are given in a muscle every day or every week until the level of vitamin B12 in your blood increases. After your vitamin B12 blood level returns to normal, you may get a shot only once a month. For less severe [MEDICAL CONDITIONS], your doctor may recommend large doses of vitamin B12 pills. A vitamin B12 nose gel and spray also are available. These products may be useful for people who have trouble swallowing pills, such as older people who have had [MEDICAL CONDITION]. Your signs and symptoms may begin to improve within a few days after you start treatment. Your doctor may advise you to limit your physical activity until your condition improves. If your [MEDICAL CONDITIONS] is caused by something other than a lack of [MEDICATION NAME] factor, you may get treatment for [REDACTED]. For example, your doctor may prescribe medicines to treat a condition that prevents your body from absorbing vitamin B12. Based on the sample residents reviewed, there was 1 resident who received B-12 IM. According to facilit

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well being for three Residents (R #8, R #1, R #4) of six residents reviewed for pain, positioning, and activities of daily living. 1.) CNAs (Certified Nurse Aides) induced and ignored R #8's pain while providing personal care. The CNAs did not communicate R #8's symptoms of pain or a change in skin condition to licensed personnel. R #8's pain was not assessed by licensed personnel daily, every shift, as prescribed. Staff did not monitor or address the effectiveness of R #8's treatment for [REDACTED]. 2.) Staff did not check, change or reposition R #1 for over three hours. 3.) Staff did not assess R #4's pain nor offer pain medication for pain relief. This failure could affect 62 residents dependent on staff for bathing, repositioning, and/or incontinent care at risk for discomfort and the development of pressure sores and infections. The findings included: 1.) R #8: R #8's undated Face Sheet documented an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Admission/Re-Admission Data Summary dated 05/15/17 documented Skin Condition: Superficial irritation to coccyx 10 X 12 centimeters, surgical site to area below left knee 25 centimeters long closed with 31 staples, and surgical site to area below right knee 24 centimeters long closed with 27 staples. Incontinent of bladder and bowel, pads, briefs used. R #8's Weekly Skin assessment dated [DATE] documented See Admission Assessment. R #8's Start-Up Orders dated 05/15/17 documented Cleanse superficial irritation to coccyx with normal saline and 4X4 gauze, apply A & D Ointment q (every) shift and per each incontinent episode. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/15/17 documented by Licensed Vocational Nurse B revealed Skin Risk Score 15- High Risk. Care Plan/Goal: Will resolve without complications. Location: Peri Area and buttocks and scrotum. Description: Rash/redness. R #8's May 2017 Medication Administration Record [REDACTED]. The MAR/TAR documented an assessment of pain on 05/01/17 on each shift and on 05/02/17 only the 6:00 a.m.-2:00 p.m. shift was assessed and documented. There was no documentation providing evidence that R #8's pain was assessed from 05/02/17 beginning at 2:01 p.m. thru 05/26/17. R #8's attached Pain Management Flowsheet dated May 2017 revealed no entries were documented on the form. The facility's A-D Wing Shower Sheets dated 05/16/17, 05/18/17, 05/20/17, 05/23/17 revealed R #8's scheduled shower days were Tuesday, Thursday, and Saturday. The attached Nursing Assistant Daily Body Observation Form dated 05/18/17 revealed Guidelines: Complete during shower or bath for each resident scheduled. Mark on the diagram the location of the skin problem with an X. Check the box indicating the type of problem or write in the space provided. Inform the charge nurse of the skin problem. The charge nurse must sign the form after they review the information. The form should be turned into the DON/designee on a daily basis. If the skin problem appears serious, immediately notify the charge nurse. The form was labeled with R #8's name however, the form was not completed and no reviewer signature was present. The other Shower Sheets and attached Nursing Assistant Daily Body Observation Forms for the rest of the dates above did not include a Nursing Assistant Daily Body Observation Form for R #8. R #8's Weekly Skin assessment dated [DATE] revealed an X on the front lower genital area and the buttocks of the body figure indicating the site of skin impairment however, there was no description of the type of skin impairment. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/19/17 documented by LVN B revealed Noted with redness/rash to peri area and buttocks. R #8's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #8 had unclear speech, rarely/never made self understood, and sometimes understood others. R #8 had short and long-term memory problems and had severely impaired daily decision making skills. R #8 was totally dependent on one to two person physical assistance for bed mobility, transfers, dressing, bathing, and personal hygiene. R #8 was always incontinent of bladder and bowel. R #8's staff assessment for pain indicated non-verbal sounds and facial expressions as indicators of pain observed. R #8 was determined at risk for pressure ulcers with no current pressure ulcers. R #8's skin condition assessment did not indicate any skin problems. R #8's Care Plan dated 05/23/17 documented: -Pain, due to recent surgical procedures (R #8) will require use of [MEDICATION NAME] pain medication .(R #8) will be monitored for effective pain relief as evidenced by no facial grimacing, no vocalization of pain. No yelling out when he is moved . -Due to recent bilateral BKA ([MEDICAL CONDITION]) (R #8) is unable to move about independently and cannot bear weight. (R #8) is unable to move or shift in his bed due to poor cognition and he requires two people to help with any transfer or change in body position He requires one person total assist for bathing due to his poor cognition . -(R #8) has bladder and bowel incontinence related to dementia and decreased sensation .(R #8) will have incontinent care after each incontinent episode (R #8) will have moisture barrier to skin with each incontinence care . -(R #8) has difficulty making self understood related to his advancing dementia .(R #8) will be observed for non-verbal signs of distress: guarding, moaning, restless, grimacing, fidgeting .(R #8's) needs will be anticipated by staff due to his inability to communicate . -I am at risk for pressure ulcer related to decreased mobility, incontinence of bladder and bowel .Avoid shearing my skin during positioning, transferring, and turning. Keep clean and dry as possible. Minimize skin exposure to moisture. Provide incontinent care after each incontinent episode. Avoid hot water and use mild cleansing agent that minimizes irritation and dryness of the skin, avoid friction to skin. Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity. Use moisture barrier product to perineal area . Observation of R #8 on 05/23/17 at 9:50 a.m. revealed R #8 was reclined back in his Geriatric (Geri) chair positioned in front of the A-Unit nurses station. R #8 was restless and uneasy, displaying facial grimacing, as he unsuccessfully attempted to raise and reposition his buttocks off the chair. R #8 continuously yelled out Me duele la cola, Aye Aye Aye Aye (My butt hurts, ouch ouch ouch). Two nurses were observed to sit at the nurse's station, directly across from R #8 but did not address or intervene to assess R #8. At 9:56 a.m., CNA E approached R #8 as R #8 again said Me duele la cola; CNA E told R #8 Okay, we are going to give you a shower. CNA E escorted R #8 into the shower room and began to undress him with the assistance of CNA F. CNA E and CNA F assisted to transfer R #8 to the shower bed and immediately after R #8's buttocks touch the shower bed, he began to yell out Aye Aye Aye, me duele la cola, dios mio (my god). Both CNAs ignored R #8's verbalization of pain and continued to provide R #8 a shower. R #8's inner groin and scrotum were raw and chaffed, beef red in color, and with multiple areas of denuding. As CNA F positioned the shower head toward R #8's genital area, R #8 yelled out Aye, Aye, Aye dios mio as the water fell on his genitals and groin. CNA F lathered a washcloth with soap and cleansed R #8's groin areas and genitals using rough long downward [MEDICAL CONDITION]. R #8 yelled while clinching his eyes shut and said Aye, aye, aye ya no, me dule dios mio (ouch, ouch, ouch, no more, it hurts, my god). CNAs E and F told R #8 they were sorry but they needed to clean him and continued to repeat the process. CNA E and F turned R #8 to his right side and again R #8 yelled out Aye, Aye, Aye. R #8's buttocks, anus, and upper thighs were beef red, chaffed, and had multiple area of denuding. CNA F again lathered a washcloth with soap and water and began to scrub R #8's perineum and buttocks then rinsed them with water. The entire time of cleansing and rinsing, R #8 yelled out loud Aye, Aye, me duele ya, ya, ya, dios mio. Upon drying R #8, CNAs E and F used the towel to wipe, using downward long stokes, R #8's inner groin areas, scrotum, and buttocks; the entire time R #8 was screaming. A 10:21 a.m., CNA F applied Dermaseptin (skin barrier protectant) cream on R #8's reddened, chaffed, denuded areas on his inner groins, scrotum, and buttocks and then applied a clean brief; R #8 yelled throughout the application saying no, no, ya, no (no more). CNA E explained R #8 was going to be dressed and prepared to go to his doctor's appointment scheduled for noon time. Observation of R #8 on 05/23/17 from 11:40 a.m. to 12:00 p.m. revealed R #8 was transferred to the Emergency Medical Service (EMS) stretcher with the assistance of two male paramedics and LVN A. LVN A said R #8 was going to a doctor's appointment and anticipated his return to the facility in approximately three hours. LVN A said she did not check or change R #8's brief prior to him leaving the facility and did not know when his brief was last changed. Interview with CNAs E and F on 05/23/17 at 1:55 p.m. revealed both staff denied checking or changing R #8's brief prior to his departure of the facility for his appointment. Neither CNAs were aware of what time R #8 left for his appointment. CNAs E and F said R #8 required a check, change, and reposition every two hours. CNA F said R #8's brief was due to be checked and changed at approximately 12:30- 12:45 p.m. CNAs E and F stated they did not inform the nurse of R #8's yelling or reddened skin. CNAs E and F said they did not know how long R #8 had his groin and perineum reddened and chaffed. CNAs E and F said R #8's reddened areas appeared to be hurting him upon touched when asked if they thought R #8 was having pain at any time throughout the shower. On 05/23/17 at 3:50 p.m., observation revealed R #8 was taken to his room via stretcher by two EMS employees and transfered back to bed. Surveyor requested CNA R to check R #8 for incontinence. CNA R removed R #8's brief and said, he is soaked. CNA R said she would have to get the assistance of another aide to change R #8's brief. CNA R left the room and returned with CNA S. CNAs R and S removed R #8's urine soaked brief and and placed a clean brief on R #8 without providing incontinent care. On 05/23/17 at 4:05 p.m., interview with CNA R said she and CNA S should have washed the urine off R #8's skin, but CNA R said that CNA S had already starting appling R #8's diaper before she had a chance to provide incontinent care. CNA R said R #8 could develop a rash or skin irritation if he was not provided incontinent care with brief change. Observation of R #8 on 05/24/17 at 10:55 a.m. revealed CNAs F and J were preparing to provide R #8 with incontinent care. R #8 was lying in bed, on his back. CNA F opened R #8's soiled brief and positioned her left hand on R #8's pubic region, lifting his skin taut then with a disposable cleansing wipe, wiped his left inner groin area using a long downward stoke. R #8 began to scream Aye, Aye, Aye Jesus Christ Aye, Aye, Aye, Ya as he tensed his body tight, and shook his pelvic region. CNA F wiped R #8's right inner groin and scrotum and again R #8 began to yell loudly. R #8 was turned to his right side and again CNA F wiped R #8's perineum, anus, and buttocks using long downward [MEDICAL CONDITION] causing R #8 to yell saying Aye, Aye, Aye, ya no. CNA J tells CNA F to call the nurse because He is raw and it's hurting him. CNA F applied Dermaseptin cream on R #8's perineum and buttocks and again, R #8 began to yell. The surveyor asked R #8 three times while he received incontinent care if he was in pain however, R #8 did not provide a verbal response however, he displayed facial grimacing and yelled out symptoms of pain. Interview with LVN A on 05/24/17 at 11:13 a.m. revealed she was not aware of R #8 having any skin issues other than his surgical incisions. LVN A said she had not been informed by any CNAs of R #8 having any altered skin impairments. LVN A said if there were any skin issues then staff would report them to the treatment nurse. LVN A said the CNAs completed a Nursing Assistant Daily Body Observation Form for every resident bather/showered and turned in to her or who ever the charge nurse was. LVN B stated she was responsible for reviewing the forms within her shift. LVN B said she had not seen any form for R #8 that indicated any skin impairments. Interview with LVN B on 05/24/17 at 11:20 a.m. revealed LVN B identified herself as the Treatment Nurse. LVN B said she last assessed R #8 on 05/19/17 after his return from the hospital on [DATE]. LVN B said on 05/19/17, R #8 had redness to his buttocks. LVN B said the reddened area was tender to touch as evidenced by R #8 saying aye' when the area was touched. LVN B stated R #8's reddened areas were not chaffed or denuded at that time and denied redness to his inner groins. LVN B said she had not been informed of R #8's reddened areas worsening. LVN B said she would not know unless she was informed or when she assessed him during his weekly skin assessment. LVN B said any nurse could assess and inform the physician of any skin issues. LVN B said R #8 currently had A & D ointment ordered for his skin irritation to his buttocks. This surveyor informed LVN B of R #8's skin impairment to his perineum and buttocks. The surveyor informed LVN B of observation of staff applying Dermaseptin to R #8's redness; LVN B said They should be using A & D. Upon the surveyor's request, LVN B entered R #8's room and searched the room for A & D ointment. After LVN B looked in R #8's top dresser drawer, there were two tubes of ProCare A & D ointments. LVN B showed the surveyor the tubes and said this is what the physician ordered. During this time CNAs F and J were assisting in repositioning R #8 and when asked by the surveyor if they had used this cream on R #8, both CNAs said No. Both CNAs denied being informed they were to use the A & D ointment on R #8. LVN B explained the A & D ointment was a petroleum based product used as a skin barrier/protectant and the Dermaseptin was not a petroleum based skin protectant. LVN B said I will call the doctor to change the order to Dermaseptin since that's what is being used. *LVN B did not assess R #8's skin at any time prior to calling R #8's physician. R #8's Physician's Telephone Orders dated 05/24/17 documented D/C (discontinue order to apply A & D ointment to scrotum and resident buttocks. N.O. (new order): Apply Dermaseptin Barrier Cream to peri area, scrotum, and buttocks after each incontinent episode. Interview with the Director of Nurses (DON) on 05/24/17 at 11:47 a.m. revealed she was made aware of observations of R #8. The DON said she was not aware of R #8 having any skin impairment. The DON stated the CNAs should have immediately contacted R #8's nurse when they saw his skin red and irritated then gently pat the area for cleaning, instead of wiping or rubbing it, which causes skin irritation and discomfort. The DON stated the facility procedure for monitoring each resident's skin was the CNAs documented any skin impairments observed during showers on the Nursing Assistant Daily Body Observation Form then give the form to the charge nurse for review. The DON stated the Charge Nurse was responsible to review the forms and follow-up on any concerns. The DON said she expected each nurse to conduct a head to toe assessment of their assigned resident at least once per shift. The DON said if the skin concern was a pressure ulcer or a complicated wound then the nurse was to inform the Treatment Nurse. The DON stated CNAs and nurses were responsible for on-going identification and assessment of each resident's pain. The DON said if R #8 was yelling and saying no or stop, then CNAs should have stopped manipulating the area of pain and immediately contacted R #8's nurse. The DON said in R #8's situation, There was a breakdown in communication and the resident suffered and was not getting treatment or appropriate treatment. The DON said staff should have been using the treatment ordered by R #8's physician. The DON said the negative effect of this situation was that R #8 endured pain and could develop behavioral issues due to not wanting a shower because he would relate personal care and showers to pain that could lead to inaccurate [DIAGNOSES REDACTED]. Further interview with the DON on 05/24/17 at 3:26 p.m. revealed the surveyor informed the DON of LVN B receiving a change of treatment order from A & D ointment to the Dermseptin cream. The surveyor again informed the DON of observations of staff already using the Dermaseptin cream and asked the DON how long a treatment was used before a nurse would question the effectiveness of the treatment. The DON stated treatments should be monitored daily and after 4-5 days, if no change or improvement was noted then the nurse was responsible for informing the physician of the status of the treatment. The surveyor accompanied the DON into R #8's room, at the surveyor's request. The DON assessed R #8's perineal and buttocks. The DON stated Oh my, if I had that irritation, I would be screaming in pain too. The DON gently palpated R #8's inner right groin and R #8 yelled saying Aye, Aye, Aye and then moaned loudly. The DON asked R #8 if he had pain but there was no return verbal response from R #8. The DON said R #8 definitely had pain to the reddened areas on his perineum, buttocks, anus, and posterior upper thighs upon touch. The DON asked CNA K, whom was assisting the DON to turn R #8, how long R #8 was reddened. CNA K stated R #8 had been like this since he came in. The DON stated R #8's physician would be called and informed that the treatment he initially ordered had not been carried through since staff had been using the Dermaseptin instead of the A & D ointment and if a change of treatment is recommended since the Dermaseptin had not been effective, as well as the pain R #8 endured upon manipulation to those areas. The DON said R #8 should be assessed for pain daily, every shift. After informed of R #8's pain assessment section on the TAR being blank, the DON said all she could conclude was that the assessments were not done if it was not documented. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/24/17 documented by the DON revealed Incontinence Associated [MEDICAL CONDITION] Goal: Resolve without further skin involvement and resident discomfort. Location: Peri Area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Treatment Change: Dermaseptin Ointment after each incontinent episode. Assess q day. Evaluation Results: Incontinence Associated [MEDICAL CONDITION]. [DIAGNOSES REDACTED] with partial thickness erosions and [MEDICAL CONDITION] with deep pink to purple in color areas: Peri area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Areas are painful to touch, warm to touch with some weepy serous exudate present. The facility's Pain Management Policy and Procedure dated 11/2013 documented It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life,,,The home recognizes that a response to pain is subjective and individual .The home will treat the resident under the premise that pain is present whenever the resident says that it is. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities . 2.) R #1: R #1's undated Face Sheet documented an [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #1's Care Plan dated 03/27/17 documented Pressure Ulcer: I am at risk for skin breakdown related to decreased mobility, diabetes, and incontinence .Approaches: .Keep clean and dry as possible. Provide incontinence care after each incontinent episode. Turn and reposition at least every two hours and PRN . R #1's Quarterly MDS dated [DATE] documented R #1 had no speech, rarely/never made self understood or understood others. R #1 had short and long-term memory problems and had severely impaired daily decision making skills. R #1 was totally dependent on one to two person physical assistance for bed mobility, transfers, dressing, bathing, and personal hygiene. R #1 was always incontinent of bladder and bowel. R #1 was determined at risk for pressure ulcers. Observation of R #1 on 05/23/17 at 10:42 a.m. revealed CNAs G and H were providing R #1 with a bed bath with R #1's Family Member (FM) A at the bedside. At 11:21 a.m., the CNA's positioned R #1 on her right side with pillows between her legs and behind her back. Observation of R #1 on 05/23/17 at 12:00 p.m. revealed R #1 continued to lay on her right side with the pillows positioned in the same areas. R #1's eyes were closed and FM A continued to sit at the bedside. Observation of R #1 on 05/23/17 at 1:54 p.m. revealed R #1 remained in the same position as at 12:00 p.m. FM A remained at the bedside. On 05/23/17 at 2:30 p.m., as the surveyor was approaching R #1's room, FM A was standing at the doorway and asked the surveyor if she had seen any of the staff. FM A said no one had come back to check and turn R #1. Observation of R #1 revealed she remained in the same position as first seen at 11:21 a.m. The surveyor approached CNA I in the hallway and asked if he had repositioned R #1 lately. CNA I said he had just began his shift at 1:00 p.m. and had not seen R #1. CNA I retrieved CNA S from the hallway and both staff entered R #1's room and provided R #1 with incontinent care and repositioning. During the care, FM A began to tell CNA I that R #1 had not been changed or turned since her bath that was before lunch time. CNA I told FM A that R #1 should be changed and repositioned at least every two hours. 3.) R #4: Review of R#4's Admission Record (undated) revealed she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. R#4 was [AGE] years old. Review of R#4's Admission Minimum Data Set ((MDS) dated [DATE] revealed she was admitted from an acute hospital and had moderate difficulty hearing. R#4 had a hearing aid or other appliance for hearing. R#4 usually understood others and was usually understood. R#4's Brief Interview for Mental Status (BIMS) score was 01 points, indicating severe cognitive impairment. R#4 was totally dependent on others for transfer and wheelchair mobility and was not ambulatory. She required total assistance with toileting and extensive assistance with dressing, bathing and personal hygiene. R#4 was always incontinent of bowel and bladder. R#4 had some days of feeling down. R#4 had two Stage two pressure ulcers. A pain assessment was not completed because R#4 was rarely or never understood. Review of R#4's Quarterly MDS dated [DATE] revealed she was assessed as having minimal hearing difficulty and did not use a hearing aid or other hearing appliance. R#4 could usually make herself understood and could usually understand others. R#4's BIMS score was 06, indicating less cognitive impairment than at the time of admission. R#4's functional impairment related to Activities of Daily Living remained the same as at the time of admission. R#4 remained incontinent of bowel and bladder. R#4 had one Stage Two pressure ulcer. The MDS indicated R#4 rarely had pain. Review of R#4's Care Plan with a problem start date of 11/23/16 and update of 05/22/17 revealed: - I will maintain my current communication D/T (due to) HOH (hard of hearing) and wear a hearing aid in my left ear. I prefer Spanish speaking but can understand English. Approaches included making sure R#4's hearing aid was in her left ear while awake. -I have ineffective coping as evidenced by sad, worried facial expressions, loss of interest, withdrawal from activities/interests R/T (related to) early onset Dementia, sadness of being in the nursing home. I do not wish to talk to anyone about my mood. Approaches included giving her choices, giving her support and encouraging expression of feelings, listening carefully and spending time with her. -There was no care plan for pain. Review of Monthly Summary dated 05/04/17 revealed R#4's hearing was highly impaired and she used a hearing aid. Review of R#4's Weekly Skin assessment dated [DATE] revealed she had a skin concern on her left hip area in the back. Review of R#4's Skin Assessment Flow Sheet - Pressure Injury dated 05/19/17 revealed R#4 had a Stage 3 pressure injury. Review of Physician order [REDACTED].#4's coccyx with Normal Saline, pat dry, apply collagen (cut to fit) and cover with Allevyn dressing QD (every day) on Monday, Wednesday and Friday and PRN (as needed) until resolved. Review of Physician order [REDACTED]. There were no other pain medications listed on the Physician order [REDACTED]. On 05/22/17 at 12:10 p.m., while on initial tour, surveyor observed R#4 being pushed down the 200 hall in her wheelchair at a rapid pace. Observation of R#4 revealed she was crying and holding onto the seat of the wheelchair tightly with both hands. Surveyor asked R#4 why she was crying, and R#4 spoke in Spanish and continued to cry. Surveyor understood R#4 to say her stomach and her head hurt, and she was dizzy. Surveyor tried to speak a little louder and drew closer to R#4's ear, asking questions in English and Spanish, but R#4 continued to cry and did not appear to understand surveyor's questions or comments. With the assistance of Licensed Vocational Nurse (LVN) V, who knelt down by R#4 and spoke to her R#4 in a loud voice close to her hear, in Spanish, R#4 said she had fallen a long time ago and had tumors in her head that caused her pain. R#4 said her bottom hurt because she fell flat on her bottom many years ago. LVN V said R#4 had a pressure ulcer on her bottom. LVN V said R#4 did not like to get out of bed and did not like to go into the dining room to eat. Certified Nursing Assistant (CNA) I, who was pushing R#4 down the hall, said he had just gotten R#4 out of bed and she was asleep and did not want to get up. In an observation and interview at 10:50 a.m. on 05/23/17 in R#4's room, CNA I said R#4 was often crying when he got her up out of bed and also started crying when he put her back to bed. R#4 complained that her legs hurt and her whole body hurt. CNA I said R#4 wanted to stay in bed and said she was in pain. CNA I said R#4 was a picky person and had lived by herself out in the country before coming to live at the nursing home a few months ago. Interview at 10:55 a.m. on 05/23/17 with CNA P, who was in R#4's room assisting R#4 with her hair after a shower, said R#4 complained of pain to her ears. When asked if R#4 ever took pain medication, CNA P said R#4 only took aspirin. Surveyor asked R#4 if she would like something for pain; R#4 responded, Si se tienes, (yes if you have). CNA P said she would tell the nurse. Review of R#4's PRN Medications Flowsheet received on 05/23/17 revealed no administration of [MEDICATION NAME] 325 mg during the month of May, 2017. Review of Phy X Progress Notes dated 03/02/17 revealed no new orders. Review of Care Conference Report for R#4 dated 03/03/17 revealed R#4 might need her ears checked for wax and possible [MEDICATION NAME] treatment (ear wax removal) due to decreased hearing. A communication note would be sent to her physician. Review of Medical Fax Referral dated 03/03/17 to Physician (Phy) X revealed May we have an order for [REDACTED]. In an interview at 11:15 a.m. on 05/23/17, LVN O, MDS Nurse, Surveyor asked if the physician had responded. LVN O said Phy X had seen R#4 the same day and had not ordered any new treatments so it appeared Phy X did not see a need for the [MEDICATION NAME] treatment for [REDACTED]. Phone call received from Phy X at 12:15 p.m. on 05/23/17 regarding the order for a [MEDICATION NAME] treatment for [REDACTED].#4 needed the treatment. Phy X said he responded by sending a fax to the nursing facility asking why R#4 needed the [MEDICATION NAME] treatment but he did not receive confirmation that the nursing facility received this fax. Phy X said R#4 did have a hard time hearing and he said there had been no followup on the [MEDICATION NAME] treatment. Observation and Interview with R#4 at 3:20 p.m. on 05/25/17, sitting in her wheelchair in the 200 hall, revealed R#4 had a headache. LVN L spoke to R#4 in Spanish and R#4 said she had a sharp pain in her head but could not identify a number from one to ten. LVN L told the charge nurse on the 200 hall that R#4 was complaining of pain. The charge nurse said R#4 had a new order for [MEDICATION NAME] prn and Acetominophen prn. The charge nurse said R#4 was being given one of each of these medications to help her with pain. Observation and interview of R#4 at 4:10 p.m. on 05/25/17 revealed she was sitting in the common area for residents on her hall. Surveyor asked R#4 if she was feeling better and R#4 responded A little bit. According to the facility's Centers for Medicare and Medicaid Services Form 672 dated 05/22/17, there were 62 residents dependent on staff for bathing, repositioning, and/or incontinent care.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures that prohibit and prevent abuse and neglect for two Residents (R #3 and R #8) of 20 residents who were reviewed for neglect. The facility failed to: --to properly conduct a skin assessment for R#8 when he vocalized pain and discomfort during care and --ensure R#3 physician's orders [REDACTED]. These failures could affect one resident who had orders to receive Vitamin B-12 IM and one resident whose skin assessment was not conducted, placing 29 residents at risk for moderate to severe pain, and neglect. Findings: R #8: R #8's undated Face Sheet documented an [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #8's Admission/Re-Admission Data Summary dated 05/15/17 documented Skin Condition: Superficial irritation to coccyx 10 X 12 centimeters, surgical site to area below left knee 25 centimeters long closed with 31 staples, and surgical site to area below right knee 24 centimeters long closed with 27 staples. Incontinent of bladder and bowel, pads, briefs used. R #8's Weekly Skin assessment dated [DATE] documented See Admission Assessment. R #8's Start-Up Orders dated 05/15/17 documented Cleanse superficial irritation to coccyx with normal saline and 4X4 gauze, apply A & D Ointment q (every) shift and per each incontinent episode. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/15/17 documented by Licensed Vocational Nurse B revealed Skin Risk Score 15- High Risk. Care Plan/Goal: Will resolve without complications. Location: Peri Area and buttocks and scrotum. Description: Rash/redness. R #8's May 2017 Medication Administration Record [REDACTED]. The MAR/TAR documented an assessment of pain on 05/01/17 on each shift and on 05/02/17 only the 6:00 a.m.-2:00 p.m. shift was assessed and documented. There was no documentation providing evidence that R #8's pain was assessed from 05/02/17 beginning at 2:01 p.m. thru 05/26/17. R #8's attached Pain Management Flowsheet dated May 2017 revealed no entries were documented on the form. The facility's A-D Wing Shower Sheets dated 05/16/17, 05/18/17, 05/20/17, 05/23/17 revealed R #8's scheduled shower days were Tuesday, Thursday, and Saturday. The attached Nursing Assistant Daily Body Observation Form dated 05/18/17 revealed Guidelines: Complete during shower or bath for each resident scheduled. Mark on the diagram the location of the skin problem with an X. Check the box indicating the type of problem or write in the space provided. Inform the charge nurse of the skin problem. The charge nurse must sign the form after they review the information. The form should be turned into the DON/designee on a daily basis. If the skin problem appears serious, immediately notify the charge nurse. The form was labeled with R #8's name however, the form was not completed and no reviewer signature was present. The other Shower Sheets and attached Nursing Assistant Daily Body Observation Forms for the rest of the dates above did not include a Nursing Assistant Daily Body Observation Form for R #8. R #8's Weekly Skin assessment dated [DATE] revealed an X on the front lower genital area and the buttocks of the body figure indicating the site of skin impairment however, there was no description of the type of skin impairment. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/19/17 documented by LVN B revealed Noted with redness/rash to peri area and buttocks. R #8's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #8 had unclear speech, rarely/never made self understood, and sometimes understood others. R #8 had short and long-term memory problems and had severely impaired daily decision making skills. R #8 was totally dependent on one to two person physical assistance for bed mobility, transfers, dressing, bathing, and personal hygiene. R #8 was always incontinent of bladder and bowel. R #8's staff assessment for pain indicated non-verbal sounds and facial expressions as indicators of pain observed. R #8 was determined at risk for pressure ulcers with no current pressure ulcers. R #8's skin condition assessment did not indicate any skin problems. R #8's Care Plan dated 05/23/17 documented: -Pain, due to recent surgical procedures (R #8) will require use of [MEDICATION NAME] pain medication .(R #8) will be monitored for effective pain relief as evidenced by no facial grimacing, no vocalization of pain. No yelling out when he is moved . -Due to recent bilateral BKA ([MEDICAL CONDITION]) (R #8) is unable to move about independently and cannot bear weight. (R #8) is unable to move or shift in his bed due to poor cognition and he requires two people to help with any transfer or change in body position He requires one person total assist for bathing due to his poor cognition . -(R #8) has bladder and bowel incontinence related to dementia and decreased sensation .(R #8) will have incontinent care after each incontinent episode (R #8) will have moisture barrier to skin with each incontinence care . -(R #8) has difficulty making self understood related to his advancing dementia .(R #8) will be observed for non-verbal signs of distress: guarding, moaning, restless, grimacing, fidgeting .(R #8's) needs will be anticipated by staff due to his inability to communicate . -I am at risk for pressure ulcer related to decreased mobility, incontinence of bladder and bowel .Avoid sharing my skin during positioning, transferring, and turning. Keep clean and dry as possible. Minimize skin exposure to moisture. Provide incontinent care after each incontinent episode. Avoid hot water and use mild cleansing agent that minimizes irritation and dryness of the skin, avoid friction to skin. Use absorbent, skin-friendly pads/briefs to maintain personal hygiene and dignity. Use moisture barrier product to perineal area . Observation of R #8 on 05/23/17 at 9:50 a.m. revealed R #8 was reclined back in his Geriatric (Geri) chair positioned in front of the A-Unit nurses station. R #8 was restless and uneasy, displaying facial grimacing, as he unsuccessfully attempted to raise and reposition his buttocks off the chair. R #8 continuously yelled out Me duele la cola, Aye Aye Aye Aye (My butt hurts, ouch ouch ouch). Two nurses were observed to sit at the nurse's station, directly across from R #8 but did not address or intervene to assess R #8. At 9:56 a.m., CNA E approached R #8 as R #8 again said Me duele la cola; CNA E told R #8 Okay, we are going to give you a shower. CNA E escorted R #8 into the shower room and began to undress him with the assistance of CNA F. CNA E and CNA F assisted to transfer R #8 to the shower bed and immediately after R #8's buttocks touch the shower bed, he began to yell out Aye Aye Aye, me duele la cola, dios mio (my god). Both CNAs ignored R #8's verbalization of pain and continued to provide R #8 a shower. R #8's inner groin and scrotum were raw and chaffed, beef red in color, and with multiple areas of denuding. As CNA F positioned the shower head toward R #8's genital area, R #8 yelled out Aye, Aye, Aye dios mio as the water fell on his genitals and groin. CNA F lathered a washcloth with soap and cleansed R #8's groin areas and genitals using rough long downward [MEDICAL CONDITION]. R #8 yelled while clinching his eyes shut and said Aye, aye, aye ya no, me dule dios mio (ouch, ouch, ouch, no more, it hurts, my god). CNAs E and F told R #8 they were sorry but they needed to clean him and continued to repeat the process. CNA E and F turned R #8 to his right side and again R #8 yelled out Aye, Aye, Aye. R #8's buttocks, anus, and upper thighs were beef red, chaffed, and had multiple area of denuding. CNA F again lathered a washcloth with soap and water and began to scrub R #8's perineum and buttocks then rinsed them with water. The entire time of cleansing and rinsing, R #8 yelled out loud Aye, Aye, me duele ya, ya, ya, dios mio. Upon drying R #8, CNAs E and F used the towel to wipe, using downward long stokes, R #8's inner groin areas, scrotum, and buttocks; the entire time R #8 was screaming. A 10:21 a.m., CNA F applied Dermaseptin (skin barrier protectant) cream on R #8's reddened, chaffed, denuded areas on his inner groins, scrotum, and buttocks and then applied a clean brief; R #8 yelled throughout the application saying no, no, ya, no (no more). CNA E explained R #8 was going to be dressed and prepared to go to his doctor's appointment scheduled for noon time. Observation of R #8 on 05/23/17 from 11:40 a.m. to 12:00 p.m. revealed R #8 was transferred to the Emergency Medical Service (EMS) stretcher with the assistance of two male paramedics and LVN A. LVN A said R #8 was going to a doctor's appointment and anticipated his return to the facility in approximately three hours. LVN A said she did not check or change R #8's brief prior to him leaving the facility and did not know when his brief was last changed. Interview with CNAs E and F on 05/23/17 at 1:55 p.m. revealed both staff denied checking or changing R #8's brief prior to his departure of the facility for his appointment. Neither CNAs were aware of what time R #8 left for his appointment. CNAs E and F said R #8 required a check, change, and reposition every two hours. CNA F said R #8's brief was due to be checked and changed at approximately 12:30- 12:45 p.m. CNAs E and F stated they did not inform the nurse of R #8's yelling or reddened skin. CNAs E and F said they did not know how long R #8 had his groin and perineum reddened and chaffed. CNAs E and F said R #8's reddened areas appeared to be hurting him upon touched when asked if they thought R #8 was having pain at any time throughout the shower. On 05/23/17 at 3:50 p.m., observation revealed R #8 was taken to his room via stretcher by two EMS employees and transferred back to bed. Surveyor requested CNA R to check R #8 for incontinence. CNA R removed R #8's brief and said, he is soaked. CNA R said she would have to get the assistance of another aide to change R #8's brief. CNA R left the room and returned with CNA S. CNAs R and S removed R #8's urine soaked brief and and placed a clean brief on R #8 without providing incontinent care. On 05/23/17 at 4:05 p.m., interview with CNA R said she and CNA S should have washed the urine off R #8's skin, but CNA R said that CNA S had already starting appling R #8's diaper before she had a chance to provide incontinent care. CNA R said R #8 could develop a rash or skin irritation if he was not provided incontinent care with brief change. Observation of R #8 on 05/24/17 at 10:55 a.m. revealed CNAs F and J were preparing to provide R #8 with incontinent care. R #8 was lying in bed, on his back. CNA F opened R #8's soiled brief and positioned her left hand on R #8's pubic region, lifting his skin taut then with a disposable cleansing wipe, wiped his left inner groin area using a long downward stoke. R #8 began to scream Aye, Aye, Aye Jesus Christ Aye, Aye, Aye, Ya as he tensed his body tight, and shook his pelvic region. CNA F wiped R #8's right inner groin and scrotum and again R #8 began to yell loudly. R #8 was turned to his right side and again CNA F wiped R #8's perineum, anus, and buttocks using long downward [MEDICAL CONDITION] causing R #8 to yell saying Aye, Aye, Aye, ya no. CNA J tells CNA F to call the nurse because He is raw and it's hurting him. CNA F applied Dermaseptin cream on R #8's perineum and buttocks and again, R #8 began to yell. The surveyor asked R #8 three times while he received incontinent care if he was in pain however, R #8 did not provide a verbal response however, he displayed facial grimacing and yelled out symptoms of pain. Interview with LVN A on 05/24/17 at 11:13 a.m. revealed she was not aware of R #8 having any skin issues other than his surgical incisions. LVN A said she had not been informed by any CNAs of R #8 having any altered skin impairments. LVN A said if there were any skin issues then staff would report them to the treatment nurse. LVN A said the CNAs completed a Nursing Assistant Daily Body Observation Form for every resident bather/showered and turned in to her or who ever the charge nurse was. LVN B stated she was responsible for reviewing the forms within her shift. LVN B said she had not seen any form for R #8 that indicated any skin impairments. Interview with LVN B on 05/24/17 at 11:20 a.m. revealed LVN B identified herself as the Treatment Nurse. LVN B said she last assessed R #8 on 05/19/17 after his return from the hospital on [DATE]. LVN B said on 05/19/17, R #8 had redness to his buttocks. LVN B said the reddened area was tender to touch as evidenced by R #8 saying aye' when the area was touched. LVN B stated R #8's reddened areas were not chaffed or denuded at that time and denied redness to his inner groins. LVN B said she had not been informed of R #8's reddened areas worsening. LVN B said she would not know unless she was informed or when she assessed him during his weekly skin assessment. LVN B said any nurse could assess and inform the physician of any skin issues. LVN B said R #8 currently had A & D ointment ordered for his skin irritation to his buttocks. This surveyor informed LVN B of R #8's skin impairment to his perineum and buttocks. The surveyor informed LVN B of observation of staff applying Dermaseptin to R #8's redness; LVN B said They should be using A & D. Upon the surveyor's request, LVN B entered R #8's room and searched the room for A & D ointment. After LVN B looked in R #8's top dresser drawer, there were two tubes of ProCare A & D ointments. LVN B showed the surveyor the tubes and said this is what the physician ordered. During this time CNAs F and J were assisting in repositioning R #8 and when asked by the surveyor if they had used this cream on R #8, both CNAs said No. Both CNAs denied being informed they were to use the A & D ointment on R #8. LVN B explained the A & D ointment was a petroleum based product used as a skin barrier/protectant and the Dermaseptin was not a petroleum based skin protectant. LVN B said I will call the doctor to change the order to Dermaseptin since that's what is being used. *LVN B did not assess R #8's skin at any time prior to calling R #8's physician. R #8's Physician's Telephone Orders dated 05/24/17 documented D/C (discontinue order to apply A & D ointment to scrotum and resident buttocks. N.O. (new order): Apply Dermaseptin Barrier Cream to peri area, scrotum, and buttocks after each incontinent episode. Interview with the Director of Nurses (DON) on 05/24/17 at 11:47 a.m. revealed she was made aware of observations of R #8. The DON said she was not aware of R #8 having any skin impairment. The DON stated the CNAs should have immediately contacted R #8's nurse when they saw his skin red and irritated then gently pat the area for cleaning, instead of wiping or rubbing it, which causes skin irritation and discomfort. The DON stated the facility procedure for monitoring each resident's skin was the CNAs documented any skin impairments observed during showers on the Nursing Assistant Daily Body Observation Form then give the form to the charge nurse for review. The DON stated the Charge Nurse was responsible to review the forms and follow-up on any concerns. The DON said she expected each nurse to conduct a head to toe assessment of their assigned resident at least once her shift. The DON said if the skin concern was a pressure ulcer or a complicated wound then the nurse was to inform the Treatment Nurse. The DON stated CNAs and nurses were responsible for on-going identification and assessment of each resident's pain. The DON said if R #8 was yelling and saying no or stop, then CNAs should have stopped manipulating the area of pain and immediately contacted R #8's nurse. The DON said in R #8's situation, There was a breakdown in communication and the resident suffered and was not getting treatment or appropriate treatment. The DON said staff should have been using the treatment ordered by R #8's physician. The DON said the negative effect of this situation was that R #8 endured pain and could develop behavioral issues due to not wanting a shower because he would relate personal care and showers to pain that could lead to inaccurate [DIAGNOSES REDACTED]. Further interview with the DON on 05/24/17 at 3:26 p.m. revealed the surveyor informed the DON of LVN B receiving a change of treatment order from A & D ointment to the Dermseptin cream. The surveyor again informed the DON of observations of staff already using the Dermaseptin cream and asked the DON how long a treatment was used before a nurse would question the effectiveness of the treatment. The DON stated treatments should be monitored daily and after 4-5 days, if no change or improvement was noted then the nurse was responsible for informing the physician of the status of the treatment. The surveyor accompanied the DON into R #8's room, at the surveyor's request. The DON assessed R #8's perineal and buttocks. The DON stated Oh my, if I had that irritation, I would be screaming in pain too. The DON gently palpated R #8's inner right groin and R #8 yelled saying Aye, Aye, Aye and then moaned loudly. The DON asked R #8 if he had pain but there was no return verbal response from R #8. The DON said R #8 definitely had pain to the reddened areas on his perineum, buttocks, anus, and posterior upper thighs upon touch. The DON asked CNA K, whom was assisting the DON to turn R #8, how long R #8 was reddened. CNA K stated R #8 had been like this since he came in. The DON stated R #8's physician would be called and informed that the treatment he initially ordered had not been carried through since staff had been using the Dermaseptin instead of the A & D ointment and if a change of treatment is recommended since the Dermaseptin had not been effective, as well as the pain R #8 endured upon manipulation to those areas. The DON said R #8 should be assessed for pain daily, every shift. After informed of R #8's pain assessment section on the TAR being blank, the DON said all she could conclude was that the assessments were not done if it was not documented. R #8's Skin Assessment Flow Sheet-Non-Pressure Injury Conditions dated 05/24/17 documented by the DON revealed Incontinence Associated [MEDICAL CONDITION] Goal: Resolve without further skin involvement and resident discomfort. Location: Peri Area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Treatment Change: Dermaseptin Ointment after each incontinent episode. Assess q day. Evaluation Results: Incontinence Associated [MEDICAL CONDITION]. [DIAGNOSES REDACTED] with partial thickness erosions and [MEDICAL CONDITION] with deep pink to purple in color areas: Peri area, bilateral groin areas, bilateral buttocks, coccyx area, anal area, and upper inner thighs. Areas are painful to touch, warm to touch with some weepy serous exudate present. The facility's Pain Management Policy and Procedure dated 11/2013 documented It is the policyof this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life,,,The home recognizes that a response to pain is subjective and individual .The home will treat the resident under the premise that pain is present whenever the resident says that it is. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities . R#3 Review of R#3's Face Sheet undated revealed R#3 was a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE]. R#3 had [DIAGNOSES REDACTED]. Review of R#3's Physician Telephone Order dated 03/06/17 revealed an order for [REDACTED]. Review of R#3's March 2017 Medication Administration Review (MAR) revealed an order for [REDACTED]. Further review revealed R#3 was administered Vitamin B-12 1000 mg on 03/07/17, 03/14/17, and 03/21/17. Review of R#3's Physician Telephone Order dated 03/26/17 revealed an order for [REDACTED]. Review of R#3's Physician Telephone Order dated 04/08/17 revealed R#3 was readmitted to the facility. Review of R#3's Start Up Orders dated 04/08/17 revealed R#3 had a Physician order [REDACTED].#3 received a Vitamin B-12 IM on 04/17/17 and 04/24/17. Review of R #3's laboratory results dated [DATE] R #3's Hemoglobin was 11.6 (low) and Hematocrit was 33.0 (low) and MCV was 87 (Range: 80-97) Review of R#3's May 2017 MAR indicated [REDACTED]. During an interview on 05/23/17 at 4:01 p.m. the Director of Nurses (DON) reviewed R#3's April 2017 Start Up orders and May 2017 MARs for R#3 to receive Vitamin B-12 IM once a week. The DON stated R#3 received a Vitamin B-12 IM on 04/17/17 and 04/24/17. The DON reviewed R#3's May 2017 MARs, and further stated the order was not transcribed into the May 2017 MARS. The DON stated according to the Physician order [REDACTED].#3 should have received Vitamin B-12 IM weekly and had missed 4 doses of Vitamin B-12 IMs. The DON stated she did not know why R#3 had missed the Vitamin B-12 IM as the Assistant DON (ADON) transcribed all the new orders and the DON did not know why the new order was not listed in R#3's May MARs. The DON stated this was a medication error. During an interview on 05/23/17 at 4:40 p.m. accompanied with the DON and LVN M, LVN M opened the medication cart and we observed two sealed individual Vitamin B-12 vials ordered for R#3 as of 04/09/17. LVN M reviewed R#3's May 2017 MARs that was kept on the medication cart for administering of medications and stated R#3 did not have an order for [REDACTED]. Review of R#3's Physician Telephone Order dated 05/23/17 revealed a clarification order for B-12 1000 mg IM Q month (every 24th). During an interview on 05/24/17 at 9:47 a.m. the ADON stated she got clarification orders yesterday (05/23/17) after surveyor had spoken to the DON. The ADON stated R#3's order for B-12 IM was changed to once a month on the 24th. The ADON stated she was responsible for transcribing all Physician order [REDACTED].#3's May 2017 MARs. The ADON stated she thought she had overlooked R#3's B-12 IM physician order. During a telephone interview on 05/25/17 at 11:00 a.m. R#3's Physician stated R#3 was a new patient and had an order to receive B-12 IM injections. R#3's Physician stated the facility had not informed her and therefore was unaware that R#3 had missed 4 doses of B-12 IM as ordered upon R#3's readmission on 04/08/17. R#3's Physician was asked what adverse effects could R#3 have if R#3 did not receive B-12 as ordered, R#3's Physician stated she could become Anemic. R#3's Physician stated R#3 now had a new order dated 05/23/17, for B 12 IM to be administered 1 X month on the 24th. During an interview on 05/25/17 at 12:00 p.m. the ADON stated she could not explain why R#3's Physician order [REDACTED]. The ADON stated she thought she overlooked R#3's B-12 order. The ADON was asked what adverse effect could R#3 have if not following a physician order [REDACTED].#3's Dx of [MEDICAL CONDITIONS] meant but was unable to explain what it was. The ADON stated she did not give medications. The ADON stated she forgot what [MEDICAL CONDITIONS] was and thought it would cause weakness, loss of appetite, and thought it may decrease the blood cell count. During an interview on 05/26/17 at 10:37 a.m., the Corporate Registered Nurse (CRN) stated R#3 did not have a Dx of [MEDICAL CONDITIONS] as indicated on R#3's Physician Telephone order (TO) dated 03/06/17. The CRN further stated the writing on the TO had two different hand writings and she did not know who had written in R#3's Dx of [MEDICAL CONDITIONS]. CRN further stated that a nurse could not diagnose a resident and again stated R#3 did not have a Dx of [MEDICAL CONDITIONS]. The CRN stated R#3 had an order for [REDACTED].#3 received two B-12 IM prior to her hospitalization and two more after her return. The CRN stated the new orders superseded the old orders and the new Orders did not indicate R#3 had a Dx of [MEDICAL CONDITIONS]. R#3's readmission orders [REDACTED]. The CRN was informed R#3 had missed 4, B-12 IM's in May 2017 as the order was not transcribed to reflect on R#3's May 2017 MARs. The CRN stated she was aware the facility had a system failure but did not agree that R#3 had a Dx of [MEDICAL CONDITIONS]. During an interview on 05/26/17 at 11:52 a.m. LVN L stated she was the person responsible for writing in R#3's Dx of [MEDICAL CONDITIONS]. LVN L stated she clarified the Telephone order dated 03/06/17 with the DON because the telephone order did not have a Dx for the B-12 order and she was trained that each order must have a Dx. LVN L stated the DON was in agreement that R#3's B-12 IM order was for Dx of [MEDICAL CONDITIONS]. Review of the facility's Policy and Procedure on Abuse-Reportable Events, effective date 02/2008, revised date 05/2014. Policy: It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or my be adversely affected by abuse or neglect caused by another person. Definitions: Abuse: Any act, failure to act, or incitement to act done willfully, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. This includes financial, verbal, sexual, mental/psychological, or physical abuse, including corporal punishment, involuntary seclusion, or any other actions within this definition. Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. According to NIH https://www.nhlbi.nih.gov/health/health-topics/topics/[MEDICAL CONDITION]/signs referenced on 06/08/17 revealed A lack of vitamin B12 (vitamin B12 deficiency) causes the signs and symptoms of [MEDICAL CONDITIONS]. Without enough vitamin B12, your body can't make enough healthy red blood cells, which causes [MEDICAL CONDITION]. Some of the signs and symptoms of [MEDICAL CONDITIONS] apply to all types of [MEDICAL CONDITION]. Other signs and symptoms are specific to a lack of vitamin B12. Signs and Symptoms of [MEDICAL CONDITION] The most common symptom of all types of [MEDICAL CONDITION] is fatigue (tiredness). Fatigue occurs because your body doesn ' t have enough red blood cells to carry oxygen to its various parts. A low red blood cell count also can cause shortness of breath, dizziness, headache, coldness in your hands and feet, pale or yellowish skin, and chest pain. A lack of red blood cells also means that your heart has to work harder to move oxygen-rich blood through your body. This can lead to irregular heartbeats called arrhythmias (ah-RITH-me-ahs), heart murmur, an enlarged heart, or even heart failure. Signs and Symptoms of Vitamin B12 Deficiency Vitamin B12 deficiency may lead to nerve damage. This can cause tingling and numbness in your hands and feet, muscle weakness, and loss of reflexes. You also may feel unsteady, lose your balance, and have trouble walking. Vitamin B12 deficiency can cause weakened bones and may lead to [MEDICAL CONDITION]. Severe vitamin B12 deficiency can cause neurological problems, such as confusion, dementia, depression, and memory loss. Other symptoms of vitamin B12 deficiency involve the digestive tract. These symptoms include nausea (feeling sick to your stomach) and vomiting, heartburn, abdominal bloating and gas, constipation or diarrhea, loss of appetite, and weight loss. An enlarged liver is another symptom . Complete Blood Count Often, the first test used to diagnose many types of [MEDICAL CONDITION] is a complete blood count (CBC). This test measures many parts of your blood. For this test, a small amount of blood is drawn from a vein (usually in your arm) using a needle. A CBC checks your hemoglobin (HEE-muh-glow-bin) and hematocrit (hee-MAT-oh-crit) levels. Hemoglobin is an iron-rich protein that helps red blood cells carry oxygen from the lungs to the rest of the body. Hematocrit is a measure of how much space red blood cells take up in your blood. A low level of hemoglobin or hematocrit is a sign of [MEDICAL CONDITION]. The normal range of these levels may be lower in certain racial and ethnic populations. Your doctor can explain your test results to you. The CBC also checks the number of red blood cells, white blood cells, and platelets (PLATE-lets) in your blood. Abnormal results may be a sign of [MEDICAL CONDITION], another blood disorder, an infection, or another condition. Finally, the CBC looks at mean corpuscular (kor-PUS-kyu-lar) volume (MCV). MCV is a measure of the average size of your red blood cells. MCV can be a clue as to what's causing your [MEDICAL CONDITION]. In [MEDICAL CONDITIONS], the red blood cells tend to be larger than normal. Specific Types of Treatment . [MEDICAL CONDITIONS] usually is easy to treat with vitamin B12 shots or pills. If you have severe [MEDICAL CONDITIONS], your doctor may recommend shots first. Shots usually are given in a muscle every day or every week until the level of vitamin B12 in your blood increases. After your vitamin B12 blood level returns to normal, you may get a shot only once a month. For less severe [MEDICAL CONDITIONS], your doctor may recommend large doses of vitamin B12 pills. A vitamin B12 nose gel and spray also are available. These products may be useful for people who have trouble swallowing pills, such as older people who have had [MEDICAL CONDITION]. Your signs and symptoms may begin to improve within a few days after you start treatment. Your doctor may advise you to limit your physical activity until your condition improves. If your [MEDICAL CONDITIONS] is caused by something other than a lack of [MEDICATION NAME] factor, you may get treatment for [REDACTED]. For example, your doctor may prescribe medicines to treat a condition that prevents your body from absorbing vitamin B12. Based on the sample residents reviewed, there was one resident who received B-12 IM. <b

Based on interview and record review, the facility failed to follow written policy and procedures to ensure each resident was free from neglect, for one Residents (R#3) of seven residents reviewed for Abuse and Neglect. The facility did not provide R #3 with her scheduled [MEDICATION NAME] for six days resulting in withdrawal signs and symptoms and mental distress. This failure could affect 31 residents who were prescribed benzodiazepines in the facility by placing them at risk mental and physical distress. The findings were: According to: https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s052lbl.pdf Referenced on [DATE] at 4:31 p.m. revealed; Abuse and dependence. Taking [MEDICATION NAME] can cause physical and psychological dependence. Physical and psychological dependence is not the same as drug addiction. Your healthcare provider can tell you more about the differences between physical and psychological dependence and drug addiction. Withdrawal symptoms. You may have withdrawal symptoms if you stop taking [MEDICATION NAME] suddenly. Withdrawal symptoms can be serious and include [MEDICAL CONDITION]. Mild withdrawal symptoms include a depressed mood and trouble sleeping. Talk to your healthcare provider about slowly stopping [MEDICATION NAME] to avoid withdrawal symptoms. [MEDICAL CONDITION]. Stopping [MEDICATION NAME] can cause [MEDICAL CONDITION] and [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]). Mania. [MEDICATION NAME] may cause an increase in activity and talking (hypomania and mania) in people who have depression. The most common side effects of [MEDICATION NAME] include drowsiness and light-headedness. These are not all the possible side effects of [MEDICATION NAME]. Call your doctor for medical advice about side effects . Dose Reduction Because of the danger of withdrawal, abrupt discontinuation of treatment should be avoided (see WARNINGS, PRECAUTIONS, DRUG ABUSE AND DEPENDENCE). In all patients, dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage. Although there are no systematically collected data to support a specific discontinuation schedule, it is suggested that the daily dosage be decreased by no more than 0.5 mg every three days. Some patients may require an even slower dosage red DRUG ABUSE AND DEPENDENCE . .Physical and Psychological Dependence Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazepines, including [MEDICATION NAME]. The symptoms can range from mild dysphoria and [MEDICAL CONDITION] to a major syndrome that may include abdominal and muscle cramps, vomiting, sweating, tremors and convulsions. Distinguishing between withdrawal emergent signs and symptoms and the recurrence of illness is often difficult in patients undergoing dose reduction. The long term strategy for treatment of [REDACTED]. When necessary, immediate management of withdrawal symptoms requires re-institution of treatment at doses of [MEDICATION NAME] sufficient to suppress symptoms. There have been reports of failure of other benzodiazepines to fully suppress these withdrawal symptoms . Facility Policy and Procedure dated ,[DATE] titled Abuse-Reportable Events revealed, It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Definitions .NEGLECT: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Review of facility Job Description for Charge Nurse LVN signed and dated [DATE] revealed, Essential Functions: .Observes, assesses and reports condition/changes, and documentation .Receives, transcribes, and executes physicians' orders .Administers medications as prescribed .Contributes to the assurance of resident care consistent with acceptable standards of care and established policy and procedure . Review of facility policy and procedure dated ,[DATE] titled Ordering and Receiving Controlled Medications .3. The pharmacy or nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled medication prescribed for a resident as applicable per state law. This log is placed in the MAR or narcotic book to be counted every shift .4 .In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order. If unable to obtain another written prescription and provide the medication prior to the depletion of the current supply, the pharmacy will notify the nursing care center immediately. 5 Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand . R#3's Face Sheet revealed R #3 was a [AGE] year old female admitted to the facility [DATE] with the following Diagnosis: [REDACTED]. R #3's Discharge MDS dated [DATE] revealed R #3's assessment for BIMS and Mood was blank. R #3 was totally dependent with bed mobility and transfers eating and personal hygiene care. R #3 was always incontinent of bowel and bladder. R #3's cognitive skills for daily decision making were severely impaired. R #3's Care Plan (last reviewed/revised) [DATE] revealed PROBLEM I receive antianxiety medication R/T anxiety AEB (as exhibited by) crying episodes. [MEDICATION NAME] per order .GOAL I will be prescribed the lowest effective dose of medication and still have my mood managed over the next review period .APPROACH Assess my functional status prior to initiation of drug use to serve as a baseline .Monitor my functional status every shift. Monitor my mood and response to medication .Quantitatively and objectively document my behavior/mood. R #3's Physician Start Up Orders dated [DATE] revealed [MEDICATION NAME] 0.25 mg 1 PO QD DX: Anxiety ([MEDICATION NAME] (benzodiazapines) is an antianxiety medication) R #3's Consolidated Physician order [REDACTED]. once a day and [MEDICATION NAME] 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on [DATE] on Physicians plan to control R #3's anxiety there was a written note [MEDICATION NAME] 0.25 PO Daily R #3's Medication Flowsheet dated [DATE] -[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On the back of the Medication Flowsheet there was a noted for the following dates [DATE], [DATE], [DATE], [DATE] stating [MEDICATION NAME] was not given due to medication not in house. R #3's Treatment Flowsheet dated [DATE]-[DATE] revealed on the Anti-Anxiety Use it was documented from [DATE] through [DATE] that R #3 had no behaviors related to anti-anxiety medication use on all three shifts. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 7:00 p.m., Resident did not have [MEDICATION NAME] 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . XXX[DATE] 11:00 p.m. MD office was faxed & informed that Pt did not have [MEDICATION NAME] in the facility. Morning staff will follow up in AM . XXX[DATE] 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. [MEDICATION NAME] 0.25 mg PO given . XXX[DATE] 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 3:15 p.m. resident was wheezing and a nebulizer treatment was administered wheezing or breathing did not change after breathing treatment was administered. R #3's Physician was notified and R #3 was sent out to the hospital. Review of R #3's PRN Medications Flowsheet dated [DATE], R #3's Oxygen Saturation levels before respiratory treatment was 84% and after the the respiratory treatment R #3's O2 Saturation was 92% Review of R #3's hospital admission History and Physical dated [DATE] revealed This is a [AGE] year old female. She has a past history of Alzheimer's dementia. She has had elevated troponin and [MEDICAL CONDITION]. Because she was struggling to breathe, family decided on comfort measures only for which she was admitted to hospice .Impression: 1.[MEDICAL CONDITION] 2. Elevated cardiac enzymes . On [DATE] at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on [DATE] she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her [MEDICATION NAME] and LVN P said he would check. LVN P said R #3 had not received any [MEDICATION NAME] in ,[DATE] days because R #3 did not have any [MEDICATION NAME] left. FM X said R #3 had received [MEDICATION NAME] every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 [MEDICATION NAME]. On [DATE] at 4:20 p.m., Surveyor called R #3's Physician and left a message for Physician to return my call. The Physician did not return call during this investigation. On [DATE] at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her [MEDICATION NAME] and he took a [MEDICATION NAME] from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no [MEDICATION NAME] in stock and R #3 was completely out of her [MEDICATION NAME] for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her [MEDICATION NAME]. LVN P said he was written up for taking the [MEDICATION NAME] from another resident but he said he would rather take the write up than see a resident suffer. On [DATE] at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of [DATE] and told the DON that he had taken another resident's [MEDICATION NAME] to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. The DON said LVN P should have called Pham-America to deliver the medicine or call the local Pharmacy to have them deliver the [MEDICATION NAME]. The DON said [MEDICATION NAME] cannot be abruptly stopped because it could cause respiratory arrest and death. Surveyor showed the DON R #3's Treatment Flowsheet dated [DATE]-[DATE] which showed no behaviors related to anti-anxiety medication use on all three shifts. The DON said the assessments looked like a cookie cutter Monkey see Monkey do and said she doubted the assessments were accurate due to the fact R #3 did not receive [MEDICATION NAME] for over five days. DON said, she doubted the assessments were accurate. On [DATE] at 5:15 p.m., interview with the Administrator said she did not report misappropriation of medications because she did not think of misappropriation as taking from one resident's medication supply and giving to another resident. The Administrator said the staff were in-serviced by the DON on Abuse, Neglect and re-ordering medications. On [DATE] at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the [MEDICATION NAME] for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the [MEDICATION NAME] was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On [DATE] at 1:25 p.m., interview with LVN B (Charge Nurse for the 6:00 a.m.-2:00 p.m. shift) said she does not recall anyone asking her to re-order [MEDICATION NAME] for R #3. LVN B said it was the responsibility of every nurse in the facility to re-order medications when a resident's medications run low. LVN B said she was unaware R #3 did not have any scheduled [MEDICATION NAME] left because R #3 received her routine [MEDICATION NAME] in the evening. LVN B said if a resident ran out of a medicine controlled or not, the nurse can always call the Physician for a refill or sometimes they could use the local Pharmacy if there was no [MEDICATION NAME] in the Emergency Kit. LVN B said if a resident has been taking a benzodiazepines for an extended period of time, and abruptly stops taking the medication, the resident could have a [MEDICAL CONDITION], it could be deadly. On [DATE] at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in ,[DATE] she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have [MEDICATION NAME] available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled [MEDICATION NAME] over a course of ,[DATE] days. Surveyor asked LVN A if she should know the indications of use and adverse effects of [MEDICATION NAME] and LVN A said, yes. LVN A said she documented on the back of R #3's MAR that R #3 did not have [MEDICATION NAME] in house. LVN A said she documented on the 24 hour report that R #3 was out of [MEDICATION NAME] because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the [MEDICATION NAME]. LVN A said she did not call the Physician or the DON because she did not want to bother them. Review of In-Service Training Report dated [DATE] revealed Subject: .2) How to do initial ordering and re-ordering of medications . 4.) Documentation on MAR and in chart if medication not given. 5.) Do not borrow medications from other residents .7.) Use approved progress notes .8.) Use Progress Note NOT NSG. Progress Note .9) Night shift to do all monthly orders .How to Order, reorder and recieve non-narcotics and narcotics from the pharmacy. According to the facility Physician order [REDACTED].

Based on record review, and interview the facility failed to ensure services provided were provided by qualified persons in accordance with each resident's written plan of care and physicians orders for one Resident (R #3) of seven residents reviewed for quality of care. -The facility did not follow R #3's written plan of care and receive [MEDICATION NAME] as ordered by physician. -The facility did not follow the physician order [REDACTED]. This failure could place the 31 residents prescribed antianxiety/benzodiazepines at risk for mental and physical decompensation. The findings included: R#3's Face Sheet revealed R #3 was a [AGE] year old female admitted to the facility [DATE] with the following Diagnosis: [REDACTED]. R #3's Discharge MDS dated [DATE] revealed R #3's assessment for BIMS and Mood was blank. R #3 was totally dependent with bed mobility and transfers eating and personal hygiene care. R #3 was always incontinent of bowel and bladder. R #3's cognitive skills for daily decision making were severely impaired. R #3's Care Plan (last reviewed/revised) [DATE] revealed PROBLEM I receive antianxiety medication R/T anxiety AEB crying episodes. [MEDICATION NAME] per order .GOAL I will be prescribed the lowest effective dose of medication and still have my mood managed over the next review period .APPROACH Assess my functional status prior to initiation of drug use to serve as a baseline .Monitor my functional status every shift. Monitor my mood and response to medication .Quantitatively and objectively document my behavior/mood. R #3's Physician Start Up Orders dated [DATE] revealed [MEDICATION NAME] 0.25 mg 1 PO QD DX: Anxiety ([MEDICATION NAME] (benzodiazepine) is an antianxiety medication) R #3's Consolidated Physician Oder Report dated [DATE]-[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day and [MEDICATION NAME] 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on [DATE] on Physicians plan to control R #3's anxiety there was a written note [MEDICATION NAME] 0.25 PO Daily R #3's Medication Flowsheet dated [DATE] -[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On the back of the Medication Flowsheet there was a noted for the following dates [DATE], [DATE], [DATE], [DATE] stating [MEDICATION NAME] was not given due to medication not in house. R #3's Treatment Flowsheet dated [DATE]-[DATE] revealed on the Anti-Anxiety Use it was documented from [DATE] through [DATE] that R #3 had no behaviors related to anti-anxiety medication use on all three shifts. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 7:00 p.m., Resident did not have [MEDICATION NAME] 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . XXX[DATE] 11:00 p.m. MD office was faxed & informed that Pt did not have [MEDICATION NAME] in the facility. Morning staff will follow up in AM . XXX[DATE] 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. [MEDICATION NAME] 0.25 mg PO given . XXX[DATE] 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . On [DATE] at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on [DATE] she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her [MEDICATION NAME] and LVN P said he would check. LVN P said R #3 had not received any [MEDICATION NAME] in ,[DATE] days because R #3 did not have any [MEDICATION NAME] left. FM X said R #3 had received [MEDICATION NAME] every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 [MEDICATION NAME]. On [DATE] at 4:20 p.m., Surveyor called R #3's Physician and left a message for Physician to return my call. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 3:15 p.m. resident was wheezing and a nebulizer treatment was administered wheezing or breathing did not change after breathing treatment was administered. R #3's Physician was notified and R #3 was sent out to the hospital. Review of R #3's PRN Medications Flowsheet dated [DATE], R #3's Oxygen Saturation levels before respiratory treatment was 84% and after the the respiratory treatment R #3's O2 Saturation was 92% Review of R #3's hospital admission History and Physical dated [DATE] revealed This is a [AGE] year old female. She has a past history of Alzheimer's dementia. She has had elevated troponin and [MEDICAL CONDITION]. Because she was struggling to breathe, family decided on comfort measures only for which she was admitted to hospice .Impression: 1.[MEDICAL CONDITION] 2. Elevated cardiac enzymes . On [DATE] at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her [MEDICATION NAME] and he took a [MEDICATION NAME] from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no [MEDICATION NAME] in stock and R #3 was completely out of her [MEDICATION NAME] for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her [MEDICATION NAME]. LVN P said he was written up for taking the [MEDICATION NAME] from another resident but he said he would rather take the write up than see a resident suffer. On [DATE] at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of [DATE] and told the DON that he had taken another resident's [MEDICATION NAME] to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. The DON said LVN P should have called Pham-America to deliver the medicine or call the local Pharmacy to have them deliver the [MEDICATION NAME]. The DON said [MEDICATION NAME] cannot be abruptly stopped because it could cause respiratory arrest and death. Surveyor showed the DON R #3's Treatment Flowsheet dated [DATE]-[DATE] which showed no behaviors related to anti-anxiety medication use on all three shifts. The DON said the assessments looked like a cookie cutter Monkey see Monkey do and said she doubted the assessments were accurate due to the fact R #3 did not receive [MEDICATION NAME] for over five days. On [DATE] at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the [MEDICATION NAME] for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the [MEDICATION NAME] was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On [DATE] at 1:25 p.m., interview with LVN B (Charge Nurse for the 6:00 a.m.-2:00 p.m. shift) said she does not recall anyone asking her to re-order [MEDICATION NAME] for R #3. LVN B said it was the responsibility of every nurse in the facility to re-order medications when a resident's medications run low. LVN B said she was unaware R #3 did not have any scheduled [MEDICATION NAME] left because R #3 received her routine [MEDICATION NAME] in the evening. LVN B said if a resident ran out of a medicine controlled or not, the nurse can always call the Physician for a refill or sometimes they could use the local Pharmacy if there was no [MEDICATION NAME] in the Emergency Kit. LVN B said if a resident has been taking a benzodiazepine for an extended period of time, and abruptly stops taking the medication, the resident could have a [MEDICAL CONDITION], it could be deadly. On [DATE] at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in ,[DATE] she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have [MEDICATION NAME] available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled [MEDICATION NAME] over a course of ,[DATE] days. Surveyor asked LVN A if she should know the indications of use and adverse effects of [MEDICATION NAME] and LVN A said, yes. LVN A said she documented on the back of R #3's MAR that R #3 did not have [MEDICATION NAME] in house. LVN A said she documented on the 24 hour report that R #3 was out of [MEDICATION NAME] because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the [MEDICATION NAME]. LVN A said she did not call the Physician or the DON because she did not want to bother them. According to: https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s052lbl.pdf Referenced on [DATE] at 4:31 p.m. revealed; Abuse and dependence. Taking [MEDICATION NAME] can cause physical and psychological dependence. Physical and psychological dependence is not the same as drug addiction. Your healthcare provider can tell you more about the differences between physical and psychological dependence and drug addiction. Withdrawal symptoms. You may have withdrawal symptoms if you stop taking [MEDICATION NAME] suddenly. Withdrawal symptoms can be serious and include [MEDICAL CONDITION]. Mild withdrawal symptoms include a depressed mood and trouble sleeping. Talk to your healthcare provider about slowly stopping [MEDICATION NAME] to avoid withdrawal symptoms. [MEDICAL CONDITION]. Stopping [MEDICATION NAME] can cause [MEDICAL CONDITION] and [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]). Mania. [MEDICATION NAME] may cause an increase in activity and talking (hypomania and mania) in people who have depression. The most common side effects of [MEDICATION NAME] include drowsiness and light-headedness. These are not all the possible side effects of [MEDICATION NAME]. Call your doctor for medical advice about side effects . Dose Reduction Because of the danger of withdrawal, abrupt discontinuation of treatment should be avoided (see WARNINGS, PRECAUTIONS, DRUG ABUSE AND DEPENDENCE). In all patients, dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage. Although there are no systematically collected data to support a specific discontinuation schedule, it is suggested that the daily dosage be decreased by no more than 0.5 mg every three days. Some patients may require an even slower dosage red DRUG ABUSE AND DEPENDENCE . .Physical and Psychological Dependence Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazapines, including [MEDICATION NAME]. The symptoms can range from mild dysphoria and [MEDICAL CONDITION] to a major syndrome that may include abdominal and muscle cramps, vomiting, sweating, tremors and convulsions. Distinguishing between withdrawal emergent signs and symptoms and the recurrence of illness is often difficult in patients undergoing dose reduction. The long term strategy for treatment of [REDACTED]. When necessary, immediate management of withdrawal symptoms requires re-institution of treatment at doses of [MEDICATION NAME] sufficient to suppress symptoms. There have been reports of failure of other benzodiazapines to fully suppress these withdrawal symptoms . Review of In-Service Training Report dated [DATE] revealed Subject: .2) How to do initial ordering and re-ordering of medications . 4.) Documentation on MAR and in chart if medication not given. 5.) Do not borrow medications from other residents .7.) Use approved progress notes .8.) Use Progress Note NOT NSG. Progress Note .9) Night shift to do all monthly orders .How to Order, reorder and recieve non-narcotics and narcotics from the pharmacy. According to the facility Physician order [REDACTED].

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure accurate acquiring and administration of medications for two Residents (R #3 and R #8) of eight residents reviewed for pharmacy services. -The facility did not provide Xanax as ordered by the physician for six days. -LVN P took Xanax from R #8's supply and gave the Xanax to R #3 These failures affected placed 31 other residents ordered Benzodiazepines at risk of receiving inaccurate acquiring and administration of medication. The findings were: R #3's Physician Start Up Orders dated 01/05/17 revealed Xanax 0.25 mg 1 PO QD DX: Anxiety (Xanax (benzodiazepine) is an antianxiety medication) R #3's Consolidated Physician Oder Report dated 03/01/17-04/30/17 revealed Xanax 0.25 mg. once a day and Xanax 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on 03/02/17 on Physicians plan to control R #3's anxiety there was a written note Xanax 0.25 PO Daily R #3's Medication Flowsheet dated 03/01/17 -03/31/17 revealed Xanax 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials 03/16/17, 03/17/17, 03/18/17, 03/19/17, 03/20/17, and 03/21/17. On the back of the Medication Flowsheet there was a noted for the following dates 03/17/17, 03/18/17, 03/19/17, 03/20/17 stating Xanax was not given due to medication not in house. R #3's All Disciplines To Use Progress Notes revealed on 03/22/17 at 7:00 p.m., Resident did not have Ativan 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . The other resident was R #8. .03/23/17 11:00 p.m. MD office was faxed & informed that Pt did not have Xanax in the facility. Morning staff will follow up in AM . .03/23/17 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. Xanax 0.25 mg PO given . .03/23/17 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . On 04/11/17 at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on 03/22/17 she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her Xanax and LVN P said he would check. LVN P said R #3 had not received any Xanax in 5-6 days because R #3 did not have any Xanax left. FM X said R #3 had received Xanax every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 Xanax. On 04/11/17 at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her Xanax and he took a Xanax from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no Xanax in stock and R #3 was completely out of her Xanax for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her Xanax. On 04/11/17 at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of 03/22/17 and told the DON that he had taken another resident's Xanax to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. On 04/12/17 at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the Xanax for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the Xanax was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On 04/12/17 at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in 02/2017 she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have Xanax available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled Xanax over a course of 5-6 days. Surveyor asked LVN A if she should know the indications of use and adverse effects of Xanax and LVN A said, yes. LVN A said she documented on the back of R #3's MAR indicated [REDACTED]. LVN A said she documented on the 24 hour report that R #3 was out of Xanax because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the Xanax. LVN A said she did not call the Physician or the DON because she did not want to bother them. Review of R #8's Controlled Drug Record revealed a physician's orders [REDACTED]. Further review revealed on 03/22/17 at 7:00 p.m., Xanax was signed out by LVN P and written on the Record was for (R#3) According to the facility Physician order [REDACTED].

Based on interview and record review the facility failed to provide services that met professional standards for one resident (R #3) of seven residents reviewed for professional standards of care. -LVN A did not call the Physician to re-order R #3's [MEDICATION NAME] or notify the Physician when R #3 was out of her routine ordered [MEDICATION NAME]. -LVN A was not aware of the adverse effects of not giving R #3 her prescription [MEDICATION NAME] or abruptly stopping [MEDICATION NAME]. -LVN A did not follow the facility policy and procedures for re-ordering medication. -LVN A did not effectively communicate to other health care team members that R #3 was out of [MEDICATION NAME] and how to re-order [MEDICATION NAME]. These deficient practices could have adversely affected 31 residents in the facility prescribed benzodiazepines The findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; .(D) Accurately and completely report and document: (i) the clients status including signs and symptoms; (ii) nursing care rendered; .(v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client ' s status; .(N) Clarify any order or treatment regime that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; . Review of facility Job Description for Charge Nurse LVN signed and dated [DATE] revealed, Essential Functions: .Observes, assesses and reports condition/changes, and documentation .Receives, transcribes, and executes physicians' orders .Administers medications as prescribed .Contributes to the assurance of resident care consistent with acceptable standards of care and established policy and procedure . Review of facility policy and procedure dated ,[DATE] titled Ordering and Receiving Controlled Medications .3. The pharmacy or nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled medication prescribed for a resident as applicable per state law. This log is placed in the MAR indicated [REDACTED].In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order. If unable to obtain another written prescription and provide the medication prior to the depletion of the current supply, the pharmacy will notify the nursing care center immediately. 5 Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand . R#3's Face Sheet revealed R #3 was a [AGE] year old female admitted to the facility [DATE] with the following Diagnosis: [REDACTED]. R #3's Discharge MDS dated [DATE] revealed R #3's assessment for BIMS and Mood was blank. R #3 was totally dependent with bed mobility and transfers eating and personal hygiene care. R #3 was always incontinent of bowel and bladder. R #3's cognitive skills for daily decision making were severely impaired. R #3's Care Plan (last reviewed/revised) [DATE] revealed PROBLEM I receive antianxiety medication R/T anxiety AEB crying episodes. [MEDICATION NAME] per order .GOAL I will be prescribed the lowest effective dose of medication and still have my mood managed over the next review period .APPROACH Assess my functional status prior to initiation of drug use to serve as a baseline .Monitor my functional status every shift. Monitor my mood and response to medication .Quantitatively and objectively document my behavior/mood. R #3's Physician Start Up Orders dated [DATE] revealed [MEDICATION NAME] 0.25 mg 1 PO QD DX: Anxiety ([MEDICATION NAME] (benzodiazepine) is an antianxiety medication) R #3's Consolidated Physician Oder Report dated [DATE]-[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day and [MEDICATION NAME] 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on [DATE] on Physicians plan to control R #3's anxiety there was a written note [MEDICATION NAME] 0.25 PO Daily R #3's Medication Flowsheet dated [DATE] -[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On the back of the Medication Flowsheet there was a noted for the following dates [DATE], [DATE], [DATE], [DATE] stating [MEDICATION NAME] was not given due to medication not in house. R #3's Treatment Flowsheet dated [DATE]-[DATE] revealed on the Anti-Anxiety Use it was documented from [DATE] through [DATE] that R #3 had no behaviors related to anti-anxiety medication use on all three shifts. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 7:00 p.m., Resident did not have [MEDICATION NAME] 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . XXX[DATE] 11:00 p.m. MD office was faxed & informed that Pt did not have [MEDICATION NAME] in the facility. Morning staff will follow up in AM . XXX[DATE] 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. [MEDICATION NAME] 0.25 mg PO given . XXX[DATE] 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . On [DATE] at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on [DATE] she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her [MEDICATION NAME] and LVN P said he would check. LVN P said R #3 had not received any [MEDICATION NAME] in ,[DATE] days because R #3 did not have any [MEDICATION NAME] left. FM X said R #3 had received [MEDICATION NAME] every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 [MEDICATION NAME]. On [DATE] at 4:20 p.m., Surveyor called R #3's Physician and left a message for Physician to return my call. On [DATE] at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her [MEDICATION NAME] and he took a [MEDICATION NAME] from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no [MEDICATION NAME] in stock and R #3 was completely out of her [MEDICATION NAME] for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her [MEDICATION NAME]. LVN P said he was written up for taking the [MEDICATION NAME] from another resident but he said he would rather take the write up than see a resident suffer. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 3:15 p.m. resident was wheezing and a nebulizer treatment was administered wheezing or breathing did not change after breathing treatment was administered. R #3's Physician was notified and R #3 was sent out to the hospital. Review of R #3's PRN Medications Flowsheet dated [DATE], R #3's Oxygen Saturation levels before respiratory treatment was 84% and after the the respiratory treatment R #3's O2 Saturation was 92% Review of R #3's hospital admission History and Physical dated [DATE] revealed This is a [AGE] year old female. She has a past history of Alzheimer's dementia. She has had elevated troponin and [MEDICAL CONDITION]. Because she was struggling to breathe, family decided on comfort measures only for which she was admitted to hospice .Impression: 1.[MEDICAL CONDITION] 2. Elevated cardiac enzymes . On [DATE] at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of [DATE] and told the DON that he had taken another resident's [MEDICATION NAME] to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. The DON said LVN P should have called Pham-America to deliver the medicine or call the local Pharmacy to have them deliver the [MEDICATION NAME]. The DON said [MEDICATION NAME] cannot be abruptly stopped because it could cause respiratory arrest and death. Surveyor showed the DON R #3's Treatment Flowsheet dated [DATE]-[DATE] which showed no behaviors related to anti-anxiety medication use on all three shifts. The DON said the assessments looked like a cookie cutter Monkey see Monkey do and said she doubted the assessments were accurate due to the fact R #3 did not receive [MEDICATION NAME] for over five days. On [DATE] at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the [MEDICATION NAME] for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the [MEDICATION NAME] was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On [DATE] at 1:25 p.m., interview with LVN B (Charge Nurse for the 6:00 a.m.-2:00 p.m. shift) said she does not recall anyone asking her to re-order [MEDICATION NAME] for R #3. LVN B said it was the responsibility of every nurse in the facility to re-order medications when a resident's medications run low. LVN B said she was unaware R #3 did not have any scheduled [MEDICATION NAME] left because R #3 received her routine [MEDICATION NAME] in the evening. LVN B said if a resident ran out of a medicine controlled or not, the nurse can always call the Physician for a refill or sometimes they could use the local Pharmacy if there was no [MEDICATION NAME] in the Emergency Kit. LVN B said if a resident has been taking a benzodiazepine for an extended period of time, and abruptly stops taking the medication, the resident could have a [MEDICAL CONDITION], it could be deadly. On [DATE] at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in ,[DATE] she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have [MEDICATION NAME] available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled [MEDICATION NAME] over a course of ,[DATE] days. Surveyor asked LVN A if she should know the indications of use and adverse effects of [MEDICATION NAME] and LVN A said, yes. LVN A said she documented on the back of R #3's MAR indicated [REDACTED]. LVN A said she documented on the 24 hour report that R #3 was out of [MEDICATION NAME] because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the [MEDICATION NAME]. LVN A said she did not call the Physician or the DON because she did not want to bother them. According to the facility Physician order [REDACTED].

Based on interview and record review, the facility failed to ensure each resident was free from neglect, for one Residents (R#3) of seven residents reviewed for Abuse and Neglect. The facility did not provide R #3 with her scheduled [MEDICATION NAME] for six days resulting in withdrawal signs and symptoms and mental distress. This failure could affect 31 residents who were prescribed benzodiazepines in the facility by placing them at risk mental and physical distress. The findings were: R#3's Face Sheet revealed R #3 was a [AGE] year old female admitted to the facility [DATE] with the following Diagnosis: [REDACTED]. R #3's Discharge MDS dated [DATE] revealed R #3's assessment for BIMS and Mood was blank. R #3 was totally dependent with bed mobility and transfers eating and personal hygiene care. R #3 was always incontinent of bowel and bladder. R #3's cognitive skills for daily decision making were severely impaired. R #3's Care Plan (last reviewed/revised) [DATE] revealed PROBLEM I receive antianxiety medication R/T anxiety AEB (as exhibited by)crying episodes. [MEDICATION NAME] per order .GOAL I will be prescribed the lowest effective dose of medication and still have my mood managed over the next review period .APPROACH Assess my functional status prior to initiation of drug use to serve as a baseline .Monitor my functional status every shift. Monitor my mood and response to medication .Quantitatively and objectively document my behavior/mood. R #3's Physician Start Up Orders dated [DATE] revealed [MEDICATION NAME] 0.25 mg 1 PO QD DX: Anxiety ([MEDICATION NAME] (benzodiazapines) is an antianxiety medication) R #3's Consolidated Physician order [REDACTED]. once a day and [MEDICATION NAME] 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on [DATE] on Physicians plan to control R #3's anxiety there was a written note [MEDICATION NAME] 0.25 PO Daily R #3's Medication Flowsheet dated [DATE] -[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On the back of the Medication Flowsheet there was a noted for the following dates [DATE], [DATE], [DATE], [DATE] stating [MEDICATION NAME] was not given due to medication not in house. R #3's Treatment Flowsheet dated [DATE]-[DATE] revealed on the Anti-Anxiety Use it was documented from [DATE] through [DATE] that R #3 had no behaviors related to anti-anxiety medication use on all three shifts. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 7:00 p.m., Resident did not have [MEDICATION NAME] 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . XXX[DATE] 11:00 p.m. MD office was faxed & informed that Pt did not have [MEDICATION NAME] in the facility. Morning staff will follow up in AM . XXX[DATE] 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. [MEDICATION NAME] 0.25 mg PO given . XXX[DATE] 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 3:15 p.m. resident was wheezing and a nebulizer treatment was administered wheezing or breathing did not change after breathing treatment was administered. R #3's Physician was notified and R #3 was sent out to the hospital. Review of R #3's PRN Medications Flowsheet dated [DATE], R #3's Oxygen Saturation levels before respiratory treatment was 84% and after the the respiratory treatment R #3's O2 Saturation was 92% Review of R #3's hospital admission History and Physical dated [DATE] revealed This is a [AGE] year old female. She has a past history of Alzheimer's dementia. She has had elevated troponin and [MEDICAL CONDITION]. Because she was struggling to breathe, family decided on comfort measures only for which she was admitted to hospice .Impression: 1.[MEDICAL CONDITION] 2. Elevated cardiac enzymes . On [DATE] at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on [DATE] she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her [MEDICATION NAME] and LVN P said he would check. LVN P said R #3 had not received any [MEDICATION NAME] in ,[DATE] days because R #3 did not have any [MEDICATION NAME] left. FM X said R #3 had received [MEDICATION NAME] every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 [MEDICATION NAME]. On [DATE] at 4:20 p.m., Surveyor called R #3's Physician and left a message for Physician to return my call. Physician did not return call during this investigation. On [DATE] at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her [MEDICATION NAME] and he took a [MEDICATION NAME] from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no [MEDICATION NAME] in stock and R #3 was completely out of her [MEDICATION NAME] for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her [MEDICATION NAME]. LVN P said he was written up for taking the [MEDICATION NAME] from another resident but he said he would rather take the write up than see a resident suffer. On [DATE] at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of [DATE] and told the DON that he had taken another resident's [MEDICATION NAME] to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. The DON said LVN P should have called Pham-America to deliver the medicine or call the local Pharmacy to have them deliver the [MEDICATION NAME]. The DON said [MEDICATION NAME] cannot be abruptly stopped because it could cause respiratory arrest and death. Surveyor showed the DON R #3's Treatment Flowsheet dated [DATE]-[DATE] which showed no behaviors related to anti-anxiety medication use on all three shifts. The DON said the assessments looked like a cookie cutter Monkey see Monkey do and said she doubted the assessments were accurate due to the fact R #3 did not receive [MEDICATION NAME] for over five days. DON said, she doubted the assessments were accurate. On [DATE] at 5:15 p.m., interview with the Administrator said she did not report misappropriation of medications because she did not think of misappropriation as taking from one resident's medication supply and giving to another resident. The Administrator said the staff were in-serviced by the DON on Abuse, Neglect and re-ordering medications. On [DATE] at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the [MEDICATION NAME] for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the [MEDICATION NAME] was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On [DATE] at 1:25 p.m., interview with LVN B (Charge Nurse for the 6:00 a.m.-2:00 p.m. shift) said she does not recall anyone asking her to re-order [MEDICATION NAME] for R #3. LVN B said it was the responsibility of every nurse in the facility to re-order medications when a resident's medications run low. LVN B said she was unaware R #3 did not have any scheduled [MEDICATION NAME] left because R #3 received her routine [MEDICATION NAME] in the evening. LVN B said if a resident ran out of a medicine controlled or not, the nurse can always call the Physician for a refill or sometimes they could use the local Pharmacy if there was no [MEDICATION NAME] in the Emergency Kit. LVN B said if a resident has been taking a benzodiazepines for an extended period of time, and abruptly stops taking the medication, the resident could have a [MEDICAL CONDITION], it could be deadly. On [DATE] at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in ,[DATE] she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have [MEDICATION NAME] available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled [MEDICATION NAME] over a course of ,[DATE] days. Surveyor asked LVN A if she should know the indications of use and adverse effects of [MEDICATION NAME] and LVN A said, yes. LVN A said she documented on the back of R #3's MAR that R #3 did not have [MEDICATION NAME] in house. LVN A said she documented on the 24 hour report that R #3 was out of [MEDICATION NAME] because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the [MEDICATION NAME]. LVN A said she did not call the Physician or the DON because she did not want to bother them. According to: https://www.accessdata.fda.gov/drugsatfda_docs/label/,[DATE]s052lbl.pdf Referenced on [DATE] at 4:31 p.m. revealed; Abuse and dependence. Taking [MEDICATION NAME] can cause physical and psychological dependence. Physical and psychological dependence is not the same as drug addiction. Your healthcare provider can tell you more about the differences between physical and psychological dependence and drug addiction. Withdrawal symptoms. You may have withdrawal symptoms if you stop taking [MEDICATION NAME] suddenly. Withdrawal symptoms can be serious and include [MEDICAL CONDITION]. Mild withdrawal symptoms include a depressed mood and trouble sleeping. Talk to your healthcare provider about slowly stopping [MEDICATION NAME] to avoid withdrawal symptoms. [MEDICAL CONDITION]. Stopping [MEDICATION NAME] can cause [MEDICAL CONDITION] and [MEDICAL CONDITION] that will not stop ([DIAGNOSES REDACTED]). Mania. [MEDICATION NAME] may cause an increase in activity and talking (hypomania and mania) in people who have depression. The most common side effects of [MEDICATION NAME] include drowsiness and light-headedness. These are not all the possible side effects of [MEDICATION NAME]. Call your doctor for medical advice about side effects . Dose Reduction Because of the danger of withdrawal, abrupt discontinuation of treatment should be avoided (see WARNINGS, PRECAUTIONS, DRUG ABUSE AND DEPENDENCE). In all patients, dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage. Although there are no systematically collected data to support a specific discontinuation schedule, it is suggested that the daily dosage be decreased by no more than 0.5 mg every three days. Some patients may require an even slower dosage red DRUG ABUSE AND DEPENDENCE . .Physical and Psychological Dependence Withdrawal symptoms similar in character to those noted with sedative/hypnotics and alcohol have occurred following discontinuance of benzodiazapines, including [MEDICATION NAME]. The symptoms can range from mild dysphoria and [MEDICAL CONDITION] to a major syndrome that may include abdominal and muscle cramps, vomiting, sweating, tremors and convulsions. Distinguishing between withdrawal emergent signs and symptoms and the recurrence of illness is often difficult in patients undergoing dose reduction. The long term strategy for treatment of [REDACTED]. When necessary, immediate management of withdrawal symptoms requires re-institution of treatment at doses of [MEDICATION NAME] sufficient to suppress symptoms. There have been reports of failure of other benzodiazepines to fully suppress these withdrawal symptoms . Facility Policy and Procedure dated ,[DATE] titled Abuse-Reportable Events revealed, It is the policy of this home to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person .Definitions .NEGLECT: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness . Review of facility Job Description for Charge Nurse LVN signed and dated [DATE] revealed, Essential Functions: .Observes, assesses and reports condition/changes, and documentation .Receives, transcribes, and executes physicians' orders .Administers medications as prescribed .Contributes to the assurance of resident care consistent with acceptable standards of care and established policy and procedure . Review of facility policy and procedure dated ,[DATE] titled Ordering and Receiving Controlled Medications .3. The pharmacy or nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled medication prescribed for a resident as applicable per state law. This log is placed in the MAR or narcotic book to be counted every shift .4 .In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order. If unable to obtain another written prescription and provide the medication prior to the depletion of the current supply, the pharmacy will notify the nursing care center immediately. 5 Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand . Review of In-Service Training Report dated [DATE] revealed Subject: .2) How to do initial ordering and re-ordering of medications . 4.) Documentation on MAR and in chart if medication not given. 5.) Do not borrow medications from other residents .7.) Use approved progress notes .8.) Use Progress Note NOT NSG. Progress Note .9) Night shift to do all monthly orders .How to Order, reorder and recieve non-narcotics and narcotics from the pharmacy. According to the facility Physician order [REDACTED].

Based on 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, mental, or psychosocial status, for one Resident (R#3) of seven residents reviewed for physician consultation issues, in that: The facility did not consult with R#3's Physician when R#3 did not have [MEDICATION NAME] for six days resulting in R #3 having withdrawal symptoms. This failure could place all 31 residents receiving Benzodiazepines at risk for [MEDICAL CONDITION], withdrawal symptoms and medical complications [REDACTED]. The findings were: R#3's Face Sheet revealed R #3 was a [AGE] year old female admitted to the facility [DATE] with the following Diagnosis: [REDACTED]. R #3's Discharge MDS dated [DATE] revealed R #3's assessment for BIMS and Mood was blank. R #3 was totally dependent with bed mobility and transfers eating and personal hygiene care. R #3 was always incontinent of bowel and bladder. R #3's cognitive skills for daily decision making were severely impaired. R #3's Care Plan (last reviewed/revised) [DATE] revealed PROBLEM I receive antianxiety medication R/T anxiety AEB (as exhibited by) crying episodes. [MEDICATION NAME] per order .GOAL I will be prescribed the lowest effective dose of medication and still have my mood managed over the next review period .APPROACH Assess my functional status prior to initiation of drug use to serve as a baseline .Monitor my functional status every shift. Monitor my mood and response to medication .Quantitatively and objectively document my behavior/mood. R #3's Physician Start Up Orders dated [DATE] revealed [MEDICATION NAME] 0.25 mg 1 PO QD DX: Anxiety ([MEDICATION NAME] (benzodiazepine) is an antianxiety medication) R #3's Consolidated Physician order [REDACTED]. once a day and [MEDICATION NAME] 0.25 mg. once a day PRN R #3's All Disciplines To Use Progress Notes revealed on [DATE] on Physicians plan to control R #3's anxiety there was a written note [MEDICATION NAME] 0.25 PO Daily R #3's Medication Flowsheet dated [DATE] -[DATE] revealed [MEDICATION NAME] 0.25 mg. once a day .7:00 p.m. The following dated had initials with a circle around the initials [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On the back of the Medication Flowsheet there was a noted for the following dates [DATE], [DATE], [DATE], [DATE] stating [MEDICATION NAME] was not given due to medication not in house. R #3's Treatment Flowsheet dated [DATE]-[DATE] revealed on the Anti-Anxiety Use it was documented from [DATE] through [DATE] that R #3 had no behaviors related to anti-anxiety medication use on all three shifts. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 7:00 p.m., Resident did not have [MEDICATION NAME] 0.25 mg PO daily in the facility. Medication was pulled out from another resident that was on PRN but medication was signed out for (R #3). Medication will be ordered as soon as possible . XXX[DATE] 11:00 p.m. MD office was faxed & informed that Pt did not have [MEDICATION NAME] in the facility. Morning staff will follow up in AM . XXX[DATE] 4:00 p.m. MD has written script & facility went to his office to pick up script. Med will not be in tonight but will be pulled from E-Kit as script & SN called pharmacy to get the keycode. [MEDICATION NAME] 0.25 mg PO given . XXX[DATE] 11:45 a.m. Med. rec'd from pharmacy. Now in lock box on cart . On [DATE] at 1:10 p.m., interview with FM X said R #3 had deceased in the hospital approximately one week ago. FM X said on [DATE] she visited R #3 at the facility and found R #3 to have severe anxiety, blood shot eyes, and with any tactile stimulation R #3 was jumpy as if she were shocked and trembling. FM X said she asked LVN P if R #3 had received her [MEDICATION NAME] and LVN P said he would check. LVN P said R #3 had not received any [MEDICATION NAME] in ,[DATE] days because R #3 did not have any [MEDICATION NAME] left. FM X said R #3 had received [MEDICATION NAME] every day for over seven years and she was very concerned that the facility abruptly stopped giving R #3 [MEDICATION NAME]. R #3's All Disciplines To Use Progress Notes revealed on [DATE] at 3:15 p.m. resident was wheezing and a nebulizer treatment was administered wheezing or breathing did not change after breathing treatment was administered. R #3's Physician was notified and R #3 was sent out to the hospital. Review of R #3's PRN Medications Flowsheet dated [DATE], R #3's Oxygen Saturation levels before respiratory treatment was 84% and after the the respiratory treatment R #3's O2 Saturation was 92% Review of R #3's hospital admission History and Physical dated [DATE] revealed This is a [AGE] year old female. She has a past history of Alzheimer's dementia. She has had elevated troponin and [MEDICAL CONDITION]. Because she was struggling to breathe, family decided on comfort measures only for which she was admitted to hospice .Impression: 1.[MEDICAL CONDITION] 2. Elevated cardiac enzymes . On [DATE] at 4:20 p.m., Surveyor called R #3's Physician and left a message for Physician to return my call. The Physician did not return call during this investigation. On [DATE] at 4:30 p.m., interview with LVN P said he identified that R #3 had not received her [MEDICATION NAME] and he took a [MEDICATION NAME] from another resident to give to R #3. LVN P said he knew that was not the right thing to do but he would do the same if that was his mother. LVN P said R #3 was very anxious and there was no [MEDICATION NAME] in stock and R #3 was completely out of her [MEDICATION NAME] for days. LVN P said he was a floater and had not worked on the Hall R #3 resided in one week. LVN P said he did not know what else to do, but knew R #3 needed her [MEDICATION NAME]. LVN P said he was written up for taking the [MEDICATION NAME] from another resident but he said he would rather take the write up than see a resident suffer. On [DATE] at 5:00 p.m., interview with the DON said she received a call from LVN P on the evening of [DATE] and told the DON that he had taken another resident's [MEDICATION NAME] to give to R #3. LVN P told the DON that he was so nervous that he didn't know what else to do. The DON said LVN P should have called Pham-America to deliver the medicine or call the local Pharmacy to have them deliver the [MEDICATION NAME]. The DON said [MEDICATION NAME] cannot be abruptly stopped because it could cause respiratory arrest and death. Surveyor showed the DON R #3's Treatment Flowsheet dated [DATE]-[DATE] which showed no behaviors related to anti-anxiety medication use on all three shifts. The DON said the assessments looked like a cookie cutter Monkey see Monkey do and said she doubted the assessments were accurate due to the fact R #3 did not receive [MEDICATION NAME] for over five days. On [DATE] at 5:15 p.m., interview with the Administrator said she did not report misappropriation of medications because she did not think of misappropriation as taking from one resident's medication supply and giving to another resident. The Administrator said the staff were in-serviced by the DON on Abuse, Neglect and re-ordering medications. On [DATE] at 10:45 p.m., the DON said all nurses were responsible for re-ordering medications when a resident is low on a prescribed medication. The DON said that when she had conducted her own internal investigation she found out that one of her new nurses should have re-ordered the [MEDICATION NAME] for R #3. The DON said all nurses were in serviced on re-ordering medications as part of the orientation process at the facility. The DON said when she spoke to LVN A (new nurse) about why the [MEDICATION NAME] was not re-ordered on R #3., LVN A said she did not recall being in serviced on how to re-order controlled drugs that require a triple copy. On [DATE] at 1:25 p.m., interview with LVN B (Charge Nurse for the 6:00 a.m.-2:00 p.m. shift) said she does not recall anyone asking her to re-order [MEDICATION NAME] for R #3. LVN B said it was the responsibility of every nurse in the facility to re-order medications when a resident's medications run low. LVN B said she was unaware R #3 did not have any scheduled [MEDICATION NAME] left because R #3 received her routine [MEDICATION NAME] in the evening. LVN B said if a resident ran out of a medicine controlled or not, the nurse can always call the Physician for a refill or sometimes they could use the local Pharmacy if there was no [MEDICATION NAME] in the Emergency Kit. LVN B said if a resident has been taking a benzodiazepine for an extended period of time, and abruptly stops taking the medication, the resident could have a [MEDICAL CONDITION], it could be deadly. On [DATE] at 2:15 p.m., interview with LVN A (Charge Nurse for the 2:00p.m.-10:00 p.m. shift) said during her orientation in ,[DATE] she was taught how to re-order medications but could not remember if she was taught how to re-order controlled drugs. LVN A said she was aware R #3 did not have [MEDICATION NAME] available so she faxed two communication reports to the Physician. LVN A said she had since looked for the communication reports but could not locate anywhere in the record or the facility. LVN A said she did not know what the adverse effects would be to if a resident missed scheduled [MEDICATION NAME] over a course of ,[DATE] days. Surveyor asked LVN A if she should know the indications of use and adverse effects of [MEDICATION NAME] and LVN A said, yes. LVN A said she documented on the back of R #3's MAR that R #3 did not have [MEDICATION NAME] in house. LVN A said she documented on the 24 hour report that R #3 was out of [MEDICATION NAME] because she did not know how to re-order controlled drugs. LVN A said she thought that since the day shift nurse had more experience that the day shift charge nurse could re-order the [MEDICATION NAME]. LVN A said she did not call the Physician or the DON because she did not want to bother them. Review of In-Service Training Report dated [DATE] revealed Subject: .2) How to do initial ordering and re-ordering of medications . 4.) Documentation on MAR and in chart if medication not given. 5.) Do not borrow medications from other residents .7.) Use approved progress notes .8.) Use Progress Note NOT NSG. Progress Note .9) Night shift to do all monthly orders .How to Order, reorder and recieve non-narcotics and narcotics from the pharmacy. According to the facility Physician order [REDACTED].

Based on observation, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for two Resident (R#1 and R#2) out of five residents reviewed for accidents. The facility did not provide supervision for R1 and R2 during handling of hot coffee while in bed and did not ensure coffee was served at a safe temperature to prevent burns if spilled on a resident. R#1 sustained 2nd degree burns when he spilled hot coffee while in bed. Five days later R#2 spilled coffee on herself. These failures contributed to R#1 sustaining second degree burns to his left side of the lower abdomen, upper left thigh and lower left thigh. An Immediate Jeopardy (IJ) was determined to have existed from 09/21/16 through 10/01/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began.The Non Compliace was removed on 10/01/16 because the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids are set up appropriately for residents' use by having the drinking spout in the correct position. Failure to take temperatures of hot liquids could affect the 36 residents who required assistance of one or two staff during eating. The findings were: R#1's Face Sheet dated 09/23/16 indicated R#1's latest return to the facility was on 02/04/15. R#1's [DIAGNOSES REDACTED]. The Face Sheet indicated R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had unclear speech; was usually understood and had the ability to usually understand others. R#1 was unable to report the correct year, month or day. The MDS indicated R#1 required extensive physical assistance by two or more persons for bed mobility, transfers and toilet use. The MDS indicated for eating he required supervision (oversight, encouragement or cueing) and set-up help only. R#1's Functional Limitation in Range of Motion indicated he had impairment to one side of his upper extremities and impairment on both sides of the lower extremities. The MDS indicated R#1's mobility device was a wheelchair (manual or electric.) R#1's Care Plan dated on 06/30/16 and reviewed again on 09/21/16 indicated R#1 had Cognitive loss/Dementia and had impaired decision making. One approach listed was that staff was to determine if decisions made by R#1 could endanger him or others. Another Care Plan for R#1 Start date 01/05/16, reviewed 06/30/16, 09/30/16 and 09/21/16 for Dehydration/Fluid Maintenance indicated an approach was Assist with fluids as needed. R#1's Care Plan reviewed on 06/30/16 and again on 09/21/16 indicated R#1 required an electric wheelchair for mobility due to [DIAGNOSES REDACTED]. Incident/Accident Report on R#1 dated 09/21/16 at 8:00 a.m. indicated R#1 was trying to take the lid of the coffee and spilled the coffee on the left side of his abdomen and his thigh. Further review of Incident/Accident Final Disposition Report dated 09/21/16 indicated measures put in place were that dietary staff was to check the temperatures of hot liquids and were to keep a log; lids on hot liquids would continue to be used; inservices for dietary staff on keeping the temperatures and logs was provided by the Dietary Consultant and dietary and nursing staff were to make sure that all cups with lids were set up appropriately for residents to use with hole/spout in correct position. Further review of the Incidnet Accident Report, Suggested Investigative Action Plan dated 09/21/16 under the heading, Complete Analysis concluded that the incident could have possibly been avoided by assuring the drink spout was in the correct position and by assuring the proper temperature on the coffee. Nursing Documentation Record (NDR) dated 09/21/16 at 8:00 a.m. indicated R#1 had spilled hot coffee and had redness to the left thigh. The note indicated the resident stated he was trying to take the lid off the cup when he spilled the coffee. The note indicated the resident denied pain at this time. The note was written by Licensed Vocational Nurse (LVN) A. NDR dated 09/21/16 at 10:00 a.m. indicated LVN A had been notified by Certified Nurse Aide (CNA) B that R#1 had blisters to the burn area. LVN A wrote scalding and approximately 15 fluid filled blisters were noted. LVN A wrote R#1 complained of moderate pain and that she had given the resident pain medication for comfort and R#1 was turned to the opposite side. At this time, LVN A wrote that she had notified the Physician and the Responsible Party. NDR dated 09/21/16 at 5:00 p.m. indicated the Physician Assistant (PA) F was at the facility doing rounds. A new order indicated to use Silvadene AAA twice a day for seven days and to cover the burns with a dry dressing, for the [DIAGNOSES REDACTED]. The new order also included to Cipro (antibiotic) 500 mg (milligrams) twice a day for seven days. Skin Assessment Flow Sheet-Non-Pressure Injury Conditions (SAFS) dated 09/21/16 indicated R#1 had open blisters to the lower abdomen approximately 2.0 cm (centimeters) x 4.0 cm and fluid filled blisters 8.0 cm x 4.0 cm; the upper thigh had open blisters 12.0 cm x 3.5 cm and the lower thigh had fluid filled blisters approximately 6.0 cm x 5.0 cm. On 11/01/16, documentation on the SAFS indicated the left side of the abdomen had resolved and there remained an open area on the lower left thigh approximately 1.5 cm x 1.0 cm. for which R#1 was still receiving treatment. The Physician's Progress Note date 09/21/16, no time listed, indicated R#1 had spilled hot coffee on himself that morning and R#1 had complained of pain and blisters to the left side. The Physician indicated the left side of R#1 had second degree burns, blisters and redness. Hot Liquids Safety Evaluation for R#1 dated 9/2016 indicated risk factors: Cognition-moderately to severely impaired; Contractures in fingers/hands/wrists/elbows/or shoulders and weakness/paresis in upper extremities. R#1 was observed on 11/02/16 at 10:10 a.m. during the initial tour. The resident was in bed awake. The Assistant Director of Nurses (ADON) who accompanied the surveyor indicated R#1 was interviewable; required a hoyer/mechanical lift for transfers; had a [DIAGNOSES REDACTED]. LVN C (treatment nurse) indicated at 10:45 a.m. on 11/02/16 that R#1's burns were healed on his abdomen, under his abdominal folds and his upper thigh area. LVN C indicated there was only one open area on the lower thigh that was open. LVN C reported R#1 was in the shower room. After obtaining permission from R#1, the surveyor observed R#1 in the shower room covered up except for his left side. R#1 had a dark scar going down most of the left side of his thigh. An open area was observed on R#1's lower thigh. LVN C stated at this time, that she had measured the open area the day before and it measured 1.5 x 1.0 cm. R#1 was observed in the dining room on 11/02/16 at 11:55 a.m. The resident was utilizing his motorized wheelchair. R#1 was brought coffee in a regular cup and a plastic lid was placed on the cup. The coffee was given to R#1 by a CNA. During an interview on 11/02/16 at 1:00 p.m., R#1 showed the surveyor the mug he was using the day he was burned. The mug was a black, medium size mug and the lid fit tightly to the mug. R#1 stated he had taken off the lid when he got burned. During a telephone conversation with CNA B on 11/02/16 at 3:52 p.m., CNA B reported that she had passed out the breakfast tray and coffee to R#1 the day he was burned. CNA B stated it was around 7:40 a.m. when she had gotten a black mug of coffee for R#1. CNA B reported she had told R#1 that the coffee was very hot and for him not to remove the lid. CNA B stated she left R#1's room and a few minutes later she heard R#1 scream. CNA B added that R#1 usually ate in the dining room, but that morning his motorized wheelchair was not working. CNA B added she thought maybe the battery was not charged. She was not sure why the wheelchair was not working that morning, but that was the reason R#1 stayed in bed that morning. LVN A reported on 11/03/16 at 9:50 a.m., she had dining room duty the day R#1 spilled his coffee and was burned. LVN A stated the area was red and scalded, like an extra layer of skin. At approximately 10:00 a.m., she was notified by CNA B that R#1's skin now had blisters. LVN A stated R#1 denied having pain, but she (LVN A) knew R#1 must have had pain. R#1 had 15 blisters going down his left side, according to LVN A. LVN A stated she notified R#1's Physician and gave the resident pain medication. LVN A stated R#1's motorized wheelchair was not working the morning he was burned. She did not know if it had not been charged or what the problem was. LVN A stated she was not sure why R#1 did not go to the dining room that day. R#1 stated on 11/03/16 at 10:40 a.m. that the day before (11/02/16) was the first day he had been out of bed since he was burned. R#1 stated that sometimes staff would not charge the wheelchair and that it needed to be charged or it will die. R#1 stated he wanted to be up. The Director of Nurses (DON) stated on 11/03/16 at 3:52 p.m. that R#1 had told the DON that he was trying to turn the lid to where he could drink out of it, when he spilled the coffee and was burned. The DON added that if the spout had been turned to where R#1 could have drank out of it, he would not have had a problem. The DON stated R#1 likes to be independent and does not like to be asking for help all the time. The DON stated the staff are now taking the coffee temperatures before providing the coffee to the residents, but the staff had not taken the temperature of the coffee prior to the day R#1 was burned. The DON added a CNA was assigned to supervise the resident after he was burned while eating and drinking in bed. The DON stated R#1 was very social and liked eating in the dining room. The DON stated the staff that day told her R#1 wanted to stay in bed the day he was burned. The DON stated R#1 required set-up help since he was able to feed himself, but also needed to be checked on. Inservice Training Report dated 09/29/16 provided by the DON indicated all nursing and dietary staff were in-serviced on making sure all lids on cups and coffee cups were turned so resident could drink without having to readjust the lid. R#2 R#2's Face Sheet, undated indicated her last admission in the facility was 02/23/16. R#2's [DIAGNOSES REDACTED]. Incident/Accident Report dated 09/26/16 at 7:30 a.m. indicated R#2 was in her room when LVN E was called to R#2's room by a CNA because R#2 had spilled her coffee on herself. The report indicated R#2 was alert and oriented and that the resident's Styrofoam cup had cracked and the resident had lost control of her cup. A head to toe assessment was done and no injuries were noted. The report indicated the resident had three blankets on her, so most of the coffee was absorbed by the blankets. The measure put in place was that the resident would no longer drink from a styrofoam cup. R#2 reported on 11/03/16 at 9:30 a.m. while she was in bed in her room that she had spilled hot coffee on herself, but did not get burned. R#2 added that staff are being more careful now. LVN A reported on 11/03/16 that she had been told by LVN E about R#2 spilling her coffee on her belly and that the blankets had saved her from being burned. LVN A reported the incident occurred shortly after R#1 was burned and that now styrofoam cups are not used. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly. Burns 2000; 26:347-350.: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person's perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. The facility's Policy and Procedure on Abuse-Reportable Events, revised 08/2016 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility's Policy and Procedure on Precautions for Hot Beverages, revised 01/2016 indicated this home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. A suggested monitoring procedure for hot beverages is as follows: Initial temperature is taken when the beverage/liquid is placed into the serving container. If the temperature is above 170 degrees F, the beverage/liquid is allowed to cool to the serving temperature of 150 degrees-160 degrees F before served to dining room. Do not serve coffee or cocoa below 130 degrees F for palatability. An IJ was determined to have existed from 09/21/16 through 10/01/16. The Non Compliance was removed on 10/01/16 because observation, interview and record review indicated the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids were set up appropriately for residents' use by having the drinking spout in the correct position. The facility took the following action to correct the noncompliance: Dietary Aide (DA) D reported on 11/03/16 at 9:12 a.m. that the dietary aides were now taking coffee temperatures before providing coffee to the residents. DA D stated the coffee temperature must be 150-160 degrees F (Fahrenheit) in the kitchen. DA D stated the dietary aides had been in-serviced and written up since the coffee temperatures were not being taken prior to R#1 being burned. DA D stated the coffee temperatures had been taken consistently starting in October. DA D showed the surveyor documentation of the coffee temperatures beginning on 10/01/16. DA D stated R#1 had his own personal coffee mug and tried to adjust the lid when he spilled the coffee. Inservice Training Report dated 09/26/16 provided by the Dietary Consultant indicated dietary staff had received an in-service on hot liquids. The facility's Form CMS-672, RESIDENT CENSUS AND CONDITIONS OF RESIDENTS dated 11/02/16 indicated there were 36 residents who required assistance of one or two staff during eating.

Based on observation, record review and interview, the facility failed to accommodate one Resident (R#1) out of five residents reviewed for accommodation of individual needs and preferences. Dietary staff did not take the temperature of the coffee before providing it to the residents. The facility did not provide set-up help to enable R#1 to drink from his coffee cup without spilling it. The facility did not ensure R#1's motorized wheelchair was working on the morning of 09/21/16, as a result R#1 was left in bed to eat his breakfast and drink his hot coffee. R#1 spilled the hot coffee on himself and burned the left side of his body. These failures contributed to R#1 sustaining second [MEDICAL CONDITION] his left side of the lower abdomen, upper left thigh and lower left thigh. An Immediate Jeopardy (IJ) was determined to have existed from 09/21/16 through 10/01/16. The IJ was removed on 10/01/16 because the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature log. Dietary and nursing staff were in-serviced on making sure that all cups with lids were set up appropriately for residents' use by having the drinking spout in the correct position. Failure to take temperatures of hot liquids and to provide setup help could affect the 36 residents who required assistance of one or two staff during eating. Failure to accommodate residents by not assuring their motorized wheelchairs were in working condition could affect the one resident who used a motorized wheelchair. The findings were: R#1's Face Sheet dated 09/23/16 indicated R#1's latest return to the facility was on 02/04/15. R#1's [DIAGNOSES REDACTED]. The Face Sheet indicated R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had unclear speech; was usually understood and had the ability to usually understand others. R#1 was unable to report the correct year, month or day. The MDS indicated R#1 required extensive physical assistance by two or more persons for bed mobility, transfers and toilet use. The MDS indicated for eating he required supervision (oversight, encouragement or cueing) and set-up help only. R#1's Functional Limitation in Range of Motion indicated he had impairment to one side of his upper extremities and impairment on both sides of the lower extremities. The MDS indicated R#1's mobility device was a wheelchair (manual or electric.) R#1's Care Plan reviewed on 06/30/16 and again on 09/21/16 indicated R#1 had Cognitive loss/Dementia and had impaired decision making. One approach listed was that staff was to determine if decisions made by R#1 could endanger him or others. Another Care Plan for R#1 Start date 01/05/16, reviewed 06/30/16, 09/30/16 and 09/21/16 for Dehydration/Fluid Maintenance indicated an approach was Assist with fluids as needed. R#1's Care Plan reviewed on 06/30/16 and again on 09/21/16 indicated R#1 required an electric wheelchair for mobility due to [MEDICAL CONDITION]. Incident/Accident Report on R#1 dated 09/21/16 at 8:00 a.m. indicated R#1 was trying to take the lid of the coffee and spilled the coffee on the left side of his abdomen and his thigh. Incident/Accident Final Disposition Report dated 09/21/16 indicated measures put in place were that dietary staff was to check the temperatures of hot liquids and were to keep a log; lids on hot liquids would continue to be used; inservices for dietary staff on keeping the temperatures and logs was provided by the Dietary Consultant and dietary and nursing staff were to make sure that all cups with lids were set up appropriately for residents to use with hole/spout in correct position. Suggested Investigative Action Plan dated 09/21/16 under the heading, Complete Analysis concluded that the incident could have possibly been avoided by assuring the drink spout was in the correct position and by assuring the proper temperature on the coffee. Nursing Documentation Record (NDR) dated 09/21/16 at 8:00 a.m. indicated R#1 had spilled hot coffee and had redness to the left thigh. The note indicated the resident stated he was trying to take the lid off the cup when he spilled the coffee. The note indicated the resident denied pain at this time. The note was written by Licensed Vocational Nurse (LVN) A. NDR dated 09/21/16 at 10:00 a.m. indicated LVN A had been notified by Certified Nurse Aide (CNA) B that R#1 had blisters to the burn area. LVN A wrote scalding and approximately 15 fluid filled blisters were noted. LVN A wrote R#1 complained of moderate pain and that she had given the resident pain medication for comfort and R#1 was turned to the opposite side. At this time, LVN A wrote that she had notified the Physician and the Responsible Party. NDR dated 09/21/16 at 5:00 p.m. indicated the Physician Assistant (PA) F was at the facility doing rounds. A new order indicated to use [MEDICATION NAME] AAA twice a day for seven days and to cover [MEDICAL CONDITION] a dry dressing, for the [DIAGNOSES REDACTED]. The new order also included [MEDICATION NAME](antibiotic) 500 mg (milligrams) twice a day for seven days. Skin Assessment Flow Sheet-Non-Pressure Injury Conditions (SAFS)dated 09/21/16 indicated R#1 had open blisters to the lower abdomen approximately 2.0 cm (centimeters) x 4.0 cm and fluid filled blisters 8.0 cm x 4.0 cm; the upper thigh had open blisters 12.0 cm x 3.5 cm and the lower thigh had fluid filled blisters approximately 6.0 cm x 5.0 cm. On 11/01/16, documentation on the SAFS indicated the left side of the abdomen had resolved and there remained an open area on the lower left thigh approximately 1.5 cm x 1.0 cm. The Physician's Progress Note date 09/21/16, no time listed indicated R#1 had spilled hot coffee on himself that morning and R#1 had complained of pain and blisters to the left side. The Physician indicated the left side of R#1 had second degree burns, blisters and redness. Hot Liquids Safety Evaluation on R#1 dated 9/2016 indicated risk factors: Cognition-moderately to severely impaired; Contractures in fingers/hands/wrists/elbows/or shoulders and weakness/paresis in upper extremities. R#1 was observed on 11/02/16 at 10:10 a.m. during the initial tour. The resident was in bed awake. The Assistant Director of Nurses (ADON) who accompanied the surveyor indicated R#1 was interviewable; required a hoyer/mechanical lift for transfers; had a [DIAGNOSES REDACTED]. LVN C (treatment nurse) indicated at 10:45 a.m. on 11/02/16 that R#1'[MEDICAL CONDITION] healed on his abdomen, under his abdominal folds and his upper thigh area. LVN C indicated there was only one open area on the lower thigh that was open. LVN C reported R#1 was in the shower room. After obtaining permission from R#1, the surveyor observed R#1 in the shower room covered up except for his left side. R#1 had a large dark scar on the left side of his thigh. An open area was observed on R#1's lower thigh. LVN C stated at this time, that she had measured the open area the day before and it measured 1.5 x 1.0 cm. R#1 was observed in the dining room on 11/02/16 at 11:55 a.m. The resident was utilizing his motorized wheelchair. R#1 was brought coffee in a regular cup and a plastic lid was placed on the cup. The coffee was given by a CNA to R#1. During an interview on 11/02/16 at 1:00 p.m., R#1 showed the surveyor the mug he was using the day he was burned. The mug was a black, medium size mug and the lid fit tightly to the mug. R#1 stated he had taken off the lid when he got burned. During a telephone conversation with CNA B on 11/02/16 at 3:52 p.m., CNA B reported that she had passed out the breakfast tray and coffee to R#1 the day he was burned. CNA B stated it was around 7:40 a.m. when she had gotten a black mug of coffee for R#1. CNA B reported she had told R#1 that the coffee was very hot and for him not to remove the lid. CNA B stated she left R#1's room and a few minutes later she heard R#1 scream. CNA B added that R#1 usually ate in the dining room, but that morning his motorized wheelchair was not working. CNA B added she thought maybe the battery was not charged or she was not sure why the wheelchair was not working that morning, but that was the reason R#1 stayed in bed that morning. LVN A reported on 11/03/16 at 9:50 a.m., she had dining room duty the day R#1 spilled his coffee and was burned. LVN A stated the area was red and scalded, like an extra layer of skin. At approximately 10:00 a.m., she was notified by CNA B that R#1's skin now had blisters. LVN A stated R#1 denied having pain, but she knew he must have had pain. R#1 had 15 blisters going down his left side, according to LVN A. LVN A stated she notified R#1's physician and gave the resident pain medication. LVN A stated R#1's motorized wheelchair was not working the morning he was burned. She did not know if it had not been charged or what the problem was. LVN A stated she was not sure why R#1 did not go to the dining room that day. LVN A added that she felt R#1 was ready to get up from bed when most of [MEDICAL CONDITION] healed, but R#1's wheelchair was still not working. LVN A reported she was not sure on the date, but had recorded it on the Maintenance Log and that the Social Worker (SW) had brought someone in to fix it. Review of the Maintenance Log indicated LVN A had documented on 10/21/16 that R#1's wheelchair was not working. R#1 stated on 11/03/16 at 10:40 a.m. that the day before (11/02/16) was the first day he had been out of bed since he was burned. R#1 stated that sometimes staff would not charge the wheelchair and that it needed to be charged or it will die. R#1 stated he wanted to be up the day he was burned. The Maintenance Staff (MS) stated on 11/03/16 at 11:38 a.m. that staff will sometimes not write on the maintenance log that something is broken, instead they will tell him and he was unable to remember everything they told him. The MS stated he was aware that R#1's motorized wheelchair was not working and he had cleaned it and tried to fix it, but did not document when that was. The MS stated this occurred a few days prior to it being documented on 10/21/16. The MS's supervisor later told him he was not certified to fix the electric wheelchair and someone should be called in to fix it. The MS stated he notified the SW and she got someone to fix it. The MS stated R#1 had told him his wheelchair was not working but that he had been burned at the time and was not using the wheelchair. The SW stated on 11/03/16 the night before Halloween, she was notified that R#1's wheelchair was not working. She contacted the man that fixed the other wheelchairs and he had agreed to look at R#1's wheelchair, but had not yet made it to the facility. The SW stated no one had fixed R#1's wheelchair, but now it was working, so she did not know how that occurred. The Director of Nurses (DON) stated on 11/03/16 at 3:52 p.m. that R#1 had told the DON that he was trying to turn the lid to where he could drink out of it, when he spilled the coffee and was burned. The DON added that if the spout had been turned to where R#1 could have drank out of it, he would not have had a problem. The DON stated R#1 likes to be independent and does not like to be asking for help all the time. The DON stated the staff are now taking the coffee temperatures before providing the coffee to the residents, but the staff had not taken the temperature of the coffee prior to the day R#1 was burned. The DON added a CNA was assigned to supervise the resident after he was burned while eating and drinking in bed. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: .although [MEDICAL CONDITION] happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older adults, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person's perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes and water at 133 degrees F. caused third [MEDICAL CONDITION] 15 seconds. Water temperatures at 140 degrees F. caused third [MEDICAL CONDITION] 5 seconds. The facility's Policy and Procedure on Precautions for Hot Beverages, revised 01/2016 indicated this home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. A suggested monitoring procedure for hot beverages is as follows: Initial temperature is taken when the beverage/liquid is placed into the serving container. If the temperature is above 170 degrees F, the beverage/liquid is allowed to cool to the serving temperature of 150 degrees-160 degrees F before served to dining room. Do not serve coffee or cocoa below 130 degrees F for palatability. The Director of Nurses (DON) stated on 11/03/16 at 3:52 p.m. that R#1 was very social and liked eating in the dining room. The DON stated the staff told her the day R#1 was burned that R#1 wanted to stay in bed. The DON stated R#1 required set-up help since he was able to feed himself, but also needed to be checked on. The DON stated on 11/03/16 at 4:45 p.m. that the facility did not provide the motorized wheelchairs and the motorized wheelchairs belonged to the residents. The DON added the facility was not authorized to do maintenance on the motorized wheelchair, but could call someone to come in and fix them. The DON stated the facility had no other policy on motorized wheelchairs and maintaining them in working condition, except for the one that had already been provided to the surveyor. The facility's Policy and Procedure on Use of Wheelchair, revised 03/2012 indicated that it was the policy of the facility to utilize wheelchairs for residents and to promote safety. An IJ was determined to have existed from 09/21/16 through 10/01/16. The IJ was removed on 10/01/16 because observation, interview and record review indicated the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids were set up appropriately for residents' use by having the drinking spout in the correct position. The resident was observed utilizing his motorized wheelchair during the two day visit. The facility took the following action to correct the noncompliance: Dietary Aide (DA) D reported on 11/03/16 at 9:12 a.m. that the dietary aides were now taking coffee temperatures before providing coffee to the residents. DA D stated the coffee temperature must be 150-160 degrees F (Fahrenheit) in the kitchen. DA D stated the dietary aides had been in-serviced and written up since the coffee temperatures were not being taken prior to R#1 being burned. DA D stated the coffee temperatures had been taken consistently starting in October. DA D showed the surveyor documentation of the coffee temperatures indicating the temperatures were taken beginning 10/01/16. DA D stated R#1 had his own personal coffee mug and tried to adjust the lid when he spilled the coffee. Inservice Training Report dated 09/26/16 provided by the Dietary Consultant indicated dietary staff had received an in-service on hot liquids. Inservice Training Report dated 09/29/16 provided by the DON indicated all nursing and dietary staff were in-serviced on making sure all lids on cups and coffee cups were turned so resident could drink without having to readjust the lid. The Assistant Director of Nurses (ADON) reported on 11/03/16 at 5:00 p.m. that R#1 was the only resident in the facility with a motorized wheelchair. The facility's Form CMS-672, RESIDENT CENSUS AND CONDITIONS OF RESIDENTS dated 11/02/16 indicated there were 36 residents who required assistance of one or two staff during eating.

Based on observation, record review and interview, the facility failed to implement policies and procedures that prohibit neglect for two Resident (R#1 and R#2) out of five residents reviewed for neglect. The facility did not provide supervision for R1 and R2 during handling of hot coffee while in bed and did not ensure coffee was served at a safe temperature to [MEDICAL CONDITION] spilled on a resident. R#1 sustained 2nd [MEDICAL CONDITION] he spilled hot coffee while in bed. Five days later R#2 spilled coffee on herself. These failures contributed to R#1 sustaining second [MEDICAL CONDITION] his left side of the lower abdomen, upper left thigh and lower left thigh. An Immediate Jeopardy (IJ) was determined to have existed from 09/21/16 through 10/01/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began. The Non Compliance was removed on 10/01/16 because the Dietary Staff started taking the coffee temperatures and were in-serviced on keeping temperature log. Dietary and nursing staff were in-serviced on making sure that all cups with lids are set up appropriately for residents' use by having the drinking spout in the correct position. Failure to take temperatures of hot liquids could affect the 36 residents who required assistance of one or two staff during eating. The findings were: The facility's Policy and Procedure on Abuse-Reportable Events, revised 08/2016 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#1's Face Sheet dated 09/23/16 indicated R#1's latest return to the facility was on 02/04/15. R#1's [DIAGNOSES REDACTED]. The Face Sheet indicated R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had unclear speech; was usually understood and had the ability to usually understand others. R#1 was unable to report the correct year, month or day. The MDS indicated R#1 required extensive physical assistance by two or more persons for bed mobility, transfers and toilet use. The MDS indicated for eating he required supervision (oversight, encouragement or cueing) and set-up help only. R#1's Functional Limitation in Range of Motion indicated he had impairment to one side of his upper extremities and impairment on both sides of the lower extremities. The MDS indicated R#1's mobility device was a wheelchair (manual or electric.) R#1's Care Plan dated on 06/30/16 and reviewed again on 09/21/16 indicated R#1 had Cognitive loss/Dementia and had impaired decision making. One approach listed was that staff was to determine if decisions made by R#1 could endanger him or others. Another Care Plan for R#1 Start date 01/05/16, reviewed 06/30/16, 09/30/16 and 09/21/16 for Dehydration/Fluid Maintenance indicated an approach was Assist with fluids as needed. R#1's Care Plan reviewed on 06/30/16 and again on 09/21/16 indicated R#1 required an electric wheelchair for mobility due to [MEDICAL CONDITION]. Incident/Accident Report on R#1 dated 09/21/16 at 8:00 a.m. indicated R#1 was trying to take the lid of the coffee and spilled the coffee on the left side of his abdomen and his thigh. Further review of Incident/Accident Final Disposition Report dated 09/21/16 indicated measures put in place were that dietary staff was to check the temperatures of hot liquids and were to keep a log; lids on hot liquids would continue to be used; inservices for dietary staff on keeping the temperatures and logs was provided by the Dietary Consultant and dietary and nursing staff were to make sure that all cups with lids were set up appropriately for residents to use with hole/spout in correct position. Further review of Suggested Investigative Action Plan dated 09/21/16 under the heading, Complete Analysis concluded that the incident could have possibly been avoided by assuring the drink spout was in the correct position and by assuring the proper temperature on the coffee. Nursing Documentation Record (NDR) dated 09/21/16 at 8:00 a.m. indicated R#1 had spilled hot coffee and had redness to the left thigh. The note indicated the resident stated he was trying to take the lid off the cup when he spilled the coffee. The note indicated the resident denied pain at this time. The note was written by Licensed Vocational Nurse (LVN) A. NDR dated 09/21/16 at 10:00 a.m. indicated LVN A had been notified by Certified Nurse Aide (CNA) B that R#1 had blisters to the burn area. LVN A wrote scalding and approximately 15 fluid filled blisters were noted. LVN A wrote R#1 complained of moderate pain and that she had given the resident pain medication for comfort and R#1 was turned to the opposite side. At this time, LVN A wrote that she had notified the Physician and the Responsible Party. NDR dated 09/21/16 at 5:00 p.m. indicated the Physician Assistant (PA) F was at the facility doing rounds. A new order indicated to use [MEDICATION NAME] AAA twice a day for seven days and to cover [MEDICAL CONDITION] a dry dressing, for the [DIAGNOSES REDACTED]. The new order also included [MEDICATION NAME](antibiotic) 500 mg (milligrams) twice a day for seven days. Skin Assessment Flow Sheet-Non-Pressure Injury Conditions (SAFS) dated 09/21/16 indicated R#1 had open blisters to the lower abdomen approximately 2.0 cm (centimeters) x 4.0 cm and fluid filled blisters 8.0 cm x 4.0 cm; the upper thigh had open blisters 12.0 cm x 3.5 cm and the lower thigh had fluid filled blisters approximately 6.0 cm x 5.0 cm. On 11/01/16, documentation on the SAFS indicated the left side of the abdomen had resolved and there remained an open area on the lower left thigh approximately 1.5 cm x 1.0 cm. for which R#1 was still receiving treatment. The Physician's Progress Note date 09/21/16, no time listed, indicated R#1 had spilled hot coffee on himself that morning and R#1 had complained of pain and blisters to the left side. The Physician indicated the left side of R#1 had second degree burns, blisters and redness. Hot Liquids Safety Evaluation for R#1 dated 9/2016 indicated risk factors: Cognition-moderately to severely impaired; Contractures in fingers/hands/wrists/elbows/or shoulders and weakness/paresis in upper extremities. R#1 was observed on 11/02/16 at 10:10 a.m. during the initial tour. The resident was in bed awake. The Assistant Director of Nurses (ADON) who accompanied the surveyor indicated R#1 was interviewable; required a hoyer/mechanical lift for transfers; had a [DIAGNOSES REDACTED]. LVN C (treatment nurse) indicated at 10:45 a.m. on 11/02/16 that R#1'[MEDICAL CONDITION] healed on his abdomen, under his abdominal folds and his upper thigh area. LVN C indicated there was only one open area on the lower thigh that was open. LVN C reported R#1 was in the shower room. After obtaining permission from R#1, the surveyor observed R#1 in the shower room covered up except for his left side. R#1 had a dark scar going down most of the left side of his thigh. An open area was observed on R#1's lower thigh. LVN C stated at this time, that she had measured the open area the day before and it measured 1.5 x 1.0 cm. R#1 was observed in the dining room on 11/02/16 at 11:55 a.m. The resident was utilizing his motorized wheelchair. R#1 was brought coffee in a regular cup and a plastic lid was placed on the cup. The coffee was given to R#1 by a CNA. During an interview on 11/02/16 at 1:00 p.m., R#1 showed the surveyor the mug he was using the day he was burned. The mug was a black, medium size mug and the lid fit tightly to the mug. R#1 stated he had taken off the lid when he got burned. During a telephone conversation with CNA B on 11/02/16 at 3:52 p.m., CNA B reported that she had passed out the breakfast tray and coffee to R#1 the day he was burned. CNA B stated it was around 7:40 a.m. when she had gotten a black mug of coffee for R#1. CNA B reported she had told R#1 that the coffee was very hot and for him not to remove the lid. CNA B stated she left R#1's room and a few minutes later she heard R#1 scream. CNA B added that R#1 usually ate in the dining room, but that morning his motorized wheelchair was not working. CNA B added she thought maybe the battery was not charged. She was not sure why the wheelchair was not working that morning, but that was the reason R#1 stayed in bed that morning. LVN A reported on 11/03/16 at 9:50 a.m., she had dining room duty the day R#1 spilled his coffee and was burned. LVN A stated the area was red and scalded, like an extra layer of skin. At approximately 10:00 a.m., she was notified by CNA B that R#1's skin now had blisters. LVN A stated R#1 denied having pain, but she (LVN A) knew R#1 must have had pain. R#1 had 15 blisters going down his left side, according to LVN A. LVN A stated she notified R#1's Physician and gave the resident pain medication. LVN A stated R#1's motorized wheelchair was not working the morning he was burned. She did not know if it had not been charged or what the problem was. LVN A stated she was not sure why R#1 did not go to the dining room that day. R#1 stated on 11/03/16 at 10:40 a.m. that the day before (11/02/16) was the first day he had been out of bed since he was burned. R#1 stated that sometimes staff would not charge the wheelchair and that it needed to be charged or it will die. R#1 stated he wanted to be up. The Director of Nurses (DON) stated on 11/03/16 at 3:52 p.m. that R#1 had told the DON that he was trying to turn the lid to where he could drink out of it, when he spilled the coffee and was burned. The DON added that if the spout had been turned to where R#1 could have drank out of it, he would not have had a problem. The DON stated R#1 likes to be independent and does not like to be asking for help all the time. The DON stated the staff are now taking the coffee temperatures before providing the coffee to the residents, but the staff had not taken the temperature of the coffee prior to the day R#1 was burned. The DON added a CNA was assigned to supervise the resident after he was burned while eating and drinking in bed. The DON stated R#1 was very social and liked eating in the dining room. The DON stated the staff that day told her R#1 wanted to stay in bed the day he was burned. The DON stated R#1 required set-up help since he was able to feed himself, but aslo needed to be checked on. Inservice Training Report dated 09/29/16 provided by the DON indicated all nursing and dietary staff were in-serviced on making sure all lids on cups and coffee cups were turned so resident could drink without having to readjust the lid. R#2 R#2's Face Sheet, undated indicated her last admission in the facility was 02/23/16. R#2's [DIAGNOSES REDACTED]. Incident/Accident Report dated 09/26/16 at 7:30 a.m. indicated R#2 was in her room when LVN E was called to R#2's room by a CNA because R#2 had spilled her coffee on herself. The report indicated R#2 was alert and oriented and that the resident's syrofoam cup had cracked and the resident had lost control of her cup. A head to toe assessment was done and no injuries were noted. The report indicated the resident had three blankets on her, so most of the coffee was absorbed by the blankets. The measure put in place was that the resident would no longer drink from a styrofoam cup. R#2 reported on 11/03/16 at 9:30 a.m. while she was in bed in her room that she had spilled hot coffee on herself, but did not get burned. R#2 added that staff are being more careful now. LVN A reported on 11/03/16 that she had been told by LVN E about R#2 spilling her coffee on her belly and that the blankets had saved her from being burned. LVN A reported the incident occurred shortly after R#1 was burned and that now styrofoam cups are not used. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: .although [MEDICAL CONDITION] happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person's perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third [MEDICAL CONDITION] 5 seconds. The facility's Policy and Procedure on Abuse-Reportable Events, revised 08/2016 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility's Policy and Procedure on Precautions for Hot Beverages, revised 01/2016 indicated this home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. A suggested monitoring procedure for hot beverages is as follows: Intial temperature is taken when the beverage/liquid is placed into the serving container. If the temperature is above 170 degrees F, the beverage/liquid is allowed to cool to the serving temperature of 150 degrees-160 degrees F before served to dining room. Do not serve coffee or cocoa below 130 degrees F for palatability. An IJ was determined to have existed from 09/21/16 through 10/01/16. The Non Compliance was removed on 10/01/16 because observation, interview and record review indicated the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids were set up appropriately for residents' use by having the drinking spout in the correct position. The facility took the following action to correct the noncompliance: Dietary Aide (DA) D reported on 11/03/16 at 9:12 a.m. that the dietary aides were now taking coffee temperatures before providing coffee to the residents. DA D stated the coffee temperature must be 150-160 degrees F (Farenheit) in the kitchen. DA D stated the dietary aides had been in-serviced and written up since the coffee temperatures were not being taken prior to R#1 being burned. DA D stated the coffee temperatures had been taken consistently starting in October. DA D showed the surveyor documentation of the coffee temperatures indicating the temperatures were taken beginning 10/01/16. DA D stated R#1 had his own personal coffee mug and tried to adjust the lid when he spilled the coffee. Inservice Training Report dated 09/26/16 provided by the Dietary Consultant indicated dietary staff had received an in-service on hot liquids. The facility's Form CMS-672, RESIDENT CENSUS AND CONDITIONS OF RESIDENTS dated 11/02/16 indicated there were 36 residents who required assistance of one or two staff during eating.

Based on observation, record review and interview, the facility failed to implement policies and procedures that prohibit neglect for two Resident (R#1 and R#2) out of five residents reviewed for neglect. The facility did not provide supervision for R1 and R2 during handling of hot coffee while in bed and did not ensure coffee was served at a safe temperature to [MEDICAL CONDITION] spilled on a resident. R#1 sustained 2nd [MEDICAL CONDITION] he spilled hot coffee while in bed. Five days later R#2 spilled coffee on herself. These failures contributed to R#1 sustaining second [MEDICAL CONDITION] his left side of the lower abdomen, upper left thigh and lower left thigh. An Immediate Jeopardy (IJ) was determined to have existed from 09/21/16 through 10/01/16. The non-compliance was identified as past non-compliance since the facility recognized the failure and took corrective action to correct the non-compliance before the survey began. The Non Compliance was removed on 10/01/16 because the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids are set up appropriately for residents' use by having the drinking spout in the correct position. Failure to take temperatures of hot liquids could affect the 36 residents who required assistance of one or two staff during eating. The findings were: R#1's Face Sheet dated 09/23/16 indicated R#1's latest return to the facility was on 02/04/15. R#1's [DIAGNOSES REDACTED]. The Face Sheet indicated R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had unclear speech; was usually understood and had the ability to usually understand others. R#1 was unable to report the correct year, month or day. The MDS indicated R#1 required extensive physical assistance by two or more persons for bed mobility, transfers and toilet use. The MDS indicated for eating he required supervision (oversight, encouragement or cueing) and set-up help only. R#1's Functional Limitation in Range of Motion indicated he had impairment to one side of his upper extremities and impairment on both sides of the lower extremities. The MDS indicated R#1's mobility device was a wheelchair (manual or electric.) R#1's Care Plan dated on 06/30/16 and reviewed again on 09/21/16 indicated R#1 had Cognitive loss/Dementia and had impaired decision making. One approach listed was that staff was to determine if decisions made by R#1 could endanger him or others. Another Care Plan for R#1 Start date 01/05/16, reviewed 06/30/16, 09/30/16 and 09/21/16 for Dehydration/Fluid Maintenance indicated an approach was Assist with fluids as needed. R#1's Care Plan reviewed on 06/30/16 and again on 09/21/16 indicated R#1 required an electric wheelchair for mobility due to [MEDICAL CONDITION]. Incident/Accident Report on R#1 dated 09/21/16 at 8:00 a.m. indicated R#1 was trying to take the lid of the coffee and spilled the coffee on the left side of his abdomen and his thigh. Further reciew of Incident/Accident Final Disposition Report dated 09/21/16 indicated measures put in place were that dietary staff was to check the temperatures of hot liquids and were to keep a log; lids on hot liquids would continue to be used; inservices for dietary staff on keeping the temperatures and logs was provided by the Dietary Consultant and dietary and nursing staff were to make sure that all cups with lids were set up appropriately for residents to use with hole/spout in correct position. Further review of Suggested Investigative Action Plan dated 09/21/16 under the heading, Complete Analysis concluded that the incident could have possibly been avoided by assuring the drink spout was in the correct position and by assuring the proper temperature on the coffee. Nursing Documentation Record (NDR) dated 09/21/16 at 8:00 a.m. indicated R#1 had spilled hot coffee and had redness to the left thigh. The note indicated the resident stated he was trying to take the lid off the cup when he spilled the coffee. The note indicated the resident denied pain at this time. The note was written by Licensed Vocational Nurse (LVN) A. NDR dated 09/21/16 at 10:00 a.m. indicated LVN A had been notified by Certified Nurse Aide (CNA) B that R#1 had blisters to the burn area. LVN A wrote scalding and approximately 15 fluid filled blisters were noted. LVN A wrote R#1 complained of moderate pain and that she had given the resident pain medication for comfort and R#1 was turned to the opposite side. At this time, LVN A wrote that she had notified the Physician and the Responsible Party. NDR dated 09/21/16 at 5:00 p.m. indicated the Physician Assistant (PA) F was at the facility doing rounds. A new order indicated to use [MEDICATION NAME] AAA twice a day for seven days and to cover [MEDICAL CONDITION] a dry dressing, for the [DIAGNOSES REDACTED]. The new order also included [MEDICATION NAME](antibiotic) 500 mg (milligrams) twice a day for seven days. Skin Assessment Flow Sheet-Non-Pressure Injury Conditions (SAFS) dated 09/21/16 indicated R#1 had open blisters to the lower abdomen approximately 2.0 cm (centimeters) x 4.0 cm and fluid filled blisters 8.0 cm x 4.0 cm; the upper thigh had open blisters 12.0 cm x 3.5 cm and the lower thigh had fluid filled blisters approximately 6.0 cm x 5.0 cm. On 11/01/16, documentation on the SAFS indicated the left side of the abdomen had resolved and there remained an open area on the lower left thigh approximately 1.5 cm x 1.0 cm. for which R#1 was still receiving treatment. The Physician's Progress Note date 09/21/16, no time listed, indicated R#1 had spilled hot coffee on himself that morning and R#1 had complained of pain and blisters to the left side. The Physician indicated the left side of R#1 had second degree burns, blisters and redness. Hot Liquids Safety Evaluation for R#1 dated 9/2016 indicated risk factors: Cognition-moderately to severely impaired; Contractures in fingers/hands/wrists/elbows/or shoulders and weakness/paresis in upper extremities. R#1 was observed on 11/02/16 at 10:10 a.m. during the initial tour. The resident was in bed awake. The Assistant Director of Nurses (ADON) who accompanied the surveyor indicated R#1 was interviewable; required a hoyer/mechanical lift for transfers; had a [DIAGNOSES REDACTED]. LVN C (treatment nurse) indicated at 10:45 a.m. on 11/02/16 that R#1'[MEDICAL CONDITION] healed on his abdomen, under his abdominal folds and his upper thigh area. LVN C indicated there was only one open area on the lower thigh that was open. LVN C reported R#1 was in the shower room. After obtaining permision from R#1, the surveyor observed R#1 in the shower room covered up except for his left side. R#1 had a dark scar going down most of the left side of his thigh. An open area was observed on R#1's lower thigh. LVN C stated at this time, that she had measured the open area the day before and it measured 1.5 x 1.0 cm. R#1 was observed in the dining room on 11/02/16 at 11:55 a.m. The resident was utilizing his motorized wheelchair. R#1 was brought coffee in a regular cup and a plastic lid was placed on the cup. The coffee was given to R#1 by a CNA. During an interview on 11/02/16 at 1:00 p.m., R#1 showed the surveyor the mug he was using the day he was burned. The mug was a black, medium size mug and the lid fit tightly to the mug. R#1 stated he had taken off the lid when he got burned. During a telephone conversation with CNA B on 11/02/16 at 3:52 p.m., CNA B reported that she had passed out the breakfast tray and coffee to R#1 the day he was burned. CNA B stated it was around 7:40 a.m. when she had gotten a black mug of coffee for R#1. CNA B reported she had told R#1 that the coffee was very hot and for him not to remove the lid. CNA B stated she left R#1's room and a few minutes later she heard R#1 scream. CNA B added that R#1 usually ate in the dining room, but that morning his motorized wheelchair was not working. CNA B added she thought maybe the battery was not charged. She was not sure why the wheelchair was not working that morning, but that was the reason R#1 stayed in bed that morning. LVN A reported on 11/03/16 at 9:50 a.m., she had dining room duty the day R#1 spilled his coffee and was burned. LVN A stated the area was red and scalded, like an extra layer of skin. At approximately 10:00 a.m., she was notified by CNA B that R#1's skin now had blisters. LVN A stated R#1 denied having pain, but she (LVN A) knew R#1 must have had pain. R#1 had 15 blisters going down his left side, according to LVN A. LVN A stated she notified R#1's Physician and gave the resident pain medication. LVN A stated R#1's motorized wheelchair was not working the morning he was burned. She did not know if it had not been charged or what the problem was. LVN A stated she was not sure why R#1 did not go to the dining room that day. R#1 stated on 11/03/16 at 10:40 a.m. that the day before (11/02/16) was the first day he had been out of bed since he was burned. R#1 stated that sometimes staff would not charge the wheelchair and that it needed to be charged or it will die. R#1 stated he wanted to be up. The Director of Nurses (DON) stated on 11/03/16 at 3:52 p.m. that R#1 had told the DON that he was trying to turn the lid to where he could drink out of it, when he spilled the coffee and was burned. The DON added that if the spout had been turned to where R#1 could have drank out of it, he would not have had a problem. The DON stated R#1 likes to be independent and does not like to be asking for help all the time. The DON stated the staff are now taking the coffee temperatures before providing the coffee to the residents, but the staff had not taken the temperature of the coffee prior to the day R#1 was burned. The DON added a CNA was assigned to supervise the resident after he was burned while eating and drinking in bed. The DON stated R#1 was very social and liked eating in the dining room. The DON stated the staff that day told her R#1 wanted to stay in bed the day he was burned. The DON stated R#1 required set-up help since he was able to feed himself, but aslo needed to be checked on. Inservice Training Report dated 09/29/16 provided by the DON indicated all nursing and dietary staff were in-serviced on making sure all lids on cups and coffee cups were turned so resident could drink without having to readjust the lid. R#2 R#2's Face Sheet, undated indicated her last admission in the facility was 02/23/16. R#2's [DIAGNOSES REDACTED]. Incident/Accident Report dated 09/26/16 at 7:30 a.m. indicated R#2 was in her room when LVN E was called to R#2's room by a CNA because R#2 had spilled her coffee on herself. The report indicated R#2 was alert and oriented and that the resident's syrofoam cup had cracked and the resident had lost control of her cup. A head to toe assessment was done and no injuries were noted. The report indicated the resident had three blankets on her, so most of the coffee was absorbed by the blankets. The measure put in place was that the resident would no longer drink from a styrofoam cup. R#2 reported on 11/03/16 at 9:30 a.m. while she was in bed in her room that she had spilled hot coffee on herself, but did not get burned. R#2 added that staff are being more careful now. LVN A reported on 11/03/16 that she had been told by LVN E about R#2 spilling her coffee on her belly and that the blankets had saved her from being burned. LVN A reported the incident occurred shortly after R#1 was burned and that now styrofoam cups are not used. Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by Moritz, AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous burns. M J Pathol 1947; 23:695-720. and Stone, M, Ahmed J, Evans J. The continuing risk of domestic hot water scalds to the elderly.[MEDICAL CONDITION]; 26:347-350.: .although [MEDICAL CONDITION] happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds .sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person's perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third [MEDICAL CONDITION] 5 seconds. The facility's Policy and Procedure on Abuse-Reportable Events, revised 08/2016 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility's Policy and Procedure on Precautions for Hot Beverages, revised 01/2016 indicated this home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. A suggested monitoring procedure for hot beverages is as follows: Intial temperature is taken when the beverage/liquid is placed into the serving container. If the temperature is above 170 degrees F, the beverage/liquid is allowed to cool to the serving temperature of 150 degrees-160 degrees F before served to dining room. Do not serve coffee or cocoa below 130 degrees F for palatability. An IJ was determined to have existed from 09/21/16 through 10/01/16. The Non Compliance was removed on 10/01/16 because observation, interview and record review indicated the dietary staff started taking the coffee temperatures and were in-serviced on keeping temperature logs. Dietary and nursing staff were in-serviced on making sure that all cups with lids were set up appropriately for residents' use by having the drinking spout in the correct position. The facility took the following action to correct the non compliance: Dietary Aide (DA) D reported on 11/03/16 at 9:12 a.m. that the dietary aides were now taking coffee temperatures before providing coffee to the residents. DA D stated the coffee temperature must be 150-160 degrees F (Farenheit) in the kitchen. DA D stated the dietary aides had been in-serviced and written up since the coffee temperatures were not being taken prior to R#1 being burned. DA D stated the coffee temperatures had been taken consistently starting in October. DA D showed the surveyor documentation of the coffee temperatures. The temperature logs showed coffee temperatures were measured consistently since 10/01/16. DA D stated R#1 had his own personal coffee mug and tried to adjust the lid when he spilled the coffee. Inservice Training Report dated 09/26/16 provided by the Dietary Consultant indicated dietary staff had received an in-service on hot liquids. The facility's Form CMS-672, RESIDENT CENSUS AND CONDITIONS OF RESIDENTS dated 11/02/16 indicated there were 36 residents who required assistance of one or two staff during eating.

Based on Observation, Interview and Record Review, the facility failed to implement their procedures that would prevent the neglect of two Residents, R#2 and R#4, out of six residents reviewed for neglect. R#2: The facility did not ensure R#2 had her walker in reach when she was out of bed and she fell and fractured her hip. This failure could affect 16 residents who had a history of [REDACTED]. R#4: The facility did not implement procedures to supervise R#4 in the shower when the Certified Nurse Aide (CNA) turned away from R#4 in the shower. R#4 fell from the chair. After the first fall, the facility did not implement interventions or complete an accurate assessment to prevent additional falls. This failure could affect 75 residents who needed assistance of one or two staff with bathing. The findings were: R#2: Review of R#2's Resident Admission Record (undated) revealed that she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 had a history of [REDACTED]. R#2 was [AGE] years old. Review of Admission Progress Notes dated 04/29/15 revealed R#2 was admitted from another nursing home with a history of seizures; ambulatory with a rolling walker and was a high fall risk; and had a [DIAGNOSES REDACTED]. Review of R#2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 points, indicating that R#2 had severe cognitive impairment, with no acute change in mental status. R#2 needed extensive assistance with aid of one person when transferring and walking in the corridor, but only limited assistance (guiding and maneuvering) when walking in her room. R#2 was always incontinent of bowel and bladder. Review of Hospital Discharge Summary dated 12/28/15 revealed R#2 had a left femur (thigh bone) neck fracture at the time of hospital admission on 12/22/15. On initial tour on 12/29/15 at 2:35 p.m., Licensed Vocational Nurse (LVN) B said that R#2 had returned from the hospital on [DATE] after falling at the facility and breaking her left femur. LVN B said that R#2 had a total hip replacement. LVN B said that R#2's fall was unwitnessed and it happened over the weekend. LVN B said that R#2 looked dazed often, had to be redirected often, and cried out a lot for her grandson. LVN B said that R#2 had poor kidney function, was almost in the range for dialysis, and easily lost her balance. LVN B said that R#2 stayed in the living room of the memory unit a lot and looked out the window. Surveyor observed that R#2 was not in her room at the time that LVN B was describing R#2's condition and characteristics. Surveyor observed that R#2's bed was at regular height and there was no mat beside her bed. Observation of R#2 on 12/29/15 at 2:45 p.m. in the dining room of the Memory Unit revealed R#2 was sitting in a wheelchair at a table with other residents. R#2 had bruises on her right arm and hand. LVN C, who was in the dining room with other residents, said that R#2 pulled out intravenous (IV) needles while in the hospital and was on blood thinners which may have caused the bruising. R#2's eyes were closed. Surveyor asked R#2 if she was in pain, and she shook her head no. R#2 did not respond to any other questions. In an interview on 12/30/15 at 10:45 a.m., the Director of Nurses (DON) said that Registered Nurse (RN) E was on duty at the time that R#2 fell in the living room on 12/20/15. The DON said that R#2 was just coming back from a shoulder injury and was walking with no touch assistance. The DON said that part of the current fall precautions was placing a mat next to R#2's bed. The DON said that their facility did not use bed alarms or chair alarms as a fall prevention. The DON said that their facility did not provide one to one supervision with residents. History of Falls: 08/18/15: Review of Incident report dated 08/18/15 revealed R#2 had a fall and fractured her humerus (shoulder). In an Interview on 12/20/15 at 10:45 a m., the DON said that on 08/18/15, R#2 fell on the floor of the dining room and could not respond to the nurse who found her. The nurse was outside the dining room door. The DON said that a person who was cleaning responded to R#2 and called for help. Review of Care Plan Problems with Problem Start Date 08/28/15 included these categories: *Give resident verbal reminders not to ambulate/transfer without assistance *Cognitive Loss/Dementia *Falls *Psychotropic Drug Use *Falls related to R#2 receiving Anticonvulsant medication for treatment of [REDACTED]. Review of the Care Plan for falls with a start date of 08/28/15 revealed R#2 had an actual fall causing a fracture of her right humerus on 08/18/15. Care Plan Approaches included: *Send to ER (emergency room ) for eval (evaluation) and treat (treatment) *UA/C&S (Urinalysis with Culture and Sensitivity) *Dilantin Level *PT(Physical Therapy)/OT(Occupational Therapy) eval *Analyze resident's falls to determine pattern/trend *Observe frequently and place in supervised area when out of bed Review of Lab Report dated 09/11/15 revealed R#2 had a slightly low level of Dilantin at 9.9 ug/mL (microgram per milliliter), with a reference range of 10.0 to 20.0. Review of Medications Flowsheet for September, 2015 revealed order for Clonazepam, .25 mg twice daily for [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. *Dilantin levels to be checked once a month between the first and 31st of the month for a [DIAGNOSES REDACTED]. *A change in Dilantin dose effective 09/07/15 to Dilantin Extended capsule; 100 mg; 1 cap three times a day, for a total of 300 milligrams daily. Review of WebMD Understanding the Symptoms of Absence (Petit Mal) Seizure on 01/22/16 revealed the following symptoms of Absence Seizure: Typical: Absence seizures begin abruptly, last 10 to 30 seconds, and resolve themselves without complication. The person stops in his tracks (and/or mid-sentence), and enters a staring, trance-like state during which he is unresponsive and unaware of his surroundings. Atypical: Similar to typical seizures, but tend to begin more slowly, last longer and can include slumping or falling down. The person may also feel confused for a short time after regaining consciousness. 09/29/15: Review of Progress Notes revealed on 09/29/15 at 11:50 p.m., R#2 was found lying on the floor with a pillow under her bottom. Her head was at the foot of the bed. She had no injury and was put back in bed. Review of R#2's Care Plan revealed no updates. Review of Care Conference Report dated 10/07/15 revealed R#2 had a change in mental status and required more assistance with ADLs. R#2 used a wheelchair for mobility, was at risk for falls. There was no documentation of fall on 09/29/15. Review of Physician Z note dated 10/17/15 revealed no new orders for Dilantin dosage. 10/13/15: Review of Incident Report dated 10/13/15 signed by the DON revealed R#2 was found on the floor at 2:40 a.m., lying flat on her stomach with her face on the floor, between the foot of her bed and dresser; R#2 got up unassisted and lost her balance and fell . Measures in place on the Incident Report were: *Encourage the resident to use the call light or ask for help when wanting or needing to ambulate *Follow up on Dilantin level *PT/OT to review safety *Mat at bedside Review of Hospital exam notes dated 10/13/15 revealed R#2 had extensive swelling around the left face and left orbit with no acute facial fractures. Review of Falls Care Plan updated on 10/13/15 revealed additional measures: *Sent to ER for eval *UA (with) C&S Review of UA/C&S Lab Report dated 10/28/15 revealed no sign of infection. Review of 24 Hour Report revealed no new instructions regarding safety of R#2 other than initiation of neuro checks. In an interview at 2:00 p.m. on 01/13/16, LVN B said that R#2 fell out of bed on 10/13/15 and was found a few steps away from her bed. LVN B said that she was walking through the hall outside R#2's room and heard a trash can slide. LVN B said that she found R#2 face down on the floor. LVN B said that R#2 was not able to tell her how the fall happened but R#2 did not attempt to break her fall as she fell face down and hit her lip, which bled a great deal. LVN B said that she thought it was strange that R#2 did not attempt to break her fall with her hands. When asked if R#2 could have had a seizure, LVN B replied that R#2 had never had a seizure and the Dilantin was given as a precaution. LVN B said that she assessed R#2 and she showed no signs of having had a seizure, like losing her bowels. In the interview on 2:00 p.m. on 01/13/16, LVN B said that R#2 could not remember to use her call light but she often put that as an approach on care plans because she thought it should be on the care plan. Review of Lab Report dated 10/08/15 revealed R#2 had a low Dilantin level of 5.7 ug/mL, with a reference range of 10.0 to 20.0. Review of Lab Report dated 11/13/15 revealed R#2 had a low Dilantin level of 6.4 ug/mL, with a reference range of 10.0 to 20.0. Comments on the report were Currently on Dilantin Extended cap 100 mg (milligram) TID (three times a day). No seizures? Review of Lab Report dated 12/08/15 revealed R#2 had a low Dilantin level of 3.8 ug/mL with a reference range of 10.0 to 20.0. Comments on the report were Currently on Dilantin Extended 100 mg 1 cap (capsule) tid (three times daily). Increase Dilantin 100 mg 2 tablets BID (twice daily). Recheck level in one week. Noted 12/20/15. In an interview at 12:00 on 01/13/16, when asked why one approach on R#2's Falls Care Plan was to follow-up on her Dilantin level, since there were sometimes no changes to the dosage of Dilantin, LVN L said that if a resident had a fall and was on Dilantin, the facility followed a certain protocol from the physician. LVN L said Physician Z had his own guidelines for Dilantin levels if there was a concern regarding the mental state of a resident. 12/20/15: Review of Incident/Accident Report dated 12/20/15 revealed R#2 fell in the living room at 6:45 p.m. The fall was not witnessed. Review of Hospital Radiology Report dated 12/21/15 revealed R#2 had an impacted subcapital left femoral neck fracture. In an interview at 10:25 a.m. on 12/30/15, RN E said that on 12/20/15 at about 6:45 p.m. she was passing medications down the hall from the living room in the Memory Unit. RN E said that CNA F was passing snacks with another resident who was asking for a snack in his room. RN E said that it was just the two of them working on the Memory Unit at that time. RNE said that R#2 was found by CNA F lying on her left side inside the living room of the Memory Unit and R#2's walker and wheelchair were not within reach. RN E said that R#2 liked to ambulate with putting her hands out in front of her holding onto the wall. RN E said that R#2 required someone to put her hands onto the walker when she was getting up because she would forget to take her walker with her. RN E said that R#2 walked holding onto the hand rail and had to be redirected constantly to sit down. In an interview at 10:20 a.m. on 01/14/16, RN E said that there were no new instructions regarding safety on the 24 hour report when R#2 was released from Physical Therapy as of 12/18/15. RN E said that she worked only on weekends and there was no one in the therapy department to ask about R#2. RN E said that CNA F was sitting with R#2 on 12/20/15 in the living room and CNA F got up to get a snack for another resident, leaving R#2 unsupervised in the living room. RN E said that R#2 was very impulsive and would not use her walker, but would stand and hold onto the wall. RN E said that R#2 would put her hands out to hold onto something and would sometimes walk by herself. In the interview at 10:20 a.m. on 01/14/16, RN E said that she was aware of R#2's decline in Dilantin level. RN E said that she showed R#2's Physician a report of R#2's Dilantin level (RN E could not remember date) and the Physician said that there would be no new orders. In the interview at 10:20 a.m. on 01/14/16, RN E said that she worked doubles on the weekends and usually had only one CNA to assist residents in the Memory Unit. RN E said that she had brought up concerns about needing more CNAs in the Memory Unit to the DON and was told that they were in the process of hiring more CNAs. In an interview on 12/30/15 at 2:30 p.m., Certified Nurse Aide (CNA) F said she found R#2 on the floor on 12/20/15 at about 6:45 p.m. CNA F said that on 12/20/15, she was feeding another resident in his room and heard a loud bump on the floor and heard crying. CNA F said that she found R#2 on the floor in the living room. CNA F said that two other residents were in the living room and one of them, a non-interviewable resident, said that R#2 was jumping before she fell . CNA F said that R#2 did not have her walker or a wheelchair within reach. CNA F said that it was hard to keep R#2 occupied and R#2 was constantly on her feet, walking a lot. CNA F said that R#2 was almost like a one to one because it was hard for R#2 to remember to take her walker when she walked. In an interview at 10:45 a.m. on 01/14/16, CNA F said that she worked prn, or as needed. CNA F said that on the evening of 12/20/15, she was sitting in the living room with R#2 and another resident started crying out that he wanted a snack. CNA F said that she went to assist the other resident with the snack because the other resident did not eat lunch, and would yell non-stop that he was hungry until someone fed him. CNA F said that she had no specific safety intructions regarding R#2, and no one told her R#2 needed to have her walker near her at all times. CNA F said that she was away in the other resident's room about five minutes. CNA F said that at the time of R#2's fall on 12/20/15, R#2's walker was in the living room but not parked near where R#2 was sitting. CNA F said that there might have been another CNA working at the time that R#2 fell , but she did not remember, and it was common sense that more than one CNA needed to work at one time. CNA F said that there was only so much that she could do; one resident would get fed or changed at a time. CNA F said that it was common on weekends that they would be short-handed and it was hard to keep track of all of the residents in the Memory Unit. CNA F said that management was aware of this problem. Review of Employee Sign In Sheet dated 12/20/15 revealed RN E and CNA F worked the two to ten shift, and CNA H left at 6:00 p.m. In an interview on 12/20/15 at 11:50 a.m., the DON said that there were two CNAs and one nurse in the Memory Unit and there were plenty of people to care for the residents. In an interview on 12/30/15 at 11:45 a.m., Physical Therapist Assistant (PTA) D said that R#2 received physical therapy until 12/18/15. PTA D said that R#2 was able to ambulate with a four wheel walker but needed verbal cues to take her walker when she began walking and to also lock the brakes on the walker when she stopped. PTA D said that R#2 was at the supervision level upon discharge from physical therapy on 12/18/15, meaning she was not independent but needed someone to ensure that she took her walker with her when she got up to walk and to also remind her to put on her brakes when she stopped. PTA D said that R#2 had physical therapy from September, 2015 to December, 2015 and had made a lot of progress. Review of PT-Therapist Progress & Discharge Summary End of Goal Status as of 12/19/15: Bed Mobility from Supine to Sitting: The patient requires 4 -wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) Gait Tasks, Assistive Devices: The patient requires 4-wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) for safe ambulation for 150 feet. Transfer, General: The patient is able to safely complete all functional transfers requiring supervision (routinely requires supervision, verbal cueing and demonstration, but no physical assistance to transfer). Review of Incident Report dated 12/21/15, Description of the Allegation, revealed Resident resides in nursing home with no special supervision other than secure unit. ADLs (Activities of Daily Living) with minimal assistance. Discontinued from Therapies PT, OT and ST (Speech Therapy) on 12/19/15 where resident was ambulating with supervision. Review of Progress Notes dated 12/28/15 revealed R#2 was readmitted to the facility following a total hip replacement. The Readmission Care Plan indicated call bell within reach, encourage use of call light, assess footwear for non-skid soles. Review of Progress Notes dated 12/28/15 revealed bed in lowest position; tries to get up. Review of Progress Notes dated 12/29/15 revealed Cont. F/U (follow-up) for readmission. When in bed needs redirection because attempts to get OOB (out of bed). Observation of ten residents on 12/30/15 at 10:00 a.m. in the living room of the Memory Unit for three minutes revealed no staff members present. R#2 moved to edge of her wheelchair. LVN B arrived and redirected her to scoot back in her wheelchair. In an interview at 3:10 p.m. on 01/14/16, when asked what supervision meant, PTA D said that it meant to observe them, like reminding them to put on shoes if they were walking in their socks. When asked if there was any different meaning if the resident was in the memory unit, PTA D said no, supervision just meant reminding them. In an interview at 11:30 a.m. on 01/14/16, PTA D said that she attended morning meetings with the nursing staff and discussed residents at these meetings. PTA D said that the therapy plan of care was conveyed to nursing staff who worked directly with residents through notes in the medical record, care plan meetings, and by educating staff verbally and training them in how to provide care to residents. PTA D said that therapy staff worked Monday through Friday usually and it was up to the weekday nursing staff to pass on information to weekend nursing staff regarding safety concerns or instructions from therapy regarding patient care. In an interview at 11:45 a.m. on 01/14/16, the MDS Nurse, LVN K, said that patient information was conveyed to weekend staff by writing the information on the 24 Hour Report. Review of the 24 Hour Report for December 20, 2015, revealed R#2 was discharged from physical therapy but there was no information regarding changes in safety instructions or level of supervision for R#2. Review of 24 Hour Reports for November 1-30, 2015 revealed R#2 needed redirection to use rolling walker on 11/02/15 and 11/03/15, but no other information regarding R#2 needing mobility aids. Review of Physical Therapy Progress Notes dated 10/19/15 revealed [DIAGNOSES REDACTED]. Patient requires rolling walker and contact guard. Review of Physical Therapy Progress Notes dated 11/05/15 revealed R#2 required a rolling walker and standby assist (close enough to reach patient if assist was needed) for safe ambulation 150 feet. Review of Therapist Progress and Discharge Summary dated 12/19/15 revealed under Impact on Burden of Care/Daily Life Needs assist c (with) amb (ambulation). Review of Nursing Assistant Care Plan dated 05/16/15 revealed R#2 needed a rolling walker as an aid in mobility, and required assistance from one staff member with positioning and transfer. Review of Nursing Assistant Care Plan dated 09/28/15 revealed R#2 needed assistance with transfer and positioning from one staff person and required no aids in mobility. Review of Nursing Assistant Care Plan dated 12/28/15 revealed R#2 needed one person assistance with transfer, positioning, and no aids in mobility. In an interview on 01/14/16 at 11:50 a.m., PTA D said that once a week, therapist notes were put in resident charts and nursing staff were told verbally on a daily basis of any updates on residents. PTA D said that R#2 needed visual cueing, and someone needed to keep their eyes on her, not just reminding her to use her walker. PTA D said that residents in the Memory Unit were different than those who just needed verbal reminders. In an interview on 01/14/16 at 11:45 a.m., LVN K looked through the Nursing Assistant Care Plan ADL (Activities of Daily Living) Log Book and said that she did not see any instructions to the nurse aides who cared for R#2 other than the Nursing Assistant Care Plans dated 05/16/15, 09/28/15 and 12/28/15. LVN K said that the Nursing Assistant Care Plans were revised after care plan meetings when needed. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 had a potential therapy discharge date of [DATE]. The meeting notes were signed by the Administrator, DON, PTA D and LVN K. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 would be discharged within the next week. There were no notes regarding changes in her care or care plan. In an interview on 01/14/16 at 4:25 p.m., when asked how information is communicated to the CNAs and nurses who are responsible for resident care, the DON said that she was responsible to communicate information to the charge nurses and they would communicate to the CNAs. The DON said that they would all update CNA ADL Care Plans and that they would be updated yearly or at the time of a resident's significant change. Observation at 4:30 p.m. on 12/30/15 revealed R#2 sitting in the living room alone in a chair (not her wheelchair). In an interview at 4:35 p.m. on 12/30/15 in the hallway outside the living room, CNA G said that R#2 stayed in a stationary chair better than her wheelchair. CNA G said that there was always someone sitting next to R#2 except for now when we are moving residents. In an interview on 01/13/16 at 12:30 p.m., LVN K said that supervision of residents meant that the resident needed to be in an area that they could be visually looked at. Review of Hospital Discharge Care Plan dated 12/28/15 revealed PT (patient) will have audible alarm intact in bed and chair. In an interview on 01/14/16 at 4:25 p.m., when asked if she obtained a clarification order regarding the Discharge Care Plan for a bed and chair alarm, the DON replied that their facility did not use bed and chair alarms and a clarification order was not needed because the Discharge Order was not the same as a Physician Order. Review of Admission Care Plan dated 12/28/15 revealed the following approaches for fall prevention: *Keep call bell in reach *Encourage use of call light *Instruct resident on safety measures *Assess resident's footwear for proper fit and no skid soles. Review of Falls Care Plan dated 01/05/16 revealed the following approaches: *Administer my Dilantin per order and monitor my lab levels. *Observe frequently and place in supervised area when out of bed. *Give me verbal reminders not to ambulate/transfer without assistance *Monitor my lab values for therapeutic ranges as ordered by my physician. Review of Lab Report dated 12/29/15 revealed R#2's Dilantin level was 2.7 ug/mL. Comments on the report were Currently Dilantin 100 mg tid. Any new orders? 12/30/15: Cont (continue) (with) same Rx (prescription) and recheck in 1 week. 12/30/15: (change) to Dilantin 100 mg (two) caps to equal 200 mg bid. Review of Progress Notes dated 12/30/15 signed by the DON revealed Physician Z said that R#2 was on Dilantin related to her CVA (Cardiovascular Accident-Stroke) for prevention of seizures associated with CVA. He said he will get her up to therapeutic level. Review of physician progress notes [REDACTED].#2's Dilantin dose previously when low levels were reported in lab work because the nursing facility reported no seizure activity and R#2 was already mentally impaired. Review of hospital History and Physical dated 01/07/16 revealed R#2 was admitted to the hospital and her Dilantin level was .8. R#2 was admitted to the hospital for IV (intravenous) fluids and surgical consult for a possible Gastrostomy Tube (feeding tube). Review of physician progress notes [REDACTED]. R#2 was still in the hospital and the order was withdrawn; order would be given when R#2 returned from the hospital. In an interview on 01/14/16 at 4:25 p.m., the DON said that R#2's Epilepsy was related to her having a CVA, and it had a ICD 10 code which was a generalized code. When asked how to tell if an unwitnessed fall might have been caused by a seizure, the DON replied that from nursing experience, after a seizure the person had a postictal state (altered state of consciousness), in which they would lose control of their bowels. The DON said that if a resident had a high Dilantin level, they would get lethargic and the physician would not want the Dilantin level to get too high as it could cause grogginess. In the interview on 01/14/16 at 4:25 p.m., the DON said that she had not heard any complaints about staffing in the Memory Unit or elsewhere in the facility. When asked if there was a procedure in place or a policy regarding what action was needed when a resident needed one-on-one care, the DON said that the facility did not do one-to-one care long term. The DON said that one-to-one care would be done if there was a resident who was trying to harm themselves or others, and one-to-one care was needed short term until they could go into the hospital. When asked if R#2 needed one-to-one care, the DON responded that R#2 did not require one-to-one care. The DON said that if they could not meet a resident's needs, they would send them to the hospital, talk with the family and physician, and also talk with the Ombudsman. The DON said that she did not do this with R#2 because she did not think they could not meet R#2's needs. Review of CMS Form 802 dated 12/29/15 revealed 16 residents with a history of falls. R#4 Review of R#4's Resident Admission Record revealed she was an [AGE] year old female was admitted to the facility on [DATE] and readmitted on [DATE]. R#4's [DIAGNOSES REDACTED]. R#4 was [AGE] years old. Review of R#4's MDS dated [DATE] revealed R#4 had moderate cognitive impairment. R#4 required extensive assistance (resident involved in activity, staff provide weight bearing support) and two person physical assistance for bed mobility, transfers, toilet use and personal hygiene. R #4 required physical help for bathing and one person ' s physical assistance for support. R#4 did not walk, and her balance during transitions and walking was not steady. R #4 was only able to stabilize with staff assistance. R #4 ' s MDS indicated she had fallen within the last two to six months prior to admission or reentry. Review of the PT (Physical Therapy) Plan of Care dated 07/20/15 R #4 ended PT on 07/20/15 with a sitting balance of P Dynamic (unable to maintain balance without moderate/maximum (mod/max) support. Review of the facility's Incident/Accident report dated 07/22/15 revealed CNA I heard R #4 yelling and went to check on her. R #4 was on the floor on her right side. The charge nurse was notified. A head to toe assessment was completed. R #4 had a hematoma over her left eye brow area, swollen upper lip and swelling to her left knee. Blood from R #4 ' s mouth was cleaned and she was helped to bed. R #4 was sent to the emergency room (ER) for evaluation. The report revealed R #4 returned from the ER with bruising to her face. An undated witness statement by CNA I revealed she heard R #4 yelling. CNA I found R #4 on the floor in her room. The form indicated CNA I called the charge nurse. R #4's Fall Risk Assessment Form dated 07/22/15 revealed a score of 20. The form indicated a score of 10 or more was indicative of a high risk for falls. According to the facility's Incident/ Accident Report dated 08/06/15 Licensed Vocational Nurse (LVN) L heard a loud noise and then a scream. The report indicated LVN L went to R #4's Room and found her on the floor in the bathroom. The interview with staff revealed the CNA put R #4 on the toilet and left R#4 alone. The CNA instructed R #4 to use the call lights when she was ready. R #4 had skin tear on her left forearm about one centimeter (cm) in length. Care was provided at the facility and it was determined R #4 stood up from the toilet and fell down. In-services were provided to the CNA's on the importance of not leaving a resident unattended in bathroom. On 01/14/16 at 2:00 p.m. LVN L said on 08/06/15 she found R #4 in her room on the floor in the bathroom. R #4 told her she CNA I placed her on the toilet and did not return. R #4 said she tried to get up but fell off the toilet. LVN L stated she remembered R #4 had an adult undergarment on and having to clean her up after the fall. She stated R #4 was very impulsive and had high levels of anxiety and poor memory. LVN L said R #4 was not able to take instruction. LVN L stated R #4 should not have been left alone on the toilet because she was impulsive. LVN L said she told her charge nurse and provided a statement as to what occurred. LVN L said she was familiar with the facility policy regarding abuse/neglect and reportable incidents. She stated there was not an investigation and the incident should been reported based on the facility policy and state regulation. Review of the PT (Physical Therapy) therapist progress note and Discharge summary dated 09/09/15 revealed R #4 started PT on 08/20/15 with a sitting balance of P Dynamic (unable to maintain balance without moderate/maximum (mod/max) support, mod/max to reach ipsilateral (belonging to or occurring on the same side of the body) side and unable to cross midline). On 09/09/15 R #4 was discharged from PT with a sitting balance of P Dynamic. Review of R#4's MDS dated [DATE] revealed R#4 had severe cognitive impairment. R#4 required extensive assistance (resident involved in activity, staff provide weight bearing support) and two person physical assistance for bed mobility, transfers, toilet use and extensive assistance and one person physical assistance for personal hygiene. R #4 required physical help for bathing and one

Based on observation, record review and interview, the facility failed to implement their written policy and procedures stating that any allegation of mistreatment of [REDACTED].#1, R#2 and R#4) of six residents reviewed for mistreatment. The facility did not investigate or report to state officials R#1's allegation of verbal abuse. The facility did not thoroughly investigate R#2's fall in which she did not have her walker in reach when she was out of bed and she fell and fractured her hip. The facility did not report to state officials R#4's fall and subsequent injury to her face and eye. Failure to investigate and to report the allegation to state officials could lead to further mistreatment of [REDACTED]. The findings were: The facility's Abuse and Neglect Policy, effective date 01/2008 and revised on 05/2014 indicated verbal abuse was the use of oral, written, or gestured language that includes disparaging derogatory terms to a resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. The policy stated under Investigation that the charge nurse will assess the resident and notify the Administrator or the DON, if the Administrator is not available, of an allegation or suspicion of abuse immediately. The charge nurse will begin taking written statements from the person reporting the allegation or suspicion and any witnesses including staff, family and/or residents. The policy also stated the Abuse Coordinator would review all aspects of the investigation as soon as possible and would ensure all the reports were complete and would direct any disciplinary action that was required. The policy also stated that all alleged allegations of abuse would be reported to the appropriate state agency and to all other agencies as required by regulation. R#1: R#1's Resident Admission Record, undated indicated R#1 was admitted on [DATE] and readmitted on [DATE] with some of his [DIAGNOSES REDACTED]. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech; was understood; and had the ability to understand others. According to the MDS, R#1 was oriented to the day, month and year. R#1 was independent with eating with set up help only. R#1's Care Plan, revised on 12/02/15 indicated he was able to feed himself after his tray was set up. One of the approaches listed was to encourage independence and to praise R#1 when independent attempts were made. Complaint Investigation Worksheet, received date 11/30/15 indicated kitchen staff (KS A) was very rude when he was asked for anything. The complainant was anonymous. The Food Services Supervisor (FSS) reported on 12/30/15 at 11:17 a.m. that Kitchen Staff (KS) A was terminated from his job due to cursing at R#1. The FSS stated the Activity Director (AD) was having the resident council meeting and the AD called her into the meeting. R#1 made the allegation that KS A would refuse to give him coffee and that he had cursed at him. FSS added other residents stated KS A would say there was no cheese if they requested a cheese sandwich and would deny them coffee also. The FSS stated KS A denied the allegation and refused to sign his termination papers. R#1 was observed on 12/30/15 at 11:45 a.m. R#1 stated at that same time, that KS A told him there was no more coffee and told him, vete a la shingada de agui (get the hell out of here.) R#1 added he did not remember the date the incident occurred, but it had been reported to the Administrator. R#1 stated he had not seen KS A any longer in the facility, and thought KS A was terminated. Review of the facility's Incident/Accident Report logs for November and December 2015 did not indicate an incident on the allegation concerning R#1. Notice of Disciplinary Action on KS A dated 12/01/15 indicated KS A violated the abuse and neglect policy. The notice stated one of the residents had asked for coffee and KS A responded there was no more coffee and to get the hell out of the way. The notice also stated other residents complained they were told there was no more food. The action taken was termination effective 12/01/15. The employee and Administrator's signatures were left blank. The Notice of Disciplinary Action was signed by the FSS and the AD dated 12/02/15. Attached to the notice was a handwritten note by the AD dated 12/01/15. The note stated the residents were having a resident council meeting when one of the residents complained about the cook telling a resident there was no more coffee and to get the hell out of the way. The AD added she immediately invited the FSS to the meeting. The Administrator stated on 12/30/15 at 2:35 p.m. that she was told KS A told R#1 that something was not available, but she was not aware of the allegation that KS A had cursed at R#1. The Administrator stated she had not seen the Note of Disciplinary Action. The Administrator added that was why her signature was not on the notice. The Administrator stated the write up is all the information they had on the incident and there was no other investigation done, nor was the allegation reported to state officials. The Administrator stated staff should know to report to her any allegation of abuse, since staff received training on abuse and neglect. The Director of Nurses (DON) stated on 12/30/15 at 2:45 p.m. that she heard about the incident while in the dining room, but did not hear of the details. The DON stated there was no investigation and that the FSS had said KS A was fired because he was not being nice to the residents. The DON added she did not know the exact date the incident occurred and the incident had not been reported to state officials. The AD stated on 12/30/15 at 3:45 p.m. that during the resident council meeting on 12/01/15, she was going over the resident rights with the residents when R#1 alleged KS A was always rude and had told him to get the hell out of the way. The AD stated she went and brought the FSS to the meeting so she could hear the allegations. The AD stated other residents also stated KS A was mean and would not give them coffee when they asked. The AD stated she did not know when the incident occurred but felt it had occurred recent to the day of the allegation since R#1 was still upset by it. The AD added the FSS had reported the incident to the Administrator and they made the decision to terminate KS A. R#1 was observed on 12/31/15 at 9:30 a.m. in the dining room heading toward the kitchen with his coffee mug. R#1 was observed requesting coffee. The facility's Form CMS-672, Resident Census and Conditions of Residents dated 12/29/15 indicated there were eight residents in the facility who were independent in eating. R#2: Review of R#2's Resident Admission Record (undated) revealed that she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 had a history of [REDACTED]. R#2 was [AGE] years old. Review of Admission Progress Notes dated 04/29/15 revealed R#2 was admitted from another nursing home with a history of [MEDICAL CONDITION]; ambulatory with a rolling walker and was a high fall risk; and had a [DIAGNOSES REDACTED]. Review of R#2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 points, indicating that R#2 had severe cognitive impairment, with no acute change in mental status. R#2 needed extensive assistance with aid of one person when transferring and walking in the corridor, but only limited assistance (guiding and maneuvering) when walking in her room. R#2 was always incontinent of bowel and bladder. Review of Hospital Discharge Summary dated 12/28/15 revealed R#2 had a left femur (thigh bone) neck fracture at the time of hospital admission on 12/22/15. On initial tour on 12/29/15 at 2:35 p.m., Licensed Vocational Nurse (LVN) B said that R#2 had returned from the hospital on [DATE] after falling at the facility and breaking her left femur. LVN B said that R#2 had a total hip replacement. LVN B said that R#2's fall was unwitnessed and it happened over the weekend. LVN B said that R#2 looked dazed often, had to be redirected often, and cried out a lot for her grandson. LVN B said that R#2 had poor kidney function, was almost in the range for [MEDICAL TREATMENT], and easily lost her balance. LVN B said that R#2 stayed in the living room of the memory unit a lot and looked out the window. Surveyor observed that R#2 was not in her room at the time that LVN B was describing R#2's condition and characteristics. Surveyor observed that R#2's bed was at regular height and there was no mat beside her bed. Observation of R#2 on 12/29/15 at 2:45 p.m. in the dining room of the Memory Unit revealed R#2 was sitting in a wheelchair at a table with other residents. R#2 had bruises on her right arm and hand. LVN C, who was in the dining room with other residents, said that R#2 pulled out intravenous (IV) needles while in the hospital and was on blood thinners which may have caused the bruising. R#2's eyes were closed. Surveyor asked R#2 if she was in pain, and she shook her head no. R#2 did not respond to any other questions. In an interview on 12/30/15 at 10:45 a.m., the Director of Nurses (DON) said that Registered Nurse (RN) E was on duty at the time that R#2 fell in the living room on 12/20/15. The DON said that R#2 was just coming back from a shoulder injury and was walking with no touch assistance. The DON said that part of the current fall precautions was placing a mat next to R#2's bed. The DON said that their facility did not use bed alarms or chair alarms as a fall prevention. The DON said that their facility did not provide one to one supervision with residents. History of Falls: 08/18/15: Review of Incident report dated 08/18/15 revealed R#2 had a fall and fractured her humerus (shoulder). In an Interview on 12/20/15 at 10:45 a m., the DON said that on 08/18/15, R#2 fell on the floor of the dining room and could not respond to the nurse who found her. The nurse was outside the dining room door. The DON said that a person who was cleaning responded to R#2 and called for help. Review of Care Plan Problems with Problem Start Date 08/28/15 included these categories: *Give resident verbal reminders not to ambulate/transfer without assistance *Cognitive Loss/Dementia *Falls *[MEDICAL CONDITION] Drug Use *Falls related to R#2 receiving Anticonvulsant medication for treatment of [REDACTED]. Review of the Care Plan for falls with a start date of 08/28/15 revealed R#2 had an actual fall causing a fracture of her right humerus on 08/18/15. Care Plan Approaches included: *Send to ER (emergency room ) for eval (evaluation) and treat (treatment) *UA/C&S (Urinalysis with Culture and Sensitivity) *[MEDICATION NAME] Level *PT(Physical Therapy)/OT(Occupational Therapy) eval *Analyze resident's falls to determine pattern/trend *Observe frequently and place in supervised area when out of bed Review of Lab Report dated 09/11/15 revealed R#2 had a slightly low level of [MEDICATION NAME] at 9.9 ug/mL (microgram per milliliter), with a reference range of 10.0 to 20.0. Review of Medications Flowsheet for September, 2015 revealed order for [MEDICATION NAME], .25 mg twice daily for [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. *[MEDICATION NAME] levels to be checked once a month between the first and 31st of the month for a [DIAGNOSES REDACTED]. *A change in [MEDICATION NAME] dose effective 09/07/15 to [MEDICATION NAME] Extended capsule; 100 mg; 1 cap three times a day, for a total of 300 milligrams daily. Review of WebMD Understanding the Symptoms of Absence (Petit Mal) [MEDICAL CONDITION] on 01/22/16 revealed the following symptoms of Absence [MEDICAL CONDITION]: Typical: Absence [MEDICAL CONDITION] begin abruptly, last 10 to 30 seconds, and resolve themselves without complication. The person stops in his tracks (and/or mid-sentence), and enters a staring, trance-like state during which he is unresponsive and unaware of his surroundings. Atypical: Similar to typical [MEDICAL CONDITION], but tend to begin more slowly, last longer and can include slumping or falling down. The person may also feel confused for a short time after regaining consciousness. 09/29/15: Review of Progress Notes revealed on 09/29/15 at 11:50 p.m., R#2 was found lying on the floor with a pillow under her bottom. Her head was at the foot of the bed. She had no injury and was put back in bed. Review of R#2's Care Plan revealed no updates. Review of Care Conference Report dated 10/07/15 revealed R#2 had a change in mental status and required more assistance with ADLs. R#2 used a wheelchair for mobility, was at risk for falls. There was no documentation of fall on 09/29/15. Review of Physician Z note dated 10/17/15 revealed no new orders for [MEDICATION NAME] dosage. 10/13/15: Review of Incident Report dated 10/13/15 signed by the DON revealed R#2 was found on the floor at 2:40 a.m., lying flat on her stomach with her face on the floor, between the foot of her bed and dresser; R#2 got up unassisted and lost her balance and fell . Measures in place on the Incident Report were: *Encourage the resident to use the call light or ask for help when wanting or needing to ambulate *Follow up on [MEDICATION NAME] level *PT/OT to review safety *Mat at bedside Review of Hospital exam notes dated 10/13/15 revealed R#2 had extensive swelling around the left face and left orbit with no acute facial fractures. Review of Falls Care Plan updated on 10/13/15 revealed additional measures: *Sent to ER for eval *UA (with) C&S Review of UA/C&S Lab Report dated 10/28/15 revealed no sign of infection. Review of 24 Hour Report revealed no new instructions regarding safety of R#2 other than initiation of neuro checks. In an interview at 2:00 p.m. on 01/13/16, LVN B said that R#2 fell out of bed on 10/13/15 and was found a few steps away from her bed. LVN B said that she was walking through the hall outside R#2's room and heard a trash can slide. LVN B said that she found R#2 face down on the floor. LVN B said that R#2 was not able to tell her how the fall happened but R#2 did not attempt to break her fall as she fell face down and hit her lip, which bled a great deal. LVN B said that she thought it was strange that R#2 did not attempt to break her fall with her hands. When asked if R#2 could have had a [MEDICAL CONDITION], LVN B replied that R#2 had never had a [MEDICAL CONDITION] and the [MEDICATION NAME] was given as a precaution. LVN B said that she assessed R#2 and she showed no signs of having had a [MEDICAL CONDITION], like losing her bowels. In the interview on 2:00 p.m. on 01/13/16, LVN B said that R#2 could not remember to use her call light but she often put that as an approach on care plans because she thought it should be on the care plan. Review of Lab Report dated 10/08/15 revealed R#2 had a low [MEDICATION NAME] level of 5.7 ug/mL, with a reference range of 10.0 to 20.0. Review of Lab Report dated 11/13/15 revealed R#2 had a low [MEDICATION NAME] level of 6.4 ug/mL, with a reference range of 10.0 to 20.0. Comments on the report were Currently on [MEDICATION NAME] Extended cap 100 mg (milligram) TID (three times a day). No [MEDICAL CONDITION]? Review of Lab Report dated 12/08/15 revealed R#2 had a low [MEDICATION NAME] level of 3.8 ug/mL with a reference range of 10.0 to 20.0. Comments on the report were Currently on [MEDICATION NAME] Extended 100 mg 1 cap (capsule) tid (three times daily). Increase [MEDICATION NAME] 100 mg 2 tablets BID (twice daily). Recheck level in one week. Noted 12/20/15. In an interview at 12:00 on 01/13/16, when asked why one approach on R#2's Falls Care Plan was to follow-up on her [MEDICATION NAME] level, since there were sometimes no changes to the dosage of [MEDICATION NAME], LVN L said that if a resident had a fall and was on [MEDICATION NAME], the facility followed a certain protocol from the physician. LVN L said Physician Z had his own guidelines for [MEDICATION NAME] levels if there was a concern regarding the mental state of a resident. 12/20/15: Review of Incident/Accident Report dated 12/20/15 revealed R#2 fell in the living room at 6:45 p.m. The fall was not witnessed. Review of Hospital Radiology Report dated 12/21/15 revealed R#2 had an impacted subcapital left femoral neck fracture. In an interview at 10:25 a.m. on 12/30/15, RN E said that on 12/20/15 at about 6:45 p.m. she was passing medications down the hall from the living room in the Memory Unit. RN E said that CNA F was passing snacks with another resident who was asking for a snack in his room. RN E said that it was just the two of them working on the Memory Unit at that time. RNE said that R#2 was found by CNA F lying on her left side inside the living room of the Memory Unit and R#2's walker and wheelchair were not within reach. RN E said that R#2 liked to ambulate with putting her hands out in front of her holding onto the wall. RN E said that R#2 required someone to put her hands onto the walker when she was getting up because she would forget to take her walker with her. RN E said that R#2 walked holding onto the hand rail and had to be redirected constantly to sit down. In an interview at 10:20 a.m. on 01/14/16, RN E said that there were no new instructions regarding safety on the 24 hour report when R#2 was released from Physical Therapy as of 12/18/15. RN E said that she worked only on weekends and there was no one in the therapy department to ask about R#2. RN E said that CNA F was sitting with R#2 on 12/20/15 in the living room and CNA F got up to get a snack for another resident, leaving R#2 unsupervised in the living room. RN E said that R#2 was very impulsive and would not use her walker, but would stand and hold onto the wall. RN E said that R#2 would put her hands out to hold onto something and would sometimes walk by herself. In the interview at 10:20 a.m. on 01/14/16, RN E said that she was aware of R#2's decline in [MEDICATION NAME] level. RN E said that she showed R#2's Physician a report of R#2's [MEDICATION NAME] level (RN E could not remember date) and the Physician said that there would be no new orders. In the interview at 10:20 a.m. on 01/14/16, RN E said that she worked doubles on the weekends and usually had only one CNA to assist residents in the Memory Unit. RN E said that she had brought up concerns about needing more CNAs in the Memory Unit to the DON and was told that they were in the process of hiring more CNAs. In an interview on 12/30/15 at 2:30 p.m., Certified Nurse Aide (CNA) F said she found R#2 on the floor on 12/20/15 at about 6:45 p.m. CNA F said that on 12/20/15, she was feeding another resident in his room and heard a loud bump on the floor and heard crying. CNA F said that she found R#2 on the floor in the living room. CNA F said that two other residents were in the living room and one of them, a non-interviewable resident, said that R#2 was jumping before she fell . CNA F said that R#2 did not have her walker or a wheelchair within reach. CNA F said that it was hard to keep R#2 occupied and R#2 was constantly on her feet, walking a lot. CNA F said that R#2 was almost like a one to one because it was hard for R#2 to remember to take her walker when she walked. In an interview at 10:45 a.m. on 01/14/16, CNA F said that she worked prn, or as needed. CNA F said that on the evening of 12/20/15, she was sitting in the living room with R#2 and another resident started crying out that he wanted a snack. CNA F said that she went to assist the other resident with the snack because the other resident did not eat lunch, and would yell non-stop that he was hungry until someone fed him. CNA F said that she had no specific safety intructions regarding R#2, and no one told her R#2 needed to have her walker near her at all times. CNA F said that she was away in the other resident's room about five minutes. CNA F said that at the time of R#2's fall on 12/20/15, R#2's walker was in the living room but not parked near where R#2 was sitting. CNA F said that there might have been another CNA working at the time that R#2 fell , but she did not remember, and it was common sense that more than one CNA needed to work at one time. CNA F said that there was only so much that she could do; one resident would get fed or changed at a time. CNA F said that it was common on weekends that they would be short-handed and it was hard to keep track of all of the residents in the Memory Unit. CNA F said that management was aware of this problem. Review of Employee Sign In Sheet dated 12/20/15 revealed RN E and CNA F worked the two to ten shift, and CNA H left at 6:00 p.m. In an interview on 12/20/15 at 11:50 a.m., the DON said that there were two CNAs and one nurse in the Memory Unit and there were plenty of people to care for the residents. In an interview on 12/30/15 at 11:45 a.m., Physical Therapist Assistant (PTA) D said that R#2 received physical therapy until 12/18/15. PTA D said that R#2 was able to ambulate with a four wheel walker but needed verbal cues to take her walker when she began walking and to also lock the brakes on the walker when she stopped. PTA D said that R#2 was at the supervision level upon discharge from physical therapy on 12/18/15, meaning she was not independent but needed someone to ensure that she took her walker with her when she got up to walk and to also remind her to put on her brakes when she stopped. PTA D said that R#2 had physical therapy from September, 2015 to December, 2015 and had made a lot of progress. Review of PT-Therapist Progress & Discharge Summary End of Goal Status as of 12/19/15: Bed Mobility from Supine to Sitting: The patient requires 4 -wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) Gait Tasks, Assistive Devices: The patient requires 4-wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) for safe ambulation for 150 feet. Transfer, General: The patient is able to safely complete all functional transfers requiring supervision (routinely requires supervision, verbal cueing and demonstration, but no physical assistance to transfer). Review of Incident Report dated 12/21/15, Description of the Allegation, revealed Resident resides in nursing home with no special supervision other than secure unit. ADLs (Activities of Daily Living) with minimal assistance. Discontinued from Therapies PT, OT and ST (Speech Therapy) on 12/19/15 where resident was ambulating with supervision. Review of Progress Notes dated 12/28/15 revealed R#2 was readmitted to the facility following a total hip replacement. The Readmission Care Plan indicated call bell within reach, encourage use of call light, assess footwear for non-skid soles. Review of Progress Notes dated 12/28/15 revealed bed in lowest position; tries to get up. Review of Progress Notes dated 12/29/15 revealed Cont. F/U (follow-up) for readmission. When in bed needs redirection because attempts to get OOB (out of bed). Observation of ten residents on 12/30/15 at 10:00 a.m. in the living room of the Memory Unit for three minutes revealed no staff members present. R#2 moved to edge of her wheelchair. LVN B arrived and redirected her to scoot back in her wheelchair. In an interview at 3:10 p.m. on 01/14/16, when asked what supervision meant, PTA D said that it meant to observe them, like reminding them to put on shoes if they were walking in their socks. When asked if there was any different meaning if the resident was in the memory unit, PTA D said no, supervision just meant reminding them. In an interview at 11:30 a.m. on 01/14/16, PTA D said that she attended morning meetings with the nursing staff and discussed residents at these meetings. PTA D said that the therapy plan of care was conveyed to nursing staff who worked directly with residents through notes in the medical record, care plan meetings, and by educating staff verbally and training them in how to provide care to residents. PTA D said that therapy staff worked Monday through Friday usually and it was up to the weekday nursing staff to pass on information to weekend nursing staff regarding safety concerns or instructions from therapy regarding patient care. In an interview at 11:45 a.m. on 01/14/16, the MDS Nurse, LVN K, said that patient information was conveyed to weekend staff by writing the information on the 24 Hour Report. Review of the 24 Hour Report for December 20, 2015, revealed R#2 was discharged from physical therapy but there was no information regarding changes in safety instructions or level of supervision for R#2. Review of 24 Hour Reports for November 1-30, 2015 revealed R#2 needed redirection to use rolling walker on 11/02/15 and 11/03/15, but no other information regarding R#2 needing mobility aids. Review of Physical Therapy Progress Notes dated 10/19/15 revealed [DIAGNOSES REDACTED]. Patient requires rolling walker and contact guard. Review of Physical Therapy Progress Notes dated 11/05/15 revealed R#2 required a rolling walker and standby assist (close enough to reach patient if assist was needed) for safe ambulation 150 feet. Review of Therapist Progress and Discharge Summary dated 12/19/15 revealed under Impact on Burden of Care/Daily Life Needs assist c (with) amb (ambulation). Review of Nursing Assistant Care Plan dated 05/16/15 revealed R#2 needed a rolling walker as an aid in mobility, and required assistance from one staff member with positioning and transfer. Review of Nursing Assistant Care Plan dated 09/28/15 revealed R#2 needed assistance with transfer and positioning from one staff person and required no aids in mobility. Review of Nursing Assistant Care Plan dated 12/28/15 revealed R#2 needed one person assistance with transfer, positioning, and no aids in mobility. In an interview on 01/14/16 at 11:50 a.m., PTA D said that once a week, therapist notes were put in resident charts and nursing staff were told verbally on a daily basis of any updates on residents. PTA D said that R#2 needed visual cueing, and someone needed to keep their eyes on her, not just reminding her to use her walker. PTA D said that residents in the Memory Unit were different than those who just needed verbal reminders. In an interview on 01/14/16 at 11:45 a.m., LVN K looked through the Nursing Assistant Care Plan ADL (Activities of Daily Living) Log Book and said that she did not see any instructions to the nurse aides who cared for R#2 other than the Nursing Assistant Care Plans dated 05/16/15, 09/28/15 and 12/28/15. LVN K said that the Nursing Assistant Care Plans were revised after care plan meetings when needed. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 had a potential therapy discharge date of [DATE]. The meeting notes were signed by the Administrator, DON, PTA D and LVN K. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 would be discharged within the next week. There were no notes regarding changes in her care or care plan. In an interview on 01/14/16 at 4:25 p.m., when asked how information is communicated to the CNAs and nurses who are responsible for resident care, the DON said that she was responsible to communicate information to the charge nurses and they would communicate to the CNAs. The DON said that they would all update CNA ADL Care Plans and that they would be updated yearly or at the time of a resident's significant change. Observation at 4:30 p.m. on 12/30/15 revealed R#2 sitting in the living room alone in a chair (not her wheelchair). In an interview at 4:35 p.m. on 12/30/15 in the hallway outside the living room, CNA G said that R#2 stayed in a stationary chair better than her wheelchair. CNA G said that there was always someone sitting next to R#2 except for now when we are moving residents. In an interview on 01/13/16 at 12:30 p.m., LVN K said that supervision of residents meant that the resident needed to be in an area that they could be visually looked at. Review of Hospital Discharge Care Plan dated 12/28/15 revealed PT (patient) will have audible alarm intact in bed and chair. In an interview on 01/14/16 at 4:25 p.m., when asked if she obtained a clarification order regarding the Discharge Care Plan for a bed and chair alarm, the DON replied that their facility did not use bed and chair alarms and a clarification order was not needed because the Discharge Order was not the same as a Physician Order. Review of Admission Care Plan dated 12/28/15 revealed the following approaches for fall prevention: *Keep call bell in reach *Encourage use of call light *Instruct resident on safety measures *Assess resident's footwear for proper fit and no skid soles. Review of Falls Care Plan dated 01/05/16 revealed the following approaches: *Administer my [MEDICATION NAME] per order and monitor my lab levels. *Observe frequently and place in supervised area when out of bed. *Give me verbal reminders not to ambulate/transfer without assistance *Monitor my lab values for therapeutic ranges as ordered by my physician. Review of Lab Report dated 12/29/15 revealed R#2's [MEDICATION NAME] level was 2.7 ug/mL. Comments on the report were Currently [MEDICATION NAME] 100 mg tid. Any new orders? 12/30/15: Cont (continue) (with) same Rx (prescription) and recheck in 1 week. 12/30/15: (change) to [MEDICATION NAME] 100 mg (two) caps to equal 200 mg bid. Review of Progress Notes dated 12/30/15 signed by the DON revealed Physician Z said that R#2 was on [MEDICATION NAME] related to [MEDICAL CONDITION](Cardiovascular Accident-Stroke) for prevention of [MEDICAL CONDITION] associated with [MEDICAL CONDITION]. He said he will get her up to therapeutic level. Review of physician progress notes [REDACTED].#2's [MEDICATION NAME] dose previously when low levels were reported in lab work because the nursing facility reported no [MEDICAL CONDITION] activity and R#2 was already mentally impaired. Review of hospital History and Physical dated 01/07/16 revealed R#2 was admitted to the hospital and her [MEDICATION NAME] level was .8. R#2 was admitted to the hospital for IV (intravenous) fluids and surgical consult for a possible Gastrostomy Tube (feeding tube). Review of physician progress notes [REDACTED].

Based on Observation, Interview and Record Review, the facility failed to implement their procedures that would prevent the neglect of two Residents, R#2 and R#4, out of six residents reviewed for neglect. R#2: The facility did not ensure R#2 had her walker in reach when she was out of bed and she fell and fractured her hip. This failure could affect 16 residents who had a history of [REDACTED]. R#4: The facility did not implement procedures to supervise R#4 in the shower when the Certified Nurse Aide (CNA) turned away from R#4 in the shower. R#4 fell from the chair. After the first fall, the facility did not implement interventions or complete an accurate assessment to prevent additional falls. This failure could affect 75 residents who needed assistance of one or two staff with bathing. The findings were: R#2: Review of R#2's Resident Admission Record (undated) revealed that she was admitted to the facility on [DATE] and readmitted from the hospital on [DATE]. R#2's [DIAGNOSES REDACTED]. R#2 had a history of [REDACTED]. R#2 was [AGE] years old. Review of Admission Progress Notes dated 04/29/15 revealed R#2 was admitted from another nursing home with a history of [MEDICAL CONDITION]; ambulatory with a rolling walker and was a high fall risk; and had a [DIAGNOSES REDACTED]. Review of R#2's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of five out of 15 points, indicating that R#2 had severe cognitive impairment, with no acute change in mental status. R#2 needed extensive assistance with aid of one person when transferring and walking in the corridor, but only limited assistance (guiding and maneuvering) when walking in her room. R#2 was always incontinent of bowel and bladder. Review of Hospital Discharge Summary dated 12/28/15 revealed R#2 had a left femur (thigh bone) neck fracture at the time of hospital admission on 12/22/15. On initial tour on 12/29/15 at 2:35 p.m., Licensed Vocational Nurse (LVN) B said that R#2 had returned from the hospital on [DATE] after falling at the facility and breaking her left femur. LVN B said that R#2 had a total hip replacement. LVN B said that R#2's fall was unwitnessed and it happened over the weekend. LVN B said that R#2 looked dazed often, had to be redirected often, and cried out a lot for her grandson. LVN B said that R#2 had poor kidney function, was almost in the range for [MEDICAL TREATMENT], and easily lost her balance. LVN B said that R#2 stayed in the living room of the memory unit a lot and looked out the window. Surveyor observed that R#2 was not in her room at the time that LVN B was describing R#2's condition and characteristics. Surveyor observed that R#2's bed was at regular height and there was no mat beside her bed. Observation of R#2 on 12/29/15 at 2:45 p.m. in the dining room of the Memory Unit revealed R#2 was sitting in a wheelchair at a table with other residents. R#2 had bruises on her right arm and hand. LVN C, who was in the dining room with other residents, said that R#2 pulled out intravenous (IV) needles while in the hospital and was on blood thinners which may have caused the bruising. R#2's eyes were closed. Surveyor asked R#2 if she was in pain, and she shook her head no. R#2 did not respond to any other questions. In an interview on 12/30/15 at 10:45 a.m., the Director of Nurses (DON) said that Registered Nurse (RN) E was on duty at the time that R#2 fell in the living room on 12/20/15. The DON said that R#2 was just coming back from a shoulder injury and was walking with no touch assistance. The DON said that part of the current fall precautions was placing a mat next to R#2's bed. The DON said that their facility did not use bed alarms or chair alarms as a fall prevention. The DON said that their facility did not provide one to one supervision with residents. History of Falls: 08/18/15: Review of Incident report dated 08/18/15 revealed R#2 had a fall and fractured her humerus (shoulder). In an Interview on 12/20/15 at 10:45 a m., the DON said that on 08/18/15, R#2 fell on the floor of the dining room and could not respond to the nurse who found her. The nurse was outside the dining room door. The DON said that a person who was cleaning responded to R#2 and called for help. Review of Care Plan Problems with Problem Start Date 08/28/15 included these categories: *Give resident verbal reminders not to ambulate/transfer without assistance *Cognitive Loss/Dementia *Falls *[MEDICAL CONDITION] Drug Use *Falls related to R#2 receiving Anticonvulsant medication for treatment of [REDACTED]. Review of the Care Plan for falls with a start date of 08/28/15 revealed R#2 had an actual fall causing a fracture of her right humerus on 08/18/15. Care Plan Approaches included: *Send to ER (emergency room ) for eval (evaluation) and treat (treatment) *UA/C&S (Urinalysis with Culture and Sensitivity) *[MEDICATION NAME] Level *PT(Physical Therapy)/OT(Occupational Therapy) eval *Analyze resident's falls to determine pattern/trend *Observe frequently and place in supervised area when out of bed Review of Lab Report dated 09/11/15 revealed R#2 had a slightly low level of [MEDICATION NAME] at 9.9 ug/mL (microgram per milliliter), with a reference range of 10.0 to 20.0. Review of Medications Flowsheet for September, 2015 revealed order for [MEDICATION NAME], .25 mg twice daily for [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. *[MEDICATION NAME] levels to be checked once a month between the first and 31st of the month for a [DIAGNOSES REDACTED]. *A change in [MEDICATION NAME] dose effective 09/07/15 to [MEDICATION NAME] Extended capsule; 100 mg; 1 cap three times a day, for a total of 300 milligrams daily. Review of WebMD Understanding the Symptoms of Absence (Petit Mal) [MEDICAL CONDITION] on 01/22/16 revealed the following symptoms of Absence [MEDICAL CONDITION]: Typical: Absence [MEDICAL CONDITION] begin abruptly, last 10 to 30 seconds, and resolve themselves without complication. The person stops in his tracks (and/or mid-sentence), and enters a staring, trance-like state during which he is unresponsive and unaware of his surroundings. Atypical: Similar to typical [MEDICAL CONDITION], but tend to begin more slowly, last longer and can include slumping or falling down. The person may also feel confused for a short time after regaining consciousness. 09/29/15: Review of Progress Notes revealed on 09/29/15 at 11:50 p.m., R#2 was found lying on the floor with a pillow under her bottom. Her head was at the foot of the bed. She had no injury and was put back in bed. Review of R#2's Care Plan revealed no updates. Review of Care Conference Report dated 10/07/15 revealed R#2 had a change in mental status and required more assistance with ADLs. R#2 used a wheelchair for mobility, was at risk for falls. There was no documentation of fall on 09/29/15. Review of Physician Z note dated 10/17/15 revealed no new orders for [MEDICATION NAME] dosage. 10/13/15: Review of Incident Report dated 10/13/15 signed by the DON revealed R#2 was found on the floor at 2:40 a.m., lying flat on her stomach with her face on the floor, between the foot of her bed and dresser; R#2 got up unassisted and lost her balance and fell . Measures in place on the Incident Report were: *Encourage the resident to use the call light or ask for help when wanting or needing to ambulate *Follow up on [MEDICATION NAME] level *PT/OT to review safety *Mat at bedside Review of Hospital exam notes dated 10/13/15 revealed R#2 had extensive swelling around the left face and left orbit with no acute facial fractures. Review of Falls Care Plan updated on 10/13/15 revealed additional measures: *Sent to ER for eval *UA (with) C&S Review of UA/C&S Lab Report dated 10/28/15 revealed no sign of infection. Review of 24 Hour Report revealed no new instructions regarding safety of R#2 other than initiation of neuro checks. In an interview at 2:00 p.m. on 01/13/16, LVN B said that R#2 fell out of bed on 10/13/15 and was found a few steps away from her bed. LVN B said that she was walking through the hall outside R#2's room and heard a trash can slide. LVN B said that she found R#2 face down on the floor. LVN B said that R#2 was not able to tell her how the fall happened but R#2 did not attempt to break her fall as she fell face down and hit her lip, which bled a great deal. LVN B said that she thought it was strange that R#2 did not attempt to break her fall with her hands. When asked if R#2 could have had a [MEDICAL CONDITION], LVN B replied that R#2 had never had a [MEDICAL CONDITION] and the [MEDICATION NAME] was given as a precaution. LVN B said that she assessed R#2 and she showed no signs of having had a [MEDICAL CONDITION], like losing her bowels. In the interview on 2:00 p.m. on 01/13/16, LVN B said that R#2 could not remember to use her call light but she often put that as an approach on care plans because she thought it should be on the care plan. Review of Lab Report dated 10/08/15 revealed R#2 had a low [MEDICATION NAME] level of 5.7 ug/mL, with a reference range of 10.0 to 20.0. Review of Lab Report dated 11/13/15 revealed R#2 had a low [MEDICATION NAME] level of 6.4 ug/mL, with a reference range of 10.0 to 20.0. Comments on the report were Currently on [MEDICATION NAME] Extended cap 100 mg (milligram) TID (three times a day). No [MEDICAL CONDITION]? Review of Lab Report dated 12/08/15 revealed R#2 had a low [MEDICATION NAME] level of 3.8 ug/mL with a reference range of 10.0 to 20.0. Comments on the report were Currently on [MEDICATION NAME] Extended 100 mg 1 cap (capsule) tid (three times daily). Increase [MEDICATION NAME] 100 mg 2 tablets BID (twice daily). Recheck level in one week. Noted 12/20/15. In an interview at 12:00 on 01/13/16, when asked why one approach on R#2's Falls Care Plan was to follow-up on her [MEDICATION NAME] level, since there were sometimes no changes to the dosage of [MEDICATION NAME], LVN L said that if a resident had a fall and was on [MEDICATION NAME], the facility followed a certain protocol from the physician. LVN L said Physician Z had his own guidelines for [MEDICATION NAME] levels if there was a concern regarding the mental state of a resident. 12/20/15: Review of Incident/Accident Report dated 12/20/15 revealed R#2 fell in the living room at 6:45 p.m. The fall was not witnessed. Review of Hospital Radiology Report dated 12/21/15 revealed R#2 had an impacted subcapital left femoral neck fracture. In an interview at 10:25 a.m. on 12/30/15, RN E said that on 12/20/15 at about 6:45 p.m. she was passing medications down the hall from the living room in the Memory Unit. RN E said that CNA F was passing snacks with another resident who was asking for a snack in his room. RN E said that it was just the two of them working on the Memory Unit at that time. RNE said that R#2 was found by CNA F lying on her left side inside the living room of the Memory Unit and R#2's walker and wheelchair were not within reach. RN E said that R#2 liked to ambulate with putting her hands out in front of her holding onto the wall. RN E said that R#2 required someone to put her hands onto the walker when she was getting up because she would forget to take her walker with her. RN E said that R#2 walked holding onto the hand rail and had to be redirected constantly to sit down. In an interview at 10:20 a.m. on 01/14/16, RN E said that there were no new instructions regarding safety on the 24 hour report when R#2 was released from Physical Therapy as of 12/18/15. RN E said that she worked only on weekends and there was no one in the therapy department to ask about R#2. RN E said that CNA F was sitting with R#2 on 12/20/15 in the living room and CNA F got up to get a snack for another resident, leaving R#2 unsupervised in the living room. RN E said that R#2 was very impulsive and would not use her walker, but would stand and hold onto the wall. RN E said that R#2 would put her hands out to hold onto something and would sometimes walk by herself. In the interview at 10:20 a.m. on 01/14/16, RN E said that she was aware of R#2's decline in [MEDICATION NAME] level. RN E said that she showed R#2's Physician a report of R#2's [MEDICATION NAME] level (RN E could not remember date) and the Physician said that there would be no new orders. In the interview at 10:20 a.m. on 01/14/16, RN E said that she worked doubles on the weekends and usually had only one CNA to assist residents in the Memory Unit. RN E said that she had brought up concerns about needing more CNAs in the Memory Unit to the DON and was told that they were in the process of hiring more CNAs. In an interview on 12/30/15 at 2:30 p.m., Certified Nurse Aide (CNA) F said she found R#2 on the floor on 12/20/15 at about 6:45 p.m. CNA F said that on 12/20/15, she was feeding another resident in his room and heard a loud bump on the floor and heard crying. CNA F said that she found R#2 on the floor in the living room. CNA F said that two other residents were in the living room and one of them, a non-interviewable resident, said that R#2 was jumping before she fell . CNA F said that R#2 did not have her walker or a wheelchair within reach. CNA F said that it was hard to keep R#2 occupied and R#2 was constantly on her feet, walking a lot. CNA F said that R#2 was almost like a one to one because it was hard for R#2 to remember to take her walker when she walked. In an interview at 10:45 a.m. on 01/14/16, CNA F said that she worked prn, or as needed. CNA F said that on the evening of 12/20/15, she was sitting in the living room with R#2 and another resident started crying out that he wanted a snack. CNA F said that she went to assist the other resident with the snack because the other resident did not eat lunch, and would yell non-stop that he was hungry until someone fed him. CNA F said that she had no specific safety intructions regarding R#2, and no one told her R#2 needed to have her walker near her at all times. CNA F said that she was away in the other resident's room about five minutes. CNA F said that at the time of R#2's fall on 12/20/15, R#2's walker was in the living room but not parked near where R#2 was sitting. CNA F said that there might have been another CNA working at the time that R#2 fell , but she did not remember, and it was common sense that more than one CNA needed to work at one time. CNA F said that there was only so much that she could do; one resident would get fed or changed at a time. CNA F said that it was common on weekends that they would be short-handed and it was hard to keep track of all of the residents in the Memory Unit. CNA F said that management was aware of this problem. Review of Employee Sign In Sheet dated 12/20/15 revealed RN E and CNA F worked the two to ten shift, and CNA H left at 6:00 p.m. In an interview on 12/20/15 at 11:50 a.m., the DON said that there were two CNAs and one nurse in the Memory Unit and there were plenty of people to care for the residents. In an interview on 12/30/15 at 11:45 a.m., Physical Therapist Assistant (PTA) D said that R#2 received physical therapy until 12/18/15. PTA D said that R#2 was able to ambulate with a four wheel walker but needed verbal cues to take her walker when she began walking and to also lock the brakes on the walker when she stopped. PTA D said that R#2 was at the supervision level upon discharge from physical therapy on 12/18/15, meaning she was not independent but needed someone to ensure that she took her walker with her when she got up to walk and to also remind her to put on her brakes when she stopped. PTA D said that R#2 had physical therapy from September, 2015 to December, 2015 and had made a lot of progress. Review of PT-Therapist Progress & Discharge Summary End of Goal Status as of 12/19/15: Bed Mobility from Supine to Sitting: The patient requires 4 -wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) Gait Tasks, Assistive Devices: The patient requires 4-wheeled walker and supervision (oversight, encouragement, needs verbal cueing but no physical assist) for safe ambulation for 150 feet. Transfer, General: The patient is able to safely complete all functional transfers requiring supervision (routinely requires supervision, verbal cueing and demonstration, but no physical assistance to transfer). Review of Incident Report dated 12/21/15, Description of the Allegation, revealed Resident resides in nursing home with no special supervision other than secure unit. ADLs (Activities of Daily Living) with minimal assistance. Discontinued from Therapies PT, OT and ST (Speech Therapy) on 12/19/15 where resident was ambulating with supervision. Review of Progress Notes dated 12/28/15 revealed R#2 was readmitted to the facility following a total hip replacement. The Readmission Care Plan indicated call bell within reach, encourage use of call light, assess footwear for non-skid soles. Review of Progress Notes dated 12/28/15 revealed bed in lowest position; tries to get up. Review of Progress Notes dated 12/29/15 revealed Cont. F/U (follow-up) for readmission. When in bed needs redirection because attempts to get OOB (out of bed). Observation of ten residents on 12/30/15 at 10:00 a.m. in the living room of the Memory Unit for three minutes revealed no staff members present. R#2 moved to edge of her wheelchair. LVN B arrived and redirected her to scoot back in her wheelchair. In an interview at 3:10 p.m. on 01/14/16, when asked what supervision meant, PTA D said that it meant to observe them, like reminding them to put on shoes if they were walking in their socks. When asked if there was any different meaning if the resident was in the memory unit, PTA D said no, supervision just meant reminding them. In an interview at 11:30 a.m. on 01/14/16, PTA D said that she attended morning meetings with the nursing staff and discussed residents at these meetings. PTA D said that the therapy plan of care was conveyed to nursing staff who worked directly with residents through notes in the medical record, care plan meetings, and by educating staff verbally and training them in how to provide care to residents. PTA D said that therapy staff worked Monday through Friday usually and it was up to the weekday nursing staff to pass on information to weekend nursing staff regarding safety concerns or instructions from therapy regarding patient care. In an interview at 11:45 a.m. on 01/14/16, the MDS Nurse, LVN K, said that patient information was conveyed to weekend staff by writing the information on the 24 Hour Report. Review of the 24 Hour Report for December 20, 2015, revealed R#2 was discharged from physical therapy but there was no information regarding changes in safety instructions or level of supervision for R#2. Review of 24 Hour Reports for November 1-30, 2015 revealed R#2 needed redirection to use rolling walker on 11/02/15 and 11/03/15, but no other information regarding R#2 needing mobility aids. Review of Physical Therapy Progress Notes dated 10/19/15 revealed [DIAGNOSES REDACTED]. Patient requires rolling walker and contact guard. Review of Physical Therapy Progress Notes dated 11/05/15 revealed R#2 required a rolling walker and standby assist (close enough to reach patient if assist was needed) for safe ambulation 150 feet. Review of Therapist Progress and Discharge Summary dated 12/19/15 revealed under Impact on Burden of Care/Daily Life Needs assist c (with) amb (ambulation). Review of Nursing Assistant Care Plan dated 05/16/15 revealed R#2 needed a rolling walker as an aid in mobility, and required assistance from one staff member with positioning and transfer. Review of Nursing Assistant Care Plan dated 09/28/15 revealed R#2 needed assistance with transfer and positioning from one staff person and required no aids in mobility. Review of Nursing Assistant Care Plan dated 12/28/15 revealed R#2 needed one person assistance with transfer, positioning, and no aids in mobility. In an interview on 01/14/16 at 11:50 a.m., PTA D said that once a week, therapist notes were put in resident charts and nursing staff were told verbally on a daily basis of any updates on residents. PTA D said that R#2 needed visual cueing, and someone needed to keep their eyes on her, not just reminding her to use her walker. PTA D said that residents in the Memory Unit were different than those who just needed verbal reminders. In an interview on 01/14/16 at 11:45 a.m., LVN K looked through the Nursing Assistant Care Plan ADL (Activities of Daily Living) Log Book and said that she did not see any instructions to the nurse aides who cared for R#2 other than the Nursing Assistant Care Plans dated 05/16/15, 09/28/15 and 12/28/15. LVN K said that the Nursing Assistant Care Plans were revised after care plan meetings when needed. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 had a potential therapy discharge date of [DATE]. The meeting notes were signed by the Administrator, DON, PTA D and LVN K. Review of Weekly Medicare Meeting notes dated 12/17/15 revealed R#2 would be discharged within the next week. There were no notes regarding changes in her care or care plan. In an interview on 01/14/16 at 4:25 p.m., when asked how information is communicated to the CNAs and nurses who are responsible for resident care, the DON said that she was responsible to communicate information to the charge nurses and they would communicate to the CNAs. The DON said that they would all update CNA ADL Care Plans and that they would be updated yearly or at the time of a resident's significant change. Observation at 4:30 p.m. on 12/30/15 revealed R#2 sitting in the living room alone in a chair (not her wheelchair). In an interview at 4:35 p.m. on 12/30/15 in the hallway outside the living room, CNA G said that R#2 stayed in a stationary chair better than her wheelchair. CNA G said that there was always someone sitting next to R#2 except for now when we are moving residents. In an interview on 01/13/16 at 12:30 p.m., LVN K said that supervision of residents meant that the resident needed to be in an area that they could be visually looked at. Review of Hospital Discharge Care Plan dated 12/28/15 revealed PT (patient) will have audible alarm intact in bed and chair. In an interview on 01/14/16 at 4:25 p.m., when asked if she obtained a clarification order regarding the Discharge Care Plan for a bed and chair alarm, the DON replied that their facility did not use bed and chair alarms and a clarification order was not needed because the Discharge Order was not the same as a Physician Order. Review of Admission Care Plan dated 12/28/15 revealed the following approaches for fall prevention: *Keep call bell in reach *Encourage use of call light *Instruct resident on safety measures *Assess resident's footwear for proper fit and no skid soles. Review of Falls Care Plan dated 01/05/16 revealed the following approaches: *Administer my [MEDICATION NAME] per order and monitor my lab levels. *Observe frequently and place in supervised area when out of bed. *Give me verbal reminders not to ambulate/transfer without assistance *Monitor my lab values for therapeutic ranges as ordered by my physician. Review of Lab Report dated 12/29/15 revealed R#2's [MEDICATION NAME] level was 2.7 ug/mL. Comments on the report were Currently [MEDICATION NAME] 100 mg tid. Any new orders? 12/30/15: Cont (continue) (with) same Rx (prescription) and recheck in 1 week. 12/30/15: (change) to [MEDICATION NAME] 100 mg (two) caps to equal 200 mg bid. Review of Progress Notes dated 12/30/15 signed by the DON revealed Physician Z said that R#2 was on [MEDICATION NAME] related to [MEDICAL CONDITION](Cardiovascular Accident-Stroke) for prevention of [MEDICAL CONDITION] associated with [MEDICAL CONDITION]. He said he will get her up to therapeutic level. Review of physician progress notes [REDACTED].#2's [MEDICATION NAME] dose previously when low levels were reported in lab work because the nursing facility reported no [MEDICAL CONDITION] activity and R#2 was already mentally impaired. Review of hospital History and Physical dated 01/07/16 revealed R#2 was admitted to the hospital and her [MEDICATION NAME] level was .8. R#2 was admitted to the hospital for IV (intravenous) fluids and surgical consult for a possible Gastrostomy Tube (feeding tube). Review of physician progress notes [REDACTED]. R#2 was still in the hospital and the order was withdrawn; order would be given when R#2 returned from the hospital. In an interview on 01/14/16 at 4:25 p.m., the DON said that R#2's [MEDICAL CONDITION] was related to her having a [MEDICAL CONDITION], and it had a ICD 10 code which was a generalized code. When asked how to tell if an unwitnessed fall might have been caused by a [MEDICAL CONDITION], the DON replied that from nursing experience, after a [MEDICAL CONDITION] the person had a postictal state (altered state of consciousness), in which they would lose control of their bowels. The DON said that if a resident had a high [MEDICATION NAME] level, they would get lethargic and the physician would not want the [MEDICATION NAME] level to get too high as it could cause grogginess. In the interview on 01/14/16 at 4:25 p.m., the DON said that she had not heard any complaints about staffing in the Memory Unit or elsewhere in the facility. When asked if there was a procedure in place or a policy regarding what action was needed when a resident needed one-on-one care, the DON said that the facility did not do one-to-one care long term. The DON said that one-to-one care would be done if there was a resident who was trying to harm themselves or others, and one-to-one care was needed short term until they could go into the hospital. When asked if R#2 needed one-to-one care, the DON responded that R#2 did not require one-to-one care. The DON said that if they could not meet a resident's needs, they would send them to the hospital, talk with the family and physician, and also talk with the Ombudsman. The DON said that she did not do this with R#2 because she did not think they could not meet R#2's needs. Review of CMS Form 802 dated 12/29/15 revealed 16 residents with a history of falls. R#4 Review of R#4's Resident Admission Record revealed she was an [AGE] year old female was admitted to the facility on [DATE] and readmitted on [DATE]. R#4's [DIAGNOSES REDACTED]. R#4 was [AGE] years old. Review of R#4's MDS dated [DATE] revealed R#4 had moderate cognitive impairment. R#4 required extensive assistance (resident involved in activity, staff provide weight bearing support) and two person physical assistance for bed mobility, transfers, toilet use and personal hygiene. R #4 required physical help for bathing and one person ' s physical assistance for support. R#4 did not walk, and her balance during transitions and walking was not steady. R #4 was only able to stabilize with staff assistance. R #4 ' s MDS indicated she had fallen within the last two to six months prior to admission or reentry. Review of the PT (Physical Therapy) Plan of Care dated 07/20/15 R #4 ended PT on 07/20/15 with a sitting balance of P Dynamic (unable to maintain balance without moderate/maximum (mod/max) support. Review of the facility's Incident/Accident report dated 07/22/15 revealed CNA I heard R #4 yelling and went to check on her. R #4 was on the floor on her right side. The charge nurse was notified. A head to toe assessment was completed. R #4 had a hematoma over her left eye brow area, swollen upper lip and swelling to her left knee. Blood from R #4 ' s mouth was cleaned and she was helped to bed. R #4 was sent to the emergency room (ER) for evaluation. The report revealed R #4 returned from the ER with bruising to her face. An undated witness statement by CNA I revealed she heard R #4 yelling. CNA I found R #4 on the floor in her room. The form indicated CNA I called the charge nurse. R #4's Fall Risk Assessment Form dated 07/22/15 revealed a score of 20. The form indicated a score of 10 or more was indicative of a high risk for falls. According to the facility's Incident/ Accident Report dated 08/06/15 Licensed Vocational Nurse (LVN) L heard a loud noise and then a scream. The report indicated LVN L went to R #4's Room and found her on the floor in the bathroom. The interview with staff revealed the CNA put R #4 on the toilet and left R#4 alone. The CNA instructed R #4 to use the call lights when she was ready. R #4 had skin tear on her left forearm about one centimeter (cm) in length. Care was provided at the facility and it was determined R #4 stood up from the toilet and fell down. In-services were provided to the CNA's on the importance of not leaving a resident unattended in bathroom. On 01/14/16 at 2:00 p.m. LVN L said on 08/06/15 she found R #4 in her room on the floor in the bathroom. R #4 told her she CNA I placed her on the toilet and did not return. R #4 said she tried to get up but fell off the toilet. LVN L stated she remembered R #4 had an adult undergarment on and having to clean her up after the fall. She stated R #4 was very impulsive and had high levels of anxiety and poor memory. LVN L said R #4 was not able to take instruction. LVN L stated R #4 should not have been left alone on the toilet because she was impulsive. LVN L said she told her charge nurse and provided a statement as to what occurred. LVN L said she was familiar with the facility policy regarding abuse/neglect and reportable incidents. She stated there was not an investigation and the incident should been reported based on the facility policy and state regulation. Review of the PT (Physical Therapy) therapist progress note and Discharge summary dated 09/09/15 revealed R #4 started PT on 08/20/15 with a sitting balance of P Dynamic (unable to maintain balance without moderate/maximum (mod/max) support, mod/max to reach ipsilateral (belonging to or occurring on the same side of the body) side and unable to cross midline). On 09/09/15 R #4 was discharged from PT with a sitting balance of P Dynamic. Review of R#4's MDS dated [DATE] revealed R#4 had severe cognitive impairment. R#4 required extensive assistance (resident involved in activity, staff provide weight bearing support) and two person physical assistance for bed mobility, transfers, toilet use and extensive assistance and one person physical assistance for personal hygiene. R #4 required physical help for bathing and one person's physical assistance for sup

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services that would promote healing and prevent new pressure ulcers from developing for one of six Sample Residents who had pressure ulcers (SR #3). On 02/25/11, SR #3 was admitted to the facility with three Stage 2 pressure ulcers (one on the sacrum and two on the right thigh). By 03/03/11 SR #3 had developed one Stage 2 pressure ulcer on the right outer ankle. By 03/30/11 SR #3 had developed two Stage 2 pressure ulcers on the heel of the left foot. By 04/01/11 SR #3 had developed a second Stage 2 pressure ulcer on the sacrum. Although SR #3 was admitted with pressure ulcers and assessed as being at high risk for the development of pressure ulcers, SR #3 did not receive adequate services to prevent the development of four new avoidable pressure ulcers. The failure to provide adequate services to promote healing and prevent development of new pressure ulcers could affect the 14 residents in the facility that were identified as having pressure ulcers. Findings included: SR #3's Record of Admission Face Sheet dated 02/28/11 revealed that SR #3 was admitted on [DATE]. Admitting [DIAGNOSES REDACTED]. Review of SR #3's Admission/Readmission Data Summary form dated 02/25/11 revealed the presence of three "open areas" on SR #3's skin. One was at the lower middle back, the sacrum, one was on the posterior right thigh and one was on the right inner thigh. SR#3's Braden Scale for Predicting Pressure Sore Risk (a list of six factors that are used to evaluate/predict the risk that an individual has of developing pressure ulcers) dated 02/25/11, 03/04/11, 03/11/11, and 03/18/11, assigned SR #3 a score of 11 (a score of 11 indicates a high risk of developing pressure ulcers). A pressure ulcer is an area of localized injury to the skin and/or deeper tissue, usually over a bony area, that results from pressure. Review of SR #3's Skin Evaluation Flowsheet - Pressure Ulcer started on 02/25/11, revealed that SR #3 had three Stage 2 pressure ulcers (partial thickness loss of skin that looks like an open ulcer with a red/pink wound bed), one at the sacrum, one on the back of the right thigh and one on the right inner thigh. Documentation made on 03/02/11 indicated that the two pressure ulcers on the right thigh were completely healed. SR #3's Physician's "Start Up Orders" (admission orders repo (reposition) Q2H (every 2 hours) X 10 minutes." SR #3's Treatment Sheet started on 02/25/11 revealed that wound treatments were initiated on the Stage 2 pressure ulcers at the sacrum and right thigh. It was documented that the two pressure ulcers on SR #3's right thigh had healed completely on 02/28/11. SR #3's Admission Care Plan was a standardized five page form that was dated 02/25/11. The first page was partially filled in and the remaining four pages that included a plan for "pressure sores/skin care" were left blank. There were no other care plans on SR #3's chart. Review of SR #3's admission Minimum Data Set (MDS) - Version 3.0, dated 03/09/11, revealed that SR #3: 1. had no speech 2. rarely/never was able to make his needs understood, and rarely/never understood verbal content 3. had severely impaired cognitive skills for daily decision making (never/rarely made decisions) 4. had an altered level of consciousness continuously. 5. was totally dependent and required two person physical assistance with bed mobility, transfers, dressing, and toilet use. 6. was totally dependent and required one person physical assist with eating and personal hygiene. 7. was totally dependent on staff for bathing 8. was described as having lower extremity impairment on both sides. 9. was always incontinent (unable to control passage of urine and feces) 10. had an abdominal feeding tube and received over 51% of total calories and more than 501 milliliters (approximately 17 ounces) of fluid per day through this tube 11. was at risk for developing pressure ulcers and had two Stage 2 pressure ulcers at the time the MDS assessment was completed. One of the two pressure ulcers had been present on SR #3 at the time of admission to the facility. 12. required the use of pressure reducing device for bed and ulcer care 13. the MDS signature sheet documented the signature of Licensed Vocational Nurse (LVN) "M" the facility MDS/Care Plan Coordinator. Resident/Visitor/Staff Incident/Accident Report dated 03/11/11 was initiated in response to the identification of a Stage 2 pressure ulcer to the right outer ankle on 03/10/11. Actions to prevent the development of pressure ulcers prior to the onset of the new ulcer were listed as including the use of a pressure reducing mattress and turning and repositioning every two hours. Actions to be taken to prevent development of new ulcers included reposition every two hours and use of a pillow to "float" resident off his right side. On 04/01/11, the facility provided a list of residents who had been identified as having pressure ulcers. SR #3 was listed with the following: 1. "Stage 2 (pressure ulcer) sacral admitted with 02/25/11" 2. "Stage 2 Rt (right) outer ankle In house 03/03/11" (facility acquired) 3. "Stage 2 Lt (left) heel #1 In house 03/30/11" (facility acquired) 4. "Stage 2 Lt heel #2 In house 03/30/11" (facility acquired) On 04/01/11 at 10:10 a.m., SR #3 was observed in his room in bed. SR #3 was lying on his back asleep. SR #3 had boots on both feet (devices used to relieve pressure on feet that could be caused by contact with the bed mattress) but did not appear to have pillows or wedges to float his back off of the mattress. The head of the bed was raised to a 30 degree angle. An infusion pump was at the bedside. Formula Glucerna 1.5 cal was infusing at the rate of 73 mililiters (ml) per hour (approximately 2.4 ounces per hour) through clear plastic tubing to a feeding tube in SR #3's abdomen. The second bed in the room was not occupied and linens had been removed to reveal a light green mattress. The color of the mattress on SR #3's bed could not be seen clearly through linens. There was no machine set up on the footboard of SR #3's bed that would have indicated the use of an air (pressure relieving) mattress. On 04/01/11 at 10:30 a.m., SR #3 was in his room. He was lying in bed on his back. No pillow or wedge was noted in use. Boots were in place on both feet. On 04/01/11 at 10:45 a.m., SR #3 was in his room. He was lying in bed on his back at a slight angle to the right. No pillow or wedge was noted in use to keep resident from lying on his back. Boots were in place. On 04/01/11 at 11:05 a.m., SR #3 was in his room. He lying in bed on his back at a slight angle to the right. No pillow or wedge was noted in use. The head of the bed was flat. The infusion pump had been turned off. Boots were in place. On 04/01/11 at 11:40 a.m., SR #3 was in his room. He was lying on his back. The head of the bed was flat. The infusion pump was turned off. Boots were in place. On 04/01/11 at 1:12 p.m., SR #3 was in his room. He was lying on his back. Licensed Vocational Nurse (LVN) "U" was performing a skin assessment. Boots were in place. On 04/01/11 at 2:08 p.m., SR #3 was in his room. He was lying on his back. No pillow or wedge was noted in use to float his back off of the mattress. The head of the bed was raised to a 45 degree angle. Boots were on both of SR #3's feet. On 04/01/11 at 2:53 p.m., SR #3 was in his room. He was lying on his back at a slight angle to the right. No pillow or wedge was noted in use. Head of the bed was raised to a 45 degree angle. Boots were in place. On 04/01/11 at 3:02 p.m., Certified Nurses Assistant (CNA) "CC" stated that residents who were mainly in bed were assisted to reposition every two hours. On 04/01/11 at 3:10 p.m., SR #3 was in his room. He was lying on his back. No pillow or wedge was noted in use. LVN "V" administered medications to SR #3 through the abdominal feeding tube. On 04/01/11 at 3:48 p.m., CNA "DD" stated that residents who were mainly in bed were assisted to reposition every two hours. On 04/01/11 at 4:00 p.m., SR #3 was in his room. He was lying on his back at a slight angle to the right. No pillow or wedge was noted in use. Boots were in place on both of SR #3's feet. On 04/01/11 at 4:28 p.m., SR #3 was in his room. He was lying on his back at a slight angle to the right. No pillow or wedge was noted in use. Boots were in place. On 04/01/11 at 4:47 p.m., LVN "A", the Wound Care Nurse, was preparing to provide wound treatments to SR #3 when it was noted that SR #3 required incontinent care. LVN "A" called for CNAs to provide incontinent care while LVN "A" prepared materials needed for SR #3's wound care. LVN "A's" procedure cart was next to the second bed in the room which had no linens covering a light green mattress. When asked if the light green mattress would help to reduce pressure, LVN "A" stated that the light green color mattresses in use at the facility were not designed to be either pressure reducing or pressure relieving. On 04/01/11 at 5:10 p.m., SR #3 was in his room. He was lying on his back and was provided incontinent care. The mattress that was on SR #3's bed was noted to be a light green color, one that would not help to reduce or relieve pressure. There was no pillow or wedge in use to keep SR #3 from turning fully on his back. Following the incontinent care, SR #3 received wound care immediately. He was turned from side to side for this care. Boots were removed from SR #3's feet for wound treatments and then replaced at the end of the treatments. On 04/01/11 at 5:25 p.m., SR #3 was provided wound care by LVN "A". Following was observed: -Right outer ankle: Open shallow area of skin, approximately 3 centimeters (cm) X 2.5 cm with a pink wound bed, small amount of dried skin (scab), no pus or drainage, no odor -Lower middle back (sacrum): Two shallow open areas of skin adjacent to each other, one slightly higher on the back than the other and clearly distinguished as being two separate areas. Ulcer #1, the ulcer that was higher on the back, was approximately 2 x 2 cm in size with a pink wound bed, no drainage or odor. Ulcer #2 was approximately 1 x 1cm in size with a pink wound bed, no drainage or odor. LVN "A" stated that ulcer #2 was first noted on 04/01/11 during this wound care session. -Left heel ulcer was approximately 1.5 cm x 1 cm in size with red wound bed, no drainage or odor. Left lateral ankle was approximately 1 x 0.5 cm in size with pink wound bed, no drainage or odor. On 04/01/11 at 6:45 p.m., SR #3 was in his room. He was lying on his left side. Foot boots were on both of his feet. Head of the bed was raised at 30 degree angle. No pillows or wedge were in use. On 04/05/11 at 9:16 a.m., SR #3 was in his room. He was lying on his back. There were no pillows or wedge noted to be in use to float him off of his back. SR #3's bed was noted to be equipped with a navy blue color mattress. The color of the mattress was noted as the linens did not entirely conceal the mattress. Boots were not on SR #3's feet. On 04/06/11 at 10:15 a.m., LVN "A" reported in response to questions regarding an information print-out provided by the facility on the Panacea Tender and Tender Plus Stage II pressure reduction mattress that the color of the mattress was blue. When asked if the light green mattresses in the facility also had the same pressure reduction features, LVN "A" said "No, but you won't find any green mattresses here anymore. They have all been changed out. Now all (of the mattresses) are blue (pressure reducing)." LVN "A" said that the mattresses had all been changed to the pressure reducing type on 04/02/11. On 04/05/11 at 9:46 a.m., SR #3 was out of his room. Social Services staff "AA" said that SR #3 had been taken to the hospital for a procedure to replace an abdominal feeding tube. On 04/05/11 at 10:38 a.m., SR #3 was back from the hospital, in his room, and positioned in bed on his back at a slight angle to the right. No pillow or wedge was noted in use. Boots were in place on both of SR #3's feet. On 04/05/11 at 1:30 p.m., CNA "S" reported having given SR #3 incontinent care and positioning at "noon." On 04/05/11 at 12:58 p.m., SR #3 was in his room. He was lying on his back at a slight angle to the right. No pillow or wedge was noted in use. Boots were in place. On 04/05/11 at 12:58 p.m., surveyor asked SR #3 if staff had helped him to turn/reposition that day. He first shook his head "no" then held up one finger (pointing up). When asked if this meant one time, SR #3 nodded "yes." On 04/05/11 at 10:05 a.m., Interim Administrator "I" stated, that there were no "bedfast" residents in the facility. She said "Even those (residents) on tube feedings spend the majority of their time in chairs." On 04/05/11 at 3:18 p.m., Interim Director of Nurses (DON) Registered Nurse (RN) "T" stated that SR #3 was assisted to turn and reposition every two hours. She stated that CNAs made rounds and assisted residents to turn every two hours. On 04/06/11 at 9:28 a.m., surveyor asked SR #3 if staff had helped him to get out of bed the day before; SR #3 nodded "yes." When asked if staff helped him to get out of bed everyday, SR #3 shook his head "no." When asked if he would like to get out of bed everyday, SR #3 nodded "yes." When asked if staff had helped him to turn/reposition that morning (04/06/11), SR #3 shook his head "no." On 04/06/11 at 10:50 a.m., LVN "M", the MDS/Care Plan Coordinator, stated that resident Admission Care Plans were filled in by the nurse performing an admission evaluation on a resident. LVN "M" completed a formal care plan "usually within the first 20 days after admission." Surveyor requested SR #3's care plan. LVN "M" said that she did not have SR #3's chart. Upon surveyor's request to review SR #3's chart, LVN "M" said "well, his is not on (his)chart." LVN "M" estimated that it would be another two days before the formal care plan was in SR #3's chart. LVN "M" said that she was late in formulating care plans and had been late since "your last survey" (recertification survey exit 02/18/11). On 04/06/11 at 11:14 a.m., Activities Director "X" stated that she would go into SR #3's room every day to every other day and speak with him. She said that SR #3 would respond to questions by shaking his head to say "no" and nodding his head to say "yes." Facility Policy and Procedure "Skin, Preventative Guideline for Residents at Risk for Pressure Ulcers", dated 08/2009, stated "It is the policy of this home to provide preventative measure for residents at risk for pressure ulcers." Procedures listed for providing pressure relief included "reposition/turn at least every two (2) hours" and using "pressure-reducing devices for bed". The policy listed areas that were most prone to breakdown as including the sacrum/coccyx, heels, and malleolus (bony protuburance on both sides of the ankle joint). Facility Policy and Procedure "Treatment Guidelines for Pressure Ulcers Stage II", dated 08/2009, stated "It is the policy of this home to utilize treatment guidelines when providing care for residents with pressure ulcers." Procedures to be taken included "institute the use of pressure reducing devices for bed" and "reposition/turn the resident at least every two (2) hours day and night." According to a list provided by the facility on 04/01/11, there were 14 residents in the facility who had pressure ulcers. During the investigation and at the exit conference on 04/06/11 at 1:18 p.m., the facility was given the opportunity to present further information regarding the deficient practice. The facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two of six Sample Residents (SRs #6 and #7) observed for weight loss when: 1. SR#6's weight decreased from 95 pounds on 01/17/11 to 89.8 pounds on 02/16/11. SR#6's weekly weights indicated a weight loss and the Speech Therapist changed SR#6's diet on 01/26/11 from mechanical soft to thin puree without consulting the Dietitian or SR #6's Physician. SR#6 was administered the incorrect rate of enteral feeding formula during several observations and was observed not to receive enteral feeding during scheduled times. 2. the facility was unable to ensure that SR#7 maintained acceptable parameters of body weight from 02/08/11 (when SR#7 weighed 124 pounds) to 02/16/11 (when SR#7 weighed 115.5 pounds). SR #7 was administered an incorrect feeding formula at an incorrect rate per the physician's orders [REDACTED]. Failure to maintain acceptable parameters of body weight could lead to unnecessary significant weight loss, expedite the deterioration of a resident's physical, mental and psychological well being, and raise the resident's susceptiblity to additional health issues and could affect six residents with weight loss concerns. The findings: 1) SR#6's face sheet revealed SR#6 went to the hospital on [DATE] and had been re-admitted to the facility on [DATE] with a gastrostomy tube. SR#6's [DIAGNOSES REDACTED]. SR#6's January 2011 Enteral Feeding Record revealed: -01/07/11 through 01/15/11 = no Glucerna formula listed. -01/16/11 thur 01/20/11= Glucerna 1.2 at 90 cc/hr at 6:00 p.m. to 6:00 a.m. was given. -01/21/11 thru 01/31/11 = Glucerna 1.5 at 72cc/hr x12 at 6:00 p.m. to 6:00 a.m. was given. SR#6's February 2011 Enteral Feeding Record revealed: -02/01/11 thru 02/15/11 = Glucerna 1.2 at 90 ml/hr x 12 at 7:00 p.m. to 7:00 a.m. was given. -02/16/11 = Glucerna 1.2, at 90 ml/hr x 12, at 6:00 p.m. to 6:00 a.m. was given. This formula was discontinued on 02/17/11 -02/17/11 = Glucerna 1.5 cal at 95 ml/hr x 12 at 6:00 p.m. to 6:00 a.m. SR#6's physician's orders [REDACTED]. SR#6's Dietitian Progress Notes dated 01/17/11 revealed SR#6 was receiving Glucerna 1.2 at 90 milliliters (ml) per hour (hr) for 12 hr duration (6:00 p.m. to 6:00 a.m.), to continue weekly weights, and to consult the Dietitian if weight loss occurs on weekly weights. SR#6's Dietitian Progress Notes dated 02/15/11 revealed SR#6 was on a mechanical soft, chopped meats, LCS diet, and tube feeding, Glucerna 1.2 calories at 90 milliliters (ml) per hour for a duration of 12 hours (hrs) to provide 1800 ml. On 02/15/11 at 8:30 a.m.during initial tour, surveyor observed SR#6's closed feeding pump system in her room. The pump was turned off. Surveyor observed SR#6's feeding pump had a bottle of formula, Glucerna 1.2 cal, dated 02/14/11, with a start time of 6:00 p.m./a.m (was unable to determine as written), with a rate of 72 milliliter per hour (mL/hr) and had an amount of 1000 mL remaining in the bottle. During observation, Licensed Vocational Nurse (LVN) "I" stated SR#6's downtime was from 6:00 a.m. to 6:00 p.m. If SR #6's formula was started at 6:00 p.m. on 02-14-11 at a rate of 72 mL/hr, SR #6 would have received a total of 864 mL by 6:00 a.m. on 02-15-11. If SR #6's formula was started at 6:00 p.m. on 02-14-11 at the rate of 90 mL as ordered by the physician on 01-29-11 and confirmed by Dietitian's Progress Note on 02-15-11, SR #6 would have received a total of 1080 mL by 6:00 a.m. on 02-15-11. On 02/15/11 at 2:40 p.m. surveyor entered SR#6's room. Surveyor observed SR#6's feeding pump was turned off. SR#6's feeding pump had a bottle of formula Glurcerna 1.2 cal, dated 02/14/11, with the start time of 6:00 a.m/p.m (not able to determine as written), with a rate of 72 ml/hr and had an amount of 1000 mL remaining in the bottle. On 02/16/11 at 10:00 a.m. surveyor interviewed the Dietitian. The Dietitian stated she had completed SR#6's Nutrition Progress Notes on 02/15/11. Surveyor asked the Dietitian what type of diet SR#6 was on. The Dietitian stated SR#6 was on a mechanical soft, chopped meats, LCS diet. The Dietitian stated SR#6 recently had a [DEVICE] due to poor intake and was receiving Glucerna 1.2 at 90 ml/hr x 12 hrs. The Dietitian stated the feeding pump was on from 6:00 p.m. to 6:00 a.m. On 02/16/11 at 6:30 p.m. surveyor observed SR#6 seated in her wheelchair outside of her room in Hall A. SR #6 was not receiving her tube feeding. On 02/16/11 at 6:35 p.m. surveyor observed LVN "I" in the dining room wiping down the tables and SR#6 seated in her wheelchair outside of her room in Hall A. SR #6 was not receiving her tube feeding. On 02/16/11 at 6:40 p.m. surveyor observed LVN "I" pass by SR#6's room pushing a barrel of dirty bibs. SR#6 was observed seated in her wheelchair outside of her room in Hall A. SR #6 was not receiving her tube feeding. On 02/16/11 at 7:00 p.m. surveyor observed LVN "I" seated at Nurses Station on Hall A and SR#6 was observed seated in her wheelchair outside of her room in Hall A. SR #6 was not receiving her tube feeding. On 02/16/11 at 8:05 p.m. surveyor observed SR#6 in her room with her family. Surveyor observed SR#6's feeding pump was turned on. SR#6's feeding pump had a bottle of Glucerna 1.2 cal, dated 02/16/11, with the start time of 7:00 p.m., with a rate of 72 mL/hr, and 1500 ml remaining in the bottle. Although SR #6's physician's orders [REDACTED]. On 02/17/11 at 8:03 a.m. surveyor entered SR#6's room and observed SR#6's feeding pump turned off. SR#6's feeding pump had a bottle of formula, Glucerna 1.2 cal, dated 02/16/11, with the start time of 7:00 p.m., with a rate of 72 mL/hr, and had an amount of 900 mL remaining in the bottle. The Glucerna bottle held 1500 mL, so 600 mL were administered. If SR #6's formula was started at 7:00 p.m. on 02-16-11 at a rate of 72 mL/hr, SR #6 would have received a total of 864 mL by 7:00 a.m. on 02-17-11. If SR #6's formula was started at 7:00 p.m. on 02-16-11 at the rate of 90 mL as ordered by the physician confirmed by Dietitian's Progress Note, SR #6 would have received a total of 1080 mL by 7:00 a.m. on 02-15-11, rather than the 600 mL that was administered. On 02/17/11 at 10:25 a.m. surveyor conducted an interview with LVN "P". Surveyor asked LVN "P" what type of formula SR#6 was on. LVN "P" stated SR#6 was previously on Glucerna 1.2 at a rate of 72 cc/hr. LVN "P" stated SR#6's formula was now changed to Glucerna 1.5 at a rate of 95 cc/hr. Surveyor and LVN "P" entered SR#6's room and observed SR#6's feeding pump. SR#6's feeding pump had a bottle of Glucerna 1.2 cal dated 02/16/11 with a start time of 7:00 p.m., and had an amount of 900 ml out of 1500 mL remaining in the bottle. LVN "P" stated SR#6's rate had been changed several times. Surveyor and LVN "P" reviewed SR#6's last physician's orders [REDACTED]. The physician's orders [REDACTED]. LVN "P" did not provide any further information to contradict the physician's orders [REDACTED]. SR#6's Admission/Readmission Data Summary dated 01/05/11 revealed SR#6 was to receive a mechanical soft, chopped meat LCS (low-concentrated sweets) diet. SR#6's Physician's Telephone Order dated 01/06/11 revealed SR#6 was on a "LCS mech (mechanical) soft, chopped meats diet." SR#6's Therapy Weekly Progress Summary dated 01/26/11 revealed "pt (patient) was given a 3 day trial of thin pureed. Pt responded positively to diet change. Pt is to stay on this diet." Surveyor asked the Dietitian if she had completed the Dietitian Consultation as ordered by SR#6's Physician dated 01/25/11. The Dietitian stated she had not been informed of SR#6's Physician request for a consultation, but had run across SR#6's Physician order [REDACTED]. The Dietitian stated she had completed SR#6's Consultation on 02/15/11, and made some recommendations, but they had not been put into in effect yet. Surveyor asked the Dietitian how the staff communicated a change in diet to the Dietary Manager. The Dietitian stated the nurses completed a communication form slip that was sent to the Dietary Manager and the Dietary Manager made the change. On 02/16/11 at 8:12 a.m. surveyor observed SR#6 seated in her wheelchair at a table in the dining room. Certified Nurse Aide (CNA) "G" was seated at SR#6's table and surveyor observed CNA "G" attempt to feed SR#6 a pureed breakfast. Surveyor observed SR#6's tray slip and it revealed SR#6 was on a LCS/Pureed diet. On 02/16/11 at 8:33 a.m. surveyor asked CNA "G" what type of diet SR#6 was on. CNA "G" stated a pureed diet. On 02/16/11 at 10:50 a.m. surveyor conducted an interview with the Director of Nurses (DON). Surveyor asked the DON the process for how a physician's orders [REDACTED]. The DON stated the Nurse was supposed to call the Dietitian to inform her of the order. Surveyor asked the DON how a change of diet was communicated to the Dietary Manager. The DON stated the nurse that received the order would send a communication form to dietary. On 02/16/11 at 12:40 p.m. surveyor observed SR#6 seated at a table in the dining room. CNA "H" was feeding SR#6 her lunch. Surveyor observed SR#6's meal served to be pureed. Surveyor asked CNA "H" what type of diet SR#6 was on. CNA "H" stated SR#6 was on a pureed diet. On 02/16/11 at 12:45 p.m., surveyor observed the Dietitian in the kitchen and asked her to come to SR#6's table. The Dietitian observed SR#6 was being fed a pureed diet. Surveyor asked the Dietitian to clarify SR#6's diet. The Dietitian stated SR#6 was on a mechanical soft diet and proceeded to the kitchen to get SR#6 a plate that consisted of a mechanical soft diet. When the Dietitian returned to SR#6's table with a plate of mechanical soft, Licensed Vocational Nurse, (LVN) "I" stated that SR#6 was on a pureed diet. LVN "I" stated she had spoken to Speech Therapist "J" about placing SR#6 on a three-day trial pureed diet as SR#6 was losing weight. LVN "I" stated she had spoken to SR#6's family and they were in agreement. Speech Therapist "J" was present and stated she had changed SR#6's diet on 01/26/11 when she had submitted the Nursing-Dietary Communication Form to the Dietary Manager. Surveyor asked the Dietitian, who was present, if she was aware of the change, the Dietitian stated she was not. The Dietary Manager, who was present, stated she had changed SR#6's diet as of 01/26/11 when she received the communication form from the Speech Therpist "J". Surveyor asked Speech Therapist "J" and LVN "I" if they had contacted SR#6's Physician regarding the diet change. LVN "I" stated she had called SR#6's Physician regarding the three-day trial but had not contacted SR#6's Physician to notify that SR#6's diet had been changed from the three day trial pureed diet to a pureed diet on 01/26/11. Speech Therapist "J" stated she did not contact SR#6's Physician as she was not aware that she had to notify SR#6's Physician to change the diet. Review of SR#6's weekly weights revealed the following: * 01/17/11---95 * 02/07/11---90 * 01/24/11---90 * 02/14/11---no weight noted * 01/"3"/11---95 * 01/31/11---88 On 02/16/11 at 4:05 p.m. surveyor observed Restorative Aide (RA) "M" and RA "N" weighed SR#6 in her room. RA "M" stated she usually weighed SR#6 on Wednesdays. RA "M" and RA "N" weighed SR#6 using a hoyer lift. SR#6's weight was shown as 89.8 pounds (lbs). On 02/16/11 at 6:15 p.m. surveyor observed SR#6 seated at a table in the dining room and RA "N" attemped to feed SR#6 her pureed dinner. Review of SR#6's Physician order [REDACTED]. 2.) SR#7's Care Plan dated 08/20/10 and 11/18/10 indicated SR#7 required a therapeutic diet due to [DIAGNOSES REDACTED]. Interventions included to monitor weight gain/loss for a month and report to Physician. Review of "Transfer to other facility Form" dated 02/08/11 indicated SR#7 returned to the facility on [DATE], following hospitalization . SR#7's Physician's start up orders dated 02/08/11 indicated SR#7 had [DIAGNOSES REDACTED]. SR#7's Minimum Data Set ((MDS) dated [DATE] indicated SR#7 had minimal difficulty hearing, had clear speech, was sometimes understood, sometimes understood others, had impaired vision, and cognitive skills for daily decision making were severely impaired (never /rarely made decisions). The MDS indicated SR#7's weight was 124 pounds and SR#7 received all nutrition through a gastrostomy tube (GT, a tube surgically inserted in the abdomen to provide nutritional feedings). SR#7's Physician's start up orders dated 02/08/11 indicated PEG tube feeding (Percutaneous Endoscopic Gastrostomy - a feeding tube insertion into the stomach): - [MEDICATION NAME] 1.2 at 60 cc/hr x 22 daily(dly), - Water (H20) [MEDICATION NAME] via tube every (Q) 6 hrs to equal 150 mls. SR#7's Nutrition Progress Notes dated 02/14/11 indicated the Registered Dietitian Consultant (RDC) recommended to: -Discontinue current tube feeding order of [MEDICATION NAME] 1.5 at 48 milliliters/hour (ml/hr) x 22 hrs (on 9 am, off 7 am) to provide 1056 ml, 1584 kcal, 67 gram protein, 803 ml free water (H20) 106% RDI due to weight loss. RDC recommended: -tube feeding two Cal HN at 51 ml/hr x 22 hrs to provide 1122 mls, 2244 kcal, 94 gram protein, 785 ml free H20,118% RDI (40.1 kcal/kgABW,1.7 g pro/kg ABW, -Discontinue current flush order due to does not meet estimated fluid needs and due to recommended tube feeding change, - Change Multivitamin to Multivitamin with minerals to promote wound healing, -[MEDICATION NAME] or [MEDICATION NAME] one package to promote wound healing - Vitamin C 500 milligrams (mgs) twice daily (bid) and Zinc Sulfate 220 mgs daily x 30 days and - Obtain [MEDICATION NAME] to assess visceral protein status On 02/16/11 surveyor reviewed SR#7's Physician's Telephone Orders and noted RDC's recommendations dated 02/14/11 were not addressed. On 02/17/11 at 11:45 am., surveyor reviewed SR#7's Physician's Telephone Orders and noted RDC's recommendations dated 02/14/11 were not addressed. Review of the facility's weight book on 02/17/11 indicated that SR#7 weighed 124 pounds on 02/08/11 and on 02/16/11 weighed 115 pounds (a loss of nine pounds). On 02/16/11 at 12:15 pm., surveyor observed SR#7 in bed, and the closed [DEVICE] pump system was turned off. The formula was [MEDICATION NAME] 1.5 cal. The formula bag label indicated it was hung on 02/15/11 at 6:30 a.m. There was 1000 cc in the bag. The infusion bag held a total of 1500 cc. (One cc is equivalent to one ml. Infused at 60 cc/hr from 6:30 a.m. on 02-15-11 for 22 hours as ordered by the physician, SR #7 should have received 1320 cc as of 4:30 a.m. on 02-16-11, which would have left only 180 cc (not 1000 cc) in the bag. In addition, a new bag would have been hung on 02-16-11 before our observation at 12:15 p.m. Although the physician ordered [MEDICATION NAME] 1.2, SR #7 was receiving [MEDICATION NAME] 1.5.) On 02/16/11 at 12:35 pm., surveyor interviewed LVN "F" who stated she could not explain why SR#7 had 1000 cc in the formula bag. LVN "F" stated the formula was off from the time the Certified Nurse Aides (CNAs) asked her to disconnect the [DEVICE] feed between 10:00 a.m. and 11:00 a.m. to take SR#7 to the shower. LVN "F" stated the CNAs did not inform her when they brought back SR#7 to his room. LVN "F" hung a new bag of [MEDICATION NAME] 1.5 formula to infuse at 48 cc's per hour. (The pump was infusing at a rate of 48cc/hr rather than the 60cc/hr as ordered by the physician, and the formula was [MEDICATION NAME] 1.5 rather than the [MEDICATION NAME] 1.2 ordered by the physician) On 02/16/11 at 3:05 and 5:55 p.m., surveyor observed SR#7 in bed. The [DEVICE] pump was infusing [MEDICATION NAME] 1.5 at a rate of 48 cc per hour. (The pump was infusing at a rate of 48cc/hr rather than the 60cc/hr as ordered by the physician, and the formula was [MEDICATION NAME] 1.5 rather than the [MEDICATION NAME] 1.2 ordered by the physician) On 02/17/11 at 8:00 and 11:47 a.m., surveyor observed SR#7 in bed. The [DEVICE] pump was infusing [MEDICATION NAME] 1.5 at a rate of 48 cc per hour. (The pump was infusing at a rate of 48cc/hr rather than the 60cc/hr as ordered by the physician, and the formula was [MEDICATION NAME] 1.5 rather than the [MEDICATION NAME] 1.2 ordered by the physician) On 02/17/11 at 11:46 a.m. surveyor interviewed LVN "E" who stated she did not know about SR#7's RDC recommendations. The RDC usually gives the DON the residents' new recommendations. On 02/17/11 at 11:47 a.m. surveyor interviewed the DON who stated the Charge Nurses notify/consult the Physician of the resident's recommendations by faxing or calling and follow up with the Physician's office for orders. On 02/18/11 at 9:45 a.m. surveyor interviewed the DON regarding SR#7's RDC recommendations dated 02/14/11. The DON stated she did not receive the RDC's recommendation for SR#7. The DON stated she spoke with the RDC. The RDC informed her that she placed SR#7's progress notes with recommendations in SR#7's chart. Then the RDC stated she placed the recommendations in the DON's box in the business office. The DON stated she found SR#7's recommendation in the Assistant Director of Nurses' (ADON) box in the business center instead of her (DON's) box. The DON stated the RDC turned in her copy of SR#7's recommendation on the evening of 02/16/11 (she did not know the time). The DON stated the facility's protocol regarding RDC's recommendation is: -the DON receives the RDC's recommendation, -gives recommendation to the Charge Nurse, -Charge Nurse calls the residents' Physician and gets an order, and -the Physicians orders are written, The DON stated the Charge Nurses are familiar with the protocol and that the facility does not have a written protocol, but she would check. On 02/18/11 at 12:00 p.m., surveyor observed SR#7 in bed. The [DEVICE] pump was infusing Two Cal HN at a rate of 51 cc per hour. The formula label indicated formula was hung at 12:00 a.m. on 02/18/11. There was 500 cc in the bag. Nursing Policy and Procedure: Subject: Diet Manual and Diet Orders, Effective 1/2008 Policy: "The Physician will prescibe diets in accordance with the approved Diet Manual. A written order must appear on the medical record before the resident may be served." #3. "Nursing will obtain physician's diet orders that are in compliance with the Diet Manual or obtain the diet order changes or clarifications before delivery of the meal. Non-specific diets such as low sodium, Diet as tolerated, diabetic, dysphagia, etc are not acceptable." #4 Changes in diet orders initiated by the Speech Therapist (SLP) are for "consistency only". The therapeutic diet order remains the same." #5 The Food and Nutrition Services Department is to be informed of any chagnes listed below in a timely manner via the Nursing/Dietary Communication form. They are to be written exactly as written on the physician's orders [REDACTED]. a. New or change of diet, supplement, snack or shake. f. Change of consistency and/or thickened liquids. h. Enteral Feeding Initiation or Changes i. Resident food complaints, concerns or special requirements. The facility provided a list of six residents with significant weight loss provided by the facility dated 02/15/11. On 02/18/11 at approximately 9:45 p.m., during the exit conference the Administrator was asked if he had any additional information and Administrator said "no."