Every finding on record at Meridian Care of Hebbronville

Based on observation, interviews, and record reviews, the facility failed to ensure the right to be free from abuse for one (Resident #1) of 8 residents reviewed for abuse. The facility failed to protect Resident #1 on 05/08/26 from LW who verbally and physically abused Resident #1 when she slapped the resident in the face and called the resident a whore, fucking crazy, and stupid. CNA A failed to intervene and report while the altercation between the LW and Resident #1 occurred. This deficient practice could place residents at risk of harm, humiliation, and a diminished quality of life. The noncompliance was identified as PNC. The noncompliance began on05/08/28 and ended on 05/10/26. The facility had corrected the noncompliance before the survey began. The findings were:Record review of Resident #1's Face sheet revealed an [AGE] year-old female with an admission date of 08/18/22 and an original date of 11/20/18. Diagnoses included generalized anxiety, dementia, seizures, and schizophrenia. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. She was completely independent for all ADL's, including ambulation, eating, toileting, transferring, and dressing. She was continent of bladder and bowel. She had a continuous behavior of disorganized thinking, verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) 4-6 days but less than daily. Her active diagnoses included medically complex conditions, non-Alzheimer's dementia, seizure disorder, and anxiety disorder.Record review of Resident #1's care plan dated 07/06/25 revised 05/08/26 revealed: Has persistent anger manifested by verbal accusations toward staff; repetitive religious statements; refusing staff entry into her room. Goal: Will have no episodes of anger weekly by next review in 90 days. Target Date: 08/11/2026. -Interventions: Always approach the resident calmly and unhurriedly. Speak in a calm voice. Attempt to refocus behavior to something positive when exhibiting anger. Attempt to resolve the area of upset. Encourage activities of choice. Explain all procedures before performing. If possible, stop giving care when the resident is angry and attempt later. Resident #1 has the potential to demonstrate verbally abusive behaviors r/t Dementia; Schizoaffective Disorder. Behavior is demonstrated by:1. Following staff around and telling them they do not need to go into her room. 2. There is never any staff in the unit when the CNA and the Activity Director are there along with volunteers. 3. Gets her cell phone and will call the facility phone every 5 minutes, demanding to speak with administration regarding employee issues when there are no issues after speaking with her. I will demonstrate effective coping skills through the review date. Target Date: 08/11/2026Analyze key times, places, circumstances, triggers, and de-escalation factors, and document. Assess and anticipate residents' needs: food, thirst. toileting needs, comfort level, body positioning, pain, etc. Assess the resident's coping skills and support system. Assess the resident's understanding of the situation. Allow time for the resident to express self and their feelings towards the situation. Evaluate for side effects of medications Monitor and document observed behavior and attempted interventions in the behavior log. Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. Psychiatric/Psychogeriatric consult as indicated. When I become agitated: Intervene before agitation escalates; Guide away from the source of distress; Engage calmly in conversation; If the response is aggressive, staff to walk calmly away, and approach later. Resident #1 has a behavior problem r/t schizoaffective disorder as evidenced by: Refusing medication, accusations of staff and other residents. Update: 10/15/25 = Continues to refuse oral medications, throwing glasses across the hallway, throwing her clothes out of the room into the hallway, claiming staff are evil. I will have no evidence of behavior problems by the review date. Target Date: 08/11/2026 Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet my needs. Assist me in developing more appropriate methods of coping and interacting to express feelings appropriately. Caregivers to provide opportunities for positive interaction and attention. Stop and talk with him/her as we pass by. Document behavioral symptoms. Educate family/caregivers on successful coping and interaction strategies, encouragement and active support. If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. Minimize potential for disruptive behaviors by offering tasks that divert attention. Monitor behavior episodes and attempt to determine underlying causes. Consider location, time of day, people involved, and situations. Document behavior and potential causes. Praise any indication of progress/improvement in behavior. Record review of the facility incident report dated 05/08/26 at 7:37 a.m. revealed an alleged abuse incident for Resident #1.Record review of the police report dated 05/08/26 at 8:34 a.m. revealed a suspect (LW), victim (Resident #1), witness (MS), (CNA A), (LVN B).NARRATIVE:On 05/08/2026 at approximately 8:34 AM, dispatch advised the local Deputy to respond to 606 W. Gruy, the facility, regarding an incident report involving an altercation. that occurred at the facility. Upon arrival, the local Deputy made contact with the administrator of the facility. ADM stated that an employee, LW, and Resident #1 had been involved in an altercation. ADM provided video footage of the incident. According to the footage, LW was pushing two cans with lids and entered one of the rooms. As the door slightly closed, it struck one of the lids, causing it to fall to the ground. While LW was inside the room, Resident #1 walked by the area where the cans were located. MS asked Resident #1 why she had dropped the lid. Resident #1 stated that she did not drop the lid. MS then left the area and called LVN B. LW then stated that she was the one who dropped the lid. Resident #1 became upset and began arguing with LW. Both parties started yelling at each other. CNA A positioned herself between Resident #1 and LW due to both individuals being visibly upset and aggressive toward one another. Resident #1 then moved around CNA A and stood face-to-face with LW. Resident #1 proceeded to spit in LW's face. LW then pushed Resident #1 and struck her on the face while yelling at her in Spanish, asking how she would feel if someone spit in her face. CNA A was able to separate Resident #1 from the area and de-escalate the situation. Local Deputy later spoke with LW, who stated that Resident #1 became upset after MS accused her of dropping the lid. LW stated that she informed MS that she was the one who had dropped the lid, after which Resident #1 began yelling at her, and she responded by yelling back. At approximately 11:37 AM, the local deputy was advised that Resident #1 was being transported to a nearby city for medical evaluation due to a bruise and laceration to the left side of her nose/eye area.Local Deputy made contact with Resident #1's family member and advised her to provide all paperwork and medical documentation received from the hospital. On 05/09/2026 at approximately 2:30 PM, a local deputy met with Resident #1's family member at the local Sheriff's Office and made copies of the hospital paperwork. Local Deputy gathered all video footage related to the incident and will forward the footage to the local JP Office. Observation of the laundry room in the secured unit on 06/02/2026 at 12:12 p.m. revealed it was across the hall from the common area. Resident #1's room was 3 doors down on the same side of the hall as the laundry room. There was a shower room on the other side of the hallway near the back door. There were two large barrel-type trash cans on wheels inside the shower room. Observation of the facility's surveillance video footage dated 05/08/26 from 7:37:27-7:38:32 a.m., revealed Resident #1 and the LW, positioned face to face, yelling at each other about one foot from one another, in the hallway. CNA A was seen to exit a room and was observed to intermittently stand between Resident #1 and the LW and then moved herself to the side to observe and listen to the argument. Resident #1 was heard calling the LW a witch and the LW's response was lo que le paso a usted por andar de puta con otro viego [that's what happened to you for being a whore out there with another man]. Resident #1 raised her right hand as to try to hit the LW then the LW raised her right hand as if she was going to hit Resident #1, all while still loudly yelling at each other in the face, now closer in proximity. CNA A then positions positioned herself between both ladies, Resident #1 lightly pushed the CNA A and slapped the CNA's hands away from her, CNA A looked at Resident #1 and asked Resident #1 to go that way. Resident #1 took a couple of steps backward when the LW yelled at Resident #1 que le [NAME] [what's wrong with you] then Resident #1 repeats the same phrase to the LW while getting closer to her, then the LW was heard calling Resident #1 pinche loca [fucking crazy], also telling her you think I am going to put up with you. Resident #1 then steps up to the LW and spits in the LW's face. In response, the LW immediately raised her right hand and slaps Resident #1 on the left side of her face while saying A mi no me escupes estupida [you don't spit at/on me stupid]. CNA A was seen to again position herself between the ladies immediately after the LW slaps Resident #1. The LW then was observed to continue to attempt to confront and get in Resident #1's face while continuously saying Do you want me to spit on you?Observation of a 1 minute 4 second video surveillance titled Unit Back Door dated 05/08/26 at 7:37:28 showed the LW laundry worker and Resident #1 yelling at each other in close proximity of one another. They were positioned by a shower room at the end of the main hall, near an exit door. The LW was coming out of the shower room rolling two large trash barrels with lids. At 11 seconds, CNA A appears from the common room and attempts to (inaudibly) deescalate the situation. At 35 seconds, the LW walks away from Resident #1 pushing the barrels. Resident #1 pursues the LW, yelling. At 53 seconds, the LW had stopped in the hallway and Resident #1 walked directly up to her and appeared to spit. The LW squinted and suddenly brought her right arm from her side in a sweeping motion toward Resident #1's face. Resident #1's head tilted back with the impact. CNA A was able to put distance between the LW and Resident #1 using her body and arms. Resident #1 swatted at and made contact with CNA A's arms on several occasions. There was no evidence of LVN B or the MS entering the secured unit.Record review of the LW's personnel file revealed suspension then termination on 05/08/26. There were no other disciplinary actions from hire date of 02/02/25. She had one job change from Housekeeping to Laundry on 02/19/26. The LW was unavailable for interview after multiple attempts throughout the investigation.In an interview with the ADM on 06/02/2026 at 2:27 p.m., she said local police did not arrest the LW at the time but Resident #1's family member pressed charges. She said she spoke with the LW who had no previous problems. She said the LW had been educated annually and quarterly on Abuse and Neglect, Resident Rights, HIPPA, and Elopement. She said on 05/08/26 after the incident, the LW kept repeating to her, I'm sorry I put you in this situation and Resident #1 made me mad because she spit in my face. The ADM said the LW said she did not know why she did not walk away. The ADM said Resident #1 had severe behavioral issues but had not physically abused anyone nor spit on anyone, including staff & residents. The ADM said Resident #1 would get verbally abusive with other residents or staff. She said Resident #1 was very religious and paranoid. In an interview with the ADM on 06/04/2026 at 3:07 p.m., she said the local police updated her that the LW had a warrant out for her arrest, but they could not find nor contact her; she was not at home nor would answer any calls.In an interview with CNA A on 06/02/2026 at 3:55 p.m., she said she had worked at the facility for three years. CNA A confirmed her handwriting and signature on a witness statement dated 05/08/26. She said she usually worked in the secure unit. She said she was very familiar with Resident #1. She said she had seen Resident #1 yell at another resident and yell in their face but never spit, pinched, grabbed hair or any other physical aggression. She said Resident #1 was already a unit resident when she started working there. She said she knew the LW. She said they were not friends outside of work and did not know her personally. She said the laundry room was inside the secure unit. She said the LW did not really interact with the residents but would answer questions if they asked. She said the LW interacted with the unit staff normally, was pleasant and funny. She said she was feeding another resident when she heard yelling, so she went toward the sound and saw the LW and Resident #1 arguing but did not know what they were yelling about. She said they were really loud. talking fast and speaking in English and Spanish. She said they were about less than a foot from each other's face. She said she saw Resident #1 spit a lot into the LW's face. She said she was between them at this point. She said the LW reached around her with an open hand and hit Resident #1 in the face. She said Resident #1's head tilted back but she did not stumble or cry out. CNA A said by then, LVN B had arrived and redirected Resident #1. She said the LW kept yelling at Resident #1 as she walked away. She said it happened so fast she wished she could have done something more to protect Resident #1. She said she was in shock when the LW reacted that way. She said staff had in-services on abuse right after the incident. She was able to name the different types of abuse. In an interview with LVN B on 06/02/2026 at 4:28 p.m., she said she worked at the facility for about 5 years. She said she helped out in the secure unit and worked mostly on the floor. She said Resident #1 was nice but had episodes of pacing, insulting people and got in their face, but had never heard or saw her get physical with anyone. She said she was the charge nurse the day of the incident. She said the MS came from the secure unit to get her and said, urgently, LW and Resident #1 were arguing. She said when she got back there, the 2 were yelling at each other really loudly in the hallway. She said the LW was by the laundry room and Resident #1 was closer to her room. She said she kept telling the LW to go and leave while she escorted Resident #1 to her room. She said the LW would not stop screaming and yelling at Resident #1. She said she did not see the spitting or the hitting. In an interview with the MS on 06/02/2026 at 4:42 p.m., he said he worked at the facility since 2016. He confirmed his handwriting and signature on his witness statement dated 05/08/26. He said he was in his office (inside the secured unit) when he heard a trash can lid hit the floor. He said he asked the LW what happened and she told him she dropped it by accident because the barrel was too full. He said he left the unit and a few minutes later, he heard loud voices and got the charge nurse, LVN B, from the dining room and followed her back over to the unit. He said CNA A was separating the LW and Resident #1 with her arms outstretched when he got there but he did not see the spitting or hitting. He said he was told by the ADM to bring the LW to her office. He said the LW was crying out of anger-she was very upset and shaking. He said he did not know what may have triggered the outburst or who was having a bad day or what, but he told the LW she knew better and she would never win an argument with someone with dementia. He said abuse training was mandatory and was not sure if staff had to make up the training if they missed them. He said he only trained his staff on laundry and housekeeping matters.In an interview with HSK D on 06/03/2026 at 8:40 a.m., she said she worked at the facility for 2 months, April 15th. She said her boss was the MS. She said she received abuse and caregiving training on the first day she started. She said she also had housekeeping training. She said she had not worked in the secured unit. In an interview with RN E on 06/03/2026 at 8:46 a.m., she said she worked at the facility for 2 years. She said mandatory abuse training was conducted upon hire and yearly. She said the last abuse training was a couple of weeks ago. She said she did not know if laundry workers got the same training on abuse and caregiving. She said she had been the recipient of Resident #1's episodes. She said she would redirect/deescalate Resident #1 by talking calmly with her. In an interview with HSK F on 06/03/2026 at 8:58 a.m., she said she worked at the facility for 3 months. She said her boss was the MS. She said she watched videos on her first day for ANE & dementia. She said she worked in the secured unit often. She said she was off the day of the incident but heard about it. She said she would have told someone immediately. She said Resident #1 got in her face a couple of times but never hit or put her hands on her. She said she would have walked away as soon as Resident #1 began escalating, and the LW should have walked away.In an interview with CNA G on 06/03/2026 at 8:40 a.m., she said she worked at the facility for over a year. She said she received ANE and caregiving training a few weeks ago and every 3 months. She said she had never seen resident to resident or staff to resident abuse. She said she was off the day of the incident. She said she heard Resident #1 spit on the LW and staff intervened. She said she did not ask questions. She said she would have just walked away from the bickering. In an interview with LAU H on 06/03/2026 at 9:20 a.m., she said she worked at the facility for 4-5 months. She said the MS was her boss. She said she watched videos on abuse and caregiving when she first started but none since. She said she worked in the secured unit fairly often. She said she did housekeeping on the side but did not interact with the residents. She said Resident #1 spit on the LW and the LW swung at the resident. She said if it was her, she would have backed away and got the CNA/and/or the Charge nurse. She said the laundry worker only spoke Spanish, so they did not converse. In an interview with DON K on 06/03/2026 at 11:29 a.m., she said she worked at the facility since 2018 and had the title of DON since 2024. She said there was an altercation between Resident #1 and the LW in the secured unit on the morning of 05/08/26 that became physical. She said the altercation could have been avoided by walking away from the situation. She said she was not sure why the altercation happened because it was so unexpected. She said staff had training upon hire and in-services at least every month. She said Resident #1 had behaviors of refusing oral medications, but would allow her to inject her when the behaviors were escalating. She said the cycle was, takes meds, refuses, escalates, gets a shot, repeat. She said this pattern occurred about every 2 months sometimes less, sometimes more. She said Resident #1 got an injection at the hospital after the incident for increasing agitation. She said a med aide, 2 nurses, and the activities director were always available to relieve staff in the secured unit or help. She said she did not know why the events happened as they did. She said staff immediately received an in-service on abuse. She said she talked with staff on what to do in that kind of situation. She said most of the residents in the secured unit were there for elopement risk and others did better in a more quiet environment. Policies for Dementia care, supervision and what working on the unit means requested at this time.In an interview with ADON J on 06/03/2026 at 10:45 a.m., she said she had worked at the facility 25 years. She said Resident #1 obviously upset the laundry worker is what she understood and as a result of putting her hand on Resident #1.- we all know better. She said she was not at the facility that day and was unable to speak with the LW. She said they had no specific training to the unit. She said upon hire, staff were trained on behaviors, falls, and abuse 3-4 times a year. She said the facility tried to keep employees consistent in the unit. She said there was not always a nurse in the secured unit, but the nurses did rounds every hour or hour and a half She said there was a CNA there consistently. She said there were 4 residents that were incontinent. During the day, the med aide or a nurse or whoever was available would go back there to help out and ensure someone was available in case of a situation when the CNA was busy. She said the CNA's were supposed to call the charge nurse when they needed to perform incontinent care or feed a resident. She said the LW should have walked away. She said one of the charge nurses should have already been there because CNA A was feeding a resident. She said Resident #1 and the LW should have been separated immediately. She said all staff had been trained to be able to stop the situation. She said the training was mandatory. She said she was responsible for making sure all staff were trained for abuse, neglect, and dementia caregiving, She said Resident #1 had slapped a nurse before but did not remember who or under what circumstances. She said Resident #1 refused to take medications. She said nurses had to get physician orders every 4-5 months for an injection when Resident #1 became unmanageable. She said Resident #1's family member was involved in that she answered her phone or in a couple of days would call back. She said Resident #1's family member visited Resident #1 only about once a month. She said Resident #1 called the LW a worker of iniquity, wicked and that God made things happen. ADON J said Resident #1 told her god pushed her when she fell to teach her a (unknown) lesson. ADON J said Resident #1 would not say the LW hit her or that she spit. She said Resident #1 never said she was in any pain. In an interview with the ADM on 06/03/2026 at 1:48 p.m., she was asked for video footage that showed beginning to end of the situation. This was to verify the timing the MS asked about the trash can lids, told LVN B, and LVN B's arrival to the secure unit. She said she spoke with CNA A about being afraid and protecting the Resident #1. She said she told her she could have done more such as tell the LW to leave immediately.In a phone interview with CNA A on 06/03/2026 at 2:01 p.m., she said she did not have her phone on her to call for help when she heard the LW and Resident #1 yelling. She said she did not call anyone before she started feeding the resident because it was in the morning and never would have thought anything like that would have happened. She said her phone was on the counter out of reach. She said she did not use her phone because she had an automatic reaction to go towards the yelling. She said she regretted not calling for help before she reached the 2 people (Resident #1 and the LW). She said the ADM talked to her that day and got her statement. She said the ADM told her she should have had the phone in her pocket and asked how she was. She said the whole situation was out of the ordinary. She said her phone was on the counter and she was feeding a resident. She said the MS was in his office and the LW was getting dirty linen and she heard him ask Resident #1 not to drop the lids. Then the LW told him she was the one who dropped the lids. She said the MS had gone to the front and came back to get the LW after the incident. She said Resident #1 apologized to her. She said she was not fearful of Resident #1. She said LVN B came in right after the LW 1 struck Resident #1. She said the situation probably could have been handled better by her. In a phone interview with LVN B on 06/03/2026 at 2:24 p.m., she said when she was made aware of the conflict in the secure unit by the MS, she went in there and the LW was near the laundry room door and Resident #1 was on the other side of the MS office, and CNA A was standing between them. She said the LW and Resident #1 were yelling at each other. She said it was not until after the spitting and hitting that she went in. She said CNA A did not let her know she was feeding residents, leaving the other residents unsupervised. She said staff should always deescalate and call for help when needed and always protect the residents before anything else. She said staff had been trained for this. She said she was not sure what could have been done to prevent this from happening other than 1:1 the resident or educate the staff on when to walk away. She said they all knew what to do, but another person back there probably would have prevented the outcome.Observation and interview with Resident #1 on 06/03/2026 at 4:25 p.m. revealed she had just returned from an appointment. Resident #1 was appropriately dressed and ambulatory. Resident #1 was sitting in her room when she granted permission to speak to this state surveyor. Resident #1 was able to state her name, was able to state the correct day but was unaware of the time. Resident #1 was aware she was in the nursing facility. Resident #1 said she said she remembered the incident. She said the LW abused her and had a problem with her. She said she confronted the LW with using the patient restroom across the hall from her where she could see her going in and & out. She said the LW pushed her because a little saliva came out when she was talking to her. She said it was not herself who lost their temper. She said the LW was a hater and the lord would make the decisions. She said she had been in the facility 8 years and she gave everything to the lord. She said she was not an evil doer and was god's follower. She said those, like the LW, that made evil or stayed up at night to make evil will be punished by god. She said the LW told her she looked like she had the devil in her. She told LW she had the devil in her and it was god that was fighting through her to fight the evil spirit that was fighting me. She said when she was 3 years old, her aunt and her were attacked by a black dog and her aunt had a nervous breakdown because of it. She said she herself was in such a state of shock, she was not treated properly and the state of shock turned into epilepsy. She said when she accepted god, she was healed and free of nervousness. Record Review of in-services revealed the following: -11/17/25-Abuse, Neglect, and Exploitation, Dementia and Behavior. -01/05/26-Caring for people who have dementia, falls & fall risk management, Abuse & Neglect, Misappropriation of resident's funds and belongings. [not signed by the LW 1]-01/07/26-Missing clothing [signed by the LW 1]. -01/26/26-Fire Prevention & Safety. [not signed by the LW 1]-02/02/26-Ensure resident's clothing is placed in right rooms [signed by the LW 1]. -02/09/26 Infection prevention & control, handwashing, responding to call bells timely, assisting residents with all meal set-ups. [not signed by the LW 1]-03/09/26-Resident Rights, Abuse & Neglect P&P [signed by the LW 1]. -03/23/26-Vaping in building, restraint reduction & preventing falls [signed by the LW 1]. -05/08/26-Mock fire drill, Firewatch, reporting a fire alarm, Fire & smoke barrier doors, Fire safety & prevention. [not signed by the LW]-05/08/26-05/10/26-Abuse & Neglect Policy & Procedures, Dementia, Dementia with Behaviors. [not signed by the LW 1] - 100% of the facility staff were provided the inservice by 05/10/26 as verified by in-services signatures sheets and facility staff roster.-06/01/26-Abuse & neglect Policy & Procedures.Record review of hospital records dated 05/08/26 at 12:18 p.m., revealed the chief complaint was domestic violence. The visit diagnoses were urinary tract infection, assault, and bruise of face. Resident #1 is an 80 y.o. female with history of bipolar disorder, schizophrenia, dementia, hypertension, who presents to the Emergency Department from nursing facility after reportedly being shoved by one of the housekeepers at the facility. EMS noted that patient had engaged in a verbal argument with the housekeeper and the housekeeper shoved her. She denies any head injury and witnesses noted no fall, head injuries. Patient currently denies any pain at this time. History provided independently by patient.Physical Exam: Ecchymosis to left superior nasal bridge without tenderness. Oriented to person, place, and time. Thought content is delusional. Discussed patient's case with family member at bedside, who states that patient had an altercation with a housekeeper at the nursing home and notes the ecchymosis to the left upper nasal bridge is new. We will CT head and maxillofacial with patient and family member consent. CT results: 1. No acute facial fracture. 2. Small focus of soft tissue gas lateral to the posterior aspect of the left maxillary sinus without associated fluid collection. 3. 1. No acute intracranial abnormality. Medical Decision Making: This is a [AGE] year-old female who presented via EMS from nursing facility for evaluation after reported altercation with a housekeeper where patient was arguing with a housekeeper and was reportedly shoved. She denies any fall, head injuries, any other injuries but family member, who was not present but was informed, requested patient to be evaluated in the ER.On initial evaluation, patient is alert to person and place but she does speak in tangential thoughts but is redirectable. She does have ecchymosis to the left superior nasal bridge area but has no orbital entrapment. Pupils are equal reactive to light bilaterally. She has no facial tenderness. No C, T, L-spine tenderness. Moving all extremity spontaneously. We informed her plans to check out her blood work as well as urine to rule out UTI. She expressed understanding agrees with plan. Family member later arrived at bedside and stated that this is about patient's baseline mental status but noted that she has been a little bit more delusional recently but has calmed down since being here. She is requesting additional imaging and noted that the bruising on her mother's face was new. Due to this new finding, we obtain consent from patient to proceed with CT imaging, which she is agreeable with. Her urinalysis did show evidence of UTI and she was given IM Rocephin. While waiting for results, she got increasingly anxious and was given a small dose of dropendol to help calm her down. CT head did not show any intracranial hemorrhage. CT maxillofacial did not show any new fractures. Discussed all findings and results with patient's family member and patient and patient family member stated that that employee who assaulted patient was arrested and stated that she has a safe place to go to. They will file a police report about the incident.All results and findings discussed with patient and family member understands and agrees with plans for discharge home. All questions answered. Return precautions given for any new or worsening symptoms. Patient stable for discharge at this time.Record review of the facility's CNA training titled, Curriculum for Nurse Aides in Long Term Care dated March 2024 was used in conjunction with videos titled, The Nursing Assistant Dementia Care Parts 1,2, and 3. The curriculum outlined Major Losses and Changes Associated with Aging, Development tasks Associated with Aging, Normal Responses to Losses and Changes Associated with Aging, Culture Change-Influence on residents' needs, person directed care, Specific Behavioral Problems-Considerations for Care, Causes of Behavioral Problems, Behavior Management, Role of the Nurse Aide in Assisting with Specific Behavior Management Plans. Behavior Management is Restorative Care, Specific Behavior Problems, A[TRUNCATED

Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #5) reviewed for medication errors. 1. The facility failed to hold Resident #5's losartan (blood pressure medication) when Resident #5's blood pressure was outside of physician's parameters on November 6th and 26th of 2025. 2. The facility failed to hold Resident #5's hydralazine (blood pressure medication) when Resident #5's blood pressure was outside of physician's parameters on November 2nd, 6th, 17th, and 26th of 2025. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.The findings include:Record review of Resident #5's face sheet, dated 12/02/25, reflected an [AGE] year-old male with an original admission date of 06/11/14 and a current admission date of 11/10/20. Resident #5's pertinent diagnosis included essential hypertension (high blood pressure with no single identifiable cause, developing gradually from a mix of genetics, age, and lifestyle factors like poor diet, obesity, inactivity, and stress). Record review of Resident #5's Quarterly MDS assessment, dated 11/10/25, reflected a BIMS score of 0 which indicated severe cognitive impairment. Record review of Resident #5's comprehensive care plan, dated 12/02/25, reflected the focus [Resident #5] has a history of CVA (a sudden disruption of blood flow to the brain, causing brain cells to die from lack of oxygen, leading to potential disability or death) and bradycardia (slow heart rate). An intervention listed for the focus included Administer medications as prescribed. Record review of Resident #5's order summary reflected an active order for Losartan Potassium Tablet 100 MG. Give 1 tablet via G-tube one time a day related to essential (primary) hypertension. Hold if SBP less than 120 or DBP less than 60 initiated on 05/02/25. Further review reflected an active order for hydralazine HCL Oral Tablet 25 MG. Give 1 tablet via G-tube two times a day related to essential (primary) hypertension. Hold if SPB less than 110 or DBP less than 60 initiated on 07/16/25. Record review of Resident #5's MAR for November 2025 reflected losartan and hydralazine were administered by RN C on 11/06/25 and 11/26/25 with blood pressures 155/55 and 117/50 respectively. Further review reflected hydralazine was administered by RN F on 11/02/25 and 11/17/25 with blood pressures 91/56 and 111/59 respectively. In an interview with RN C at 3:54 PM on 12/03/25, RN C stated she always checked a resident's blood pressure before administering medications designed to raise or lower their blood pressure. RN C stated administering blood pressure medications outside of physician's parameters could lead to hypotension (low blood pressure), causing excessive sweating or clammy skin. RN C stated she did not remember the specific instances on 11/06/25 or 11/26/25. RN C stated, based on the MAR, it did look like she administered blood pressure medications to Resident #5 outside of parameters. In an interview with RN F at 6:02 PM on 12/03/25, RN F stated he always checked a resident's blood pressure before administering medications designed to raise or lower their blood pressure. RN F stated if a resident's blood pressure dropped too low it could cause the resident to become unresponsive. RN F stated, based on the MAR, it looked like he administered hydralazine to Resident #5 on 11/02/25 and 11/17/25 outside of parameters. RN F stated he thought he made an error in recording the information because he would have held the medications based on Resident #5's blood pressure at the time. In an interview with the DON at 8:25 AM on 12/04/25, the DON stated a resident's blood pressure should be checked before administering blood pressure altering medications to them. The DON stated hypotension could cause dizziness, light-headedness, and cause the resident to faint. The DON stated blood pressure medications should not have been administered outside of parameters unless the nurse was given specific instructions by the physician. Record review of the facility's policy Administering Oral Medications, dated October 2010, reflected the following policies: .1. Verify that there is a physician's medication order for this procedure.6. Check the label on the medication and confirm the medication name and dose with the MAR.

Based on observation, 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 of 5 residents (Resident #13 and Resident #36) reviewed for documentation. The facility failed to ensure LVN A documented relevant information (redness/rash to abdomen) and did not document incorrect information (dependence on staff for eating due to tube feeding) on Resident #13's admission Nursing Assessment form dated 11/26/25. The facility failed to ensure LVN B documented relevant information (presence of arterial ulcers, pressure ulcer, abrasion, and redness/rash to abdomen) and did not document incorrect information (reason for skilled services: PEG tube, the presence of an IV and enteral (tube) feeding, and dependence on staff for eating due to tube feeding) on Resident #13's Daily Skilled Nurses Notes form dated 11/27/25, 12/02/25, and 12/03/25. The facility failed to ensure RN C documented relevant information (presence of arterial ulcers, pressure ulcer, abrasion, and redness/rash to abdomen) and did not document incorrect information (reason for skilled services: PEG tube, the presence of an IV and enteral (tube) feeding, and dependence on staff for eating due to tube feeding) on Resident #13's Daily Skilled Nurses Notes form dated 11/28/25. The facility failed to ensure LVN D documented relevant information (presence of arterial ulcers, pressure ulcer, abrasion, and redness/rash to abdomen) and did not document incorrect information (reason for skilled services: PEG tube, the presence of an IV and enteral (tube) feeding, and dependence on staff for eating due to tube feeding) on Resident #13's Daily Skilled Nurses Notes form dated 11/29/25. The facility failed to ensure Resident #36's blood pressures were taken as ordered for the month of November 2025. These failures could place residents at risk for errors in care and treatment and not receiving the services needed to attain or maintain their highest practicable physical well-being. Record review of Resident #13's face sheet dated 12/03/25 reflected a [AGE] year-old male originally admitted to the facility on [DATE]. Diagnoses included gastrostomy infection (infection of the opening where a tube used to provide nutrition, hydration, and medication was surgically implanted through the abdomen into the stomach), dementia (progressive loss of intellectual functioning, thinking, remembering, and reasoning skills), type 2 diabetes (chronic condition that happens when blood sugar levels are persistently high), Parkinson's disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), dysphagia (difficulty swallowing), and moderate protein-calorie malnutrition ((an imbalance between the nutrients needed to function and the nutrients received). Record review of Resident #13's quarterly MDS dated [DATE] reflected a BIMS score of 15 which indicated he was cognitively intact, and he had a feeding tube and a mechanically altered therapeutic diet. Record review of Resident #13's hospital record dated 11/24/25 reflected he was admitted to the hospital on [DATE] and his gastrostomy (feeding) tube was removed on 11/23/25 while he was in the hospital. Record review of Resident #13's Weekly Skin assessment dated [DATE] reflected he had abrasions to his nose with small red scabs, 2 arterial ulcers (painful deep sores caused by poor circulation) to the back of his left lower leg, and an arterial ulcer to his left heel.Record review of Resident #13's Order Summary Report dated 12/03/25 reflected an order that stated, Stage 2 to sacrum: cleanse with wound cleanser, pat dry with 4x4 (gauze), apply {skin barrier cream] and collagen powder and secure with bordered dressing every day shift for treatment. Record review of Resident #13's progress notes dated 11/03/25 to 12/03/25 reflected he returned to the facility on [DATE] at 7:30 PM. Record review of Resident #13's admission Nursing assessment dated [DATE] at 7:30 PM by LVN A reflected in Section C: Skin Integrity: LVN A did not document Resident #13's redness/rash on his abdomen and in comments she stated: PEG tube removed at hospital. Resident with clean and dry dressing in place. LVN A documented Resident #13 was dependent (he needed total assistance with eating) and did not mark he was on a mechanically altered diet and had a pressure ulcer present in Section D: Oral/Nutrition. Record review of Resident #13's assessments reflected the following: Daily Skilled Nurses Notes dated 11/27/25 at 9:56 AM and 11/30/25 at 10:10 AM, LVN B documented (incorrect information) or failed to document (relevant information): Section 2. Medicare Diagnosis: 1. Document reason resident is on Medicare Skilled Services: PEG TUBE, PARKINSONS (Incorrect information) 5. Devices and Treatments: Enteral Feeding and IV were checked as active. (Incorrect information)Section 3. Functional Status: SELF PERFORMANCE- Eating (how resident ate and drank/ if resident was on a g-tube), LVN B marked Total Dependence (FULL staff performance/ NO help from resident) and on staff support provided, LVN B marked 1-person physical assist. (Incorrect information) Section 8a- Skin issues, LVN B failed to document any of Resident #13's 3 arterial ulcers, stage 2 pressure ulcer (a shallow wound with a pink or red base with skin loss, abrasions, and blisters possible), abrasion to his nose, or redness/rash to his abdomen. (Relevant information)Section 8c- Gastrointestinal, LVN B marked yes; Resident #13 had a feeding tube. (Incorrect information)Section 10- Additional Notes, LVN B documented, Resident up to wheelchair in therapy no acute distress and no complaints pain or SOB. Resident continues on 02 per nasal cannula. Resident continues with 3+ edema to lower extremities. Resident is able to voice needs effectively. He requires extensive assistance with ADLS and transfers. Resident eating well. G- tube patent and flushing well. Bolus if intake less than 50%. Will continue to monitor for any changes in condition. [sic] (Contains incorrect information) Daily Skilled Nurses Notes dated 11/28/25 at 9:36 AM, RN C documented or failed to document all the same information as LVN B on 11/27/25 except for: Section 10- Additional Notes, RN C documented, Resident up to wheelchair, in no acute distress. no complaints of discomfort or pain. Continues on 02 per nasal cannula, and edema to lower extremities. Resident is able to voice needs effectively. He requires extensive assistance with ADLS and transfers. Resident eating well. G- tube patent and flushing well. Bolus if intake less than 50%. Will continue to monitor for any changes in condition. [sic] (Contains the same incorrect information) Daily Skilled Nurses Notes dated 11/29/25 at 3:57 PM, LVN D documented or failed to document all the same information as RN C on 11/28/25 including Section 10- Additional Notes. Daily Skilled Nurses Notes dated 12/01/25 at 12:43 PM, LVN E documented or failed to document all the same information as LVN B on 11/27/25 except for Section 10- Additional Notes Daily Skilled Nurses Notes dated 12/02/25 at 3:09 PM and 12/03/25 at 12:44 PM, LVN B documented or failed to document all the same information as LVN E on 12/01/25 including Section 10- Additional Notes. Observation and interview of Resident #13 on 12/03/25 reflected resident sitting in his wheelchair in his room with a rolling table in front of him. Resident #13 was eating graham crackers and drinking water without difficulty. Resident #13 stated his feeding tube was removed while he was at the hospital on [DATE] because it had not been used in about 6 months and there was an infection on his abdomen where it was at. Resident #13 stated he had open sores on his lower left leg, left heel, and his sacrum and redness and rash to his abdomen where his feeding tube had been and where the gauze was at. In a telephone interview on 12/03/25 at 4:55 PM, LVN A stated the admission Assessment was a blank form that was not pre-filled with information. LVN A stated she marked dependent for nutrition by accident because Resident #13 ate by himself. LVN A stated the Daily Skilled Nurses Notes assessment auto- populated when the form was opened. In an interview on 12/03/25 at 3:51 PM, RN C stated Resident #13 did not still have a feeding tube, and it was removed while he was in the hospital. RN C stated the Daily Skilled Nurses Notes form was a new note each time, and she pulled up another screen to copy the previous note. She stated she overlooked the feeding tube and the IV check boxes, and they should not have been checked. She stated the comments were her own comments and not copy/pasted, but she did follow the notes from the previous note. She stated it was important to not use information from anyone else's notes because that was her assessment of the resident, and the previous information could have been incorrect. She stated she did not document any of his wounds on the Daily Skilled Nurses Notes form because she did not have specific measurements of them. RN C stated in-services on documentation and skills were done upon hire and annually. She did not recall the last in-service for documentation. In an interview on 12/03/25 at 2:32 PM, LVN B stated Resident #13 went to the hospital for an infection to his feeding tube site and was on antibiotics by mouth while in the hospital for 4 days then continued on antibiotics when he returned to the facility. LVN B stated the feeding tube was removed because it had not been used for several months. When asked why he documented peg tube and Parkinson's as the reason for skilled assessment, LVN B stated he probably just did not look at it again. LVN B stated the Daily Skilled Nurses Notes form auto-populated when it was opened. LVN B stated Resident #13 had an IV, a long time ago. LVN B stated he went through all the check boxes when he opened the form, but he probably just went through it fast and did not catch those boxes that should have been unchecked. LVN B stated he noticed on 11/30/25 that his comments were not correct but did not catch the check boxes. He stated if things were just copied/pasted, important information could be missed. LVN B stated he believed the ADON and DON audited the Daily Skilled Nurses Notes to ensure they were accurate, but it was the nurse's responsibility to ensure they were documented correctly. In an interview on 12/03/25 at 5:43 PM, the ADON stated the Daily Skilled Nurses Notes had an option to copy the previous note to a new note. The ADON stated Resident #13's feeding tube was removed while he was at the hospital due to infection at the insertion site. She stated she thought the MDS coordinator would review those notes on skilled residents, but she and the DON did not review them. She stated it was important the information was correct because it was a full assessment of the resident. If the information was not correct, a nurse that was not familiar with the resident would be reading the wrong information on the resident. The ADON stated when the Daily Skilled Nurses Notes contained all the same wrong information, it told her the nurses were not reading what they documented on the assessment and possibly meant the nurses were not assessing the resident. The ADON stated billing for Medicare and Medicaid may have been done from the Daily Skilled Nurses Notes. She stated in-services on documentation were quarterly, and she was unsure of when the last one was. In an interview on 12/04/25 at 8:25 AM, the DON stated the Daily Skilled Nurses Notes form was a head-to-toe assessment of how the resident did during that shift, and the nurse was supposed to assess the resident before documenting the daily skilled note. The DON stated the daily skilled note was reviewed by the MDS nurse daily, who should have caught the errors. She stated it was also reviewed by the regional MDS nurse. The DON stated the MDS information came from the Daily Skilled Nurses Notes, and it was also used during a RUG (Resource Utilization Groups) review for Medicare. She stated it was important the forms were accurate so the information could be followed through. The DON stated when the nurse entered a new Daily Skilled Nurses Note, there was a button to be able to copy an old one and put that information into the new note. In an interview on 12/04/25 at 9:01AM, the MDS nurse stated the Daily Skilled Nurses Notes assessment was used for Resident #13 because he was also a VA patient and the VA requested daily skilled notes. She stated it was important for those notes to be accurate because she reviewed them when she completed the MDS. The MDS nurse stated Resident #13's quarterly MDS would be completed today because it was due yesterday. The MDS nurse stated she reviewed the daily skilled notes when she was ready to do the MDS, but she saw the resident daily and if she found incorrect information after seeing the resident, she would let the nurses know. She stated she reviewed the functional abilities daily for 3 days when the resident was admitted or readmitted and for the 3 days look back when the MDS was due. The MDS nurse stated if the MDS was submitted with the wrong information, she would have to submit a correction and she would know if there was an error because she did audits of them every 2-3 weeks that covered the previous 30 days. The MDS nurse stated the purpose of the MDS, was to maintain and improve the resident's level of function, and you had to know your resident so it gave State and CMS an accurate view of the resident. She stated CMS based the PDPM (Patient Driven Payment Model; how the facility got paid for Medicare residents) off the MDS and if it was inaccurate, the facility had to repay/ refund the money paid by Medicare. The MDS nurse stated CMS had OIG audits every 2 years to ensure facilities were not being paid fraudulently. She stated she looked at the CNA tasks daily to see what they were documenting in terms of ADL assistance needed and if she saw something that was not accurate, she would talk to them about documenting it correctly. In an interview on 12/04/25 at 9:35 AM, the Adm stated the MDS had to be accurate to be able to take care of the resident appropriately and for billing purposes. She stated the MDS was looked at to see how Medicare/Medicare was going to reimburse for the resident's care based on the level of care needed. The Adm stated if the MDS was not accurate, the facility could be underpaid, overpaid, or lose all reimbursement. Record review of Resident #36's face sheet dated 12/03/25 reflected an [AGE] year-old female with an original admission date of 11/27/23. Diagnoses included dementia (progressive loss of intellectual functioning, thinking, remembering, and reasoning skills) and high blood pressure. Record review of Resident #36's quarterly MDS dated [DATE] reflected a BIMS of 13 (cognition intact) and an active diagnosis of high blood pressure. Record review of Resident d#36's care plan dated 05/20/25 reflected: Resident #36 received medication to treat a diagnosis of hypertension (high blood pressure). Resident #36's blood pressure would be stable during and until the next quarterly review. Report any significant abnormal results to the MD. Medication to treat hypertension per the MD orders. Monitor blood pressure as ordered and notify MD if results are high or low. Record review of Resident #36's blood pressure reading log and documentation for the month of November 2025 reflected: 11/25/2025 12:22 P.M.118 / 70 mmHg 11/25/2025 02:40 P.M. 118 / 70 mmHg 11/25/2025 09:05 A.M. 118 / 70 mmHg 11/24/2025 12:50 P.M. 112 / 66 mmHg 11/24/2025 09:51 A.M. 112 / 66 mmHg 11/22/2025 10:43 A.M. 121 / 73 mmHg 11/22/2025 09:18 A.M. 121 / 73 mmHg 11/21/2025 01:13 P.M. 127 / 71 mmHg 11/21/2025 08:01 A.M. 127 / 71 mmHg 11/19/2025 10:05 A.M. 124 / 59 mmHg 11/19/2025 08:28 A.M. 124 / 59 mmHg 11/18/2025 08:57 A.M. 100 / 66 mmHg 11/18/2025 08:07 A.M. 100 / 66 mmHg 11/15/2025 02:33 P.M. 117 / 68 mmHg 11/15/2025 01:53 P.M. 117 / 68 mmHg 11/13/2025 09:23 A.M. 123 / 68 mmHg 11/13/2025 08:18 A.M. 123 / 68 mmHg 11/11/2025 12:06 P.M. 127 / 63 mmHg 11/11/2025 08:04 A.M. 127 / 63 mmHg 11/10/2025 09:50 A.M. 122 / 64 mmHg 11/10/2025 08:34 A.M. 122 / 64 mmHg 11/2/2025 10:01 A.M. 118 / 70 mmHg 11/2/2025 08:58 A.M. 118 / 70 mmHg In an interview on 12/03/25 at 09:56 AM, Resident #36 stated she has not had any problems with her blood pressure that she could remember, and staff takes her blood pressure every day. In an interview on 12/03/25 at 2:46 PM, LVN B stated that at times the same blood pressure reading was reused for Resident #36. LVN B explained Resident #36 often had her blood pressure taken in the morning and then again shortly after, for her scheduled blood-pressure-altering medication. LVN B stated the facility system used to document blood pressures included a recall button that allowed the previous readings to be pulled up, and at times, those previous readings were used if Resident #36's blood pressure had been recently taken. LVN acknowledged that previous blood pressure readings should not be reused as blood pressures can change from the original time it was taken. LVN B stated it was important to obtain and document accurate blood pressure measurements to ensure Resident #36's medication needs were met and properly tracked and trended for any abnormalities. In an interview on 12/03/25 at 5:41 PM, the ADON stated that the same or previous blood pressure readings should not be reused on any residents. The ADON stated by doing so, staff would not be aware of any potential changes in the residents' condition if the blood pressure had changed. The ADON stated accurate blood pressure measurements should be taken and recorded each time to ensure the resident was receiving the necessary dose of the medication and to also track and trend any patterns the resident may be experiencing. In an interview on 12/04/2025 at 8:37 AM, the DON stated staff should not be reusing any blood pressure reading since blood pressure readings can fluctuate throughout the day. The DON stated when she spoke to some of the nursing staff about the reused blood pressure readings, nursing staff stated it was because Resident #36 had a blood pressure altering medication scheduled for the morning and an order to also assess vitals every shift and those blood pressures were done closely together so they were reused. The DON stated she informed nursing staff that all blood pressure readings should be documented accurately and taken each time regardless of the time taken. The DON stated it was important to accurately document Resident #36's and all residents' vitals to track and trend any abnormalities and to ensure the medication was given as prescribed. Record review of facility's Charting and Documentation policy dated July 2017 reflected: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. changes in the resident's condition;

Based on observations, interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 5 residents (Resident #38) whose care plans were reviewed. The facility failed to ensure Resident #38's call light was within reach at all times while in his room, as stated in the care plan. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services, and the implementation of personalized plan of care developed to address their specific needs. The findings included: Record review of Resident #38's face sheet dated 12/03/25 reflected a [AGE] year-old male with an original admission date of 05/13/17. Diagnoses included dementia (progressive loss of intellectual functioning, thinking, remembering, and reasoning skills), blindness to right and left eye, Alzheimer's disease (generalized degeneration of the brain), and schizophrenia (serious mental health condition that affects how people think, feel and behave). Record review of Resident #38's care plan dated last review on 11/04/25 reflected: Resident #38 required assistance with ADLs due to Blindness. Call light within reach at all times when in room. Record review of Resident #38's quarterly MDS dated [DATE] reflected a BIMS of 3 (cognition severely impaired) and needed substantial/maximal assistance - (Helper does more than half the effort), helper lifts or holds trunk or limbs and provides more than half the effort with toileting, personal hygiene and bathing. Resident #38 was not interviewable. Observation of Resident #38 call light on: On 12/02/2025 at 9:06 AM, Resident #38 was lying in bed, and the call light was seen under the bed, and it was not in reach. On 12/02/2025 at 5:32 PM, the call light was seen under the bed, and it was not in reach. On 12/02/2025 at 6:13 PM, the call light was seen under the bed, and it was not in reach. On 12/03/2025 at 8:33 AM, the call light was hanging over the bed rail almost on the floor and was not in reach. On 12/03/2025 at 10:56 AM, the call light was hanging over the right-side bottom bed rail almost on the floor and was not in reach. On 12/03/25 at 1:34 PM, call light not in reach hanging over bed rail almost on the floor. In an interview on 12/03/2025 at 2:24 PM, LVN B stated the care plans should be followed for each resident since it was their individualized plan of care. LVN B stated he did check in on all residents when he rounded, and he did check on Resident #38 but did not realize he did not have his call light within reach. LVN B stated he should have made sure the call light was in reach in case the resident needed assistance or there was an emergency. LVN B stated it was important to follow Resident #38's care plan since that was an individualized plan of care for the resident. LVN B stated if Resident #38 was unable to reach his call light, he would not be able to call for assistance. In an interview on 12/03/25 at 2:36 PM, CNA G stated earlier she did see that Resident #38's call light was hanging off the bed. LVN G stated she picked it up and clipped it to the bed sheet, so it was within reach. CNA G stated Resident #38 had a history of throwing his call light off the bed. CNA G stated it was important that Resident #38 had his call light in case there was an emergency, or if he needed assistance. In an interview on 12/03/25 at 5:32 PM, the ADON stated it was all staff's responsibility to ensure the residents' call light was within reach in case the resident needed assistance or there was an emergency. The ADON stated Resident #38 has a history of refusing care and medications, but she was unaware if Resident #38 had a history of throwing his call light off the bed. The ADON stated Resident #38 was visually impaired, and staff needed to ensure his call light was always within reach, so the individualized plan of care was being followed. In an interview on 12/04/25 at 8:35 AM, the DON stated call lights should be within reach for all residents so they can call for assistance if needed. The DON stated anybody can make sure the resident has the call light within reach just like anyone can answer the call light. The DON stated it was important to follow Resident #38's plan of care since it was individualized and set to meet the residents' needs. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated March 2022 reflected: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being Record review of the facility's Call System, Resident policy dated September 2022 reflected: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly from assistance for his/her bed, from toileting/bathing facilities and from the floor. 6. Calls for assistance are answered as soon as possible, but no later than 5 minutes. Urgent requests for assistance are addressed immediately.

Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 residents (Resident #9) reviewed for respiratory care. The facility failed to ensure LVN A transcribed a physician's telephone order during her shift for oxygen at 2 Lpm as needed to maintain oxygen levels above 90% into PCC for Resident #9. This deficient practice could place residents at-risk for insufficient or inappropriate care due to other staff not being aware the physician's order existed. The findings include:Record review of Resident #9's face sheet, dated 12/02/25, reflected an [AGE] year-old female with an original admission date of 01/13/19 and a current admission date of 04/02/19. Resident #9's pertinent diagnosis included unspecified dementia without behavior disturbance (a diagnostic term for dementia where the specific type, such as Alzheimer's or vascular dementia, is not yet determined). Record review of Resident #9's Quarterly MDS assessment, dated 11/11/25, reflected a BIMS score of 15 which indicated no cognitive impairment. Further review reflected Resident #9 had not used oxygen in the last 14 days. Record review of Resident #9's comprehensive care plan, dated 12/02/25, reflected it did not include any sections related to oxygen use. Record review of Resident #9's order summary, dated 12/02/25, reflected it contained no orders for oxygen at 2 Lpm as needed to maintain oxygen levels above 90%. Record review of nurse's progress notes reflected a note was created by LVN A on 12/02/25 at 8:14 PM with an effective date of 12/01/25 at 11:15 PM that stated [Resident #9] with complaints of SOB. Residents O2 at 90% [room air] . MD notified. [new order] received for oxygen as needed at 2 lpm via nasal cannula for SOB to maintain O2 sat[uration] above 90%. Rp notified. During an observation of Resident #9 in her room at 10:15 AM on 12/02/25, Resident #9 was laying in bed receiving oxygen via nasal cannula at 2 lpm. In an interview with Resident #9 at 10:15 AM on 12/02/25, Resident #9 stated she had not been on oxygen very long. Resident #9 stated she felt a little short of breath the night before, so the nurse gave her some oxygen. In an interview with LVN A at 4:51 PM on 12/03/25, LVN A stated Resident #9 complained of shortness of breath at around 11:15 PM on 12/01/25, so she called the physician. LVN A stated the physician gave her an order over the telephone for oxygen at 2 lpm as needed to maintain oxygen saturation over 90%. LVN A stated she got busy after that and forgot to put the order into PCC. LVN A stated it was important to put orders into PCC (computer charting system for resident medical records) when they were received from the physician so other nurses were up to date on the proper care for residents. In an interview with the DON at 8:25 AM on 12/04/25, the DON stated any telephone orders from the physician should have been immediately entered into PCC. The DON stated it was important to enter new orders into PCC quickly so the oncoming nurse would know what was going on with the resident. The DON stated LVN A should have put the order from the physician into PCC right after she got off the phone with him at around 11:15 PM on 12/01/25. Record review of the facility's policy Telephone Orders, dated February 2014, reflected the following policy: .1.Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record.2. The entry must contain the instructions from the physician, date, time and the signature and title of the person transcribing the information.

Based on interview and record review, the facility failed to readmit one of five residents (Resident #1), immediately, or to the next available bed after the hearing officer determined the discharge was inappropriate. The ADM failed to allow Resident #1 to return to the facility when the hearing officer determined Resident #1's discharge was inappropriate and Resident #1 won his discharge appeal. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest practicable well-being and at risk of a diminished quality of life.The findings included:Record review of Resident #1's face sheet dated 10/28/25 revealed a [AGE] year-old male with an admission date of 04/17/23 and a discharge date of 04/11/25. Resident #1's pertinent diagnosis included bipolar disorder (a chronic mental health condition characterized by extreme mood swings between highs and lows). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated his cognition was intact. Record review of Resident #1's comprehensive care plan dated 04/11/25 revealed the focuses [Resident #1] demonstrates verbally abusive behaviors daily toward staff and residents, 4/11/25 = UPDATE: Resident continues to be verbally abusive towards staff/residents calling them names, cursing at them, and I have a cognitive impairment due to: Bipolar Disorder. Record review of discharge notice given to Resident #1 dated 04/11/25 revealed Resident #1 was discharged from the facility effective 04/11/25 because his behavioral status endangers the safety of individuals in the facility. Further review revealed Resident #1 had the Right to Appeal: as outlined in the Department of Human Services' Fair Hearings Fraud and Civil Rights Handbook, you have a right to appeal to the Facility's decision to discharge you. Record review of Fair Hearing document on Resident #1's discharge date d 07/28/25 revealed the Lead Hearings Officer gave the following instructions to the facility: Instructions: In accordance with this decision, [facility] is instructed to allow Appellant to remain in, or immediately be re-admitted back into, its facility, if the Appellant and his representative so desire, and not transfer or discharge the Appellant from the facility. Record review of the Action Taken on Hearing Decision document produced by the facility dated 08/08/25 revealed the facility stated there was no action required because Facility does not have an attending physician that will accept resident back into facility. In an interview with the MD at 4:20 PM on 10/28/25, the MD stated he was the medical director and primary physician for every resident at the facility. The MD stated he had taken care of Resident #1 at the facility before his discharge on [DATE]. The MD stated Resident #1 was extremely disruptive while he was a resident at the facility and he did not want to treat him anymore. The MD stated he recommended Resident #1 go to a behavioral facility. The MD stated he did not want Resident #1 back at the facility. The MD stated there were no other doctors that he knew of around the facility that could treat Resident #1. In an interview with the DON at 10:01 AM on 10/29/25, the DON stated Resident #1 was involved in a lot of incidents at the facility including threatening physical violence against both residents and staff. The DON stated she believed the reason Resident #1 was not allowed back in the facility was because there was not a physician to oversee his care. In an interview with the ADM at 10:59 AM on 10/29/25, the ADM stated Resident #1 was discharged from the facility on 04/11/25 because she was concerned about the safety of other residents and her staff. The ADM stated she understood that Resident #1 won his appeal on his discharge from the facility. The ADM stated the MD did not want Resident #1 back in the facility and he refused to treat him. The ADM stated there were no other doctors in the area that could treat Resident #1 in the facility, so they were unable to readmit him. The ADM stated she spoke to Resident #1 on the phone after the appeal decision, but she told him he could not come back because the MD refused to treat him. The ADM stated she sent the response to the Hearings Officer on 08/08/25 that stated that there were no doctors at the facility to treat Resident #1 so they could not readmit him. The ADM stated she had not heard anything since then from the Hearings Officer. The ADM stated she did not attempt to find a new doctor that could treat Resident #1 at the facility. A policy was requested from the ADM on 10/28/25 outlining the proper procedures for a discharge but none was provided. The ADM did provide a signed admission agreement by Resident #1, but it did not list the specific information that was required during the appeal process of a discharge.

Based on interviews and record review, the facility failed to ensure that one of five residents (Resident #1) reviewed for transfer or discharge had the required contents in the written notice. The facility discharged Resident #1 on 4/11/25 without including a specific location where Resident #1 was going after discharge. This failure could put residents at risk for inappropriate discharge from the facility.The findings included:Record review of Resident #1's face sheet dated 10/28/25 revealed a [AGE] year-old male with an admission date of 04/17/23 and a discharge date of 04/11/25. Resident #1's pertinent diagnosis included bipolar disorder (a chronic mental health condition characterized by extreme mood swings between highs and lows). Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated his cognition was intact. Record review of Resident #1's comprehensive care plan dated 04/11/25 revealed the focuses [Resident #1] demonstrates verbally abusive behaviors daily toward staff and residents, 4/11/25 = UPDATE: Resident continues to be verbally abusive towards staff/residents calling them names, cursing at them, and I have a cognitive impairment due to: Bipolar Disorder. Record review of discharge notice given to Resident #1 dated 04/11/25 revealed Location of discharge: Facility of choice and if you select no location the facility social worker will assist you with locating an appropriate placement. In an interview with the DON at 10:01 AM on 10/29/25, the DON stated she was at the facility when Resident #1 was discharged but did not take part in creating the discharge notice. The DON stated it was not 100% clear on the discharge notice where Resident #1 was being discharged to go. The DON stated it was important to put a specific location on the discharge notice to ensure residents had a safe place to go after leaving the facility. In an interview with the ADM at 10:59 AM on 10/29/25, the ADM stated she filled out the discharge notice but received assistance from her regional team. The ADM stated it was not 100% clear on the discharge notice where Resident #1 was being sent. The ADM stated Resident #1's home address was written at the top of the discharge notice, and that was the location he was being sent to. The ADM stated it was important to be clear with the discharge notice to ensure residents had a safe place to go after leaving the facility. A policy was requested from the ADM on 10/28/25 outlining the proper procedures for a discharge but none was provided. The ADM did provide a signed admission agreement by Resident #1, but it did not list the specific information that was required to be on a discharge notice.

Based on observation, interview and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications for one of one resident (Resident #8) reviewed for enteral feeding tubes. The facility failed to ensure staff followed physician ordered water flushes before and after medication administration given via the G-Tube for Resident #8. This failure could place residents at risk of tube obstruction and a decrease in hydration. Findings include: Record review of Resident #8's Admission Record revealed an [AGE] year-old male originally admitted on [DATE] and most recently admitted on [DATE]. His diagnoses included G tube status (tube inserted into the stomach for feeding, medication administration, and/or hydration), dysphagia (difficulty swallowing), and cerebral infarction due to thrombosis (stroke due to blood clot in the brain). Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS score of 12 which indicated mild cognitive impairment. Record review of Resident #8's care plan on 9/4/24 revealed in part: Focus: Resident #8 has G-tube placement for medication administration r/t dysphagia. Goal: Resident #8 will be free of aspiration through the review date. Interventions: Flush g-tube with 60cc water before and after medication administration, and flush g-tube with 5cc water between medications every shift. Record review of Resident #8's Order Summary Report dated 9/4/24 revealed in part: Check placement of G tube prior to use every shift for placement. Flush G tube with 5ml of water between each medication administration every shift. Flush G tube with 60ml of water before and after medication administration every shift. Colace Capsule 100mg. Give 1 tablet via G tube two times a day related to constipation. Cymbalta Oral Capsule Delayed Release Particles 20mg. Give 1 capsule via G tube one time a day related to major depressive disorder. DO NOT CRUSH. GlycoLax Powder. Give 17gm via G Tube one time a day for constipation. Mix with 4oz-8oz of water. Keppra Solution 100mg/ml. Give 5ml via G tube two times a day for seizures. Losartan Potassium Tablet 100mg. Give 1 tablet via G tube one time a day related to hypertension. Hold if SBP less than 120 or DBP less than 60. Mucinex Fast-Max DM Max Oral Liquid 20mg-400mg/20ml. Give 20ml via G tube two times a day for congestion for 1 month. Order start date 8/29/24. Namenda Tablet 10mg. Give 1 tablet via G tube two times a day related to dementia. Phenytoin Suspension 125mg/5ml. Give 4ml via G tube two times a day related to convulsions. Observation of medication administration on 9/4/24 at 10:02am for Resident #8 revealed after LVN C appropriately checked Resident #8's blood pressure (124/68) then sanitized her hands, she retrieved each of Resident #8's medications from the medication cart. Each tablet or capsule was taken out of its pill pack or bottle and placed in separate medication cups. Each tablet was crushed individually in separate pouches and placed in separate medication cups. The Cymbalta capsule was opened, and its contents emptied into a medication cup. Each of the liquid medications were measured out into separate medication cups. LVN C filled 5 plastic 8 ounce cups with water and placed the medications and the cups of water on the resident's rolling table and took them inside the room with her. LVN C washed her hands appropriately and put on a gown and gloves. LVN C attached a 60ml syringe to Resident #8's G tube and aspirated (drew back the piston) to check for residual. LVN C then used her stethoscope to insure proper placement of the G tube. LVN C flushed Resident #8's G tube with 60ml of water, added approximately 5-10ml of water to each medication cup and added approximately 8 ounces of water to the GlycoLax powder. LVN C gave each medication through the G tube with 5ml water flushes between each medication. LVN C gave Resident #8 the GlycoLax. After LVN C gave Resident #8 all his medications, she flushed his G tube with 10ml of water. When asked how much water she flushed the G tube with when she was done, LVN C stated, 10mls. In an interview 9/4/24 at 10:38am, LVN C was asked to read Resident #8's orders regarding medication administration through his G tube. LVN C stated the orders read to flush with 5ml of water between each medication and flush with 60ml before and after medication administration. When asked how much water she flushed Resident #8's G tube with when she was finished with his medications, she stated she flushed it with 10ml of water. LVN C stated it was important to flush the G tube with 60ml of water to ensure that all of the medication was flushed through the G tube. LVN C stated if the resident did not receive all his medications, his medication levels could be off and he could have a seizure or complications. LVN C stated if the g-tube was not flushed properly, it could clog. LVN C stated they were in-serviced on G tubes and medication administration about every three months and the last was a few months ago. In an interview on 9/4/24 at 3:34pm, the DON stated it was important to flush the G tube with 60ml of water after medication administration to ensure that no medications stayed in the tube and potentially caused a blockage. The DON stated a blockage could lead to resident not getting their medications and having an adverse reaction. The DON stated a blockage could also lead to a rupture of the G tube or having to replace it. The DON stated the facility did skills checkoffs upon hire and annually for all nursing staff. In an interview on 9/5/24 at 09:26am, the Admin stated it was important to follow the provider's orders when any medications were given to any resident. The Admin stated it was important to flush the G tube with 60ml of water to ensure that all of the medications were given and water could flow easily through it. Record review revealed the facility had an in-service on medications administered via G tube and by mouth on 3/25/24 and LVN C signed it. Record review revealed LVN C completed a competency assessment for administering medications through an enteral tube on 4/25/24. The assessment was signed by the DON. Record review of the facility's policy on Administering Medications through an Enteral Tube dated November 2018 reflected in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube. General Guidelines: 14. When the last of the medication begins to drain from the tubing, flush the tubing with 15m of warm purified water (or the prescribed amount).

Based on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5% or greater. The medication error rate was 33.33% based on 10 errors out of 30 opportunities for 2 (Resident # 26 and Resident #6) of 3 residents observed for medication administration in that: 1. The facility failed to ensure that MA B did not mix eight crushed medications in one pill cup for Resident #26. 2. The facility failed to ensure that MA B did not incorrectly hold medications based on administration parameters for Resident #6. These failures could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions. The findings included: 1. Resident #26 Record review of Resident #26's Admission Record revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dysphagia (difficulty swallowing), Alzheimer's disease (brain disorder that causes memory loss and other cognitive impairment), dementia (decline in cognitive abilities), gastritis (inflammation of the stomach lining), and epigastric pain (upper abdominal pain). Record review of Resident #26's Quarterly MDS dated [DATE] revealed a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #26's Order Summary Report on 9/4/24 revealed in part: May alter medications by crushing or opening caps and administer in food and/or liquid every shift. buPROPion HCL Oral Tablet 100mg. Give 3 tablets by mouth one time a day for depression. 3 tabs to = 300mg. Carvedilol Oral Tablet 25mg. Give 1 tablet by mouth two times a day for HTN. Hold if BP less than 110/60. Docusate Sodium Oral Tablet 100mg. Give 1 tablet by mouth one time a day for constipation. Lasix Oral Tablet 20mg. Give 1 tablet by mouth one time a day for HTN/edema. Lisinopril Oral Tablet 20mg. Give 1 tablet by mouth one time a day for HTN. Hold if BP less than 110/60 and notify charge nurse. Multivitamin-Minerals Oral Tablet. Give 1 tablet by mouth one time a day for supplement. Namenda Oral Tablet 5mg. Give 1 tablet by mouth two times a day r/t Alzheimer's disease. Nutren 2.0 Oral Liquid. Give 120ml by mouth four times a day for maintain weight. Reglan Oral Tablet 10mg. Give 1 tablet by mouth before meals related to GERD. There was no order stating that medications could be cocktailed (mixed together) after crushing them. Observation of medication administration on 9/4/24 at 9:38am for Resident #26 revealed after MA B appropriately checked Resident #26's blood pressure (131/86) and pulse (71), then sanitized her hands, she retrieved each of Resident #26's medications from the medication cart. Each tablet was taken out of its pill pack or bottle and placed in separate medication cups. The liquid supplement was measured out into an 8 ounce plastic cup. Each tablet was crushed individually in separate pouches. The crushed tablets were then all combined in one medication cup. Pudding was added to the cup and the crushed tablets were mixed into the pudding. The resident was given the tablets mixed with the pudding by MA B in 3 spoonfuls. Afterward, MA B handed Resident #26 the liquid supplement cup and encouraged her to drink it. 2. Resident #6 Record review of Resident #6's Admission Record revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included essential (primary) hypertension (high blood pressure), atherosclerotic heart disease (plaque build-up in the arteries in the heart), combined systolic and diastolic congestive heart failure (the heart muscles do not work properly allowing excess fluid buildup in the lungs and other tissues), peripheral vascular disease (reduced blood flow to organs and limbs), chronic kidney disease, and traumatic subdural hemorrhage (brain bleed caused by hitting the head). Record review of Resident #6's Quarterly MDS dated [DATE] revealed a BIMS score of 8 which indicated moderate cognitive impairment. Record review of Resident #6's Order Summary Report on 9/4/24 revealed orders that read in part: Allopurinol Tablet 100mg. Give 1 tablet by mouth three times a day for gout. Cholecalciferol Oral Tablet 125mcg. Give 1 tablet by mouth one time a day for supplement. Cyanocobalamin Tablet 500mcg. Give 1 tablet by mouth one time a day for vitamin. Ferrous Sulfate Oral Solution 220mg/5ml. Give 7.5ml by mouth two times a day for anemia. 7.5ml to=330mg. Folic Acid Tablet 1mg. Give 1 tablet my mouth one time a day for supplement. Isosorbide Mononitrate Oral Tablet 10mg. Give 1.5 tablet by mouth one time a day for 1.5 tabs=15mg related to hypertension. Notify MD if pulse below 60 for further orders. Lactulose Oral Solution 20gm/30ml. Give 30ml by mouth one time a day related to constipation and cirrhosis of liver. Lasix Oral Tablet 20mg. Give 1 tablet by mouth one time a day related to combined congestive heart failure. Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth one time a day related to hypertension. Hold if pulse below 60 and notify MD. Namenda Oral Tablet 5mg. Give 1 tablet by mouth two times a day for dementia. Nutren 2.0 Oral Liquid. Give 90ml by mouth four times a day for maintain weight. Vericiguat Oral Tablet 2.5mg. Give 1 tablet by mouth one time a day for heart failure. Administer with food. Hold if systolic less than 90 and notify MD. Observation of medication administration on 9/4/24 at 9:51am for Resident #6 revealed after MA B appropriately checked Resident #6's blood pressure (99/65) and pulse (64), then sanitized her hands, she retrieved each of Resident #6's medications, except the Isosorbide and the Metoprolol, from the medication cart. Each tablet was taken out of its pill pack or bottle and placed in separate medication cups. The liquid supplement was measured out into an 8 ounce plastic cup. Resident #6 was given a cup of water and was able to take her medications. Afterward, MA B handed Resident #6 the liquid supplement cup and encouraged her to drink it. In an interview on 9/4/24 at 2:49pm, MA B stated the doctor said that it was OK to mix the medications together. When asked if there was an order to mix the medications, MA B stated there was not and that she is not supposed to mix them without an order. MA B stated mixing the medications without an order could lead to medication interactions that could be harmful to the resident. When asked about holding the medications for Resident #6, MA B stated the orders for both Isosorbide and Metoprolol had a hold if the resident's systolic blood pressure (the top number) was below 110 or the resident's diastolic blood pressure (the bottom number) was below 60. MA B stated the Metoprolol also had a hold order if the resident's pulse was below 60. When asked what the orders read for Resident #6's Isosorbide, MA B stated the Isosorbide had an order to notify the provider if the pulse was below 60 for further orders. MA B stated the order for Resident #6's Metoprolol stated to hold if pulse was below 60 and notify the provider. MA B stated neither medication had an order to hold depending on blood pressure parameters. MA B stated that those were the hold parameters for most blood pressure medications and she thought that Resident #6's blood pressure medications had the same parameters. MA B stated if blood pressure medications were held when not indicated, it could lead to the resident's blood pressure going up which could lead the resident to have a bad outcome. MA B stated it was important that physician's orders were followed to ensure that the resident got the right medication, right dose, etc. MA B stated she had been at the facility as a medication aide for about 2 years. MA B stated the facility did an in-service annually on medication administration. MA B stated she did not remember if they did a skills check off upon hire. MA B stated she did continuing education every year for her medication aide certification. In an interview on 9/4/24 at 3:34pm, the DON stated that they had gotten a verbal ok from the provider to cocktail medications, but there had not been a written order for it. The DON stated she called the NP earlier to clarify that it was ok to cocktail Resident #26's medications and that she put the order in after she talked to him. When asked about Resident #6's blood pressure medications, the DON stated anytime a blood pressure medication was held, the MA notified the charge nurse. The charge nurse then notified the provider to find out if there were any new orders. If the provider was not notified that medications were held, he would not know if the medications were effective or not or if the dosage/frequency needed to be changed. The DON stated that most blood pressure medication orders should include hold parameters. The DON stated the facility did skills checkoffs upon hire and annually for all nursing staff. In an interview on 9/5/24 at 9:26am, the Admin stated on 9/4/24, she had a discussion with nursing staff about not cocktailing medications without an order. The Admin stated if medications were mixed without the provider's knowledge or an order, it could lead to medication interactions which could lead to bad outcomes for residents. She stated the pharmacist routinely checked medications to make sure that there were no adverse drug interactions and if a potential adverse interaction was found, the pharmacist would notify the provider. The provider would then decide on what to do. The Admin stated that the provider was aware of medications being cocktailed but had not put any orders in for it. The Admin stated the DON contacted the provider on 9/4/24 and got orders to be able to mix medications for some residents. When asked about holding medications, the Admin stated if medications were held, the charge nurse was to be notified. The charge nurse would notify the provider for further orders. The Admin stated if blood pressure medications were held without contacting the provider, it could lead to worsening of symptoms for the resident such as blood pressure rising later in the day which could cause headaches, dizziness, nausea, or worse. The Admin stated staff has skills check offs done upon hire and annually. Record review revealed MA B had completed 7 hours of medication aide continuing education on 5/7/24. Record review of the facility's Administering Medications Policy dated April 2019 revealed in part: Policy Heading: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #4) of two residents observed for infection control practices during wound care in that: 1.) The facility failed to ensure LVN A performed hand hygiene for at least 20 seconds during and after wound care for Resident #4. This failure could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. The findings included: Record review of Resident #4's Face Sheet dated 9/4/24 reflected a [AGE] year-old male with an original admitted [DATE]. His diagnoses included dementia (decline in cognitive abilities that affects a person's ability to perform everyday activities), chronic obstructive pulmonary disease (ongoing lung condition caused by lung damage), and Parkinson's disease (brain disorder that affects movement and causes tremor, and stiffness). Record review of Resident #4's care plan dated 5/3/24 reflected: Resident #4 had a Stage 4 (sores extend below the subcutaneous fat into deep tissue) to right heel. Interventions included: Reposition every 2 hours as needed to prevent any further pressure injuries. Skilled nurse to off load heel with pillows while in bed and wear heel protectors. Skilled nurse to perform daily wound treatment as ordered. Skilled nurse to perform weekly skin assessments. Skilled nurse to report any changes in skin condition to doctor and responsible party. Record review of physician orders dated 9/4/24 reflected: Cleanse with wound cleanser, pat dry with 4x4 (absorbent medical pad), apply moistened collagen pad cut to size, cover with gauze, wrap with kerlix (woven gauze used for wound care) and secure with tape every day shift every Monday, Wednesday, and Friday for wound treatment and as needed for as needed for soiled or damaged dressing. During an observation of wound care for Resident #8 on 09/04/24 at 12:51 PM LVN A washed her hands for 17 seconds prior to beginning wound care and 16 seconds after wound care was completed. In an interview on 09/04/24 at 1:27 PM 09/04/24 01:27 PM LVN A stated handwashing should be done for at least 20 seconds to prevent the spread of germs and infections. LVN A stated by not washing hands for 20 seconds or greater, it could lead to Resident #4's wound becoming infected or not healing properly. LVN A stated staff were in-serviced frequently on hand hygiene and infection control but could not remember when the last in-service was. In an interview on 09/04/24 at 3:27 PM the DON stated handwashing should be at least 20 seconds or greater when lathering hands. The DON stated by not washing hands for 20 seconds are greater could increase the chances of spreading germs. The DON stated she could not remember when the last in-service on handwashing was but a handwashing in-service and return demonstration was conducted on 9/4/24 with all nursing staff with no concerns identified. Record review of facility's Handwashing/Hand Hygiene policy revised on October 2023 reflected: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Procedure Washing Hands 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Record review of www.cdc.gov webpage titled About Handwashing dated 2/16/24 reflected: Washing your hands is easy, and it's one of the most effective ways to prevent the spread of germs. Follow these five steps every time. 1. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. 2. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. 3. Scrub your hands for at least 20 seconds. Need a timer? Hum the Happy Birthday song from beginning to end twice. 4. Rinse your hands well under clean, running water. 5. Dry your hands using a clean towel or an air dryer.

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 (200 Hall) of 2 nourishment rooms reviewed for food safety in that: The temperature of the refrigerator in the nourishment room on the 200 Hall was not maintained at the correct temperature and was not maintained clean. These deficient practices could place residents at risk of receiving contaminated or spoiled food. The findings were: During an observation and interview on 12/02/20 at 1:00 p.m., the Dietary Manager (DM) explained the process to provide snacks for residents by storing snacks in the Nourishment Room on Hall 200. When the refrigerator door was opened, the temperature on the tube type thermometer read 50 degrees Fahrenheit. Two trays of chicken salad sandwiches, ham and cheese sandwiches and 12 plastic cups of fruit and pureed chicken salad were observed labeled and dated 12/03/20 (discard date). The freezer door was then opened and several small bags of frozen Ice Packs were observed and the tube thermometer of the freezer read 12 degrees Fahrenheit. The bottom of the freezer was observed to have a white frozen spill and did not appear to have been cleaned. The DM took the trays back to the kitchen to take the temperature of the sandwiches. The temperatures of several of the sandwiches were measured using a dial food thermometer at 42-43 degrees Fahrenheit and the chicken salad pureed cup was 45 degrees Fahrenheit. The temperatures were retaken by the DM using a digital thermometer and the temperatures of the sandwiches read 54 degrees Fahrenheit and the chicken salad in the cup measured 52 degrees Fahrenheit. The DM told the cook to discard all the food since they were all above the safe temperature level. During an interview and observation on 12/02/20 at 1:20 p.m. with the Maintenance/Housekeeping Supervisor (MHS) in the Hall 200 Nourishment Room, the MHS checked the refrigerator and freezer tube thermometers and stated the temperature in the refrigerator was 60 degrees Fahrenheit. The freezer thermometer measured 12 degrees. When asked who was responsible for taking the temperatures and cleaning, the MHS stated the housekeepers do these tasks. The MHS pointed to a monthly calendar beside the door in a plastic sleeve protector. The calendar for December had been initialed by Housekeeper A (Hsk A) for 12/01/20 and 12/02/20. The MHS stated this indicated the name of the housekeeper who had cleaned the refrigerator. The MHS could not locate the temperature log so asked Hsk A to show him where she kept the log. Hsk A located the log on a shelf in a cart beside the refrigerator. Record review of the log for the month of December 2020 for the refrigerator and freezer indicated that the temperature was 31 degrees Fahrenheit for the refrigerator and freezer on 12/01/20 and 40 degrees Fahrenheit for the refrigerator on 12/02/20 and 10 degrees for the freezer on 12/02/20. There was an additional entry for 12/02/20 under the freezer temperatures that indicated the freezer was at 40 degrees Fahrenheit. During the interview on 12/02/20 at 1:20 p.m. the MHS stated he checks the refrigerator/freezer cleaning and temperature logs a couple of times per week but did not have a regular schedule to check them. During an interview on 12/02/20 at 3:14 p.m., Hsk A stated we take the temperatures to make sure the food doesn't spoil. Hsk A further indicated she understood the dates on the food were the dates by which food either had to be consumed or thrown away. Hsk A stated she usually checked the refrigerator at the end of the day to clean it, check the temperature and discard any food left with the use by date. Hsk A stated she would report any issues with the temperatures to the MHS or Adm. Hsk A could not explain how she got the temperatures of 31 degrees for both the refrigerator and freezer on 12/02/20. Record review of inservice materials dated 12/02/20 included a diagram titled Safe Food Cooking & Storage Temperatures copyrighted 2001, which read Safe refrigerator temperature is below 40 degrees Fahrenheit and above 32 degrees Fahrenheit. Safe freezer temperature is below 0 degrees Fahrenheit. Record review of the undated facility policy for Refrigerators and Freezers revealed: Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers . 10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. Record review of the Texas Food Establishment Rules (TFER), p. 107, §228.113(1) revealed that equipment food contact surfaces shall be clean to sight and touch. Record review of the Texas Food Establishment Rules (TFER), p. 44, §228.63 revealed (1) Except as specified in paragraph (2) of this subsection, refrigerated, time/temperature controlled for safety food shall be at a temperature of 5 degrees Celsius (41 degrees Fahrenheit) or below when received.

Based on observation, interviews and record review the facility failed to implement an infection 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 1 of 1 resident (R #1) and 1 of 1 facility reviewed for infection control practices in that: A resident (R #1) who had been out of the facility with family members for an overnight stay was not placed in the Warm Zone of the facility and monitored for COVID-19 (a new respiratory disease which can cause mild to severe illness with most severe illness in adults [AGE] years and older) following his return to facility. This failure could place residents at risk for being exposed to COVID-19, health complications, and death. Findings include: Record review of Face Sheet dated 10/29/20 for R#1 documented an [AGE] year-old male admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of (Name of lab company) lab COVID-19 test result dated 10/12/20 for R #1 revealed a negative test. Record review of electronic record census data revealed R#1 was moved from the Hot Zone to the Cold Zone on 10/15/20. Record review of Nurses Notes dated 10/27/20 read Resident taken out on pass with RP (Responsible Party) for wife's funeral services tomorrow. Resident departed facility ambulating with assistance of walker. No distress noted upon departure. Face mask in place. Record review of Nurses Notes dated 10/28/20 read Resident brought back to facility by RP. Was out on pass for wife's funeral services. No acute distress noted. Resident escorted to room. An observation on 10/29/20 at 4:21 PM, revealed R#1 asleep in his room with a roommate present. The room was in the Cold Zone of the facility (non-COVID-19 area). During an interview on 10/29/20 at 4:56 PM, the DON stated they follow COVID -19 recommendations from HHSC (Health and Human Services Commission), CDC (Centers for Disease Control and Prevention) and CMS (Centers for Medicare and Medicaid Services). During an interview on 10/29/20 at 4:59 PM, the Director of Nurses (DON) said R#1 and his roommate had recovered from COVID-19. The DON stated that normally, if a resident goes out of the facility for over 24 hours, when they come back they are placed in the Warm Zone (quarantine area) and monitored for COVID-19 symptoms for 14 days. The DON stated she was not sure why R#1 had been allowed to return to his regular room in the Cold Zone and should have been placed in the Warm Zone per COVID-19 protocols. The DON stated, I guess we should move him to the Warm Zone. Record review of the facility's undated Transmission Based Precautions policy did not address COVID-19 or quarantine/isolation policies. According to HHSC COVID-19 Response for Nursing Facilities Version 3.6 dated 10/08/20: New admissions, readmissions, and residents who have spent one or more nights away from the facility are all considered residents with unknown COVID-19 status. All residents with unknown COVID-19 status must be quarantined for 14 days.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (1) of one resident (Residents #2) in that, Resident #2, did not receive his medication [MEDICATION NAME] (Celecoxib) as ordered for 13 doses due to the facility having run out. This deficient practice has the potential to place residents at the facility that receive medications at risk for receiving less than therapeutic benefits from their medications should doses be missed because the medications are not available. Findings included: Review of Resident #2's Face sheet, dated 05/09/19, revealed an [AGE] year old man admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's MDS, dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 6 (Severely impaired cognition), he required extensive assistance with a two person physical assist with bed mobility, transferring, dressing, toileting, required extensive assistance with a one person physical assist with personal hygiene, eating, was totally dependent with bathing, used a wheelchair, and was always incontinent of the bladder and bowel. Review of R#2's Care Plan dated 05/15/17 revealed, Focus: R#2 had a history of [REDACTED]. Goal: Discomfort will be minimized as much as possible this 3 months Interventions: Dress R#2 appropriately, Keep family and MD (Doctor of Medicine) updated, Position R#2 frequently for comfort, Provide range of motion and activities of daily living. Review of R # 2's nurses notes dated 03/02/19 at 8:35 pm revealed, R#2 arrived back and was escorted by 2 family members. R#2's family member (asked) skilled nurse if MD (Doctor of Medicine) could be called to discontinue [MEDICATION NAME] (treats nerve and muscle pain ) medication and family member asked if R#2 could be put on [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] that treats pain) instead. Skilled nurse informed Nurse Practitioner of family's request and new orders received from Nurse Practitioner to discontinue [MEDICATION NAME] and start [MEDICATION NAME] 100 mg twice a day by mouth. Responsible party was made aware of changes on medication. Review of R#2's physician's orders [REDACTED]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's (MONTH) 2019 MAR (Medication Administration Record) revealed R#2 missed a dose of [MEDICATION NAME] on 04/04/19, two doses of [MEDICATION NAME] on 04/05/19, two doses of [MEDICATION NAME] on 04/06/19, two doses of [MEDICATION NAME] on 04/07/19, two doses of [MEDICATION NAME] on 04/08/19, two doses of [MEDICATION NAME] on 04/09/19, and two doses of [MEDICATION NAME] on 04/10/19. Review of R#2's nurses' notes dated 4/4/19 at 6:51 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION] take with food; Medication not available. Review of R#2's nurses notes dated 4/5/19 at 10:23 AM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/5/19 at 4:34 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/6/19 at 6:48 AM revealed, Note Text: [MEDICATION NAME]; Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/6/19 at 5:13 PM revealed, Note Text: [MEDICATION NAME]; Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/7/19 at 6:32 AM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/7/19 at 8:03 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/8/19 at 8:42 AM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/8/19 at 5:06 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; take with food; Medication not available. Review of R#2's nurses notes dated 4/9/19 at 6:44 AM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; Take with food; Medication not available. Review of R#2's nurse's notes dated 4/9/19 at 5:32 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; Take with food; Medication not available. Review of R#2's nurses notes dated 4/10/19 at 6:59 AM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; Take with food; Medication not available. Review of R#2's nurses notes dated 4/10/19 at 4:16 PM revealed, Note Text: [MEDICATION NAME] Capsule 100 MG; Give 1 capsule by mouth two times a day for anti-[MEDICAL CONDITION]; Take with food; Medication not available. During an interview on 05/09/19 at 8:32 AM with CMA (Certified Medication Aide) V, she stated the facility process for ordering medications is to place a medication sticker with the barcode, name of medication, and resident's name on a form, give it to the nurse who would sign and fax it to the pharmacy. CMA V further stated if she found the medication was not in the medication cart, she would ask the nurse if it was in the stat (immediate) safe and if the medication was not available, I'll document the medication is not available or pending pharmacy delivery in the MAR. During an interview on 05/09/19 at 8:16 AM with CMA Z she was asked what the process was for ordering medications. CMA Z stated, What we do when a blister packet reaches the blue portion which has 5 medications left, I place the medication sticker on the order sheet, give it to the nurse who would sign and fax it to the pharmacy. By next morning we will have the medication. CMA Z further stated if she found the medication was not in the medication cart, she would ask the nurse if it was in the stat (immediate) safe and if the medication was not available, I'll document the medication is not available or pending pharmacy delivery in the MAR. During an interview on 5/09/19 at 8:41 AM with LVN (Licensed Vocational Nurse) B she was asked what is the process with ordering medications. LVN B replied, With ordering meds, we have to get an order from the doctor, notify family to obtain their consent, and fax the order to the pharmacy. When asked what the process was for reordering medications LVN B stated, On a blister pack there's a certain amount of pills left, about 5, when it hits the blue portion, I will get the sticker (LVN B showed surveyor a blister pack with blue portion having 5 pills left with a barcode, resident's name, and the name of the medication, dose, route, time) and LVN B showed Surveyor the form they place the sticker on titled, Pharmacy Reorder Sheet. LVN B stated, I put the date on the form, fax it to the pharmacy, and wait for a confirmation to let me know the fax was sent. When asked where faxed Reorder Sheets were from previous months are, LVN B stated, We give them to our ADON and they are filed. When asked what happens when they do not have a medication in the cart LVN B stated, If I need a certain medication that I don't have in my cart, I check the stat safe that is in the medication room, and if I don't have it there, then I'll document medication not available or pending pharmacy. When asked where staff documented medications that were not available, LVN B replied, I document medication not available in the Medication Administration Record, [REDACTED]. There is where you type your note that the medication is not available. During an interview on 05/09/19 at 9:52 AM with the DON (Director of Nursing) she was asked why R#2 missed his doses of [MEDICATION NAME] for 5 days. The DON stated, The order for R#2's [MEDICATION NAME] was called into the pharmacy and they stated they did not have it. When asked what the process was when the nurse or CMA did not have the medication in their cart, the DON stated, We do have a stat safe and if we do not have the medication in there, we will call the local pharmacy. When asked if R#2 should have had the [MEDICATION NAME] available on the days R#2 missed his doses of [MEDICATION NAME], the DON stated, Yes R#2 should have had the [MEDICATION NAME] available to take on those days. Surveyor requested the Facility Policy for ordering medications on 05/09/19 at 9:52 AM from the DON and it was not provided. Interview on 5/09/19 at 9:16 AM with Pharmacy staff revealed that they carried [MEDICATION NAME].

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, for one Resident (R#1), of three residents reviewed, in that: CNA (Certified Nurse Aide) B failed to ensure the shower chair was locked during R#1's transfer from bed to shower chair. This failure could place all 23 residents who require assistance with transfers at risk for injury. The finding were: Record review of R#1's Admission Record revealed R#1 was admitted to the facility on [DATE] and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. Record review of R#1's Quarterly MDS (Minimum Data Set) assessment, dated 01/08/18, revealed R#1: -was sometimes understood by others and sometimes able to understand others, and -was totally dependent on two staff for bed mobility, transfers, dressing, and toilet use. On 02/06/18 at 4:18 p.m., surveyor observed CNA A and CNA B transfer R#1 from bed to shower chair via a Hoyer lift. CNA A and CNA B applied the sling under R#1 and attached the sling to the hooks on the Hoyer lift. CNA A operated the Hoyer and lifted R#1 up from bed. CNA B stood behind the shower chair and guided R#1 down to the shower chair. Surveyor noted that the shower chair was not locked. In an interview on 02/06/18 at 4:31 p.m., CNA A said that they were in-serviced on different topics every two weeks. CNA A said that they were instructed to lock the brakes on shower chairs, Geri chairs, and wheelchairs during transfers. In an interview on 02/06/18 at 4:35 p.m., CNA B said that they were in-serviced frequently on different topics. CNA B said that they were instructed to lock the brakes on shower chairs and wheelchairs during transfers. CNA B said the shower chair was not locked during R#1's transfer. In an interview on 02/06/18 at 5:00 p.m. the DON (Director of Nurses) said staff were to lock the brakes on wheelchairs, the Hoyer lift, the shower chairs, or anything else with wheels that had the potential to move during transfers. The DON said staff was in-serviced on transfers on 12/04/17. Record review of the facility's policy titled, Lifting Machine, Using a Mechanical, revised (MONTH) (YEAR), revealed: Purpose The purpose of this procedure is to establish the general principle of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions. Steps in the Procedure: 7. Make sure the lift is stable and locked. The facility's policy did not indicate if wheelchairs or shower chairs were to be locked during transfers. The facility's, Resident Census and Conditions of Residents (672 Form) indicated 23 residents required assistance from one or two staff members for transfers.

Based on observation, record review, and interview the facility failed to ensure residents have the right to be free from neglect for four (R #1, R #2, R #3, and R #5) of six residents reviewed for pressure ulcers. R #5: The facility failed to: -reposition R #5 every two hours as her plan of care indicated; -ensure R #5's left heel was properly offloaded; -provide effective offloading techniques. R #5 was admitted to the facility with a Stage 4 to her left heel and developed two Stage 2 facility acquired medical device related pressure ulcers. R #3: The facility failed to: -provide incontinent care when R #3's brief was wet; -correctly identify and document R #3's left heel pressure ulcer; -properly stage R #3's left heel ulcer; -correctly measure R #3's sacral ulcer; -correctly identify and document the location of R #3's right foot ulcer; -accurately stage R #3's facility acquired Right Ischial Tuberosity Stage 3 ulcer; -provide R #3 with treatment and dressing changes to all his pressure ulcers per the physician's orders [REDACTED].>-provide R #3 with heel offloading techniques, when in bed; -reposition/offload R #3's sacrum off the wheelchair for over two hours. R #3 was admitted to the facility with bilateral heel stage 3 pressure ulcers and further acquired a Right Ischial Tuberosity Stage 3 pressure ulcer. R #1: The facility failed to: -repositioned R #1 every hour as his plan of care indicated; -provide R #1 with heel protectors and offloading interventions on both feet instead of just the right foot; -ensure R #1 was relieved of pressure on his right lateral foot pressure ulcer; -assess, monitor, and ensure R #1's specialized low air loss mattress was set according to his current weight as per the manufacturer's recommendations. R #1 was admitted to the facility with a stage 4 pressure ulcer to his left lateral foot. R #2: The facility failed to: -provide treatment and dressing change to R #2's pressure ulcer per the physician's orders [REDACTED]. R #2 was admitted with a Left Trochanter Stage 4 pressure ulcer. The facility failed to initiate education for R #1, R #2, and R #5's specialized low air loss mattresses to include monitoring the mattress pressure for correct individualized firmness settings. These failures could place nine residents with pressure ulcers and 29 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #5: R #5's Face Sheet dated 07/10/17 documented a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Admission Nursing assessment dated [DATE] documented Left Heel Stage 4 Pressure Ulcer- 8.3 x 7.0 x 0.0, 70% yellow slough, 20% red, 10% black to left heel . The assessment provided definitions of stages that included: -Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1- Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle area are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage 4- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #5's Braden Scale for Predicting Pressure Sore Risk dated 11/30/15 documented 13, moderate risk. R #5's Braden Scale for Predicting Pressure Sore Risk dated 01/25/17 documented 11, high risk. R #5's Annual Minimum Data Set ((MDS) dated [DATE] documented R #5: -had no speech -rarely/never made self understood and rarely/never understood others -had severely impaired cognitive skills for decision making -was totally dependent with one person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some of the wound bed. Often includes undermining and tunneling. 7.2 x 3.2 x 1.0 centimeters(cm). Was present upon admission. R #5's Braden Scale for Predicting Pressure Sore Risk dated 04/03/17 documented 9, very high risk. R #5's Care Plan revised 05/21/17 documented: -(R #5) has a [DIAGNOSES REDACTED].Interventions: Administer medications as ordered; Provide diet and supplements per MD (Medical Doctor) order . -Potential for skin breakdown related to impaired mobility due to hx (history) [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) Interventions: Total assist turn and reposition q (every) two hours by CNA (Certified Nurse Aide); CNA to notify nurse of any noted redness to skin; Licensed Nurse to perform complete head to toe assessment q week; Document and notify family and MD for any skin breakdown; Pressure relieving mattress; Nutritional supplements to assist in maintaining healthy skin integrity; Float heels with pillow or heel protectors . -(R #5) has Stage 4 to left heel related to vascular insufficiency .Interventions: Juven (supplement that supports growth and maintenance of muscle tissue) BID (twice a day) for supplement; Avoid exposure to temperature extremes .; Avoid mechanical trauma .;Ensure appropriate protective devices are applied to affected areas; Monitor pressure areas of color, sensation, temperature; Monitor/document wound: size, depth, margins, periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene; Document progress in wound healing on an ongoing basis. Notify MD as indicated .Position resident off affected area. Change position every hour and PRN; Treat wound as per facility protocol . R #5's Weekly Pressure Ulcer Record dated 06/03/17 documented Bedridden, contracted, Left Heel Pressure Stage 4- 5.2 x 4.4 x 0.0. R #5's Skin Assessment Profile dated 07/04/17 documented Left Heel Stage 4- 4.1 x 3.3 x 0.0, serosanguineous drainage, red wound condition . R #5's Skin Assessment Profile dated 07/11/17 documented Left Heel Stage 4- 6.0 x 3.0 x 0.0, serosanguineous drainage, red wound condition . R #5's July 2017 Medication Review Report documented Stage 4 to left heel: Cleanse with normal saline, pat dry with 4x4's, apply [MEDICATION NAME] (collagen and oxidized regenerated cellulose), cover with [MEDICATION NAME], cover with gauze, wrap with kerlix, secure with tape every day every Monday, Wednesday, and Friday .Juven 1 packet via [DEVICE] BID supplement mix with 4-6 ounces of water Vitamin C 500 milligrams (mg) tid (three times a day) .Zinc 50 mg q day via [DEVICE] one time a day. R #5's Weekly Pressure Ulcer Record dated 07/10/17 documented: Date of Onset: 07/10/17. 1.) Site: Right Ear- Pressure 1.2 x 0.3 x 0.0 cm 2.) Site: Left ear- Pressure 0.5 x 0.3 x 0.0 cm Scant serous drainage, pink/beefy red wound bed, surrounding skin color pink, normal surrounding tissue .Preventive measures: turn every - hours, pressure relieving device, high protein supplement, multivitamin/zinc. There was no entry to indicate how often to reposition. R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind left ear- 1.2 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind right ear- 0.5 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . Observation of R #5 during initial tour on 07/10/17 at 2:57 p.m., accompanied by Registered Nurse (RN) A, revealed R #5 layed on her back with a pillow tucked behind her right torso. R #5's pelvis rested on the mattress and her bilateral feet were raised off the mattress by the use of Prevalon (heel protector). R #5 layed on an inflated overlay mattress which the mattress pump was set at the farthest firm position. R #5's eyes were closed and did not respond to verbal stimuli. R #5 was receiving oxygen via a nasal cannula, with the portion of the cannula that layed behind each ear was wrapped with gauze. RN A said R #5 was unable to communicate her needs and was dependent on staff for all adl's (activities of daily living). Observation of R #5 on 07/10/17 at 5:12 p.m. revealed R #5 remained laying on her back with a pillow tucked on the right side of her torso, still with her buttocks resting on the mattress. R #5's heel protectors were in position however, her left heel was not in the protector and rested on the mattress. Observation of R #5 on 07/10/17 at 5:36 p.m. revealed R #5 remained in the same position as at 2:57 p.m. This surveyor retrieved RN A. RN A said R #5 should have been repositioned every two hours. RN A observed R #5 and confirmed R #5 was in the same position as seen during initial wounds. RN A repositioned R #5's left foot correctly into the heel protector and confirmed R #5's left heel was resting on the bed yet, it should have been raised off the bed. RN A said the purpose of using pillows and repositioning every two hours was to relieve pressure off of the pressure points off the buttocks and sacrum. Upon the surveyor's request, RN A slid her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the mattress and were not offloaded. RN A said R #5's mattress felt firm and did not know anything about the mattress or what setting the mattress pump was appropriate for R #5. RN A approached Certified Nurse Aide (CNA) H and asked CNA H what time she repositioned R #5. CNA H responded About 2:15 p.m. I was going to go in there to change and turn her but I was waiting for the other CNA to finish bathing her resident then the dinner trays came out. RN A said relieving pressure by repositioning at least every two hours was important to prevent pressure ulcer development and/or deterioration of existing ulcers. R #5's Telephone physician's orders [REDACTED]. Observation of R #5 on 07/11/17 at 8:21 a.m. revealed R #5 had a pillow behind her right upper back and her torso was slightly tilted toward her left side and another pillow under her left arm. R #5's pelvis remained in straight alignment with her buttocks resting on the mattress. R #5 had heel protectors in place. Observation of R #5 on 07/11/17 at 11:22 a.m. revealed R #5 layed in the same position as seen at 8:21 a.m. LVN B entered the room and began performing wound care on R #5. LVN B said R #5 was admitted to the facility with a Stage 4 pressure ulcer to her left heel that measured 8.3 x 7.0 x 0.0 centimeters. LVN B said the last measurement was on 07/04/17 and it measured 4.1 x 3.3 x 0.0 cm. LVN B removed R #5's old dressing which presented with old dried brown, red, and light yellow drainage. LVN B stated It has hypergranulation red tissue with macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) tissue surrounding the wound. The wound bed is dark brown/black. There is purple tissue injury at 12 o'clock - 3 o'clock. It measures 6.0 x 3.0 x 0.0. Upon the surveyor's request, LVN B tucked her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the bed. LVN B said the pillow behind R #5's right back was there in attempt to relieve pressure off of R #5's right buttocks and sacrum. LVN B agreed the offloading attempt was ineffective. LVN B preceded to adjust R #5's oxygen tubing away from behind her ears. R #5 had small superficial red open area behind each ear. LVN B measured the ulcers on each ear and said The right ear is 1.2 x 0.3 x 0.0 cm and the left ear is 0.5 x 0.3 x 0.0 cm. LVN B confirmed R #5 received her ulcers behind her ears from the oxygen tubing applying pressure to the site. Interview with CNAs J and K on 07/11/17 at 11:55 a.m. revealed they stated they last repositioned R #5 at approximately 9:15 a.m. CNA K said R #5 was laying on her back before she placed a pillow behind R #5's right back. CNA K was asked if placing one pillow on the upper back would effectively offload R #5's buttocks off the bed; CNA K hesitated then said I'm not sure. CNAs J and K entered R #5's room and provided R #5 with incontinent care. Once R #5 was toward her right side, there were multiple indented, red lines all along R #5's left hip and thigh. Interview with the Assistant DON (ADON) on 07/11/17 at 5:21 p.m. revealed she said the facility did not apply or maintain any of the hospice air mattresses. The ADON said Hospice sets up the mattresses and do not give us any instructions for them. If there is a problem we just call hospice and they come out to check them. The surveyor accompanied the ADON into R #5's room and asked the ADON to feel the air mattress. The ADON said, It's pretty firm. We don't know what is the appropriate setting for her because the settings options only include firm and soft. Hers is set all the way to the firmest position. R #1: R #1's Face Sheet dated 07/10/17 documented an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Gastrostomy Status, and Hypertension. R #1's Annual/Re-Admission MDS dated [DATE] documented R #1: -had clear speech -sometimes made self understood and sometimes understood others -had severely impaired cognitive skills for decision making -was totally dependent with one-two person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer present upon admission- 9.5 x 6.5 x 1.0 cm. R #1's Skin Assessment Profile dated 05/06/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 6.5 x 1.1 cm, serosanguineous drainage, 20% yellow, 80% red, periwound purple . R #1's Skin Assessment Profile dated 05/20/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 5.0 x 0.5 cm, purulent, tan, opaque drainage, 75% eschar (slough or piece of black dead tissue), 25% red . R #1's Care Plan dated 05/21/17 documented: Wound treatment: Stage 4 to right foot upper lateral aspect .Interventions: Assess skin weekly; Dietary consult and recommendations for nutritional supplement; Float heels with heel protectors or pillow; Monitor and report to MD any signs and symptoms of pain prior to treatment; Treat wound per MD orders; turn and reposition q hourly; Nutritional supplement per MD order .I require total assist with all ADLs (activities of daily living) . R #1's July 2017 Medication Review Report documented Stage 4 to right foot upper lateral aspect: cleanse, pat dry with 4x4's, apply Santyl (an enzymatic [MEDICATION NAME] ointment) to none viable area, apply [MEDICATION NAME] (antibiotic) to viable area, cover with gauze, wrap with kerlix, wrap with coban or elastic wrap, and secure with tape every day on non-hospice days- every Tuesdays, Thursdays, Saturday, Sundays .Vitamin C 500 mg via [DEVICE] daily. Zinc 50 mg via [DEVICE] q hs (bedtime) for wound healing. Juven 1 packet via [DEVICE] two times a day for wound healing mixed with 120 ml of water. R #1's Skin Assessment Profile dated 07/04/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 6.5 x 1.5 x 0.1 cm, serosanguineous drainage, 5% yellow, 95% red . Observation of R #1 on 07/10/17 at 3:05 p.m., during initial rounds, accompanied by RN A, revealed R #1 layed on a Low Air Loss Alternating Mattress with the pump set at 9 (350 pounds). R #1 layed on his back with his buttocks resting on the mattress and his legs were folded and positioned on his right side, with his left leg over the right leg. R #1 was alert and verbal however, speech was unclear. R #1 did not appropriately answer any questions. R #1 had bilateral upper and lower extremity contractures. R #1 had a Prevalon boot on his right foot but not the left foot. Observation of R #1 on 07/10/17 at 5:18 p.m. revealed R #1 remained in the same position as last seen at 3:05 p.m. Observation of R #1 on 07/10/17 at 5:36 p.m. revealed R #1 remained in the same position. The surveyor retrieved RN A into R #1's room; RN A said R #1 should be repositioned at least every two hours. CNA H entered R #1's room and said she last repositioned R #1 at approximately 2:30 p.m. CNA H said she had not repositioned R #1 because she was waiting for the other CNA to finish showering another resident and then dinner trays arrived and assisted other residents to eat. RN A informed the surveyor of R #1 having a Stage 4 pressure ulcer on his outer lateral aspect of his right foot. RN A removed R #1's covers and informed the surveyor that R #1's legs remain folded at all times due to contractures. RN A agreed R #1's current position was causing pressure directly on his coccyx and his right foot Stage 4 pressure ulcer. RN A said Pressure should be kept off his right foot as much as possible. RN A stated she did not know why R #1 only had one prevalon boot then stated Maybe because he only has an ulcer on the right foot. RN A stated out loud that the pump setting was set at 9 then said she did not know anything about R #1's air mattress other than the mattress came from hospice and hospice set up the mattress. RN A said if something happened to the mattress then she would call hospice to check it. RN A said the hospice nurse visited R #1 every week. RN A stated R #1 having direct pressure on his right foot pressure ulcer and not being repositioned every two hours could cause his pressure ulcer to worsen and not heal. Observation on 07/11/17 at 8:23 a.m. revealed R #1 layed on his back with his head of bed elevated. R #1 had a pillow on each side of his hips with his left leg over the right leg with both raised and folded on his right side. R #1 had a Prevalon boot on his right foot only. Observation of R #1 on 07/11/17 at 10:37 a.m. revealed R #1 layed in the same position as seen at 8:23 a.m. On 06/11/17 at 12:11 a.m., the surveyor accompanied LVN B into R #1's room. R #1 layed in the same position as seen at 8:23 a.m. and 10:37 a.m. LVN B was informed of R #1 being observed in the same position since 8:23 a.m. LVN B said she would ensure R #1 was repositioned after she performed wound care. LVN B confirmed R #1's current position was putting pressure on his right lateral foot pressure ulcer. LVN B said R #1's positioning should be kept off his right lateral foot. LVN B preceded to remove R #1's right foot dressing that had dry brown/red drainage. R #1's right outer lateral foot was approximately the length of the surveyor's index finger and the width greater than one millimeter. The ulcer was open with a red wound bed and slowly seeped serosanguineous drainage. After LVN B cleansed R #1 ulcer, the ulcer began to bleed heavily, dripping blood onto the bed. LVN B measured R #1's ulcer and said 5.3 X 2.2 X 0.1 cm. LVN B re-dressed R #1's right foot then repositioned him to his left side with the assistance of CNA L. LVN B instructed CNA L to ensure R #1 was repositioned every two hours and to refrain from putting pressure on R #1's right lateral foot. LVN B asked CNA L to look for R #1's left foot Prevalon boot. CNA L looked throughout R #1's room and informed LVN B he could not find a Prevalon boot. LVN B instructed CNA L that R #1 needed a heel protector to prevent development of a pressure ulcer on his left foot and instructed CNA L to go find a heel protector for R #1's left foot. A few minutes later, CNA L returned to R #1's room with a cloth heel protector and placed it on R #1's left foot. LVN B confirmed R #1's air mattress pump was set at 9. The surveyor asked LVN B what the number 9 meant and LVN B said she did not know. The surveyor asked LVN B to read the numbers above the number 9 and LVN B said 350 pounds. LVN B confirmed R #1 was not 350 pounds. LVN B said she did not know anything about the air mattress because the mattress belonged to hospice and hospice set up and maintained the mattress. LVN B checked R #1's most current weight via the computer and said (R #1) weighs 165.0 pounds. Review of R #1's 2017 Monthly Weight Record revealed R #1's weight on 07/10/17 was 165.0 pounds. Interview with the ADON on 07/11/17 at 5:22 p.m. revealed she pressed down on R #1's mattress and said It's kind of hard, it is set at 9- 350 pounds. He is not 350 pounds. The ADON adjusted the setting on the pump to a 4 (175 pounds). The ADON said If the mattress is too hard or even too soft, the resident could develop pressure ulcers or have worsening of their ulcers. The ADON said the facility did not have any manufacturer's recommendations/user guide for any specialized mattresses/pumps but would immediately call to get some. R #1's undated Alternating Pressure Mattress User Manual provided by the DON on 07/12/17 revealed The patient comfort pressure ranges from soft (level 1) to firm (level 9). The comfort control displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set appropriate comfort pressure level depending on the patient weight . R #3: R #3's Face Sheet dated 07/12/17 documented an [AGE] year-old male initially admitted [DATE], discharged to the hospital on [DATE] and re-admitted [DATE] with the [DIAGNOSES REDACTED]. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/11/17 documented 14- moderate risk. R #3's Significant Change MDS dated [DATE] documented R #3: -had clear speech -usually made self understood and usually understood others -had a Brief Interview of Mental Status (BIMS) score of 5 (severely impaired) -required extensive assistance with one-two person physical assist for bed mobility, dressing, eating, toilet use, and personal hygiene. R #3 was totally dependent with two person physical assist for transfers -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 2 present upon admission/re-entry and two Stage 3 pressure ulcers present upon admission- 1.0 x 3.2 x 0.0 cm. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/27/17 documented 14- moderate risk. R #3's Care Plan revised 06/14/17 documented: -Stage 2 right heel .Interventions: Keep clean and dry; Treat sore per MD orders, notify if ineffective; Assess skin weekly; Monitor and Report to MD any signs and symptoms of infection; Monitor for pain; Vitamin c and Zinc supplements, see MD orders for details; Weekly wound care; Clinic evaluation (at local hospital) Wound Treatment Center on Thursdays. -(R #3) has actual impairment to skin integrity related to a Stage 3 to his left buttocks, updated 07/10/17 .Interventions: Avoid scratching and keep hands and body parts from excessive moisture .; Treatment per MD order; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. to MD., Weekly Wound Care Treatment Center on Thursdays. -Stage 3 to left heel .Interventions: Daily and weekly skin checks to heel; Monitor for pain; Notify MD and family of changes; Treatment per MD orders; Vitamin C and Zinc for supplements, see MD orders for details; Weekly wound care at Wound Treatment Center on Thursdays .Check frequently for bowel incontinence and provide peri-care after each episode .Provide pressure redistribution surface to bed, chair PRN (as needed) .Turn and reposition q 2 hours .I require extensive to total assistance with two person assistance for bed mobility, personal hygiene . -(R #3) has a Stage 3 to Sacrum .Interventions: Nutritional supplements as ordered; Assess skin weekly; Monitor and report any signs/symptoms of infection; Pain medication as ordered; Treat wound per MD orders; Turn and Reposition q 2 hours . R #3's physician's orders [REDACTED]. R #3's July 2017 Medication Review Report documented: -Stage 2 to right heel, cleanse with normal saline, pat dry with 4x4s, apply Calcium Alginate, cover with 4x4, wrap with kerlix, wrap with elastic bandage, secure with tape every day every Monday, Wednesday, Friday . -Stage 3 to left buttocks: cleanse with normal saline, pat dry with 4x4, apply Santyl and cover with Allevyen (bacterial barrier dressing for exudate management) every shift every other day . -Stage 3 left heel: cleanse with wound cleanser, pat dry with 4x4, apply Santyl, cover with 4x4, wrap types of wounds kerlix, wrap with elastic bandage, secure with tape every Monday, Wednesday, Friday . -Stage 3 to Sacrum: cleanse with normal saline, pat dry with 4x4 gauze, apply Santyl to non-viable tissue. Apply hydrogel (ointment used for dry or slightly moist that creates a moist healing environment) to viable tissue, and cover with Allevyn every Monday, Wednesday, Friday . -Multivitamin give one tablet by mouth one time a day for supplement .Vitamin C 500 mg by mouth one time a day for wound healing .Zinc tablet 50 mg, give one tablet by mouth one time a day for wound healing . R #3's July 2017 Treatment Administration Record (TAR) revealed R #3's Right heel Stage 2, Left heel Stage 3, and Sacral Stage 3 pressure ulcers did not obtain a licensed nurse's initial to indicate treatment was performed on Monday, 07/10/17. Observation of R #3 on 07/11/17 at 8:30 a.m. revealed R #3 sat in a Geriatric-chair. Upon LVN B's request, CNAs J and L transferred R #3 from his chair to his bed. The CNAs removed R #3's pants exposing his yellow brief. The two wet indicators revealed the two lines were blue, indicating the brief was wet. The center of the brief appeared mushy. R #3 was not provided with incontinent care at this time. Interview with LVN B on 07/11/17 at 8:48 a.m. revealed she stated R #3 was admitted on [DATE] with a coccyx and left heel Stage 3 pressure ulcers. LVN B said R #3 was re-admitted on [DATE] with a right heel Stage 2 pressure ulcer from the hospital. LVN B said R #3 had an appropriate mattress for pressure ulcers, was to be repositioned and changed, if needed, every two hours, and should have heels off-loaded at all times when in bed. LVN B said R #3 did not have a specialty air mattress but he had a Panacea mattress which was appropriate for all kinds of pressure ulcers. R #3's Left Heel: R #3's Skin Assessment Profile dated 12/09/16 documented Date of initial onset: 12/09/16- Left Heel Deep Tissue Injury- 2.0 x 2.7 x 0.0 cm, red wound condition . R #3's Skin Assessment Profile dated 01/16/17 documented Date of initial onset: 12/09/16- Deep Tissue Injury- 1.0 x 0.7 x 0.0 cm, black wound condition . *The wound condition had changed from red to black by this time however, the wound continued to be identified as Deep Tissue Injury instead of Unstageable. R #3's Skin Assessment Profile dated 01/20/17 documented Date of initial onset: 12/09/16- Deep Tissue Injury- 1.0 x 1.6 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 02/01/17 documented Date of initial onset: 12/09/16- Stage 3- 1.3 x 1.5 x 0.0 cm, red wound condition . This wound was described to have black wound condition prior to this date. R #3's Skin Assessment Profile dated 02/08/17 documented Date of initial onset: 12/09/16- Stage 3- 1.8 x 1.7 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 02/22/17 documented Date of initial onset: 12/09/16- Stage 3- 3.4 x 3.6 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 03/01/17 documented Date of initial onset: 12/09/16- Stage 3- 3.5 x 2.0 x 0.0 cm, yellow wound condition, serosanguineous drainage . R #3's Skin Assessment Profile dated 03/18/17 documented Date of initial onset: 12/09/16- Stage 3- 3.0 x 2.6 x 0.0 cm, beefy red and yellow wound condition . R #3's Skin Assessment Profile dated 03/31/17 documented Date of initial onset: 12/09/16- Stage 3- 2.4 x 2.3 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/07/17 documented Date of initial onset: 12/09/16- Stage 3- 2.3 x 2.9 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/21/17 documented Date of initial onset: 12/09/16- Stage 3- 2.3 x 2.6 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/28/17 documented Date of initial onset: 12/09/16- Stage 3- 1.9 x 3.8 x 0.0 cm, red, yellow wound condition . R #3's Admission Weekly Pressure Ulcer Record dated 05/04/17 documented Date of Onset: 12/09/16- Right Heel Pressure ulcer 2.0 x 2.7 x 0.0 cm, Suspected Deep Tissue Injury, red, yellow wound bed . The site was incorrectly documented on this assessment. The site should have been Left Heel. Interview with the DON on 07/13/17 at 8:42 a.m. revealed she reviewed R #3's documentation and verified the site documented on the Admission Weekly Pressure Ulcer Record was incorrect, It should have been the Left Heel, not the Right. The nurse should have staged it at an Unstageable or a Stage 3, not a DTI, due to the black tissue and then yellow slough present in the wound. This could affect the resident's care and could lead up to deterioration of the wound if not cared for correctly. R #3's Skin Assessment Profile dated 05/05/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 1.6 x 3.5 x 0.3 cm, 90% red, 10% yellow . R #3's Skin Assessment Profile dated 05/26/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 2.0 x 4.0 x 0.2 cm, 95% red, 5% yellow . R #3's Skin Assessment Profile dated 06/09/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 4.0 x 2.5 x 0.2 cm, serous-thin, watery clear drainage, 95% red, 5% yellow, red/pink wound condition . R #3's Skin Assessment Profile dated 06/22/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 4.2 x 2.5 x 0.5 cm, 30% red, 75% yellow . R #3's Wound Healing Center Document dated 07/06/17 documented Left Posterior Foot Pressure Ulcer Stage 3- 1.9 x 3.6 x 0.8 cm . debri

Based on observation, record review, and interview the facility failed to ensure residents have the right to be free from neglect for four (R #1, R #2, R #3, and R #5) of six residents reviewed for pressure ulcers. R #5: The facility failed to: -reposition R #5 every two hours as her plan of care indicated; -ensure R #5's left heel was properly offloaded; -provide effective offloading techniques. R #5 was admitted to the facility with a Stage 4 to her left heel and developed two Stage 2 facility acquired medical device related pressure ulcers. R #3: The facility failed to: -provide incontinent care when R #3's brief was wet; -correctly identify and document R #3's left heel pressure ulcer; -properly stage R #3's left heel ulcer; -correctly measure R #3's sacral ulcer; -correctly identify and document the location of R #3's right foot ulcer; -accurately stage R #3's facility acquired Right Ischial Tuberosity Stage 3 ulcer; -provide R #3 with treatment and dressing changes to all his pressure ulcers per the physician's orders [REDACTED].>-provide R #3 with heel offloading techniques, when in bed; -reposition/offload R #3's sacrum off the wheelchair for over two hours. R #3 was admitted to the facility with bilateral heel stage 3 pressure ulcers and further acquired a Right Ischial Tuberosity Stage 3 pressure ulcer. R #1: The facility failed to: -repositioned R #1 every hour as his plan of care indicated; -provide R #1 with heel protectors and offloading interventions on both feet instead of just the right foot; -ensure R #1 was relieved of pressure on his right lateral foot pressure ulcer; -assess, monitor, and ensure R #1's specialized low air loss mattress was set according to his current weight as per the manufacturer's recommendations. R #1 was admitted to the facility with a stage 4 pressure ulcer to his left lateral foot. R #2: The facility failed to: -provide treatment and dressing change to R #2's pressure ulcer per the physician's orders [REDACTED]. R #2 was admitted with a Left Trochanter Stage 4 pressure ulcer. The facility failed to initiate education for R #1, R #2, and R #5's specialized low air loss mattresses to include monitoring the mattress pressure for correct individualized firmness settings. These failures could place nine residents with pressure ulcers and 29 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: The facility's undated Administrative Policies and Procedures: Reporting/Recognizing/Identifying Signs and Symptoms of Abuse to Facility Management documented It is the responsibility of our employees, facility consultants, attending physician's, family members, visitors, etc. to promply report any incident or suspected incident of neglect . Our facility will not condone any form of resident abuse and neglect .To assist one in recognizing incidents of abuse, the following definitions of abuse are provided: . g. Neglect- is defined as failure to provide goods and services necessary to avoid harm, mental anguish, or mental illness . The facility's Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 03/2014 documented: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident mobility status; d. Current treatments, including support surfaces; e. All active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin . Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . General Guidelines: 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Education and quality improvement. 2. When eschar is present, a pressure ulcer cannot be accurately staged until eschar is removed. 3. It may be difficult to assess pressure ulcers in residents with casts, other orthopedic devices, or support stockings . Stage 2 Protocol- Pressure Ulcer Interventions/Care Strategies: Clean, shallow, minimal drainage: 1. Protect; 2. manage drainage; 3. Promote moist wound healing; 4. Determine wound treatment per wound status. exudate, bio-burden, location, and resident's underlying support system . 5. Clean with normal saline or wound cleanser; 6. Change dressing per order and manufacturer indications. Stage 3 Protocol- Pressure Ulcer Interventions/Care Strategies: Evaluate and determine pain level with pain assessment. 1. Protect; 2. Fill dead space including tunnels and undermining; 3. Manage drainage; 4. Promote moist wound healing. No drainage: 1. Treatment: Irrigate wound with normal saline or other designated wound cleanser, Refer to Stage 2's #4 and change per order and manufacturer's guidelines. Medium to heavy drainage: Follow above procedure. Consider substituting alginate or foam with silver. Stage 4 Protocol- Pressure Ulcer Interventions/Care Strategies: 1. Protect: a. Fill dead space including tunnels and undermining; b. manage drainage; c. Promote moist wound healing. 2. Debride slough/eschar . 3. Treatment: Irrigate wound with normal saline or wound cleanser, determine wound treatment per wound status, exudate .Apply an alginate dressing, foam dressing or hydrogel to wound cavity, Cover with secondary dressing and determine change per exudate, Change per order and manufacturers guidelines . On 07/13/17 at 12:20 p.m. the DON stated all CNA's and licensed staff were educated upon hire and by yearly competencies that included: .6. residents are turned, cleaned and repositioned at least q 2 hours 7. Bed bound residents have positioning devices in place. No skin to skin contact 37. Demonstrates proper technique in the use of items to prevent skin breakdown 50. Demonstrates proper positioning of residents for safety, comfort, and prevention of contractors and decubitus ulcers . R #5: R #5's Face Sheet dated 07/10/17 documented a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Admission Nursing assessment dated [DATE] documented Left Heel Stage 4 Pressure Ulcer- 8.3 x 7.0 x 0.0, 70% yellow slough, 20% red, 10% black to left heel . The assessment provided definitions of stages that included: -Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1- Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle area are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage 4- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #5's Braden Scale for Predicting Pressure Sore Risk dated 11/30/15 documented 13, moderate risk. R #5's Braden Scale for Predicting Pressure Sore Risk dated 01/25/17 documented 11, high risk. R #5's Annual Minimum Data Set ((MDS) dated [DATE] documented R #5: -had no speech -rarely/never made self understood and rarely/never understood others -had severely impaired cognitive skills for decision making -was totally dependent with one person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some of the wound bed. Often includes undermining and tunneling. 7.2 x 3.2 x 1.0 centimeters(cm). Was present upon admission. R #5's Braden Scale for Predicting Pressure Sore Risk dated 04/03/17 documented 9, very high risk. R #5's Care Plan revised 05/21/17 documented: -(R #5) has a [DIAGNOSES REDACTED].Interventions: Administer medications as ordered; Provide diet and supplements per MD (Medical Doctor) order . -Potential for skin breakdown related to impaired mobility due to hx (history) [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) Interventions: Total assist turn and reposition q (every) two hours by CNA (Certified Nurse Aide); CNA to notify nurse of any noted redness to skin; Licensed Nurse to perform complete head to toe assessment q week; Document and notify family and MD for any skin breakdown; Pressure relieving mattress; Nutritional supplements to assist in maintaining healthy skin integrity; Float heels with pillow or heel protectors . -(R #5) has Stage 4 to left heel related to vascular insufficiency .Interventions: Juven (supplement that supports growth and maintenance of muscle tissue) BID (twice a day) for supplement; Avoid exposure to temperature extremes .; Avoid mechanical trauma .;Ensure appropriate protective devices are applied to affected areas; Monitor pressure areas of color, sensation, temperature; Monitor/document wound: size, depth, margins, periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene; Document progress in wound healing on an ongoing basis. Notify MD as indicated .Position resident off affected area. Change position every hour and PRN; Treat wound as per facility protocol . R #5's Weekly Pressure Ulcer Record dated 06/03/17 documented Bedridden, contracted, Left Heel Pressure Stage 4- 5.2 x 4.4 x 0.0. R #5's Skin Assessment Profile dated 07/04/17 documented Left Heel Stage 4- 4.1 x 3.3 x 0.0, serosanguineous drainage, red wound condition . R #5's Skin Assessment Profile dated 07/11/17 documented Left Heel Stage 4- 6.0 x 3.0 x 0.0, serosanguineous drainage, red wound condition . R #5's July 2017 Medication Review Report documented Stage 4 to left heel: Cleanse with normal saline, pat dry with 4x4's, apply [MEDICATION NAME] (collagen and oxidized regenerated cellulose), cover with [MEDICATION NAME], cover with gauze, wrap with kerlix, secure with tape every day every Monday, Wednesday, and Friday .Juven 1 packet via [DEVICE] BID supplement mix with 4-6 ounces of water Vitamin C 500 milligrams (mg) tid (three times a day) .Zinc 50 mg q day via [DEVICE] one time a day. R #5's Weekly Pressure Ulcer Record dated 07/10/17 documented: Date of Onset: 07/10/17. 1.) Site: Right Ear- Pressure 1.2 x 0.3 x 0.0 cm 2.) Site: Left ear- Pressure 0.5 x 0.3 x 0.0 cm Scant serous drainage, pink/beefy red wound bed, surrounding skin color pink, normal surrounding tissue .Preventive measures: turn every - hours, pressure relieving device, high protein supplement, multivitamin/zinc. There was no entry to indicate how often to reposition. R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind left ear- 1.2 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind right ear- 0.5 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . Observation of R #5 during initial tour on 07/10/17 at 2:57 p.m., accompanied by Registered Nurse (RN) A, revealed R #5 layed on her back with a pillow tucked behind her right torso. R #5's pelvis rested on the mattress and her bilateral feet were raised off the mattress by the use of Prevalon (heel protector). R #5 layed on an inflated overlay mattress which the mattress pump was set at the farthest firm position. R #5's eyes were closed and did not respond to verbal stimuli. R #5 was receiving oxygen via a nasal cannula, with the portion of the cannula that layed behind each ear was wrapped with gauze. RN A said R #5 was unable to communicate her needs and was dependent on staff for all adl's (activities of daily living). Observation of R #5 on 07/10/17 at 5:12 p.m. revealed R #5 remained laying on her back with a pillow tucked on the right side of her torso, still with her buttocks resting on the mattress. R #5's heel protectors were in position however, her left heel was not in the protector and rested on the mattress. Observation of R #5 on 07/10/17 at 5:36 p.m. revealed R #5 remained in the same position as at 2:57 p.m. This surveyor retrieved RN A. RN A said R #5 should have been repositioned every two hours. RN A observed R #5 and confirmed R #5 was in the same position as seen during initial wounds. RN A repositioned R #5's left foot correctly into the heel protector and confirmed R #5's left heel was resting on the bed yet, it should have been raised off the bed. RN A said the purpose of using pillows and repositioning every two hours was to relieve pressure off of the pressure points off the buttocks and sacrum. Upon the surveyor's request, RN A slid her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the mattress and were not offloaded. RN A said R #5's mattress felt firm and did not know anything about the mattress or what setting the mattress pump was appropriate for R #5. RN A approached Certified Nurse Aide (CNA) H and asked CNA H what time she repositioned R #5. CNA H responded About 2:15 p.m. I was going to go in there to change and turn her but I was waiting for the other CNA to finish bathing her resident then the dinner trays came out. RN A said relieving pressure by repositioning at least every two hours was important to prevent pressure ulcer development and/or deterioration of existing ulcers. R #5's Telephone physician's orders [REDACTED]. Observation of R #5 on 07/11/17 at 8:21 a.m. revealed R #5 had a pillow behind her right upper back and her torso was slightly tilted toward her left side and another pillow under her left arm. R #5's pelvis remained in straight alignment with her buttocks resting on the mattress. R #5 had heel protectors in place. Observation of R #5 on 07/11/17 at 11:22 a.m. revealed R #5 layed in the same position as seen at 8:21 a.m. LVN B entered the room and began performing wound care on R #5. LVN B said R #5 was admitted to the facility with a Stage 4 pressure ulcer to her left heel that measured 8.3 x 7.0 x 0.0 centimeters. LVN B said the last measurement was on 07/04/17 and it measured 4.1 x 3.3 x 0.0 cm. LVN B removed R #5's old dressing which presented with old dried brown, red, and light yellow drainage. LVN B stated It has hypergranulation red tissue with macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) tissue surrounding the wound. The wound bed is dark brown/black. There is purple tissue injury at 12 o'clock - 3 o'clock. It measures 6.0 x 3.0 x 0.0. Upon the surveyor's request, LVN B tucked her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the bed. LVN B said the pillow behind R #5's right back was there in attempt to relieve pressure off of R #5's right buttocks and sacrum. LVN B agreed the offloading attempt was ineffective. LVN B preceded to adjust R #5's oxygen tubing away from behind her ears. R #5 had small superficial red open area behind each ear. LVN B measured the ulcers on each ear and said The right ear is 1.2 x 0.3 x 0.0 cm and the left ear is 0.5 x 0.3 x 0.0 cm. LVN B confirmed R #5 received her ulcers behind her ears from the oxygen tubing applying pressure to the site. Interview with CNAs J and K on 07/11/17 at 11:55 a.m. revealed they stated they last repositioned R #5 at approximately 9:15 a.m. CNA K said R #5 was laying on her back before she placed a pillow behind R #5's right back. CNA K was asked if placing one pillow on the upper back would effectively offload R #5's buttocks off the bed; CNA K hesitated then said I'm not sure. CNAs J and K entered R #5's room and provided R #5 with incontinent care. Once R #5 was toward her right side, there were multiple indented, red lines all along R #5's left hip and thigh. Interview with the Assistant DON (ADON) on 07/11/17 at 5:21 p.m. revealed she said the facility did not apply or maintain any of the hospice air mattresses. The ADON said Hospice sets up the mattresses and do not give us any instructions for them. If there is a problem we just call hospice and they come out to check them. The surveyor accompanied the ADON into R #5's room and asked the ADON to feel the air mattress. The ADON said, It's pretty firm. We don't know what is the appropriate setting for her because the settings options only include firm and soft. Hers is set all the way to the firmest position. R #1: R #1's Face Sheet dated 07/10/17 documented an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Gastrostomy Status, and Hypertension. R #1's Annual/Re-Admission MDS dated [DATE] documented R #1: -had clear speech -sometimes made self understood and sometimes understood others -had severely impaired cognitive skills for decision making -was totally dependent with one-two person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer present upon admission- 9.5 x 6.5 x 1.0 cm. R #1's Skin Assessment Profile dated 05/06/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 6.5 x 1.1 cm, serosanguineous drainage, 20% yellow, 80% red, periwound purple . R #1's Skin Assessment Profile dated 05/20/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 5.0 x 0.5 cm, purulent, tan, opaque drainage, 75% eschar (slough or piece of black dead tissue), 25% red . R #1's Care Plan dated 05/21/17 documented: Wound treatment: Stage 4 to right foot upper lateral aspect .Interventions: Assess skin weekly; Dietary consult and recommendations for nutritional supplement; Float heels with heel protectors or pillow; Monitor and report to MD any signs and symptoms of pain prior to treatment; Treat wound per MD orders; turn and reposition q hourly; Nutritional supplement per MD order .I require total assist with all ADLs (activities of daily living) . R #1's July 2017 Medication Review Report documented Stage 4 to right foot upper lateral aspect: cleanse, pat dry with 4x4's, apply Santyl (an enzymatic [MEDICATION NAME] ointment) to none viable area, apply [MEDICATION NAME] (antibiotic) to viable area, cover with gauze, wrap with kerlix, wrap with coban or elastic wrap, and secure with tape every day on non-hospice days- every Tuesdays, Thursdays, Saturday, Sundays .Vitamin C 500 mg via [DEVICE] daily. Zinc 50 mg via [DEVICE] q hs (bedtime) for wound healing. Juven 1 packet via [DEVICE] two times a day for wound healing mixed with 120 ml of water. R #1's Skin Assessment Profile dated 07/04/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 6.5 x 1.5 x 0.1 cm, serosanguineous drainage, 5% yellow, 95% red . Observation of R #1 on 07/10/17 at 3:05 p.m., during initial rounds, accompanied by RN A, revealed R #1 layed on a Low Air Loss Alternating Mattress with the pump set at 9 (350 pounds). R #1 layed on his back with his buttocks resting on the mattress and his legs were folded and positioned on his right side, with his left leg over the right leg. R #1 was alert and verbal however, speech was unclear. R #1 did not appropriately answer any questions. R #1 had bilateral upper and lower extremity contractures. R #1 had a Prevalon boot on his right foot but not the left foot. Observation of R #1 on 07/10/17 at 5:18 p.m. revealed R #1 remained in the same position as last seen at 3:05 p.m. Observation of R #1 on 07/10/17 at 5:36 p.m. revealed R #1 remained in the same position. The surveyor retrieved RN A into R #1's room; RN A said R #1 should be repositioned at least every two hours. CNA H entered R #1's room and said she last repositioned R #1 at approximately 2:30 p.m. CNA H said she had not repositioned R #1 because she was waiting for the other CNA to finish showering another resident and then dinner trays arrived and assisted other residents to eat. RN A informed the surveyor of R #1 having a Stage 4 pressure ulcer on his outer lateral aspect of his right foot. RN A removed R #1's covers and informed the surveyor that R #1's legs remain folded at all times due to contractures. RN A agreed R #1's current position was causing pressure directly on his coccyx and his right foot Stage 4 pressure ulcer. RN A said Pressure should be kept off his right foot as much as possible. RN A stated she did not know why R #1 only had one prevalon boot then stated Maybe because he only has an ulcer on the right foot. RN A stated out loud that the pump setting was set at 9 then said she did not know anything about R #1's air mattress other than the mattress came from hospice and hospice set up the mattress. RN A said if something happened to the mattress then she would call hospice to check it. RN A said the hospice nurse visited R #1 every week. RN A stated R #1 having direct pressure on his right foot pressure ulcer and not being repositioned every two hours could cause his pressure ulcer to worsen and not heal. Observation on 07/11/17 at 8:23 a.m. revealed R #1 layed on his back with his head of bed elevated. R #1 had a pillow on each side of his hips with his left leg over the right leg with both raised and folded on his right side. R #1 had a Prevalon boot on his right foot only. Observation of R #1 on 07/11/17 at 10:37 a.m. revealed R #1 layed in the same position as seen at 8:23 a.m. On 06/11/17 at 12:11 a.m., the surveyor accompanied LVN B into R #1's room. R #1 layed in the same position as seen at 8:23 a.m. and 10:37 a.m. LVN B was informed of R #1 being observed in the same position since 8:23 a.m. LVN B said she would ensure R #1 was repositioned after she performed wound care. LVN B confirmed R #1's current position was putting pressure on his right lateral foot pressure ulcer. LVN B said R #1's positioning should be kept off his right lateral foot. LVN B preceded to remove R #1's right foot dressing that had dry brown/red drainage. R #1's right outer lateral foot was approximately the length of the surveyor's index finger and the width greater than one millimeter. The ulcer was open with a red wound bed and slowly seeped serosanguineous drainage. After LVN B cleansed R #1 ulcer, the ulcer began to bleed heavily, dripping blood onto the bed. LVN B measured R #1's ulcer and said 5.3 X 2.2 X 0.1 cm. LVN B re-dressed R #1's right foot then repositioned him to his left side with the assistance of CNA L. LVN B instructed CNA L to ensure R #1 was repositioned every two hours and to refrain from putting pressure on R #1's right lateral foot. LVN B asked CNA L to look for R #1's left foot Prevalon boot. CNA L looked throughout R #1's room and informed LVN B he could not find a Prevalon boot. LVN B instructed CNA L that R #1 needed a heel protector to prevent development of a pressure ulcer on his left foot and instructed CNA L to go find a heel protector for R #1's left foot. A few minutes later, CNA L returned to R #1's room with a cloth heel protector and placed it on R #1's left foot. LVN B confirmed R #1's air mattress pump was set at 9. The surveyor asked LVN B what the number 9 meant and LVN B said she did not know. The surveyor asked LVN B to read the numbers above the number 9 and LVN B said 350 pounds. LVN B confirmed R #1 was not 350 pounds. LVN B said she did not know anything about the air mattress because the mattress belonged to hospice and hospice set up and maintained the mattress. LVN B checked R #1's most current weight via the computer and said (R #1) weighs 165.0 pounds. Review of R #1's 2017 Monthly Weight Record revealed R #1's weight on 07/10/17 was 165.0 pounds. Interview with the ADON on 07/11/17 at 5:22 p.m. revealed she pressed down on R #1's mattress and said It's kind of hard, it is set at 9- 350 pounds. He is not 350 pounds. The ADON adjusted the setting on the pump to a 4 (175 pounds). The ADON said If the mattress is too hard or even too soft, the resident could develop pressure ulcers or have worsening of their ulcers. The ADON said the facility did not have any manufacturer's recommendations/user guide for any specialized mattresses/pumps but would immediately call to get some. R #1's undated Alternating Pressure Mattress User Manual provided by the DON on 07/12/17 revealed The patient comfort pressure ranges from soft (level 1) to firm (level 9). The comfort control displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set appropriate comfort pressure level depending on the patient weight . R #3: R #3's Face Sheet dated 07/12/17 documented an [AGE] year-old male initially admitted [DATE], discharged to the hospital on [DATE] and re-admitted [DATE] with the [DIAGNOSES REDACTED]. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/11/17 documented 14- moderate risk. R #3's Significant Change MDS dated [DATE] documented R #3: -had clear speech -usually made self understood and usually understood others -had a Brief Interview of Mental Status (BIMS) score of 5 (severely impaired) -required extensive assistance with one-two person physical assist for bed mobility, dressing, eating, toilet use, and personal hygiene. R #3 was totally dependent with two person physical assist for transfers -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 2 present upon admission/re-entry and two Stage 3 pressure ulcers present upon admission- 1.0 x 3.2 x 0.0 cm. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/27/17 documented 14- moderate risk. R #3's Care Plan revised 06/14/17 documented: -Stage 2 right heel .Interventions: Keep clean and dry; Treat sore per MD orders, notify if ineffective; Assess skin weekly; Monitor and Report to MD any signs and symptoms of infection; Monitor for pain; Vitamin c and Zinc supplements, see MD orders for details; Weekly wound care; Clinic evaluation (at local hospital) Wound Treatment Center on Thursdays. -(R #3) has actual impairment to skin integrity related to a Stage 3 to his left buttocks, updated 07/10/17 .Interventions: Avoid scratching and keep hands and body parts from excessive moisture .; Treatment per MD order; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. to MD., Weekly Wound Care Treatment Center on Thursdays. -Stage 3 to left heel .Interventions: Daily and weekly skin checks to heel; Monitor for pain; Notify MD and family of changes; Treatment per MD orders; Vitamin C and Zinc for supplements, see MD orders for details; Weekly wound care at Wound Treatment Center on Thursdays .Check frequently for bowel incontinence and provide peri-care after each episode .Provide pressure redistribution surface to bed, chair PRN (as needed) .Turn and reposition q 2 hours .I require extensive to total assistance with two person assistance for bed mobility, personal hygiene . -(R #3) has a Stage 3 to Sacrum .Interventions: Nutritional supplements as ordered; Assess skin weekly; Monitor and report any signs/symptoms of infection; Pain medication as ordered; Treat wound per MD orders; Turn and Reposition q 2 hours . R #3's physician's orders [REDACTED]. R #3's July 2017 Medication Review Report documented: -Stage 2 to right heel, cleanse with normal saline, pat dry with 4x4s, apply Calcium Alginate, cover with 4x4, wrap with kerlix, wrap with elastic bandage, secure with tape every day every Monday, Wednesday, Friday . -Stage 3 to left buttocks: cleanse with normal saline, pat dry with 4x4, apply Santyl and cover with Allevyen (bacterial barrier dressing for exudate management) every shift every other day . -Stage 3 left heel: cleanse with wound cleanser, pat dry with 4x4, apply Santyl, cover with 4x4, wrap types of wounds kerlix, wrap with elastic bandage, secure with tape every Monday, Wednesday, Friday . -Stage 3 to Sacrum: cleanse with normal saline, pat dry with 4x4 gauze, apply Santyl to non-viable tissue. Apply hydrogel (ointment used for dry or slightly moist that creates a moist healing environment) to viable tissue, and cover with Allevyn every Monday, Wednesday, Friday . -Multivitamin give one tablet by mouth one time a day for supplement .Vitamin C 500 mg by mouth one time a day for wound healing .Zinc tablet 50 mg, give one tablet by mouth one time a day for wound healing . R #3's July 2017 Treatment Administration Record (TAR) revealed R #3's Right heel Stage 2, Left heel Stage 3, and Sacral Stage 3 pressure ulcers did not obtain a licensed nurse's initial to indicate treatment was performed on Monday, 07/10/17. Observation of R #3 on 07/11/17 at 8:30 a.m. revealed R #3 sat in a Geriatric-chair. Upon LVN B's request, CNAs J and L transferred R #3 from his chair to his bed. The CNAs removed R #3's pants exposing his yellow brief. The two wet indicators revealed the two lines were blue, indicating the brief was wet. The center of the brief appeared mushy. R #3 was not provided with incontinent care at this time. Interview with LVN B on 07/11/17 at 8:48 a.m. revealed she stated R #3 was admitted on [DATE] with a coccyx and left heel Stag

Based on observation, interview, and record review the facility failed to ensure services provided as outlined by the comprehensive care plan, meet professional standards of quality for one Resident (R #1) of five residents reviewed for professional standards of clinical practice. -Registered Nurse (RN) A and the Director of Nurses (DON) failed to monitor and intervene to ensure R #5's left heel was properly offloaded and was provided effective offloading techniques. R #5 was admitted to the facility with a Stage 4 to her left heel and developed two Stage 2 facility acquired medical device related pressure ulcers. -RN A failed to monitor and intervene to ensure R #1 was repositioned R #1 every hour as his plan of care indicated, provide R #1 with heel protectors and offloading interventions on both feet instead of just the right foot, and ensure R #1 was relieved of pressure on his right lateral foot pressure ulcer. R #1 was admitted to the facility with a stage 4 pressure ulcer to his left lateral foot. The DON failed to ensure the licensed staff: -correctly identified and documented R #3's left heel pressure ulcer; -properly stage R #3's left heel ulcer; -correctly measure R #3's sacral ulcer; -correctly identify and document the location of R #3's right foot ulcer; -accurately stage R #3's facility acquired right ischial tuberosity Stage 3 ulcer; -provide R #3 with treatment and dressing changes to all his pressure ulcers per the physician's orders [REDACTED].>RN A failed to monitor and intervene to ensure R #3's heel was offloaded, when in bed; R #3 was admitted to the facility with bilateral heel stage 3 pressure ulcers and had a facility acquired Right Ischial Tuberosity Stage 3 pressure ulcer. The DON failed to ensure R #2 was provided treatment and dressing change to R #2's pressure ulcer per the physician's orders [REDACTED]. R #2 had a community acquired Left Trochanter Stage 4 pressure ulcer. The DON failed to initiate education for R #1, R #2, and R #5's specialized low air loss mattresses to include monitoring the mattresses for correct individualized firmness settings. These failures could place nine residents with pressure ulcers and 29 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: 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; .(H) Make reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; . (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications ; .(O) Implement measures to prevent exposure to infectious pathogens and communicable conditions; .(U) Supervise nursing care provided by others for whom the nurse is professionally responsible; . The facility's Pressure Ulcers/Skin Breakdown- Clinical Protocol dated 03/2014 documented: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident mobility status; d. Current treatments, including support surfaces; e. All active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin . Monitoring: 1. During resident visits, the physician will evaluate and document the progress of wound healing- especially for those with complicated, extensive, or non-healing wounds. 2. The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . General Guidelines: 1. The pressure ulcer treatment program should focus on the following strategies: a. Assessing the resident and the current status of the pressure ulcer(s). b. Current support surfaces. c. Pressure ulcer care. d. Managing bacterial colonization and infection. e. Education and quality improvement. 2. When eschar is present, a pressure ulcer cannot be accurately staged until eschar is removed. 3. It may be difficult to assess pressure ulcers in residents with casts, other orthopedic devices, or support stockings . Stage 2 Protocol- Pressure Ulcer Interventions/Care Strategies: Clean, shallow, minimal drainage: 1. Protect; 2. manage drainage; 3. Promote moist wound healing; 4. Determine wound treatment per wound status. exudate, bio-burden, location, and resident's underlying support system . 5. Clean with normal saline or wound cleanser; 6. Change dressing per order and manufacturer indications. Stage 3 Protocol- Pressure Ulcer Interventions/Care Strategies: Evaluate and determine pain level with pain assessment. 1. Protect; 2. Fill dead space including tunnels and undermining; 3. Manage drainage; 4. Promote moist wound healing. No drainage: 1. Treatment: Irrigate wound with normal saline or other designated wound cleanser, Refer to Stage 2's #4 and change per order and manufacturer's guidelines. Medium to heavy drainage: Follow above procedure. Consider substituting alginate or foam with silver. Stage 4 Protocol- Pressure Ulcer Interventions/Care Strategies: 1. Protect: a. Fill dead space including tunnels and undermining; b. manage drainage; c. Promote moist wound healing. 2. Debride slough/eschar . 3. Treatment: Irrigate wound with normal saline or wound cleanser, determine wound treatment per wound status, exudate .Apply an alginate dressing, foam dressing or hydrogel to wound cavity, Cover with secondary dressing and determine change per exudate, Change per order and manufacturers guidelines . On 07/13/17 at 12:20 p.m. the DON stated all CNA's and licensed staff were educated upon hire and by yearly competencies that included: .6. residents are turned, cleaned and repositioned at least q 2 hours 7. Bed bound residents have positioning devices in place. No skin to skin contact 37. Demonstrates proper technique in the use of items to prevent skin breakdown 50. Demonstrates proper positioning of residents for safety, comfort, and prevention of contractors and decubitus ulcers . R #5: R #5's Face Sheet dated 07/10/17 documented a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Admission Nursing assessment dated [DATE] documented Left Heel Stage 4 Pressure Ulcer- 8.3 x 7.0 x 0.0, 70% yellow slough, 20% red, 10% black to left heel . The assessment provided definitions of stages that included: -Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1- Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle area are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage 4- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #5's Braden Scale for Predicting Pressure Sore Risk dated 11/30/15 documented 13, moderate risk. R #5's Braden Scale for Predicting Pressure Sore Risk dated 01/25/17 documented 11, high risk. R #5's Annual Minimum Data Set ((MDS) dated [DATE] documented R #5: -had no speech -rarely/never made self understood and rarely/never understood others -had severely impaired cognitive skills for decision making -was totally dependent with one person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some of the wound bed. Often includes undermining and tunneling. 7.2 x 3.2 x 1.0 centimeters(cm). Was present upon admission. R #5's Braden Scale for Predicting Pressure Sore Risk dated 04/03/17 documented 9, very high risk. R #5's Care Plan revised 05/21/17 documented: -(R #5) has a [DIAGNOSES REDACTED].Interventions: Administer medications as ordered; Provide diet and supplements per MD (Medical Doctor) order . -Potential for skin breakdown related to impaired mobility due to hx (history) [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) Interventions: Total assist turn and reposition q (every) two hours by CNA (Certified Nurse Aide); CNA to notify nurse of any noted redness to skin; Licensed Nurse to perform complete head to toe assessment q week; Document and notify family and MD for any skin breakdown; Pressure relieving mattress; Nutritional supplements to assist in maintaining healthy skin integrity; Float heels with pillow or heel protectors . -(R #5) has Stage 4 to left heel related to vascular insufficiency .Interventions: Juven (supplement that supports growth and maintenance of muscle tissue) BID (twice a day) for supplement; Avoid exposure to temperature extremes .; Avoid mechanical trauma .;Ensure appropriate protective devices are applied to affected areas; Monitor pressure areas of color, sensation, temperature; Monitor/document wound: size, depth, margins, periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene; Document progress in wound healing on an ongoing basis. Notify MD as indicated .Position resident off affected area. Change position every hour and PRN; Treat wound as per facility protocol . R #5's Weekly Pressure Ulcer Record dated 06/03/17 documented Bedridden, contracted, Left Heel Pressure Stage 4- 5.2 x 4.4 x 0.0. R #5's Skin Assessment Profile dated 07/04/17 documented Left Heel Stage 4- 4.1 x 3.3 x 0.0, serosanguineous drainage, red wound condition . R #5's Skin Assessment Profile dated 07/11/17 documented Left Heel Stage 4- 6.0 x 3.0 x 0.0, serosanguineous drainage, red wound condition . R #5's July 2017 Medication Review Report documented Stage 4 to left heel: Cleanse with normal saline, pat dry with 4x4's, apply [MEDICATION NAME] (collagen and oxidized regenerated cellulose), cover with [MEDICATION NAME], cover with gauze, wrap with kerlix, secure with tape every day every Monday, Wednesday, and Friday .Juven 1 packet via [DEVICE] BID supplement mix with 4-6 ounces of water Vitamin C 500 milligrams (mg) tid (three times a day) .Zinc 50 mg q day via [DEVICE] one time a day. R #5's Weekly Pressure Ulcer Record dated 07/10/17 documented: Date of Onset: 07/10/17. 1.) Site: Right Ear- Pressure 1.2 x 0.3 x 0.0 cm 2.) Site: Left ear- Pressure 0.5 x 0.3 x 0.0 cm Scant serous drainage, pink/beefy red wound bed, surrounding skin color pink, normal surrounding tissue .Preventive measures: turn every - hours, pressure relieving device, high protein supplement, multivitamin/zinc. *There was no entry to indicate how often to reposition. R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind left ear- 1.2 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind right ear- 0.5 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . Observation of R #5 during initial tour on 07/10/17 at 2:57 p.m., accompanied by Registered Nurse (RN) A, revealed R #5 layed on her back with a pillow tucked behind her right torso. R #5's pelvis rested on the mattress and her bilateral feet were raised off the mattress by the use of Prevalon (heel protector). R #5 layed on an inflated overlay mattress which the mattress pump was set at the farthest firm position. R #5's eyes were closed and did not respond to verbal stimuli. R #5 was receiving oxygen via a nasal cannula, with the portion of the cannula that layed behind each ear was wrapped with gauze. RN A said R #5 was unable to communicate her needs and was dependent on staff for all adl's (activities of daily living). Observation of R #5 on 07/10/17 at 5:12 p.m. revealed R #5 remained laying on her back with a pillow tucked on the right side of her torso, still with her buttocks resting on the mattress. R #5's heel protectors were in position however, her left heel was not in the protector and rested on the mattress. Observation of R #5 on 07/10/17 at 5:36 p.m. revealed R #5 remained in the same position as at 2:57 p.m. This surveyor retrieved RN A. RN A said R #5 should have been repositioned every two hours. RN A observed R #5 and confirmed R #5 was in the same position as seen during initial wounds. RN A repositioned R #5's left foot correctly into the heel protector and confirmed R #5's left heel was resting on the bed yet, it should have been raised off the bed. RN A said the purpose of using pillows and repositioning every two hours was to relieve pressure off of the pressure points off the buttocks and sacrum. Upon the surveyor's request, RN A slid her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the mattress and were not offloaded. RN A said R #5's mattress felt firm and did not know anything about the mattress or what setting the mattress pump was appropriate for R #5. RN A approached Certified Nurse Aide (CNA) H and asked CNA H what time she repositioned R #5. CNA H responded About 2:15 p.m. I was going to go in there to change and turn her but I was waiting for the other CNA to finish bathing her resident then the dinner trays came out. RN A said relieving pressure by repositioning at least every two hours was important to prevent pressure ulcer development and/or deterioration of existing ulcers. RN A said she was responsible for monitoring and ensuring the CNAs implemented correct positioning and offloading techniques. R #5's Telephone physician's orders [REDACTED]. Observation of R #5 on 07/11/17 at 8:21 a.m. revealed R #5 had a pillow behind her right upper back and her torso was slightly tilted toward her left side and another pillow under her left arm. R #5's pelvis remained in straight alignment with her buttocks resting on the mattress. R #5 had heel protectors in place. Observation of R #5 on 07/11/17 at 11:22 a.m. revealed R #5 layed in the same position as seen at 8:21 a.m. LVN B entered the room and began performing wound care on R #5. LVN B said R #5 was admitted to the facility with a Stage 4 pressure ulcer to her left heel that measured 8.3 x 7.0 x 0.0 centimeters. LVN B said the last measurement was on 07/04/17 and it measured 4.1 x 3.3 x 0.0 cm. LVN B removed R #5's old dressing which presented with old dried brown, red, and light yellow drainage. LVN B stated It has hypergranulation red tissue with macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) tissue surrounding the wound. The wound bed is dark brown/black. There is purple tissue injury at 12 o'clock - 3 o'clock. It measures 6.0 x 3.0 x 0.0. Upon the surveyor's request, LVN B tucked her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the bed. LVN B said the pillow behind R #5's right back was there in attempt to relieve pressure off of R #5's right buttocks and sacrum. LVN B agreed the offloading attempt was ineffective. LVN B preceded to adjust R #5's oxygen tubing away from behind her ears. R #5 had small superficial red open area behind each ear. LVN B measured the ulcers on each ear and said The right ear is 1.2 x 0.3 x 0.0 cm and the left ear is 0.5 x 0.3 x 0.0 cm. LVN B confirmed R #5 received her ulcers behind her ears from the oxygen tubing applying pressure to the site. Interview with CNAs J and K on 07/11/17 at 11:55 a.m. revealed they stated they last repositioned R #5 at approximately 9:15 a.m. CNA K said R #5 was laying on her back before she placed a pillow behind R #5's right back. CNA K was asked if placing one pillow on the upper back would effectively offload R #5's buttocks off the bed; CNA K hesitated then said I'm not sure. CNAs J and K entered R #5's room and provided R #5 with incontinent care. Once R #5 was toward her right side, there were multiple indented, red lines all along R #5's left hip and thigh. Interview with the Assistant Director of Nurses (ADON) on 07/11/17 at 5:21 p.m. revealed she said the facility did not apply or maintain any of the hospice air mattresses. The ADON said Hospice sets up the mattresses and do not give us any instructions for them. If there is a problem we just call hospice and they come out to check them. The surveyor accompanied the ADON into R #5's room and asked the ADON to feel the air mattress. The ADON said, It's pretty firm. We don't know what is the appropriate setting for her because the settings options only include firm and soft. Hers is set all the way to the firmest position. Interview with the DON on 07/12/17 at 8:50 a.m. revealed the charge nurses and she was responsible to ensure each residents care/interventions were provided accurately and consistently as per the resident's plan of care. R #1: R #1's Face Sheet dated 07/10/17 documented an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Gastrostomy Status, and Hypertension. R #1's Annual/Re-Admission MDS dated [DATE] documented R #1: -had clear speech -sometimes made self understood and sometimes understood others -had severely impaired cognitive skills for decision making -was totally dependent with one-two person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer present upon admission- 9.5 x 6.5 x 1.0 cm. R #1's Skin Assessment Profile dated 05/06/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 6.5 x 1.1 cm, serosanguineous drainage, 20% yellow, 80% red, periwound purple . R #1's Skin Assessment Profile dated 05/20/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 5.0 x 0.5 cm, purulent, tan, opaque drainage, 75% eschar (slough or piece of black dead tissue), 25% red . R #1's Care Plan dated 05/21/17 documented: Wound treatment: Stage 4 to right foot upper lateral aspect .Interventions: Assess skin weekly; Dietary consult and recommendations for nutritional supplement; Float heels with heel protectors or pillow; Monitor and report to MD any signs and symptoms of pain prior to treatment; Treat wound per MD orders; turn and reposition q hourly; Nutritional supplement per MD order .I require total assist with all ADLs (activities of daily living) . R #1's July 2017 Medication Review Report documented Stage 4 to right foot upper lateral aspect: cleanse, pat dry with 4x4's, apply Santyl (an enzymatic [MEDICATION NAME] ointment) to none viable area, apply [MEDICATION NAME] (antibiotic) to viable area, cover with gauze, wrap with kerlix, wrap with coban or elastic wrap, and secure with tape every day on non-hospice days- every Tuesdays, Thursdays, Saturday, Sundays .Vitamin C 500 mg via [DEVICE] daily. Zinc 50 mg via [DEVICE] q hs (bedtime) for wound healing. Juven 1 packet via [DEVICE] two times a day for wound healing mixed with 120 ml of water. R #1's Skin Assessment Profile dated 07/04/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 6.5 x 1.5 x 0.1 cm, serosanguineous drainage, 5% yellow, 95% red . Observation of R #1 on 07/10/17 at 3:05 p.m., during initial rounds, accompanied by RN A, revealed R #1 layed on a Low Air Loss Alternating Mattress with the pump set at 9 (350 pounds). R #1 layed on his back with his buttocks resting on the mattress and his legs were folded and positioned on his right side, with his left leg over the right leg. R #1 was alert and verbal however, speech was unclear. R #1 did not appropriately answer any questions. R #1 had bilateral upper and lower extremity contractures. R #1 had a Prevalon boot on his right foot but not the left foot. Observation of R #1 on 07/10/17 at 5:18 p.m. revealed R #1 remained in the same position as last seen at 3:05 p.m. Observation of R #1 on 07/10/17 at 5:36 p.m. revealed R #1 remained in the same position. The surveyor retrieved RN A into R #1's room; RN A said R #1 should be repositioned at least every two hours. CNA H entered R #1's room and said she last repositioned R #1 at approximately 2:30 p.m. CNA H said she had not repositioned R #1 because she was waiting for the other CNA to finish showering another resident and then dinner trays arrived and assisted other residents to eat. RN A informed the surveyor of R #1 having a Stage 4 pressure ulcer on his outer lateral aspect of his right foot. RN A removed R #1's covers and informed the surveyor that R #1's legs remain folded at all times due to contractures. RN A agreed R #1's current position was causing pressure directly on his coccyx and his right foot Stage 4 pressure ulcer. RN A said Pressure should be kept off his right foot as much as possible. RN A stated she did not know why R #1 only had one prevalon boot then stated Maybe because he only has an ulcer on the right foot. RN A stated out loud that the pump setting was set at 9 then said she did not know anything about R #1's air mattress other than the mattress came from hospice and hospice set up the mattress. RN A said if something happened to the mattress then she would call hospice to check it. RN A said the hospice nurse visited R #1 every week. RN A stated R #1 having direct pressure on his right foot pressure ulcer and not being repositioned every two hours could cause his pressure ulcer to worsen and not heal. RN A said she had not noticed that R #1 was in the same position since 3:05 p.m. RN A said she usually tried to check all the residents about every hour and a half to two hours. RN A said she had not attempted to retrieve information on air mattresses because she assumed the company set them correctly. Observation on 07/11/17 at 8:23 a.m. revealed R #1 layed on his back with his head of bed elevated. R #1 had a pillow on each side of his hips with his left leg over the right leg with both raised and folded on his right side. R #1 had a Prevalon boot on his right foot only. Observation of R #1 on 07/11/17 at 10:37 a.m. revealed R #1 layed in the same position as seen at 8:23 a.m. On 07/11/17 at 12:11 a.m., the surveyor accompanied LVN B into R #1's room. R #1 layed in the same position as seen at 8:23 a.m. and 10:37 a.m. LVN B was informed of R #1 being observed in the same position since 8:23 a.m. LVN B said she would ensure R #1 was repositioned after she performed wound care. LVN B confirmed R #1's current position was putting pressure on his right lateral foot pressure ulcer. LVN B said R #1's positioning should be kept off his right lateral foot. LVN B preceded to remove R #1's right foot dressing that had dry brown/red drainage. R #1's right outer lateral foot was approximately the length of the surveyor's index finger and the width greater than one millimeter. The ulcer was open with a red wound bed and slowly seeped serosanguineous drainage. After LVN B cleansed R #1 ulcer, the ulcer began to bleed heavily, dripping blood onto the bed. LVN B measured R #1's ulcer and said 5.3 X 2.2 X 0.1 cm. LVN B re-dressed R #1's right foot then repositioned him to his left side with the assistance of CNA L. LVN B instructed CNA L to ensure R #1 was repositioned every two hours and to refrain from putting pressure on R #1's right lateral foot. LVN B asked CNA L to look for R #1's left foot Prevalon boot. CNA L looked throughout R #1's room and informed LVN B he could not find a Prevalon boot. LVN B instructed CNA L that R #1 needed a heel protector to prevent development of a pressure ulcer on his left foot and instructed CNA L to go find a heel protector for R #1's left foot. A few minutes later, CNA L returned to R #1's room with a cloth heel protector and placed it on R #1's left foot. LVN B confirmed R #1's air mattress pump was set at 9. The surveyor asked LVN B what the number 9 meant and LVN B said she did not know. The surveyor asked LVN B to read the numbers above the number 9 and LVN B said 350 pounds. LVN B confirmed R #1 was not 350 pounds. LVN B said she did not know anything about the air mattress because the mattress belonged to hospice and hospice set up and maintained the mattress. LVN B checked R #1's most current weight via the computer and said (R #1) weighs 165.0 pounds. Review of R #1's 2017 Monthly Weight Record revealed R #1's weight on 07/10/17 was 165.0 pounds. Interview with the ADON on 07/11/17 at 5:22 p.m. revealed she pressed down on R #1's mattress and said It's kind of hard, it is set at 9- 350 pounds. He is not 350 pounds. The ADON adjusted the setting on the pump to a 4 (175 pounds). The ADON said If the mattress is too hard or even too soft, the resident could develop pressure ulcers or have worsening of their ulcers. The ADON said the facility did not have any manufacturer's recommendations/user guide for any specialized mattresses/pumps but would immediately call to get some. R #1's undated Alternating Pressure Mattress User Manual provided by the DON on 07/12/17 revealed The patient comfort pressure ranges from soft (level 1) to firm (level 9). The comfort control displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set appropriate comfort pressure level depending on the patient weight . R #3: R #3's Face Sheet dated 07/12/17 documented an [AGE] year-old male initially admitted [DATE], discharged to the hospital on [DATE] and re-admitted [DATE] with the [DIAGNOSES REDACTED]. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/11/17 documented 14- moderate risk. R #3's Significant Change MDS dated [DATE] documented R #3: -had clear speech -usually made self understood and usually understood others -had a Brief Interview of Mental Status (BIMS) score of 5 (severely impaired) -required extensive assistance with one-two person physical assist for bed mobility, dressing, eating, toilet use, and personal hygiene. R #3 was totally dependent with two person physical assist for transfers -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 2 present upon admission/re-entry and two Stage 3 pressure ulcers present upon admission- 1.0 x 3.2 x 0.0 cm. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/27/17 documented 14- moderate risk. R #3's Care Plan revised 06/14/17 documented: -Stage 2 right heel .Interventions: Keep clean and dry; Treat sore per MD orders, notify if ineffective; Assess skin weekly; Monitor and Report to MD any signs and symptoms of infection; Monitor for pain; Vitamin c and Zinc supplements, see MD orders for details; Weekly wound care; Clinic evaluation (at local hospital) Wound Treatment Center on Thursdays. -(R #3) has actual impairment to skin integrity related to a Stage 3 to his left buttocks, updated 07/10/17 .Interventions: Avoid scratching and keep hands and body parts from excessive moisture .; Treatment per MD order; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. to MD., Weekly Wound Care Treatment Center on Thursdays. -Stage 3 to left heel .Interventions: Daily and weekly skin checks to heel; Monitor for pain; Notify MD and family of changes; Treatment per MD orders; Vitamin C and Zinc for supplements, see MD orders for details; Weekly wound care at Wound Treatment Center on Thursdays .Check frequently for bowel incontinence and provide peri-care after each episode .Provide pressure redistribution surface to bed, chair PRN (as needed) .Turn and reposition q 2 hours .I require extensive to total assistance with two person assistance for bed mobility, personal hygiene . -(R #3) has a Stage 3 to Sacrum .Interventions: Nutritional supplements as ordered; Assess skin weekly; Monitor and report any signs/symptoms of infection; Pain medication as ordered; Treat wound per MD orders; Turn and Reposition q 2 hours . R #3's physician's orders [REDACTED]. R #3's July 2017 Medication Review Report documented: -Stage 2 to right heel, cleanse with normal saline, pat dry with 4x4s, apply Calcium Alginate, cover with 4x4, wrap with kerl

Based on observation, interview, and record review the facility failed to ensure residents who entered the facility with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of new pressure ulcers for four residents (R #1, R #2, R #3, and R #5) of six residents reviewed for pressure ulcers. R #5: The facility failed to: -reposition R #5 every two hours as her plan of care indicated; -ensure R #5's left heel was properly offloaded; -provide effective offloading techniques. R #5 was admitted to the facility with a Stage 4 to her left heel and developed two Stage 2 facility acquired medical device related pressure ulcers. R #3: The facility failed to: -provide incontinent care when R #3's brief was wet; -correctly identify and document R #3's left heel pressure ulcer; -properly stage R #3's left heel ulcer; -correctly measure R #3's sacral ulcer; -correctly identify and document the location of R #3's right foot ulcer; -accurately stage R #3's facility acquired Right Ischial Tuberosity Stage 3 ulcer; -provide R #3 with treatment and dressing changes to all his pressure ulcers per the physician's orders [REDACTED].>-provide R #3 with heel offloading techniques, when in bed; -reposition/offload R #3's sacrum off the wheelchair for over two hours. R #3 was admitted to the facility with bilateral heel stage 3 pressure ulcers and further acquired a Right Ischial Tuberosity Stage 3 pressure ulcer. R #1: The facility failed to: -repositioned R #1 every hour as his plan of care indicated; -provide R #1 with heel protectors and offloading interventions on both feet instead of just the right foot; -ensure R #1 was relieved of pressure on his right lateral foot pressure ulcer; -assess, monitor, and ensure R #1's specialized low air loss mattress was set according to his current weight as per the manufacturer's recommendations. R #1 was admitted to the facility with a stage 4 pressure ulcer to his left lateral foot. R #2: The facility failed to: -provide treatment and dressing change to R #2's pressure ulcer per the physician's orders [REDACTED]. R #2 was admitted with a Left Trochanter Stage 4 pressure ulcer. The facility failed to initiate education for R #1, R #2, and R #5's specialized low air loss mattresses to include monitoring the mattress pressure for correct individualized firmness settings. These failures could place nine residents with pressure ulcers and 29 residents receiving preventive skin care at risk for developing new pressure ulcers or a decline in existing pressure ulcers. The findings included: R #5: R #5's Face Sheet dated 07/10/17 documented a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]. R #5's Admission Nursing assessment dated [DATE] documented Left Heel Stage 4 Pressure Ulcer- 8.3 x 7.0 x 0.0, 70% yellow slough, 20% red, 10% black to left heel . The assessment provided definitions of stages that included: -Suspected Deep Tissue Injury- Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage or underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. -Stage 1- Intact skin with non-blanchable redness of a localized area usually over a bony prominence . -Stage 2- Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. -Stage 3- Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle area are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. -Stage 4- Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. -Unstageable- Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. R #5's Braden Scale for Predicting Pressure Sore Risk dated 11/30/15 documented 13, moderate risk. R #5's Braden Scale for Predicting Pressure Sore Risk dated 01/25/17 documented 11, high risk. R #5's Annual Minimum Data Set ((MDS) dated [DATE] documented R #5: -had no speech -rarely/never made self understood and rarely/never understood others -had severely impaired cognitive skills for decision making -was totally dependent with one person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some of the wound bed. Often includes undermining and tunneling. 7.2 x 3.2 x 1.0 centimeters(cm). Was present upon admission. R #5's Braden Scale for Predicting Pressure Sore Risk dated 04/03/17 documented 9, very high risk. R #5's Care Plan revised 05/21/17 documented: -(R #5) has a [DIAGNOSES REDACTED].Interventions: Administer medications as ordered; Provide diet and supplements per MD (Medical Doctor) order . -Potential for skin breakdown related to impaired mobility due to hx (history) [MEDICAL CONDITION]([MEDICAL CONDITION]- stroke) Interventions: Total assist turn and reposition q (every) two hours by CNA (Certified Nurse Aide); CNA to notify nurse of any noted redness to skin; Licensed Nurse to perform complete head to toe assessment q week; Document and notify family and MD for any skin breakdown; Pressure relieving mattress; Nutritional supplements to assist in maintaining healthy skin integrity; Float heels with pillow or heel protectors . -(R #5) has Stage 4 to left heel related to vascular insufficiency .Interventions: Juven (supplement that supports growth and maintenance of muscle tissue) BID (twice a day) for supplement; Avoid exposure to temperature extremes .; Avoid mechanical trauma .;Ensure appropriate protective devices are applied to affected areas; Monitor pressure areas of color, sensation, temperature; Monitor/document wound: size, depth, margins, periwound skin, sinuses, undermining, exudates, [MEDICAL CONDITION], granulation, infection, necrosis, eschar, gangrene; Document progress in wound healing on an ongoing basis. Notify MD as indicated .Position resident off affected area. Change position every hour and PRN; Treat wound as per facility protocol . R #5's Weekly Pressure Ulcer Record dated 06/03/17 documented Bedridden, contracted, Left Heel Pressure Stage 4- 5.2 x 4.4 x 0.0. R #5's Skin Assessment Profile dated 07/04/17 documented Left Heel Stage 4- 4.1 x 3.3 x 0.0, serosanguineous drainage, red wound condition . R #5's Skin Assessment Profile dated 07/11/17 documented Left Heel Stage 4- 6.0 x 3.0 x 0.0, serosanguineous drainage, red wound condition . R #5's July 2017 Medication Review Report documented Stage 4 to left heel: Cleanse with normal saline, pat dry with 4x4's, apply [MEDICATION NAME] (collagen and oxidized regenerated cellulose), cover with [MEDICATION NAME], cover with gauze, wrap with kerlix, secure with tape every day every Monday, Wednesday, and Friday .Juven 1 packet via [DEVICE] BID supplement mix with 4-6 ounces of water Vitamin C 500 milligrams (mg) tid (three times a day) .Zinc 50 mg q day via [DEVICE] one time a day. R #5's Weekly Pressure Ulcer Record dated 07/10/17 documented: Date of Onset: 07/10/17. 1.) Site: Right Ear- Pressure 1.2 x 0.3 x 0.0 cm 2.) Site: Left ear- Pressure 0.5 x 0.3 x 0.0 cm Scant serous drainage, pink/beefy red wound bed, surrounding skin color pink, normal surrounding tissue .Preventive measures: turn every - hours, pressure relieving device, high protein supplement, multivitamin/zinc. There was no entry to indicate how often to reposition. R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind left ear- 1.2 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . R #5's Skin Assessment Profile dated 07/10/17 documented Date of initial onset: 07/10/17, Stage 2 Pressure Ulcer to behind right ear- 0.5 x 0.3 x 0.0 cm, Serous-thin, watery clear drainage, red wound condition . Observation of R #5 during initial tour on 07/10/17 at 2:57 p.m., accompanied by Registered Nurse (RN) A, revealed R #5 layed on her back with a pillow tucked behind her right torso. R #5's pelvis rested on the mattress and her bilateral feet were raised off the mattress by the use of Prevalon (heel protector). R #5 layed on an inflated overlay mattress which the mattress pump was set at the farthest firm position. R #5's eyes were closed and did not respond to verbal stimuli. R #5 was receiving oxygen via a nasal cannula, with the portion of the cannula that layed behind each ear was wrapped with gauze. RN A said R #5 was unable to communicate her needs and was dependent on staff for all adl's (activities of daily living). Observation of R #5 on 07/10/17 at 5:12 p.m. revealed R #5 remained laying on her back with a pillow tucked on the right side of her torso, still with her buttocks resting on the mattress. R #5's heel protectors were in position however, her left heel was not in the protector and rested on the mattress. Observation of R #5 on 07/10/17 at 5:36 p.m. revealed R #5 remained in the same position as at 2:57 p.m. This surveyor retrieved RN A. RN A said R #5 should have been repositioned every two hours. RN A observed R #5 and confirmed R #5 was in the same position as seen during initial wounds. RN A repositioned R #5's left foot correctly into the heel protector and confirmed R #5's left heel was resting on the bed yet, it should have been raised off the bed. RN A said the purpose of using pillows and repositioning every two hours was to relieve pressure off of the pressure points off the buttocks and sacrum. Upon the surveyor's request, RN A slid her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the mattress and were not offloaded. RN A said R #5's mattress felt firm and did not know anything about the mattress or what setting the mattress pump was appropriate for R #5. RN A approached Certified Nurse Aide (CNA) H and asked CNA H what time she repositioned R #5. CNA H responded About 2:15 p.m. I was going to go in there to change and turn her but I was waiting for the other CNA to finish bathing her resident then the dinner trays came out. RN A said relieving pressure by repositioning at least every two hours was important to prevent pressure ulcer development and/or deterioration of existing ulcers. R #5's Telephone physician's orders [REDACTED]. Observation of R #5 on 07/11/17 at 8:21 a.m. revealed R #5 had a pillow behind her right upper back and her torso was slightly tilted toward her left side and another pillow under her left arm. R #5's pelvis remained in straight alignment with her buttocks resting on the mattress. R #5 had heel protectors in place. Observation of R #5 on 07/11/17 at 11:22 a.m. revealed R #5 layed in the same position as seen at 8:21 a.m. LVN B entered the room and began performing wound care on R #5. LVN B said R #5 was admitted to the facility with a Stage 4 pressure ulcer to her left heel that measured 8.3 x 7.0 x 0.0 centimeters. LVN B said the last measurement was on 07/04/17 and it measured 4.1 x 3.3 x 0.0 cm. LVN B removed R #5's old dressing which presented with old dried brown, red, and light yellow drainage. LVN B stated It has hypergranulation red tissue with macerated (softening and breaking down of skin resulting from prolonged exposure to moisture) tissue surrounding the wound. The wound bed is dark brown/black. There is purple tissue injury at 12 o'clock - 3 o'clock. It measures 6.0 x 3.0 x 0.0. Upon the surveyor's request, LVN B tucked her right hand between R #5's buttocks and mattress and confirmed R #5's buttocks rested on the bed. LVN B said the pillow behind R #5's right back was there in attempt to relieve pressure off of R #5's right buttocks and sacrum. LVN B agreed the offloading attempt was ineffective. LVN B preceded to adjust R #5's oxygen tubing away from behind her ears. R #5 had small superficial red open area behind each ear. LVN B measured the ulcers on each ear and said The right ear is 1.2 x 0.3 x 0.0 cm and the left ear is 0.5 x 0.3 x 0.0 cm. LVN B confirmed R #5 received her ulcers behind her ears from the oxygen tubing applying pressure to the site. Interview with CNAs J and K on 07/11/17 at 11:55 a.m. revealed they stated they last repositioned R #5 at approximately 9:15 a.m. CNA K said R #5 was laying on her back before she placed a pillow behind R #5's right back. CNA K was asked if placing one pillow on the upper back would effectively offload R #5's buttocks off the bed; CNA K hesitated then said I'm not sure. CNAs J and K entered R #5's room and provided R #5 with incontinent care. Once R #5 was toward her right side, there were multiple indented, red lines all along R #5's left hip and thigh. Interview with the Assistant DON (ADON) on 07/11/17 at 5:21 p.m. revealed she said the facility did not apply or maintain any of the hospice air mattresses. The ADON said Hospice sets up the mattresses and do not give us any instructions for them. If there is a problem we just call hospice and they come out to check them. The surveyor accompanied the ADON into R #5's room and asked the ADON to feel the air mattress. The ADON said, It's pretty firm. We don't know what is the appropriate setting for her because the settings options only include firm and soft. Hers is set all the way to the firmest position. R #1: R #1's Face Sheet dated 07/10/17 documented an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Gastrostomy Status, and Hypertension. R #1's Annual/Re-Admission MDS dated [DATE] documented R #1: -had clear speech -sometimes made self understood and sometimes understood others -had severely impaired cognitive skills for decision making -was totally dependent with one-two person physical assist for bed mobility, transfers, dressing, eating, toilet use, personal hygiene -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 4 pressure ulcer present upon admission- 9.5 x 6.5 x 1.0 cm. R #1's Skin Assessment Profile dated 05/06/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 6.5 x 1.1 cm, serosanguineous drainage, 20% yellow, 80% red, periwound purple . R #1's Skin Assessment Profile dated 05/20/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 9.5 x 5.0 x 0.5 cm, purulent, tan, opaque drainage, 75% eschar (slough or piece of black dead tissue), 25% red . R #1's Care Plan dated 05/21/17 documented: Wound treatment: Stage 4 to right foot upper lateral aspect .Interventions: Assess skin weekly; Dietary consult and recommendations for nutritional supplement; Float heels with heel protectors or pillow; Monitor and report to MD any signs and symptoms of pain prior to treatment; Treat wound per MD orders; turn and reposition q hourly; Nutritional supplement per MD order .I require total assist with all ADLs (activities of daily living) . R #1's July 2017 Medication Review Report documented Stage 4 to right foot upper lateral aspect: cleanse, pat dry with 4x4's, apply Santyl (an enzymatic [MEDICATION NAME] ointment) to none viable area, apply [MEDICATION NAME] (antibiotic) to viable area, cover with gauze, wrap with kerlix, wrap with coban or elastic wrap, and secure with tape every day on non-hospice days- every Tuesdays, Thursdays, Saturday, Sundays .Vitamin C 500 mg via [DEVICE] daily. Zinc 50 mg via [DEVICE] q hs (bedtime) for wound healing. Juven 1 packet via [DEVICE] two times a day for wound healing mixed with 120 ml of water. R #1's Skin Assessment Profile dated 07/04/17 documented Date of Initial Onset: 05/06/17, Stage 4 Pressure Ulcer to Right Lateral Foot- 6.5 x 1.5 x 0.1 cm, serosanguineous drainage, 5% yellow, 95% red . Observation of R #1 on 07/10/17 at 3:05 p.m., during initial rounds, accompanied by RN A, revealed R #1 layed on a Low Air Loss Alternating Mattress with the pump set at 9 (350 pounds). R #1 layed on his back with his buttocks resting on the mattress and his legs were folded and positioned on his right side, with his left leg over the right leg. R #1 was alert and verbal however, speech was unclear. R #1 did not appropriately answer any questions. R #1 had bilateral upper and lower extremity contractures. R #1 had a Prevalon boot on his right foot but not the left foot. Observation of R #1 on 07/10/17 at 5:18 p.m. revealed R #1 remained in the same position as last seen at 3:05 p.m. Observation of R #1 on 07/10/17 at 5:36 p.m. revealed R #1 remained in the same position. The surveyor retrieved RN A into R #1's room; RN A said R #1 should be repositioned at least every two hours. CNA H entered R #1's room and said she last repositioned R #1 at approximately 2:30 p.m. CNA H said she had not repositioned R #1 because she was waiting for the other CNA to finish showering another resident and then dinner trays arrived and assisted other residents to eat. RN A informed the surveyor of R #1 having a Stage 4 pressure ulcer on his outer lateral aspect of his right foot. RN A removed R #1's covers and informed the surveyor that R #1's legs remain folded at all times due to contractures. RN A agreed R #1's current position was causing pressure directly on his coccyx and his right foot Stage 4 pressure ulcer. RN A said Pressure should be kept off his right foot as much as possible. RN A stated she did not know why R #1 only had one prevalon boot then stated Maybe because he only has an ulcer on the right foot. RN A stated out loud that the pump setting was set at 9 then said she did not know anything about R #1's air mattress other than the mattress came from hospice and hospice set up the mattress. RN A said if something happened to the mattress then she would call hospice to check it. RN A said the hospice nurse visited R #1 every week. RN A stated R #1 having direct pressure on his right foot pressure ulcer and not being repositioned every two hours could cause his pressure ulcer to worsen and not heal. Observation on 07/11/17 at 8:23 a.m. revealed R #1 layed on his back with his head of bed elevated. R #1 had a pillow on each side of his hips with his left leg over the right leg with both raised and folded on his right side. R #1 had a Prevalon boot on his right foot only. Observation of R #1 on 07/11/17 at 10:37 a.m. revealed R #1 layed in the same position as seen at 8:23 a.m. On 06/11/17 at 12:11 a.m., the surveyor accompanied LVN B into R #1's room. R #1 layed in the same position as seen at 8:23 a.m. and 10:37 a.m. LVN B was informed of R #1 being observed in the same position since 8:23 a.m. LVN B said she would ensure R #1 was repositioned after she performed wound care. LVN B confirmed R #1's current position was putting pressure on his right lateral foot pressure ulcer. LVN B said R #1's positioning should be kept off his right lateral foot. LVN B preceded to remove R #1's right foot dressing that had dry brown/red drainage. R #1's right outer lateral foot was approximately the length of the surveyor's index finger and the width greater than one millimeter. The ulcer was open with a red wound bed and slowly seeped serosanguineous drainage. After LVN B cleansed R #1 ulcer, the ulcer began to bleed heavily, dripping blood onto the bed. LVN B measured R #1's ulcer and said 5.3 X 2.2 X 0.1 cm. LVN B re-dressed R #1's right foot then repositioned him to his left side with the assistance of CNA L. LVN B instructed CNA L to ensure R #1 was repositioned every two hours and to refrain from putting pressure on R #1's right lateral foot. LVN B asked CNA L to look for R #1's left foot Prevalon boot. CNA L looked throughout R #1's room and informed LVN B he could not find a Prevalon boot. LVN B instructed CNA L that R #1 needed a heel protector to prevent development of a pressure ulcer on his left foot and instructed CNA L to go find a heel protector for R #1's left foot. A few minutes later, CNA L returned to R #1's room with a cloth heel protector and placed it on R #1's left foot. LVN B confirmed R #1's air mattress pump was set at 9. The surveyor asked LVN B what the number 9 meant and LVN B said she did not know. The surveyor asked LVN B to read the numbers above the number 9 and LVN B said 350 pounds. LVN B confirmed R #1 was not 350 pounds. LVN B said she did not know anything about the air mattress because the mattress belonged to hospice and hospice set up and maintained the mattress. LVN B checked R #1's most current weight via the computer and said (R #1) weighs 165.0 pounds. Review of R #1's 2017 Monthly Weight Record revealed R #1's weight on 07/10/17 was 165.0 pounds. Interview with the ADON on 07/11/17 at 5:22 p.m. revealed she pressed down on R #1's mattress and said It's kind of hard, it is set at 9- 350 pounds. He is not 350 pounds. The ADON adjusted the setting on the pump to a 4 (175 pounds). The ADON said If the mattress is too hard or even too soft, the resident could develop pressure ulcers or have worsening of their ulcers. The ADON said the facility did not have any manufacturer's recommendations/user guide for any specialized mattresses/pumps but would immediately call to get some. R #1's undated Alternating Pressure Mattress User Manual provided by the DON on 07/12/17 revealed The patient comfort pressure ranges from soft (level 1) to firm (level 9). The comfort control displays the patient comfort pressure levels from 0-9 and provides a guide to the caregiver to set appropriate comfort pressure level depending on the patient weight . R #3: R #3's Face Sheet dated 07/12/17 documented an [AGE] year-old male initially admitted [DATE], discharged to the hospital on [DATE] and re-admitted [DATE] with the [DIAGNOSES REDACTED]. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/11/17 documented 14- moderate risk. R #3's Significant Change MDS dated [DATE] documented R #3: -had clear speech -usually made self understood and usually understood others -had a Brief Interview of Mental Status (BIMS) score of 5 (severely impaired) -required extensive assistance with one-two person physical assist for bed mobility, dressing, eating, toilet use, and personal hygiene. R #3 was totally dependent with two person physical assist for transfers -was always incontinent of bladder and bowel -was at risk for developing pressure ulcers -had one unhealed Stage 2 present upon admission/re-entry and two Stage 3 pressure ulcers present upon admission- 1.0 x 3.2 x 0.0 cm. R #3's Braden Scale for Predicting Pressure Sore Risk dated 05/27/17 documented 14- moderate risk. R #3's Care Plan revised 06/14/17 documented: -Stage 2 right heel .Interventions: Keep clean and dry; Treat sore per MD orders, notify if ineffective; Assess skin weekly; Monitor and Report to MD any signs and symptoms of infection; Monitor for pain; Vitamin c and Zinc supplements, see MD orders for details; Weekly wound care; Clinic evaluation (at local hospital) Wound Treatment Center on Thursdays. -(R #3) has actual impairment to skin integrity related to a Stage 3 to his left buttocks, updated 07/10/17 .Interventions: Avoid scratching and keep hands and body parts from excessive moisture .; Treatment per MD order; Encourage good nutrition and hydration in order to promote healthier skin; Follow facility protocols for treatment of [REDACTED]. to MD., Weekly Wound Care Treatment Center on Thursdays. -Stage 3 to left heel .Interventions: Daily and weekly skin checks to heel; Monitor for pain; Notify MD and family of changes; Treatment per MD orders; Vitamin C and Zinc for supplements, see MD orders for details; Weekly wound care at Wound Treatment Center on Thursdays .Check frequently for bowel incontinence and provide peri-care after each episode .Provide pressure redistribution surface to bed, chair PRN (as needed) .Turn and reposition q 2 hours .I require extensive to total assistance with two person assistance for bed mobility, personal hygiene . -(R #3) has a Stage 3 to Sacrum .Interventions: Nutritional supplements as ordered; Assess skin weekly; Monitor and report any signs/symptoms of infection; Pain medication as ordered; Treat wound per MD orders; Turn and Reposition q 2 hours . R #3's physician's orders [REDACTED]. R #3's July 2017 Medication Review Report documented: -Stage 2 to right heel, cleanse with normal saline, pat dry with 4x4s, apply Calcium Alginate, cover with 4x4, wrap with kerlix, wrap with elastic bandage, secure with tape every day every Monday, Wednesday, Friday . -Stage 3 to left buttocks: cleanse with normal saline, pat dry with 4x4, apply Santyl and cover with Allevyen (bacterial barrier dressing for exudate management) every shift every other day . -Stage 3 left heel: cleanse with wound cleanser, pat dry with 4x4, apply Santyl, cover with 4x4, wrap types of wounds kerlix, wrap with elastic bandage, secure with tape every Monday, Wednesday, Friday . -Stage 3 to Sacrum: cleanse with normal saline, pat dry with 4x4 gauze, apply Santyl to non-viable tissue. Apply hydrogel (ointment used for dry or slightly moist that creates a moist healing environment) to viable tissue, and cover with Allevyn every Monday, Wednesday, Friday . -Multivitamin give one tablet by mouth one time a day for supplement .Vitamin C 500 mg by mouth one time a day for wound healing .Zinc tablet 50 mg, give one tablet by mouth one time a day for wound healing . R #3's July 2017 Treatment Administration Record (TAR) revealed R #3's Right heel Stage 2, Left heel Stage 3, and Sacral Stage 3 pressure ulcers did not obtain a licensed nurse's initial to indicate treatment was performed on Monday, 07/10/17. Observation of R #3 on 07/11/17 at 8:30 a.m. revealed R #3 sat in a Geriatric-chair. Upon LVN B's request, CNAs J and L transferred R #3 from his chair to his bed. The CNAs removed R #3's pants exposing his yellow brief. The two wet indicators revealed the two lines were blue, indicating the brief was wet. The center of the brief appeared mushy. R #3 was not provided with incontinent care at this time. Interview with LVN B on 07/11/17 at 8:48 a.m. revealed she stated R #3 was admitted on [DATE] with a coccyx and left heel Stage 3 pressure ulcers. LVN B said R #3 was re-admitted on [DATE] with a right heel Stage 2 pressure ulcer from the hospital. LVN B said R #3 had an appropriate mattress for pressure ulcers, was to be repositioned and changed, if needed, every two hours, and should have heels off-loaded at all times when in bed. LVN B said R #3 did not have a specialty air mattress but he had a Panacea mattress which was appropriate for all kinds of pressure ulcers. R #3's Left Heel: R #3's Skin Assessment Profile dated 12/09/16 documented Date of initial onset: 12/09/16- Left Heel Deep Tissue Injury- 2.0 x 2.7 x 0.0 cm, red wound condition . R #3's Skin Assessment Profile dated 01/16/17 documented Date of initial onset: 12/09/16- Deep Tissue Injury- 1.0 x 0.7 x 0.0 cm, black wound condition . *The wound condition had changed from red to black by this time however, the wound continued to be identified as Deep Tissue Injury instead of Unstageable. R #3's Skin Assessment Profile dated 01/20/17 documented Date of initial onset: 12/09/16- Deep Tissue Injury- 1.0 x 1.6 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 02/01/17 documented Date of initial onset: 12/09/16- Stage 3- 1.3 x 1.5 x 0.0 cm, red wound condition . This wound was described to have black wound condition prior to this date. R #3's Skin Assessment Profile dated 02/08/17 documented Date of initial onset: 12/09/16- Stage 3- 1.8 x 1.7 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 02/22/17 documented Date of initial onset: 12/09/16- Stage 3- 3.4 x 3.6 x 0.0 cm, black wound condition . R #3's Skin Assessment Profile dated 03/01/17 documented Date of initial onset: 12/09/16- Stage 3- 3.5 x 2.0 x 0.0 cm, yellow wound condition, serosanguineous drainage . R #3's Skin Assessment Profile dated 03/18/17 documented Date of initial onset: 12/09/16- Stage 3- 3.0 x 2.6 x 0.0 cm, beefy red and yellow wound condition . R #3's Skin Assessment Profile dated 03/31/17 documented Date of initial onset: 12/09/16- Stage 3- 2.4 x 2.3 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/07/17 documented Date of initial onset: 12/09/16- Stage 3- 2.3 x 2.9 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/21/17 documented Date of initial onset: 12/09/16- Stage 3- 2.3 x 2.6 x 0.0 cm, red, yellow wound condition . R #3's Skin Assessment Profile dated 04/28/17 documented Date of initial onset: 12/09/16- Stage 3- 1.9 x 3.8 x 0.0 cm, red, yellow wound condition . R #3's Admission Weekly Pressure Ulcer Record dated 05/04/17 documented Date of Onset: 12/09/16- Right Heel Pressure ulcer 2.0 x 2.7 x 0.0 cm, Suspected Deep Tissue Injury, red, yellow wound bed . The site was incorrectly documented on this assessment. The site should have been Left Heel. Interview with the DON on 07/13/17 at 8:42 a.m. revealed she reviewed R #3's documentation and verified the site documented on the Admission Weekly Pressure Ulcer Record was incorrect, It should have been the Left Heel, not the Right. The nurse should have staged it at an Unstageable or a Stage 3, not a DTI, due to the black tissue and then yellow slough present in the wound. This could affect the resident's care and could lead up to deterioration of the wound if not cared for correctly. R #3's Skin Assessment Profile dated 05/05/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 1.6 x 3.5 x 0.3 cm, 90% red, 10% yellow . R #3's Skin Assessment Profile dated 05/26/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 2.0 x 4.0 x 0.2 cm, 95% red, 5% yellow . R #3's Skin Assessment Profile dated 06/09/17 documented Date of initial onset: 12/09/16- Left Heel Stage 3- 4.0 x 2.5 x 0.2 cm, serous-thin, watery clear drainage, 95% red, 5% yellow, red/pink wound condition . R #3's Skin Assessment Profile dated 06/22/17 documented Date of initial onset: 12/09/16- Left Heel St

Based on observation, record review, and interview, the facility failed to assure assessments accurately reflected the resident's status, for one Resident (R#1) of 12 residents whose assessments were reviewed. R#1's Minimum Data Set (MDS) assessment was coded to indicate R#1 had no contractures/range of motion impairment to the upper or lower extremities. R#1's care plan indicated R#4 had contractures/range of motion impairment to the upper and lower extremities. This failure could place all eight residents with contractures at risk for not receiving necessary care and services. The findings included: R #1's Face Sheet dated 07/10/17 documented an [AGE] year-old male initially admitted on [DATE] and re-admitted on [DATE] with the [DIAGNOSES REDACTED]., Gastrostomy Status, and Hypertension. R #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented R #1: -had severely impaired cognitive skills for decision making -had no range of motion impairment to upper or lower extremities R #1's Quarterly MDS dated [DATE] documented R #1: -had severely impaired cognitive skills for decision making -had no range of motion impairment to upper or lower extremities R #1's Annual/Re-Admission MDS dated [DATE] documented R #1: -had severely impaired cognitive skills for decision making -had no range of motion impairment to upper or lower extremities R #1's Care Plan dated 05/21/17 documented: (R #1) has contractures to bilateral lower extremities due to impaired mobility .Interventions: Positioning devices as needed for proper body alignment; turn and reposition every two hours, apply pillows to avoid further contractures. Observation of R #1 on 06/10/17 at 3:05 p.m., during initial rounds, accompanied by Registered Nurse (RN) A revealed R #1 layed in bed on his back. R #1's legs were oddly positioned with his left leg bent forward and his right leg bent toward the right side. RN A stated R #1 had contractures to his lower extremities and decreased range of motion to his upper extremities. An interview was attempted with R #1 however, R #1 did not respond appropriately. RN A said R #1 was not interviewable. Interview with RN G on 07/12/17 at 10:55 a.m. revealed she identified herself as the MDS Coordinator. RN G reviewed R #1's last three MDS's and confirmed each MDS was incorrect due to R #1 definitely has contractures and decreased range of motion. RN G stated she would immediately fix the assessments. RN G said an accurate assessments was important in order to provide the best and most appropriate care to the resident, as possible. The facility's undated Resident Assessment Instrument (RAI) Process revealed: Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes The RAI process require that: 1. The assessment accurately reflects the resident's status . The facility's Centers for Medicare and Medicaid Services Form 672 dated 07/10/17 identified eight residents with contractures.

Based on record review and interview, the facility failed to develop a care plan to maintain the residents medical and nursing services for one resident (R#3) of 7 residents reviewed for care plans. The facility failed to maintain accurate care plans. This facility's could affect nine residents with pressure ulcers and 29 residents receiving preventive skin care at risk by not attaining or maintaining the resident's medical and nursing services. The findings: R #3's Face Sheet dated 07/12/17 documented an [AGE] year-old male initially admitted [DATE], discharged to the hospital on [DATE] and re-admitted [DATE] with the [DIAGNOSES REDACTED]. Review of R#3's Care Plan dated 07/11/17 revealed: - R #3 had a wound treatment Stage III to left heel. Interventions: stage 3 to left heel, cleanse with NS, pat dry with 4 X 4, apply Santyl to non viable tissue, apply hydrogel to viable tissue, cover with 4 X 4, wrap with kerlix, wrap with elastic bandage, secure with tape. Weekly wound care Clinic evaluation at hospital on Thursdays. - Stage II to right heel, Interventions: Cleanse with NS, pat dry with 4 X 4's , apply calcium alginate, cover with 4 X 4 wrap with Kerlix, wrap with elastic bandage, secure with tape per shift. Weekly wound care Clinic evaluation at hospital on Thursdays. Further review did not reveal any interventions for R#3 to wear heel protectors while in bed. During an interview on 07/12/17 at 9:20 a.m. the Director of Nurses (DON) reviewed R#3's Care Plan and confirmed it did not have any interventions for R#3's heel protectors to be worn while R#3 was in bed. The DON further stated if a resident was unable to move freely, independently and/or have ulcers in the lower extremity, they would automatically apply heel protectors and it should be in the resident's care plan. During an interview on 07/12/17 at 10:32 a.m. Registered Nurse (RN) G stated she completed the Care Plans. RN G was asked if R #3's heel protectors had been addressed in his Care Plan. RN G reviewed R#3's Care Plan dated 07/11/17 and stated it did not, and further stated she probably forgot to add it. RN G stated the Care Plan should include R#3's heel protectors and she would update R#3's Care Plan to include them. The facility's Medicare and Medicaid Services Form 672 dated 07/10/17 identified nine residents with pressure ulcers and 29 residents receiving preventive skin care.

Based on interview and record review the facility failed to immediately consult with the resident's physician and notify the resident's family member when there was an accident involving the resident which results in injury and has the potential of requiring physician intervention and when there was a significant change in the resident's physical condition for one Resident (R#1) of three residents reviewed for a change in condition. R#1's Physician was not consulted and the Responsible Party (RP) was not notified when R#1 experienced a fall on 08/07/13. There was no evidence of another fall or injury between 08/07/13 and 08/14/13. On 8/15/13 Resident # 1 was diagnosed with [REDACTED]. Resident # 1's physician was not consulted u ntil after Resident 1's hospitalization on [DATE]. This failure affected one resident who required a two person transfer/lift including transfer by mechanial lift and had the potential to place eight residents who required assistance for transfers at risk of not receiving the prompt treatment and medication which could result in a decline in their medical condition or death. The findings included: R#1's Admission Record dated 03/19/13 indicated R#1 was originally admitted to facility on 12/21/10 and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R#1 was totally dependent and required two person assistance for transfers. R#1's cognition was moderately impaired - decisions poor; cues/supervision required. R#1 usually understood and usually understands others. R#1 was unable to answer if she had pain or hurting at any time. R#1's Care Plan Conference Summary dated 07/30/13, revealed "Adjusted well to nursing home placement, (family members) visit daily..... No signs of skin breakdown. Requires total assist X 2 CNAs (Certified Nurse Aides) for all ADLs (Activities of Daily Living (transfers from bed to wheelchair, grooming, hygiene)). Sits up in Geri chair (a wheelchair that cannot be self propelled and reclines) at times." R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. . Nurses' Notes dated 08/13/13 indicated R#1 was showered and shower aides noticed R#1's altered mental status and body was lethargic while in the Geri chair. Facility called physician, responsible party and 911. R#1 was transferred to ER at 8 a.m. and readmitted to facility at 1:30 p.m. R#1 did not complain of pain or discomfort. On 08/14/13 at 9 a.m. the Nurses' Notes indicated R#1 was administered medications and was in no acute distress. The facility's investigation packet for incident of 08/07/13, included a witness statement dated 08/15/13 by CNA "D" indicated, "I came in to work (08/07/13)15 min (minutes) before 10 p.m. I was called to go to (R#1's) Room so I went running to her room. When I walked in (R#1) was on her knees on the floor. (CNAs "A", "B", and "C") were in the room already with (R#1). They were going to to get (R#1's) weight. (CNA "A") said they were gonna transfer (R#1) by hand, (CNA "A") and (CNA "B") but (R#1) was too heavy so they just sat her on the floor gently that she did not fall down. So I helped them transfer her from floor to bed. Went to do the ten o clock me and (CNA "E") I saw it looked swollen. So I reported it (LVN "B") she came and checked it out. (LVN "B") didn't see anything wrong because (R#1) was not complaining. So Wed (Wednesday) August 14 me and (CNA "E") were doing rounds again. We took off her sheets and saw her right leg was inward a lot, so we called our (LVN "B") she came to look at it. So she sent (R#1) out." The facility's investigation packet included a witness statement dated 08/15/13 by CNA "E" indicated "A week ago from today on 8-8-13 3 CNA's from 2-10 shift were trying to transfer a resident (R#1) from her bed to a shower chair to weigh her. The 3 CNA's (CNA "B", "A" and "C") were not able to transfer resident they then ask for help, (CNA "D", LVN "B", and LVN "A") and myself walked in to help. The 3 CNA's claim to have placed (R#1) (resident) on the floor because she was too heavy to transfer. (CNAs "D", "A", and "B") and I picked (R#1) up from the floor and transfered back to her bed. As (CNA "D") and I checked (R#1) for any skin tears, bruises, extc.(sic) we did notice some swelling to right knee we did report to our nurse, (LVN "B") and (LVN "A") as well. (LVN "B") did look at her knee and claimed that nothing was wrong. As the days went by (CNA "D") and I have reported that (R#1) was in pain and her knee did not look good. Now I do not know if the nurse wrote it down or not. Last night on 8-15-13 (CNA "D") and I were doing our 12:00 a.m. round as we walked into (R#1's) room we then removed the blanket and notice her leg twisted we did not touch her we immediately called our Charge Nurse (LVN "B.) (LVN "B") checked her out and agreed with (CNA "D") and I that her knee did not look good and you could see that the resident was in a lot of pain with her facial expressions. Right after (LVN "B") calls EMT'S to send (R#1) out." On 09/03/13 at 12:55 a.m. CNA "D" stated on 08/0713 she arrived for her 10:00 p.m. shift. Prior to start of her shift she heard a call for help and went down the hall. She observed R#1 on her knees. CNA "D" stated she did not report the incident to anyone because both the LVN from the 6 p.m. to 10 p.m. shift and the charge nurse from the 10 p.m. to 6 a.m. shift had been in the room and she "assumed they had taken care of it."CNA " D " stated on 08/07/13 she noticed (R #1 made facial expressions, like hurting, when she was turned and changed. CNA " D " told her charge nurse (LVA " A " ), who then checked {R # 1). As the days went by CNA " D " continued to notice (R #1) making faces, and her right leg looked swollen, it was bigger than the other leg. CNA " D " said (LVN " A " ) would assess and say something like she didn ' t see nothing wrong with her (R #1) did not see any distress. I know I reported concern to my charge nurse (LVN " A " ) at least 4 times. On 09/04/13 at 1:40 a.m. CNA " E " was interviewed, CNA " E " stated on 08/07/13 she had just arrived for her 10 p.m. shift when she heard her charge nurse (LVN " A " ) call for her. She stated she went down the hall and found R3 1 on her knees on the floor. The CNA ' s from the 2-10 shift were trying to transfer a resident (R #1) from her bed to a shower chair to weigh her. The 3 CNA ' s (CNA " B " . " A " , and " C " ) were not able to transfer resident, they then called for help. The 3 CNA ' s claim to have placed (R #1) resident on the floor because she was too heavy to transfer. (CNA ' s " D " , " A " and " B " ) and I picked up (R #1) for any skin tears, bruises, extc, (sic) we did notice some swelling to right knee we did report to our nurse (LVN " A " ) and (LVN " B " ) as well. We (CNA " E " and " D " reported to our nurse (LVN " A " ) that (R #1} said " OW " , (LVN " A " ) said she always makes noises. I told the nurse about my concerns at least 4 times. She looked at (R #1) and she looked fine, she told us no one else reports it just us (CNA " E " and CNA " D " ). After about one week, when (CNA " D " ) and myself turned back the sheets for (R #1} we observed her right leg was twisted. We reported it to our charge nurse (LVN " A " ) and she sent her out to the hospital. During an interview on 09/05/13 at 4:15 p.m., LVN "A" indicated R#1 was a two person assist and was unable to stand; therefore, they were required to use a mechanical lift to transfer R#1. LVN "A" stated she was present in the building on 08/07/13 at approximately 9:50 p.m. when she heard someone call for help. She went to assist and found R#1 on the floor on her knees. Three CNAs had attempted to transfer her from her bed to a shower chair, and were unable to complete the transfer. LVN "B" who had been the Charge Nurse for the 2:00 p.m. to 10:00 p.m. shift was already in R#1's room. LVN "A" stated she did not make any documentation regarding the incident until 08/15/13 when the DON interviewed her and R#1 had been sent to the hospital. LVN "A" stated she did not investigate or interview any staff regarding this incident on 08/07/13. LVN "A" said she did not contact the Physician or the Responsible Party. LVN "A" stated she did not know why the CNAs were not using the Hoyer lift (a mechanical lift). LVN "A" stated she could not say why she did not report the incident. LVN "A" stated she believed the 2:00 p.m. to 10:00 p.m. LVN (LVN "B") should have documented the incident as it had occurred on her shift, and should have contacted the Physician and Responsible Party (RP). During this same interview with LVN "A" she indicated it was not a normal practice to transfer a resident at 10:00 p.m. to be weighed but LVN "B" had assigned this task to be completed by the CNAs during their 2:00 p.m. to 10:00 p.m. shift. The CNAs were redirected to do so before leaving for the night and they took a short cut to get it done quickly. LVN "A" said weighing R#1 could have waited until the next day. LVN "A" stated she had assessed R#1 on 08/07/13 before she was lifted back to bed. During this interview she provided a drawing of the events and stated she was outside R#1's room and called for help. She could not explain how she assessed R#1 from outside the room. In an interview on 09/26/13 at 10:50 a.m., LVN "B" stated she was at the nurse ' s station on 08/07/13 at approximately 9:50 p.m. , when she heard CNAs yell for help. She went to R#1's room where she observed three CNAs (CNA "A", "B", and "C") in the room with R#1 on the floor on one knee. She stated the CNAs had attempted a two person transfer, from the bed to the shower chair. She stated the CNAs told her while transferring R#1 they realized the resident was too heavy and let her to the ground. She stated no mechanical lift was observed in the room. LVN "B" stated she asked the CNAs why no mechanical lift was used, they replied "we thought we could lift her." LVN "B" stated "the CNAs knew R#1 was a Hoyer lift. At this facility we are told if a patient is heavier than you, you should use a (mechanical lift)." One of the CNAs was very small, she questioned them again and the CNAs said they thought they could lift her. On 09/04/13 at 5:00 p.m. interview with CNA "A" revealed on 08/07/13 during her shift, at approximately 9:50 p.m. she and another CNA had atttempted to transfer R#1 from her bed to a shower chair for the purpose of obtaining a weight. CNA "A" stated R#1 was like dead weight, we didn't realize it until it was too late. CNA "A" said, she didn't fall, her legs, I can't explain, she was lowered to the floor. She had her right side of the hip and thigh on the floor, she had her knees bent, her knees went to the ground. I didn't think I had to report because my charge nurse (LVN " B " )was present. During an interview on 09/04/13 at 5:30 p.m., CNA "C" stated she did not utilize the gait belt when tranferring R#1 on 08/07/13 but she had the gait belt around her waist. In an interview on 09/05/13 at 5:50 p.m. with CNA "C" she stated on 08/07/13 she was in the room of R#1 with two other CNAs. She was holding the shower chair, and two other CNAs were trying to transfer R#1 from her bed to the shower chair. It was just prior to shift change. CNA "C" stated "I don't know what happened to her (R#1) that night we could usually do her." "I left her room, clocked out and left the building." CNA "C" stated she did not believe she had to report because her charge nurse (LVN " " B " ) was present and she believed she would report. She did not report until, 08/15/13 when the DON was conducting an investigation and asked her for a statement. CNA "C" stated "we held her, we did not let her go, she did not fall." LVN "A" documented on 08/15/13 at 1:20 a.m. "(CNAs "D" and "E") called me into (R#1's) room because her right knee was swollen. (R#1) complained of pain with touch. Physician called at 1:35 a.m. whom advised to send out to ER for X-Ray. Responsible Party called at 1:37 a.m. to notify. 911 called at 1:45 a.m. Two EMTs (Emergency Medical Technicians) in facility transferring Resident at 1:57 a.m." Director of Nurses (DON) documented on R#1's Nurses' Notes, dated 08/15/13, she was notified at 8:30 a.m. that R#1 was sent to the emergency room (ER) at approximately 2:00 a.m. for swollen right knee. The DON notified R#1's physician. She was informed by hospital staff R#1 would be admitted with right femur fracture. The DON notified R#1's Responsible Party (RP). The DON also notified R#1's RP that during her investigation she had learned of an incident that occurred on Thursday, 08/08/13. The DON explained her charge nurses said that on 08/08/13 the charge nurse for the 2:00 p.m. to 10:00 p.m. shift asked two CNAs to get a weight on R#1. The transfer was not completed and they eased resident to floor on her knees. Nurses checked R#1 and noted redness to knees before they assisted CNAs in putting R#1 back to bed. During an interview on 09/04/13 at 10:30 p.m., the DON stated upon arrival at the facility on 08/15/13 she was told R#1 had been sent to the nearest hospital. She was informed by hospital staff R#1 was admitted due to fractures. The DON stated she began the investigation. While interviewing staff she discovered R#1 had previously been involved in an incident on 08/07/13 or 08/08/13. The DON stated she found: - staff had not used a mechanical lift (Hoyer), - the incident had not been documented anywhere, - the physician had not been notified, and - the responsible party was not notified. During an interview with Physician " A " on 09/04/13 at 6:45 p.m., he stated he was not notified of (R #1) incurring a incident/fall until the Don called him after (R #1) was hosptalized on [DATE]. R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. Radiology Report dated 08/15/13 of R#1's right femur indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphyseal region is identified. The distal fragment is displaced slightly posteriorly. The tibia (shin bone) follows the distal fragment. A vertically oriented fracture through the patella (knee-cap) is also noted." According to www.britanica.com on 10/04/13 comminuted means, the broken ends of the bone are jammed together by the force of the injury. Radiology Report dated 08/15/13 of R#1's right knee indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphysis is identified with anterior apex angulation.....A fracture through the posterior aspect of the patella is also identified. R#1's Hospital Discharge Record dictated by Physician "B" on 08/18/13 at 1:54 p.m. revealed: Admitting Diagnoses: [REDACTED]. Right Patellar fracture Dehydration [MEDICAL CONDITION] (increased sodium level) Acute [MEDICAL CONDITION] Urinary Tract Infection Chronic bedridden state Discharge Diagnoses: [REDACTED]. Right patellar fracture Dehydration [MEDICAL CONDITION], resolved Acute [MEDICAL CONDITION], resolved Chronic bedridden state Urinary tract infection "Hospital Course" "A [AGE] year old female from (facility) comes in after sustaining a right distal femur fracture and right patellar fracture, unknown etiology. However, this injury can only occur in a fall in a patient who is chronically bedridden and cannot ambulate. Nonetheless, the patient was brought here and was evaluated by Orthopedics. After a lengthy discussion with the family, it was concluded the patient would be a high surgical risk candidate because of her advanced age. As a result, the decision was made to not surgically repair the fracture. The patient was placed in a straight leg brace. Plan is to allow the fracture to heal spontaneously. Even if the leg heals in a deformed state, the patient will never use the leg. The patient's life expectancy is less than a year." "As a result of the fall, the patient presented with acute [MEDICAL CONDITION], hemoglobin of 8. She received several units of blood. Her hemoglobin is now 11 and she is more stable. She also presented with BUN (Blood Urea Nitrogen - blood test) of 111 and creatinine of 1.6 and serum sodium of 150. These labs were consistent with the patient who is acutely dehydrated from this acute traumatic event. The patient is fed via PEG (Percutaneous endoscopic gastrostomy - a tube inserted into stomach for nutrition, fluids, and medications) and receives water flushes. This is to suggest that this trauma occurred at least 3 days prior to presentation resulting in her body's response to the fluid shift that would occur with this kind of injury. The patient was given hypotonic fluids with the resolution of her [MEDICAL CONDITION] and significant improvement of her acute [MEDICAL CONDITION]. Additional laboratory date revealed a urine culture positive for Proteus mirabilis resistant to more than half of the antibiotic on antiobiotic panel, but the patient is sensitive to third generation cephalosporins such as [MEDICATION NAME] or the oral form which is [MEDICATION NAME]. The patient can be discharged back to the nursing home with the same medications as prior. Recommend an air mattress and/or hospital bed. Recommend decubitus precautions. Recommend increasing the PEG free water flushes to 400 ml (milliliters) q (every) 6 for the next 5 days. We will add [MEDICATION NAME] suspension (antibiotic) 300 mg PEG b.i.d. (twice daily) x 14 days. [MEDICATION NAME] (antibiotic used to treat bacterial infections of the eye) 1 to 2 drops b.i.d. to both eyes for 7 days. Follow up Orthopedics in 2 to 4 weeks to evaluate fracture healing. We will continue all previous home medications as outlined in the nursing home medication requisition sheet." During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The facility's Resident-Data-Collection Form dated 08/19/13 indicate R#1 was readmitted to the facility on [DATE] at 18:30 (6:30 p.m.) with the [DIAGNOSES REDACTED]. Special treatments and procedures listed an imbolizer to knee. R#1's functional status indicated total assist. The facility's admission orders [REDACTED] Right distal Femoral Fracture, Right Patellar fracture, Dehydration, [MEDICAL CONDITION] (increased sodium level), Acute [MEDICAL CONDITION], and Urinary Tract Infection. R#1's Physician's Telephone Orders dated 08/19/13 indicated keep knee immobilizer on at all times. Non weight bearing to right lower extremity. R#1's Care Plan dated 08/19/13 included the approaches: keep knee immobilizer on at all times to right leg, non-weight bearing, assess right leg for rednessw/[MEDICAL CONDITION], notify physician/family of any complications, medicate for pain as needed. R#1's Care Plan dated 08/26/13 stated, "Resident had a recent fall. hospitalized for [REDACTED]. Not a candidate for Surgery. Resident is to wear knee immobilizer at all times with no weight bearing. Good family support. Received blood transfusion at hospital stay. Requires assist X 2 CNAs for all transfers." R#1's Significant Change, MDS dated [DATE], indicated R#1 required physical assistance of two or more persons for transfers. The facility's undated "Change in a Resident's Condition or Status" policy revealed: Policy Statement, "Our facility shall promptly notify...his or her Attending Physician.....of changes in the resident's medical condition...." Policy Interpretation and Implementation, "#1....Charge Nurse will notify the resident's Attending Physician....when there has been: a. an accident or incident involving the resident; b. a discovery of injuries of unknown source....d. a significant change in the resident's physical/emotional/mental condition...." The facility's Centers for Medicare and Medicaid Services, Resident Census and Conditions of Residents Form 672 listed 8 residents in the facility who require assistance with transfers. The facility was given the opportunity during the investigation and time of exit to provide additional information regarding notification of physician and responsible party of significant changes. At time of exit 09/26/13 no additional documentation was provided.

Based on record review and interview, the facility failed to implement their policies and procedures that prohibit neglect for one Resident (R#1) of three residents reviewed for accidents and injuries. R#1 required the assistance of two persons for transfers using a mechanical lift. On 08/07/13 Certified Nurse Aides attempted a manual transfer and R#1 fell to her knees. There was no evidence of another fall or injury between 08/07/13 and 08/14/13. Licensed Vocational Nurses/Charge Nurses (LVNs) "A" and "B" failed to conduct follow-up assessments and document those assessments after the 08/07/13 fall. On 8/15/13 Resident # 1 was diagnosed with [REDACTED]. Resident # 1's physician was not consulted until after Resident 1's hospitalization on [DATE]. These failures could affect all eleven residents who had experienced recent falls and subject them to possible neglect and delayed medical attention, prolonged pain and suffering and deterioration of physical and mental state. The findings included: R#1's Admission Record dated 03/19/13 indicated R#1 was originally admitted to facility on 12/21/10 and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R#1 was totally dependent and required two person assistance for transfers. R#1's cognition was moderately impaired - decisions poor; cues/supervision required. R#1 usually understood and usually understands others. R#1 was unable to answer if she had pain or hurting at any time. R#1's Care Plan Conference Summary dated 07/30/13, revealed "Adjusted well to nursing home placement, (family members) visit daily..... No signs of skin breakdown. Requires total assist X 2 CNAs (Certified Nurse Aides) for all ADLs (Activities of Daily Living (transfers from bed to wheelchair, grooming, hygiene)). Sits up in Geri chair (a wheelchair that cannot be self propelled and reclines) at times." R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. . Nurses' Notes dated 08/13/13 indicated R#1 was showered and shower aides noticed R#1's altered mental status and body was lethargic while in the Geri chair. Facility called physician, responsible party and 911. R#1 was transferred to ER at 8 a.m. and readmitted to facility at 1:30 p.m. R#1 did not complain of pain or discomfort. On 08/14/13 at 9 a.m. the Nurses' Notes indicated R#1 was administered medications and was in no acute distress. The facility's investigation packet for incident of 08/07/13, included a witness statement dated 08/15/13 by CNA "D" indicated, "I came in to work (08/07/13)15 min (minutes) before 10 p.m. I was called to go to (R#1's) Room so I went running to her room. When I walked in (R#1) was on her knees on the floor. (CNAs "A", "B", and "C") were in the room already with (R#1). They were going to to get (R#1's) weight. (CNA "A") said they were gonna transfer (R#1) by hand, (CNA "A") and (CNA "B") but (R#1) was too heavy so they just sat her on the floor gently that she did not fall down. So I helped them transfer her from floor to bed. Went to do the ten o clock me and (CNA "E") I saw it looked swollen. So I reported it (LVN "B") she came and checked it out. (LVN "B") didn't see anything wrong because (R#1) was not complaining. So Wed (Wednesday) August 14 me and (CNA "E") were doing rounds again. We took off her sheets and saw her right leg was inward a lot, so we called our (LVN "B") she came to look at it. So she sent (R#1) out." The facility's investigation packet included a witness statement dated 08/15/13 by CNA "E" indicated "A week ago from today on 8-8-13 3 CNA's from 2-10 shift were trying to transfer a resident (R#1) from her bed to a shower chair to weigh her. The 3 CNA's (CNA "B", "A" and "C") were not able to transfer resident they then ask for help, (CNA "D", LVN "B", and LVN "A") and myself walked in to help. The 3 CNA's claim to have placed (R#1) (resident) on the floor because she was too heavy to transfer. (CNAs "D", "A", and "B") and I picked (R#1) up from the floor and transfered back to her bed. As (CNA "D") and I checked (R#1) for any skin tears, bruises, extc.(sic) we did notice some swelling to right knee we did report to our nurse, (LVN "B") and (LVN "A") as well. (LVN "B") did look at her knee and claimed that nothing was wrong. As the days went by (CNA "D") and I have reported that (R#1) was in pain and her knee did not look good. Now I do not know if the nurse wrote it down or not. Last night on 8-15-13 (CNA "D") and I were doing our 12:00 a.m. round as we walked into (R#1's) room we then removed the blanket and notice her leg twisted we did not touch her we immediately called our Charge Nurse (LVN "B.) (LVN "B") checked her out and agreed with (CNA "D") and I that her knee did not look good and you could see that the resident was in a lot of pain with her facial expressions. Right after (LVN "B") calls EMT'S to send (R#1) out." On 09/03/13 at 12:55 a.m. CNA "D" stated on 08/0713 she arrived for her 10:00 p.m. shift. Prior to start of her shift she heard a call for help and went down the hall. She observed R#1 on her knees. CNA "D" stated she did not report the incident to anyone because both the LVN from the 6 p.m. to 10 p.m. shift and the charge nurse from the 10 p.m. to 6 a.m. shift had been in the room and she "assumed they had taken care of it."CNA " D " stated on 08/07/13 she noticed (R #1 made facial expressions, like hurting, when she was turned and changed. CNA " D " told her charge nurse (LVA " A " ), who then checked {R # 1). As the days went by CNA " D " continued to notice (R #1) making faces, and her right leg looked swollen, it was bigger than the other leg. CNA " D " said (LVN " A " ) would assess and say something like she didn ' t see nothing wrong with her (R #1) did not see any distress. I know I reported concern to my charge nurse (LVN " A " ) at least 4 times. On 09/04/13 at 1:40 a.m. CNA " E " was interviewed, CNA " E " stated on 08/07/13 she had just arrived for her 10 p.m. shift when she heard her charge nurse (LVN " A " ) call for her. She stated she went down the hall and found R3 1 on her knees on the floor. The CNA ' s from the 2-10 shift were trying to transfer a resident (R #1) from her bed to a shower chair to weigh her. The 3 CNA ' s (CNA " B " . " A " , and " C " ) were not able to transfer resident, they then called for help. The 3 CNA ' s claim to have placed (R #1) resident on the floor because she was too heavy to transfer. (CNA ' s " D " , " A " and " B " ) and I picked up (R #1) for any skin tears, bruises, extc, (sic) we did notice some swelling to right knee we did report to our nurse (LVN " A " ) and (LVN " B " ) as well. We (CNA " E " and " D " reported to our nurse (LVN " A " ) that (R #1} said " OW " , (LVN " A " ) said she always makes noises. I told the nurse about my concerns at least 4 times. She looked at (R #1) and she looked fine, she told us no one else reports it just us (CNA " E " and CNA " D " ). After about one week, when (CNA " D " ) and myself turned back the sheets for (R #1} we observed her right leg was twisted. We reported it to our charge nurse (LVN " A " ) and she sent her out to the hospital. During an interview on 09/05/13 at 4:15 p.m., LVN "A" indicated R#1 was a two person assist and was unable to stand; therefore, they were required to use a mechanical lift to transfer R#1. LVN "A" stated she was present in the building on 08/07/13 at approximately 9:50 p.m. when she heard someone call for help. She went to assist and found R#1 on the floor on her knees. Three CNAs had attempted to transfer her from her bed to a shower chair, and were unable to complete the transfer. LVN "B" who had been the Charge Nurse for the 2:00 p.m. to 10:00 p.m. shift was already in R#1's room. LVN "A" stated she did not make any documentation regarding the incident until 08/15/13 when the DON interviewed her and R#1 had been sent to the hospital. LVN "A" stated she did not investigate or interview any staff regarding this incident on 08/07/13. LVN "A" said she did not contact the Physician or the Responsible Party. LVN "A" stated she did not know why the CNAs were not using the Hoyer lift (a mechanical lift). LVN "A" stated she could not say why she did not report the incident. LVN "A" stated she believed the 2:00 p.m. to 10:00 p.m. LVN (LVN "B") should have documented the incident as it had occurred on her shift, and should have contacted the Physician and Responsible Party (RP). During this same interview with LVN "A" she indicated it was not a normal practice to transfer a resident at 10:00 p.m. to be weighed but LVN "B" had assigned this task to be completed by the CNAs during their 2:00 p.m. to 10:00 p.m. shift. The CNAs were redirected to do so before leaving for the night and they took a short cut to get it done quickly. LVN "A" said weighing R#1 could have waited until the next day. LVN "A" stated she had assessed R#1 on 08/07/13 before she was lifted back to bed. During this interview she provided a drawing of the events and stated she was outside R#1's room and called for help. She could not explain how she assessed R#1 from outside the room. In an interview on 09/26/13 at 10:50 a.m., LVN "B" stated she was at the nurse ' s station on 08/07/13 at approximately 9:50 p.m. , when she heard CNAs yell for help. She went to R#1's room where she observed three CNAs (CNA "A", "B", and "C") in the room with R#1 on the floor on one knee. She stated the CNAs had attempted a two person transfer, from the bed to the shower chair. She stated the CNAs told her while transferring R#1 they realized the resident was too heavy and let her to the ground. She stated no mechanical lift was observed in the room. LVN "B" stated she asked the CNAs why no mechanical lift was used, they replied "we thought we could lift her." LVN "B" stated "the CNAs knew R#1 was a Hoyer lift. At this facility we are told if a patient is heavier than you, you should use a (mechanical lift)." One of the CNAs was very small, she questioned them again and the CNAs said they thought they could lift her. On 09/04/13 at 5:00 p.m. interview with CNA "A" revealed on 08/07/13 during her shift, at approximately 9:50 p.m. she and another CNA had atttempted to transfer R#1 from her bed to a shower chair for the purpose of obtaining a weight. CNA "A" stated R#1 was like dead weight, we didn't realize it until it was too late. CNA "A" said, she didn't fall, her legs, I can't explain, she was lowered to the floor. She had her right side of the hip and thigh on the floor, she had her knees bent, her knees went to the ground. I didn't think I had to report because my charge nurse (LVN " B " )was present. During an interview on 09/04/13 at 5:30 p.m., CNA "C" stated she did not utilize the gait belt when tranferring R#1 on 08/07/13 but she had the gait belt around her waist. In an interview on 09/05/13 at 5:50 p.m. with CNA "C" she stated on 08/07/13 she was in the room of R#1 with two other CNAs. She was holding the shower chair, and two other CNAs were trying to transfer R#1 from her bed to the shower chair. It was just prior to shift change. CNA "C" stated "I don't know what happened to her (R#1) that night we could usually do her." "I left her room, clocked out and left the building." CNA "C" stated she did not believe she had to report because her charge nurse (LVN " " B " ) was present and she believed she would report. She did not report until, 08/15/13 when the DON was conducting an investigation and asked her for a statement. CNA "C" stated "we held her, we did not let her go, she did not fall." LVN "A" documented on 08/15/13 at 1:20 a.m. "(CNAs "D" and "E") called me into (R#1's) room because her right knee was swollen. (R#1) complained of pain with touch. Physician called at 1:35 a.m. whom advised to send out to ER for X-Ray. Responsible Party called at 1:37 a.m. to notify. 911 called at 1:45 a.m. Two EMTs (Emergency Medical Technicians) in facility transferring Resident at 1:57 a.m." Director of Nurses (DON) documented on R#1's Nurses' Notes, dated 08/15/13, she was notified at 8:30 a.m. that R#1 was sent to the emergency room (ER) at approximately 2:00 a.m. for swollen right knee. The DON notified R#1's physician. She was informed by hospital staff R#1 would be admitted with right femur fracture. The DON notified R#1's Responsible Party (RP). The DON also notified R#1's RP that during her investigation she had learned of an incident that occurred on Thursday, 08/08/13. The DON explained her charge nurses said that on 08/08/13 the charge nurse for the 2:00 p.m. to 10:00 p.m. shift asked two CNAs to get a weight on R#1. The transfer was not completed and they eased resident to floor on her knees. Nurses checked R#1 and noted redness to knees before they assisted CNAs in putting R#1 back to bed. During an interview on 09/04/13 at 10:30 p.m., the DON stated upon arrival at the facility on 08/15/13 she was told R#1 had been sent to the nearest hospital. She was informed by hospital staff R#1 was admitted due to fractures. The DON stated she began the investigation. While interviewing staff she discovered R#1 had previously been involved in an incident on 08/07/13 or 08/08/13. The DON stated she found: - staff had not used a mechanical lift (Hoyer), - the incident had not been documented anywhere, - the physician had not been notified, and - the responsible party was not notified. During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The DON stated she had not considered investigating any of their July and August fall incidents to rule our possible neglect or had called any of them into the State. The facility's Incident Accident Log for July and August 2013 identified 16 falls involving 11 residents. During an interview with Physician " A " on 09/04/13 at 6:45 p.m., he stated he was not notified of (R #1) incurring a incident/fall until the Don called him after (R #1) was hosptalized on [DATE]. R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. Radiology Report dated 08/15/13 of R#1's right femur indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphyseal region is identified. The distal fragment is displaced slightly posteriorly. The tibia (shin bone) follows the distal fragment. A vertically oriented fracture through the patella (knee-cap) is also noted." According to www.britanica.com on 10/04/13 comminuted means, the broken ends of the bone are jammed together by the force of the injury. Radiology Report dated 08/15/13 of R#1's right knee indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphysis is identified with anterior apex angulation.....A fracture through the posterior aspect of the patella is also identified. R#1's Hospital Discharge Record dictated by Physician "B" on 08/18/13 at 1:54 p.m. revealed: Admitting Diagnoses: [REDACTED]. Right Patellar fracture Dehydration [MEDICAL CONDITION] (increased sodium level) Acute [MEDICAL CONDITION] Urinary Tract Infection Chronic bedridden state Discharge Diagnoses: [REDACTED]. Right patellar fracture Dehydration [MEDICAL CONDITION], resolved Acute [MEDICAL CONDITION], resolved Chronic bedridden state Urinary tract infection "Hospital Course" "A [AGE] year old female from (facility) comes in after sustaining a right distal femur fracture and right patellar fracture, unknown etiology. However, this injury can only occur in a fall in a patient who is chronically bedridden and cannot ambulate. Nonetheless, the patient was brought here and was evaluated by Orthopedics. After a lengthy discussion with the family, it was concluded the patient would be a high surgical risk candidate because of her advanced age. As a result, the decision was made to not surgically repair the fracture. The patient was placed in a straight leg brace. Plan is to allow the fracture to heal spontaneously. Even if the leg heals in a deformed state, the patient will never use the leg. The patient's life expectancy is less than a year." "As a result of the fall, the patient presented with acute [MEDICAL CONDITION], hemoglobin of 8. She received several units of blood. Her hemoglobin is now 11 and she is more stable. She also presented with BUN (Blood Urea Nitrogen - blood test) of 111 and creatinine of 1.6 and serum sodium of 150. These labs were consistent with the patient who is acutely dehydrated from this acute traumatic event. The patient is fed via PEG (Percutaneous endoscopic gastrostomy - a tube inserted into stomach for nutrition, fluids, and medications) and receives water flushes. This is to suggest that this trauma occurred at least 3 days prior to presentation resulting in her body's response to the fluid shift that would occur with this kind of injury. The patient was given hypotonic fluids with the resolution of her [MEDICAL CONDITION] and significant improvement of her acute [MEDICAL CONDITION]. Additional laboratory date revealed a urine culture positive for Proteus mirabilis resistant to more than half of the antibiotic on antiobiotic panel, but the patient is sensitive to third generation cephalosporins such as [MEDICATION NAME] or the oral form which is [MEDICATION NAME]. The patient can be discharged back to the nursing home with the same medications as prior. Recommend an air mattress and/or hospital bed. Recommend decubitus precautions. Recommend increasing the PEG free water flushes to 400 ml (milliliters) q (every) 6 for the next 5 days. We will add [MEDICATION NAME] suspension (antibiotic) 300 mg PEG b.i.d. (twice daily) x 14 days. [MEDICATION NAME] (antibiotic used to treat bacterial infections of the eye) 1 to 2 drops b.i.d. to both eyes for 7 days. Follow up Orthopedics in 2 to 4 weeks to evaluate fracture healing. We will continue all previous home medications as outlined in the nursing home medication requisition sheet." During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The facility's Resident-Data-Collection Form dated 08/19/13 indicate R#1 was readmitted to the facility on [DATE] at 18:30 (6:30 p.m.) with the [DIAGNOSES REDACTED]. Special treatments and procedures listed an imbolizer to knee. R#1's functional status indicated total assist. The facility's admission orders [REDACTED] Right distal Femoral Fracture, Right Patellar fracture, Dehydration, [MEDICAL CONDITION] (increased sodium level), Acute [MEDICAL CONDITION], and Urinary Tract Infection. R#1's Physician's Telephone Orders dated 08/19/13 indicated keep knee immobilizer on at all times. Non weight bearing to right lower extremity. R#1's Care Plan dated 08/19/13 included the approaches: keep knee immobilizer on at all times to right leg, non-weight bearing, assess right leg for rednessw/[MEDICAL CONDITION], notify physician/family of any complications, medicate for pain as needed. R#1's Care Plan dated 08/26/13 stated, "Resident had a recent fall. hospitalized for [REDACTED]. Not a candidate for Surgery. Resident is to wear knee immobilizer at all times with no weight bearing. Good family support. Received blood transfusion at hospital stay. Requires assist X 2 CNAs for all transfers." R#1's Significant Change, MDS dated [DATE], indicated R#1 required physical assistance of two or more persons for transfers. The facility's undated "Change in a Resident's Condition or Status" policy revealed: Policy Statement, "Our facility shall promptly notify...his or her Attending Physician.....of changes in the resident's medical condition...." Policy Interpretation and Implementation, "#1....Charge Nurse will notify the resident's Attending Physician....when there has been: a. an accident or incident involving the resident; b. a discovery of injuries of unknown source....d. a significant change in the resident's physical/emotional/mental condition...." On 08/12/13 Abuse and Neglect Inservice had been provided to staff. On 08/16/13 Abuse Investigations / Reporting Abuse to Facility Management had been provided to staff in which CNA "B" did not attend. On 08/26/13 Restraint Reduction and Preventing Falls Inservice was conducted. The State Operations Manual Appendix PP, dated May 2012 ? 483.13(c) defines neglect as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The facility's undated "Administrative Policies and Procedures Reporting Abuse to Facility Management" policy revealed: POLICY.... "it is the responsibility of our employees...to promptly report any incident or suspected incident of neglect, including injuries of unknown source... to facility management." #7. g. Neglect is defined as failure to provide goods or services necessary to avoid physicial harm, mental anguish,... #15. Any person who has knowledge or reason to believe that a resident has been a victim of....neglect....SHALL report,......Failure to report such an incident may result in legal/criminal action being filed against the individual(s) witholding such information." #16. A person shall not knowingly - .....d. Screen reports or withhold information to reporting agencies." The facility's Incident/Accident Log documented 11 residents who had experienced recent falls and were not investigated as possible neglect. The facility was given the opportunity during the investigation and time of exit to provide additional information regarding implementation of their neglect policy and procedures. At time of exit 09/26/13 no additional documentation was provided.

Based on record review and interviews, the facility failed to 1) ensure that all alleged violations involving neglect or abuse including injuries of unknown source were: a) reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures including to the state survey and certification agency, Eight facility staff did not report R#1's 08/07/13 incident/injury to facility administrator or to the state agency for eight days. When R#1 was sent out to the hospital she was diagnosed with [REDACTED]. 2) have evidence of prevention or precautions of further potential neglect/abuse while the investigation was in progress, Three Certified Nurse Aides (CNAs) involved in R#1's 08/07/13 incident/injury were working on the same hall with the same resident for 22 days while the investigation was ongoing. 3) implement corrective action after the incident involving R#1's 08/07/13 fall and fractures Corrective action had not been implemented for three CNAs and corrective action had not been finalized for LVN "A" 17 days after their investigation. LVN "A" had been put on suspension pending the "state agencies findings." These failures could affect 12 (includes R#1) residents by placing them at a higher risk of unreported injuries, abuse, neglect, and mistreatment, delayed medical attention, prolonged pain and sufferng, deterioration of physical and mental status and a shortened life expectancy. The findings include: R#1's Admission Record dated 03/19/13 indicated R#1 was originally admitted to facility on 12/21/10 and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R#1 was totally dependent and required two person assistance for transfers. R#1's cognition was moderately impaired - decisions poor; cues/supervision required. R#1 usually understood and usually understands others. R#1 was unable to answer if she had pain or hurting at any time. R#1's Care Plan Conference Summary dated 07/30/13, revealed "Adjusted well to nursing home placement, (family members) visit daily..... No signs of skin breakdown. Requires total assist X 2 CNAs (Certified Nurse Aides) for all ADLs (Activities of Daily Living (transfers from bed to wheelchair, grooming, hygiene)). Sits up in Geri chair (a wheelchair that cannot be self propelled and reclines) at times." R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. . Nurses' Notes dated 08/13/13 indicated R#1 was showered and shower aides noticed R#1's altered mental status and body was lethargic while in the Geri chair. Facility called physician, responsible party and 911. R#1 was transferred to ER at 8 a.m. and readmitted to facility at 1:30 p.m. R#1 did not complain of pain or discomfort. On 08/14/13 at 9 a.m. the Nurses' Notes indicated R#1 was administered medications and was in no acute distress. The facility's investigation packet for incident of 08/07/13, included a witness statement dated 08/15/13 by CNA "D" indicated, "I came in to work (08/07/13)15 min (minutes) before 10 p.m. I was called to go to (R#1's) Room so I went running to her room. When I walked in (R#1) was on her knees on the floor. (CNAs "A", "B", and "C") were in the room already with (R#1). They were going to to get (R#1's) weight. (CNA "A") said they were gonna transfer (R#1) by hand, (CNA "A") and (CNA "B") but (R#1) was too heavy so they just sat her on the floor gently that she did not fall down. So I helped them transfer her from floor to bed. Went to do the ten o clock me and (CNA "E") I saw it looked swollen. So I reported it (LVN "B") she came and checked it out. (LVN "B") didn't see anything wrong because (R#1) was not complaining. So Wed (Wednesday) August 14 me and (CNA "E") were doing rounds again. We took off her sheets and saw her right leg was inward a lot, so we called our (LVN "B") she came to look at it. So she sent (R#1) out." The facility's investigation packet included a witness statement dated 08/15/13 by CNA "E" indicated "A week ago from today on 8-8-13 3 CNA's from 2-10 shift were trying to transfer a resident (R#1) from her bed to a shower chair to weigh her. The 3 CNA's (CNA "B", "A" and "C") were not able to transfer resident they then ask for help, (CNA "D", LVN "B", and LVN "A") and myself walked in to help. The 3 CNA's claim to have placed (R#1) (resident) on the floor because she was too heavy to transfer. (CNAs "D", "A", and "B") and I picked (R#1) up from the floor and transfered back to her bed. As (CNA "D") and I checked (R#1) for any skin tears, bruises, extc.(sic) we did notice some swelling to right knee we did report to our nurse, (LVN "B") and (LVN "A") as well. (LVN "B") did look at her knee and claimed that nothing was wrong. As the days went by (CNA "D") and I have reported that (R#1) was in pain and her knee did not look good. Now I do not know if the nurse wrote it down or not. Last night on 8-15-13 (CNA "D") and I were doing our 12:00 a.m. round as we walked into (R#1's) room we then removed the blanket and notice her leg twisted we did not touch her we immediately called our Charge Nurse (LVN "B.) (LVN "B") checked her out and agreed with (CNA "D") and I that her knee did not look good and you could see that the resident was in a lot of pain with her facial expressions. Right after (LVN "B") calls EMT'S to send (R#1) out." On 09/03/13 at 12:55 a.m. CNA "D" stated on 08/0713 she arrived for her 10:00 p.m. shift. Prior to start of her shift she heard a call for help and went down the hall. She observed R#1 on her knees. CNA "D" stated she did not report the incident to anyone because both the LVN from the 6 p.m. to 10 p.m. shift and the charge nurse from the 10 p.m. to 6 a.m. shift had been in the room and she "assumed they had taken care of it."CNA " D " stated on 08/07/13 she noticed (R #1 made facial expressions, like hurting, when she was turned and changed. CNA " D " told her charge nurse (LVA " A " ), who then checked {R # 1). As the days went by CNA " D " continued to notice (R #1) making faces, and her right leg looked swollen, it was bigger than the other leg. CNA " D " said (LVN " A " ) would assess and say something like she didn ' t see nothing wrong with her (R #1) did not see any distress. I know I reported concern to my charge nurse (LVN " A " ) at least 4 times. On 09/04/13 at 1:40 a.m. CNA " E " was interviewed, CNA " E " stated on 08/07/13 she had just arrived for her 10 p.m. shift when she heard her charge nurse (LVN " A " ) call for her. She stated she went down the hall and found R3 1 on her knees on the floor. The CNA ' s from the 2-10 shift were trying to transfer a resident (R #1) from her bed to a shower chair to weigh her. The 3 CNA ' s (CNA " B " . " A " , and " C " ) were not able to transfer resident, they then called for help. The 3 CNA ' s claim to have placed (R #1) resident on the floor because she was too heavy to transfer. (CNA ' s " D " , " A " and " B " ) and I picked up (R #1) for any skin tears, bruises, extc, (sic) we did notice some swelling to right knee we did report to our nurse (LVN " A " ) and (LVN " B " ) as well. We (CNA " E " and " D " reported to our nurse (LVN " A " ) that (R #1} said " OW " , (LVN " A " ) said she always makes noises. I told the nurse about my concerns at least 4 times. She looked at (R #1) and she looked fine, she told us no one else reports it just us (CNA " E " and CNA " D " ). After about one week, when (CNA " D " ) and myself turned back the sheets for (R #1} we observed her right leg was twisted. We reported it to our charge nurse (LVN " A " ) and she sent her out to the hospital. During an interview on 09/05/13 at 4:15 p.m., LVN "A" indicated R#1 was a two person assist and was unable to stand; therefore, they were required to use a mechanical lift to transfer R#1. LVN "A" stated she was present in the building on 08/07/13 at approximately 9:50 p.m. when she heard someone call for help. She went to assist and found R#1 on the floor on her knees. Three CNAs had attempted to transfer her from her bed to a shower chair, and were unable to complete the transfer. LVN "B" who had been the Charge Nurse for the 2:00 p.m. to 10:00 p.m. shift was already in R#1's room. LVN "A" stated she did not make any documentation regarding the incident until 08/15/13 when the DON interviewed her and R#1 had been sent to the hospital. LVN "A" stated she did not investigate or interview any staff regarding this incident on 08/07/13. LVN "A" said she did not contact the Physician or the Responsible Party. LVN "A" stated she did not know why the CNAs were not using the Hoyer lift (a mechanical lift). LVN "A" stated she could not say why she did not report the incident. LVN "A" stated she believed the 2:00 p.m. to 10:00 p.m. LVN (LVN "B") should have documented the incident as it had occurred on her shift, and should have contacted the Physician and Responsible Party (RP). During this same interview with LVN "A" she indicated it was not a normal practice to transfer a resident at 10:00 p.m. to be weighed but LVN "B" had assigned this task to be completed by the CNAs during their 2:00 p.m. to 10:00 p.m. shift. The CNAs were redirected to do so before leaving for the night and they took a short cut to get it done quickly. LVN "A" said weighing R#1 could have waited until the next day. LVN "A" stated she had assessed R#1 on 08/07/13 before she was lifted back to bed. During this interview she provided a drawing of the events and stated she was outside R#1's room and called for help. She could not explain how she assessed R#1 from outside the room. In an interview on 09/26/13 at 10:50 a.m., LVN "B" stated she was at the nurse ' s station on 08/07/13 at approximately 9:50 p.m. , when she heard CNAs yell for help. She went to R#1's room where she observed three CNAs (CNA "A", "B", and "C") in the room with R#1 on the floor on one knee. She stated the CNAs had attempted a two person transfer, from the bed to the shower chair. She stated the CNAs told her while transferring R#1 they realized the resident was too heavy and let her to the ground. She stated no mechanical lift was observed in the room. LVN "B" stated she asked the CNAs why no mechanical lift was used, they replied "we thought we could lift her." LVN "B" stated "the CNAs knew R#1 was a Hoyer lift. At this facility we are told if a patient is heavier than you, you should use a (mechanical lift)." One of the CNAs was very small, she questioned them again and the CNAs said they thought they could lift her. On 09/04/13 at 5:00 p.m. interview with CNA "A" revealed on 08/07/13 during her shift, at approximately 9:50 p.m. she and another CNA had atttempted to transfer R#1 from her bed to a shower chair for the purpose of obtaining a weight. CNA "A" stated R#1 was like dead weight, we didn't realize it until it was too late. CNA "A" said, she didn't fall, her legs, I can't explain, she was lowered to the floor. She had her right side of the hip and thigh on the floor, she had her knees bent, her knees went to the ground. I didn't think I had to report because my charge nurse (LVN " B " )was present. During an interview on 09/04/13 at 5:30 p.m., CNA "C" stated she did not utilize the gait belt when tranferring R#1 on 08/07/13 but she had the gait belt around her waist. In an interview on 09/05/13 at 5:50 p.m. with CNA "C" she stated on 08/07/13 she was in the room of R#1 with two other CNAs. She was holding the shower chair, and two other CNAs were trying to transfer R#1 from her bed to the shower chair. It was just prior to shift change. CNA "C" stated "I don't know what happened to her (R#1) that night we could usually do her." "I left her room, clocked out and left the building." CNA "C" stated she did not believe she had to report because her charge nurse (LVN " " B " ) was present and she believed she would report. She did not report until, 08/15/13 when the DON was conducting an investigation and asked her for a statement. CNA "C" stated "we held her, we did not let her go, she did not fall." LVN "A" documented on 08/15/13 at 1:20 a.m. "(CNAs "D" and "E") called me into (R#1's) room because her right knee was swollen. (R#1) complained of pain with touch. Physician called at 1:35 a.m. whom advised to send out to ER for X-Ray. Responsible Party called at 1:37 a.m. to notify. 911 called at 1:45 a.m. Two EMTs (Emergency Medical Technicians) in facility transferring Resident at 1:57 a.m." Director of Nurses (DON) documented on R#1's Nurses' Notes, dated 08/15/13, she was notified at 8:30 a.m. that R#1 was sent to the emergency room (ER) at approximately 2:00 a.m. for swollen right knee. The DON notified R#1's physician. She was informed by hospital staff R#1 would be admitted with right femur fracture. The DON notified R#1's Responsible Party (RP). The DON also notified R#1's RP that during her investigation she had learned of an incident that occurred on Thursday, 08/08/13. The DON explained her charge nurses said that on 08/08/13 the charge nurse for the 2:00 p.m. to 10:00 p.m. shift asked two CNAs to get a weight on R#1. The transfer was not completed and they eased resident to floor on her knees. Nurses checked R#1 and noted redness to knees before they assisted CNAs in putting R#1 back to bed. During an interview on 09/04/13 at 10:30 p.m., the DON stated upon arrival at the facility on 08/15/13 she was told R#1 had been sent to the nearest hospital. She was informed by hospital staff R#1 was admitted due to fractures. The DON stated she began the investigation. While interviewing staff she discovered R#1 had previously been involved in an incident on 08/07/13 or 08/08/13. The DON stated she found: - staff had not used a mechanical lift (Hoyer), - the incident had not been documented anywhere, - the physician had not been notified, and - the responsible party was not notified. During an interview with Physician " A " on 09/04/13 at 6:45 p.m., he stated he was not notified of (R #1) incurring a incident/fall until the Don called him after (R #1) was hosptalized on [DATE]. R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. Radiology Report dated 08/15/13 of R#1's right femur indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphyseal region is identified. The distal fragment is displaced slightly posteriorly. The tibia (shin bone) follows the distal fragment. A vertically oriented fracture through the patella (knee-cap) is also noted." According to www.britanica.com on 10/04/13 comminuted means, the broken ends of the bone are jammed together by the force of the injury. Radiology Report dated 08/15/13 of R#1's right knee indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphysis is identified with anterior apex angulation.....A fracture through the posterior aspect of the patella is also identified. R#1's Hospital Discharge Record dictated by Physician "B" on 08/18/13 at 1:54 p.m. revealed: Admitting Diagnoses: [REDACTED]. Right Patellar fracture Dehydration [MEDICAL CONDITION] (increased sodium level) Acute [MEDICAL CONDITION] Urinary Tract Infection Chronic bedridden state Discharge Diagnoses: [REDACTED]. Right patellar fracture Dehydration [MEDICAL CONDITION], resolved Acute [MEDICAL CONDITION], resolved Chronic bedridden state Urinary tract infection "Hospital Course" "A [AGE] year old female from (facility) comes in after sustaining a right distal femur fracture and right patellar fracture, unknown etiology. However, this injury can only occur in a fall in a patient who is chronically bedridden and cannot ambulate. Nonetheless, the patient was brought here and was evaluated by Orthopedics. After a lengthy discussion with the family, it was concluded the patient would be a high surgical risk candidate because of her advanced age. As a result, the decision was made to not surgically repair the fracture. The patient was placed in a straight leg brace. Plan is to allow the fracture to heal spontaneously. Even if the leg heals in a deformed state, the patient will never use the leg. The patient's life expectancy is less than a year." "As a result of the fall, the patient presented with acute [MEDICAL CONDITION], hemoglobin of 8. She received several units of blood. Her hemoglobin is now 11 and she is more stable. She also presented with BUN (Blood Urea Nitrogen - blood test) of 111 and creatinine of 1.6 and serum sodium of 150. These labs were consistent with the patient who is acutely dehydrated from this acute traumatic event. The patient is fed via PEG (Percutaneous endoscopic gastrostomy - a tube inserted into stomach for nutrition, fluids, and medications) and receives water flushes. This is to suggest that this trauma occurred at least 3 days prior to presentation resulting in her body's response to the fluid shift that would occur with this kind of injury. The patient was given hypotonic fluids with the resolution of her [MEDICAL CONDITION] and significant improvement of her acute [MEDICAL CONDITION]. Additional laboratory date revealed a urine culture positive for Proteus mirabilis resistant to more than half of the antibiotic on antiobiotic panel, but the patient is sensitive to third generation cephalosporins such as [MEDICATION NAME] or the oral form which is [MEDICATION NAME]. The patient can be discharged back to the nursing home with the same medications as prior. Recommend an air mattress and/or hospital bed. Recommend decubitus precautions. Recommend increasing the PEG free water flushes to 400 ml (milliliters) q (every) 6 for the next 5 days. We will add [MEDICATION NAME] suspension (antibiotic) 300 mg PEG b.i.d. (twice daily) x 14 days. [MEDICATION NAME] (antibiotic used to treat bacterial infections of the eye) 1 to 2 drops b.i.d. to both eyes for 7 days. Follow up Orthopedics in 2 to 4 weeks to evaluate fracture healing. We will continue all previous home medications as outlined in the nursing home medication requisition sheet." During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The facility's Resident-Data-Collection Form dated 08/19/13 indicate R#1 was readmitted to the facility on [DATE] at 18:30 (6:30 p.m.) with the [DIAGNOSES REDACTED]. Special treatments and procedures listed an imbolizer to knee. R#1's functional status indicated total assist. The facility's admission orders [REDACTED] Right distal Femoral Fracture, Right Patellar fracture, Dehydration, [MEDICAL CONDITION] (increased sodium level), Acute [MEDICAL CONDITION], and Urinary Tract Infection. R#1's Physician's Telephone Orders dated 08/19/13 indicated keep knee immobilizer on at all times. Non weight bearing to right lower extremity. R#1's Care Plan dated 08/19/13 included the approaches: keep knee immobilizer on at all times to right leg, non-weight bearing, assess right leg for rednessw/[MEDICAL CONDITION], notify physician/family of any complications, medicate for pain as needed. R#1's Care Plan dated 08/26/13 stated, "Resident had a recent fall. hospitalized for [REDACTED]. Not a candidate for Surgery. Resident is to wear knee immobilizer at all times with no weight bearing. Good family support. Received blood transfusion at hospital stay. Requires assist X 2 CNAs for all transfers." R#1's Significant Change, MDS dated [DATE], indicated R#1 required physical assistance of two or more persons for transfers. During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The DON stated she had not considered investigating any of their July and August fall incidents to rule our possible neglect or had called any of them into the State. The facility's Incident Accident Log for July and August 2013 identified 16 falls involving 11 residents. The facility's undated "Change in a Resident's Condition or Status" policy revealed: Policy Statement, "Our facility shall promptly notify...his or her Attending Physician.....of changes in the resident's medical condition...." Policy Interpretation and Implementation, "#1....Charge Nurse will notify the resident's Attending Physician....when there has been: a. an accident or incident involving the resident; b. a discovery of injuries of unknown source....d. a significant change in the resident's physical/emotional/mental condition...." Provider Letter #06-43 Guidelines for Reporting Incidents dated 01/03/07 states, "Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect, or exploitation." The facility's undated "Administrative Policies and Procedures Abuse Investigations" policy indicated: POLICY All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. PROCEDURES...#7. Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator.....#11. Should the investigation reveal that abuse occurred, the administrator will report the initial finding to the state licensing agency and others required by state and local laws (e.g. law enforcement) within 24 hours of being informed of an abuse allegation. Note: The facility's written policy states "should the (facility's) investigation reveal that abuse occurred, the administrator will report the initial finding to the state licensing agency...within 24 hours of being informed of an abuse allegation." The requirement is that once a facility is informed about an alleged violation they report it immediately to the state. In the meantime, the facility conducts their investigation and faxes their results within five days. The facility's undated "Administrative Policies and Procedures Reporting Abuse to Facility Management" policy revealed: POLICY.... "it is the responsibility of our employees...to promptly report any incident or suspected incident of neglect, including injuries of unknown source... to facility management." #7. g. Neglect is defined as failure to provide goods or services necessary to avoid physicial harm, mental anguish,... #15. Any person who has knowledge or reason to believe that a resident has been a victim of....neglect....SHALL report,......Failure to report such an incident may result in legal/criminal action being filed against the individual(s) witholding such information." #16. A person shall not knowingly - .....d. Screen reports or withhold information to reporting agencies." The facility's Incident/Accident Log documented 11 residents who had experienced recent falls and were not investigated as possible neglect. The facility was given the opportunity during the investigation and time of exit to provide additional information regarding implementation of their their neglect policy and procedures. At time of exit 09/26/13 no additional documentation was provided.

Based on record review and interviews, the facility failed to implement their written policy and procedures that prohibit neglect for one Resident (R# 1) of three Residents reviewed for accidents and injuries. 1) ensure that all alleged violations involving neglect or abuse including injuries of unknown source were: a) reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures including to the state survey and certification agency, Eight facility staff did not report R#1's 08/07/13 incident/injury to facility administrator or to the state agency for eight days. When R#1 was sent out to the hospital she was diagnosed with [REDACTED]. 2) have evidence of prevention or precautions of further potential neglect/abuse while the investigation was in progress, Three Certified Nurse Aides (CNAs) involved in R#1's 08/07/13 incident/injury were working on the same hall with the same resident for 22 days while the investigation was ongoing. 3) implement corrective action after the incident involving R#1's 08/07/13 fall and fractures Corrective action had not been implemented for three CNAs and corrective action had not been finalized for LVN "A" 17 days after their investigation. LVN "A" had been put on suspension pending the "state agencies findings." These failures could affect 12 (includes R#1) residents by placing them at a higher risk of unreported injuries, abuse, neglect, and mistreatment, delayed medical attention, prolonged pain and sufferng, deterioration of physical and mental status and a shortened life expectancy. The findings include: The facility's undated "Administrative Policies and Procedures Abuse Investigations" policy indicated: POLICY All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. PROCEDURES...#7. Employees of this facility who have been accused of resident abuse may be reassigned to nonresident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator.....#11. Should the investigation reveal that abuse occurred, the administrator will report the initial finding to the state licensing agency and others required by state and local laws (e.g. law enforcement) within 24 hours of being informed of an abuse allegation. Note: The facility's written policy states "should the (facility's) investigation reveal that abuse occurred, the administrator will report the initial finding to the state licensing agency...within 24 hours of being informed of an abuse allegation." The requirement is that once a facility is informed about an alleged violation they report it immediately to the state. In the meantime, the facility conducts their investigation and faxes their results within five days. The facility's undated "Administrative Policies and Procedures Reporting Abuse to Facility Management" policy revealed: POLICY.... "it is the responsibility of our employees...to promptly report any incident or suspected incident of neglect, including injuries of unknown source... to facility management." #7. g. Neglect is defined as failure to provide goods or services necessary to avoid physicial harm, mental anguish,... #15. Any person who has knowledge or reason to believe that a resident has been a victim of....neglect....SHALL report,......Failure to report such an incident may result in legal/criminal action being filed against the individual(s) witholding such information." #16. A person shall not knowingly - .....d. Screen reports or withhold information to reporting agencies." The facility's undated "Change in a Resident's Condition or Status" policy revealed: Policy Statement, "Our facility shall promptly notify...his or her Attending Physician.....of changes in the resident's medical condition...." Policy Interpretation and Implementation, "#1....Charge Nurse will notify the resident's Attending Physician....when there has been: a. an accident or incident involving the resident; b. a discovery of injuries of unknown source....d. a significant change in the resident's physical/emotional/mental condition...." Provider Letter #06-43 Guidelines for Reporting Incidents dated 01/03/07 states, "Facilities are also required to report certain other incidents, which may or may not constitute abuse, neglect, or exploitation." Admission Record dated 03/19/13 indicated R#1 was originally admitted to facility on 12/21/10 and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R#1 was totally dependent and required two person assistance for transfers. R#1's cognition was moderately impaired - decisions poor; cues/supervision required. R#1 usually understood and usually understands others. R#1 was unable to answer if she had pain or hurting at any time. R#1's Care Plan Conference Summary dated 07/30/13, revealed "Adjusted well to nursing home placement, (family members) visit daily..... No signs of skin breakdown. Requires total assist X 2 CNAs (Certified Nurse Aides) for all ADLs (Activities of Daily Living (transfers from bed to wheelchair, grooming, hygiene)). Sits up in Geri chair (a wheelchair that cannot be self propelled and reclines) at times." R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. . Nurses' Notes dated 08/13/13 indicated R#1 was showered and shower aides noticed R#1's altered mental status and body was lethargic while in the Geri chair. Facility called physician, responsible party and 911. R#1 was transferred to ER at 8 a.m. and readmitted to facility at 1:30 p.m. R#1 did not complain of pain or discomfort. On 08/14/13 at 9 a.m. the Nurses' Notes indicated R#1 was administered medications and was in no acute distress. The facility's investigation packet for incident of 08/07/13, included a witness statement dated 08/15/13 by CNA "D" indicated, "I came in to work (08/07/13)15 min (minutes) before 10 p.m. I was called to go to (R#1's) Room so I went running to her room. When I walked in (R#1) was on her knees on the floor. (CNAs "A", "B", and "C") were in the room already with (R#1). They were going to to get (R#1's) weight. (CNA "A") said they were gonna transfer (R#1) by hand, (CNA "A") and (CNA "B") but (R#1) was too heavy so they just sat her on the floor gently that she did not fall down. So I helped them transfer her from floor to bed. Went to do the ten o clock me and (CNA "E") I saw it looked swollen. So I reported it (LVN "B") she came and checked it out. (LVN "B") didn't see anything wrong because (R#1) was not complaining. So Wed (Wednesday) August 14 me and (CNA "E") were doing rounds again. We took off her sheets and saw her right leg was inward a lot, so we called our (LVN "B") she came to look at it. So she sent (R#1) out." The facility's investigation packet included a witness statement dated 08/15/13 by CNA "E" indicated "A week ago from today on 8-8-13 3 CNA's from 2-10 shift were trying to transfer a resident (R#1) from her bed to a shower chair to weigh her. The 3 CNA's (CNA "B", "A" and "C") were not able to transfer resident they then ask for help, (CNA "D", LVN "B", and LVN "A") and myself walked in to help. The 3 CNA's claim to have placed (R#1) (resident) on the floor because she was too heavy to transfer. (CNAs "D", "A", and "B") and I picked (R#1) up from the floor and transfered back to her bed. As (CNA "D") and I checked (R#1) for any skin tears, bruises, extc.(sic) we did notice some swelling to right knee we did report to our nurse, (LVN "B") and (LVN "A") as well. (LVN "B") did look at her knee and claimed that nothing was wrong. As the days went by (CNA "D") and I have reported that (R#1) was in pain and her knee did not look good. Now I do not know if the nurse wrote it down or not. Last night on 8-15-13 (CNA "D") and I were doing our 12:00 a.m. round as we walked into (R#1's) room we then removed the blanket and notice her leg twisted we did not touch her we immediately called our Charge Nurse (LVN "B.) (LVN "B") checked her out and agreed with (CNA "D") and I that her knee did not look good and you could see that the resident was in a lot of pain with her facial expressions. Right after (LVN "B") calls EMT'S to send (R#1) out." On 09/03/13 at 12:55 a.m. CNA "D" stated on 08/0713 she arrived for her 10:00 p.m. shift. Prior to start of her shift she heard a call for help and went down the hall. She observed R#1 on her knees. CNA "D" stated she did not report the incident to anyone because both the LVN from the 6 p.m. to 10 p.m. shift and the charge nurse from the 10 p.m. to 6 a.m. shift had been in the room and she "assumed they had taken care of it."CNA " D " stated on 08/07/13 she noticed (R #1 made facial expressions, like hurting, when she was turned and changed. CNA " D " told her charge nurse (LVA " A " ), who then checked {R # 1). As the days went by CNA " D " continued to notice (R #1) making faces, and her right leg looked swollen, it was bigger than the other leg. CNA " D " said (LVN " A " ) would assess and say something like she didn ' t see nothing wrong with her (R #1) did not see any distress. I know I reported concern to my charge nurse (LVN " A " ) at least 4 times. On 09/04/13 at 1:40 a.m. CNA " E " was interviewed, CNA " E " stated on 08/07/13 she had just arrived for her 10 p.m. shift when she heard her charge nurse (LVN " A " ) call for her. She stated she went down the hall and found R3 1 on her knees on the floor. The CNA ' s from the 2-10 shift were trying to transfer a resident (R #1) from her bed to a shower chair to weigh her. The 3 CNA ' s (CNA " B " . " A " , and " C " ) were not able to transfer resident, they then called for help. The 3 CNA ' s claim to have placed (R #1) resident on the floor because she was too heavy to transfer. (CNA ' s " D " , " A " and " B " ) and I picked up (R #1) for any skin tears, bruises, extc, (sic) we did notice some swelling to right knee we did report to our nurse (LVN " A " ) and (LVN " B " ) as well. We (CNA " E " and " D " reported to our nurse (LVN " A " ) that (R #1} said " OW " , (LVN " A " ) said she always makes noises. I told the nurse about my concerns at least 4 times. She looked at (R #1) and she looked fine, she told us no one else reports it just us (CNA " E " and CNA " D " ). After about one week, when (CNA " D " ) and myself turned back the sheets for (R #1} we observed her right leg was twisted. We reported it to our charge nurse (LVN " A " ) and she sent her out to the hospital. During an interview on 09/05/13 at 4:15 p.m., LVN "A" indicated R#1 was a two person assist and was unable to stand; therefore, they were required to use a mechanical lift to transfer R#1. LVN "A" stated she was present in the building on 08/07/13 at approximately 9:50 p.m. when she heard someone call for help. She went to assist and found R#1 on the floor on her knees. Three CNAs had attempted to transfer her from her bed to a shower chair, and were unable to complete the transfer. LVN "B" who had been the Charge Nurse for the 2:00 p.m. to 10:00 p.m. shift was already in R#1's room. LVN "A" stated she did not make any documentation regarding the incident until 08/15/13 when the DON interviewed her and R#1 had been sent to the hospital. LVN "A" stated she did not investigate or interview any staff regarding this incident on 08/07/13. LVN "A" said she did not contact the Physician or the Responsible Party. LVN "A" stated she did not know why the CNAs were not using the Hoyer lift (a mechanical lift). LVN "A" stated she could not say why she did not report the incident. LVN "A" stated she believed the 2:00 p.m. to 10:00 p.m. LVN (LVN "B") should have documented the incident as it had occurred on her shift, and should have contacted the Physician and Responsible Party (RP). During this same interview with LVN "A" she indicated it was not a normal practice to transfer a resident at 10:00 p.m. to be weighed but LVN "B" had assigned this task to be completed by the CNAs during their 2:00 p.m. to 10:00 p.m. shift. The CNAs were redirected to do so before leaving for the night and they took a short cut to get it done quickly. LVN "A" said weighing R#1 could have waited until the next day. LVN "A" stated she had assessed R#1 on 08/07/13 before she was lifted back to bed. During this interview she provided a drawing of the events and stated she was outside R#1's room and called for help. She could not explain how she assessed R#1 from outside the room. In an interview on 09/26/13 at 10:50 a.m., LVN "B" stated she was at the nurse ' s station on 08/07/13 at approximately 9:50 p.m. , when she heard CNAs yell for help. She went to R#1's room where she observed three CNAs (CNA "A", "B", and "C") in the room with R#1 on the floor on one knee. She stated the CNAs had attempted a two person transfer, from the bed to the shower chair. She stated the CNAs told her while transferring R#1 they realized the resident was too heavy and let her to the ground. She stated no mechanical lift was observed in the room. LVN "B" stated she asked the CNAs why no mechanical lift was used, they replied "we thought we could lift her." LVN "B" stated "the CNAs knew R#1 was a Hoyer lift. At this facility we are told if a patient is heavier than you, you should use a (mechanical lift)." One of the CNAs was very small, she questioned them again and the CNAs said they thought they could lift her. On 09/04/13 at 5:00 p.m. interview with CNA "A" revealed on 08/07/13 during her shift, at approximately 9:50 p.m. she and another CNA had atttempted to transfer R#1 from her bed to a shower chair for the purpose of obtaining a weight. CNA "A" stated R#1 was like dead weight, we didn't realize it until it was too late. CNA "A" said, she didn't fall, her legs, I can't explain, she was lowered to the floor. She had her right side of the hip and thigh on the floor, she had her knees bent, her knees went to the ground. I didn't think I had to report because my charge nurse (LVN " B " )was present. During an interview on 09/04/13 at 5:30 p.m., CNA "C" stated she did not utilize the gait belt when tranferring R#1 on 08/07/13 but she had the gait belt around her waist. In an interview on 09/05/13 at 5:50 p.m. with CNA "C" she stated on 08/07/13 she was in the room of R#1 with two other CNAs. She was holding the shower chair, and two other CNAs were trying to transfer R#1 from her bed to the shower chair. It was just prior to shift change. CNA "C" stated "I don't know what happened to her (R#1) that night we could usually do her." "I left her room, clocked out and left the building." CNA "C" stated she did not believe she had to report because her charge nurse (LVN " " B " ) was present and she believed she would report. She did not report until, 08/15/13 when the DON was conducting an investigation and asked her for a statement. CNA "C" stated "we held her, we did not let her go, she did not fall." LVN "A" documented on 08/15/13 at 1:20 a.m. "(CNAs "D" and "E") called me into (R#1's) room because her right knee was swollen. (R#1) complained of pain with touch. Physician called at 1:35 a.m. whom advised to send out to ER for X-Ray. Responsible Party called at 1:37 a.m. to notify. 911 called at 1:45 a.m. Two EMTs (Emergency Medical Technicians) in facility transferring Resident at 1:57 a.m." Director of Nurses (DON) documented on R#1's Nurses' Notes, dated 08/15/13, she was notified at 8:30 a.m. that R#1 was sent to the emergency room (ER) at approximately 2:00 a.m. for swollen right knee. The DON notified R#1's physician. She was informed by hospital staff R#1 would be admitted with right femur fracture. The DON notified R#1's Responsible Party (RP). The DON also notified R#1's RP that during her investigation she had learned of an incident that occurred on Thursday, 08/08/13. The DON explained her charge nurses said that on 08/08/13 the charge nurse for the 2:00 p.m. to 10:00 p.m. shift asked two CNAs to get a weight on R#1. The transfer was not completed and they eased resident to floor on her knees. Nurses checked R#1 and noted redness to knees before they assisted CNAs in putting R#1 back to bed. During an interview on 09/04/13 at 10:30 p.m., the DON stated upon arrival at the facility on 08/15/13 she was told R#1 had been sent to the nearest hospital. She was informed by hospital staff R#1 was admitted due to fractures. The DON stated she began the investigation. While interviewing staff she discovered R#1 had previously been involved in an incident on 08/07/13 or 08/08/13. The DON stated she found: - staff had not used a mechanical lift (Hoyer), - the incident had not been documented anywhere, - the physician had not been notified, and - the responsible party was not notified. During an interview with Physician " A " on 09/04/13 at 6:45 p.m., he stated he was not notified of (R #1) incurring a incident/fall until the Don called him after (R #1) was hosptalized on [DATE]. R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. Radiology Report dated 08/15/13 of R#1's right femur indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphyseal region is identified. The distal fragment is displaced slightly posteriorly. The tibia (shin bone) follows the distal fragment. A vertically oriented fracture through the patella (knee-cap) is also noted." According to www.britanica.com on 10/04/13 comminuted means, the broken ends of the bone are jammed together by the force of the injury. Radiology Report dated 08/15/13 of R#1's right knee indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphysis is identified with anterior apex angulation.....A fracture through the posterior aspect of the patella is also identified. R#1's Hospital Discharge Record dictated by Physician "B" on 08/18/13 at 1:54 p.m. revealed: Admitting Diagnoses: [REDACTED]. Right Patellar fracture Dehydration [MEDICAL CONDITION] (increased sodium level) Acute [MEDICAL CONDITION] Urinary Tract Infection Chronic bedridden state Discharge Diagnoses: [REDACTED]. Right patellar fracture Dehydration [MEDICAL CONDITION], resolved Acute [MEDICAL CONDITION], resolved Chronic bedridden state Urinary tract infection "Hospital Course" "A [AGE] year old female from (facility) comes in after sustaining a right distal femur fracture and right patellar fracture, unknown etiology. However, this injury can only occur in a fall in a patient who is chronically bedridden and cannot ambulate. Nonetheless, the patient was brought here and was evaluated by Orthopedics. After a lengthy discussion with the family, it was concluded the patient would be a high surgical risk candidate because of her advanced age. As a result, the decision was made to not surgically repair the fracture. The patient was placed in a straight leg brace. Plan is to allow the fracture to heal spontaneously. Even if the leg heals in a deformed state, the patient will never use the leg. The patient's life expectancy is less than a year." "As a result of the fall, the patient presented with acute [MEDICAL CONDITION], hemoglobin of 8. She received several units of blood. Her hemoglobin is now 11 and she is more stable. She also presented with BUN (Blood Urea Nitrogen - blood test) of 111 and creatinine of 1.6 and serum sodium of 150. These labs were consistent with the patient who is acutely dehydrated from this acute traumatic event. The patient is fed via PEG (Percutaneous endoscopic gastrostomy - a tube inserted into stomach for nutrition, fluids, and medications) and receives water flushes. This is to suggest that this trauma occurred at least 3 days prior to presentation resulting in her body's response to the fluid shift that would occur with this kind of injury. The patient was given hypotonic fluids with the resolution of her [MEDICAL CONDITION] and significant improvement of her acute [MEDICAL CONDITION]. Additional laboratory date revealed a urine culture positive for Proteus mirabilis resistant to more than half of the antibiotic on antiobiotic panel, but the patient is sensitive to third generation cephalosporins such as [MEDICATION NAME] or the oral form which is [MEDICATION NAME]. The patient can be discharged back to the nursing home with the same medications as prior. Recommend an air mattress and/or hospital bed. Recommend decubitus precautions. Recommend increasing the PEG free water flushes to 400 ml (milliliters) q (every) 6 for the next 5 days. We will add [MEDICATION NAME] suspension (antibiotic) 300 mg PEG b.i.d. (twice daily) x 14 days. [MEDICATION NAME] (antibiotic used to treat bacterial infections of the eye) 1 to 2 drops b.i.d. to both eyes for 7 days. Follow up Orthopedics in 2 to 4 weeks to evaluate fracture healing. We will continue all previous home medications as outlined in the nursing home medication requisition sheet." During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The facility's Resident-Data-Collection Form dated 08/19/13 indicate R#1 was readmitted to the facility on [DATE] at 18:30 (6:30 p.m.) with the [DIAGNOSES REDACTED]. Special treatments and procedures listed an imbolizer to knee. R#1's functional status indicated total assist. The facility's admission orders [REDACTED] Right distal Femoral Fracture, Right Patellar fracture, Dehydration, [MEDICAL CONDITION] (increased sodium level), Acute [MEDICAL CONDITION], and Urinary Tract Infection. R#1's Physician's Telephone Orders dated 08/19/13 indicated keep knee immobilizer on at all times. Non weight bearing to right lower extremity. R#1's Care Plan dated 08/19/13 included the approaches: keep knee immobilizer on at all times to right leg, non-weight bearing, assess right leg for rednessw/[MEDICAL CONDITION], notify physician/family of any complications, medicate for pain as needed. R#1's Care Plan dated 08/26/13 stated, "Resident had a recent fall. hospitalized for [REDACTED]. Not a candidate for Surgery. Resident is to wear knee immobilizer at all times with no weight bearing. Good family support. Received blood transfusion at hospital stay. Requires assist X 2 CNAs for all transfers." R#1's Significant Change, MDS dated [DATE], indicated R#1 required physical assistance of two or more persons for transfers. During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The DON stated she had not considered investigating any of their July and August fall incidents to rule our possible neglect or had called any of them into the State. The facility's Incident Accident Log for July and August 2013 identified 16 falls involving 11 residents. The facility's Incident/Accident Log documented 11 residents who had experienced recent falls and were not investigated as possible neglect. The facility was given the opportunity during the investigation and time of exit to provide additional information regarding implementation of their their neglect policy and procedures. At time of exit 09/26/13 no additional documentation was provided.

Based on observation, interview, and record review, the facility failed to ensure each resident received and provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one Resident (R#1) of one resident reviewed for pain. R#1 experienced a fall on 08/07/13. There was no evidence of another fall or injury between 08/07/13 and 08/14/13. On 8/15/13 Resident # 1 was diagnosed with [REDACTED]. Resident # 1's physician was not consulted until after Resident 1's hospitalization on [DATE]. Licensed Vocational Nurses/Charge Nurses (LVNs) "A" and "B" failed to conduct follow-up assessments and document those assessments after R#1's incident/injury. There was no revised pain relief intervention before or after Resident # 1's hospitlization to ensure adequate pain relief after Resident #1's 08/07/13 incident/injury. This failure could affect 12 residents on pain management program, placing them at risk of no timely assessment of unrelieved pain. The findings included: R#1's Admission Record dated 03/19/13 indicated R#1 was originally admitted to facility on 12/21/10 and readmitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1 was [AGE] years old. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] documented R#1 was totally dependent and required two person assistance for transfers. R#1's cognition was moderately impaired - decisions poor; cues/supervision required. R#1 usually understood and usually understands others. R#1 was unable to answer if she had pain or hurting at any time. R#1's Care Plan Conference Summary dated 07/30/13, revealed "Adjusted well to nursing home placement, (family members) visit daily..... No signs of skin breakdown. Requires total assist X 2 CNAs (Certified Nurse Aides) for all ADLs (Activities of Daily Living (transfers from bed to wheelchair, grooming, hygiene)). Sits up in Geri chair (a wheelchair that cannot be self propelled and reclines) at times." R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. . Nurses' Notes dated 08/13/13 indicated R#1 was showered and shower aides noticed R#1's altered mental status and body was lethargic while in the Geri chair. Facility called physician, responsible party and 911. R#1 was transferred to ER at 8 a.m. and readmitted to facility at 1:30 p.m. R#1 did not complain of pain or discomfort. On 08/14/13 at 9 a.m. the Nurses' Notes indicated R#1 was administered medications and was in no acute distress. The facility's investigation packet for incident of 08/07/13, included a witness statement dated 08/15/13 by CNA "D" indicated, "I came in to work (08/07/13)15 min (minutes) before 10 p.m. I was called to go to (R#1's) Room so I went running to her room. When I walked in (R#1) was on her knees on the floor. (CNAs "A", "B", and "C") were in the room already with (R#1). They were going to to get (R#1's) weight. (CNA "A") said they were gonna transfer (R#1) by hand, (CNA "A") and (CNA "B") but (R#1) was too heavy so they just sat her on the floor gently that she did not fall down. So I helped them transfer her from floor to bed. Went to do the ten o clock me and (CNA "E") I saw it looked swollen. So I reported it (LVN "B") she came and checked it out. (LVN "B") didn't see anything wrong because (R#1) was not complaining. So Wed (Wednesday) August 14 me and (CNA "E") were doing rounds again. We took off her sheets and saw her right leg was inward a lot, so we called our (LVN "B") she came to look at it. So she sent (R#1) out." The facility's investigation packet included a witness statement dated 08/15/13 by CNA "E" indicated "A week ago from today on 8-8-13 3 CNA's from 2-10 shift were trying to transfer a resident (R#1) from her bed to a shower chair to weigh her. The 3 CNA's (CNA "B", "A" and "C") were not able to transfer resident they then ask for help, (CNA "D", LVN "B", and LVN "A") and myself walked in to help. The 3 CNA's claim to have placed (R#1) (resident) on the floor because she was too heavy to transfer. (CNAs "D", "A", and "B") and I picked (R#1) up from the floor and transfered back to her bed. As (CNA "D") and I checked (R#1) for any skin tears, bruises, extc.(sic) we did notice some swelling to right knee we did report to our nurse, (LVN "B") and (LVN "A") as well. (LVN "B") did look at her knee and claimed that nothing was wrong. As the days went by (CNA "D") and I have reported that (R#1) was in pain and her knee did not look good. Now I do not know if the nurse wrote it down or not. Last night on 8-15-13 (CNA "D") and I were doing our 12:00 a.m. round as we walked into (R#1's) room we then removed the blanket and notice her leg twisted we did not touch her we immediately called our Charge Nurse (LVN "B.) (LVN "B") checked her out and agreed with (CNA "D") and I that her knee did not look good and you could see that the resident was in a lot of pain with her facial expressions. Right after (LVN "B") calls EMT'S to send (R#1) out." On 09/03/13 at 12:55 a.m. CNA "D" stated on 08/0713 she arrived for her 10:00 p.m. shift. Prior to start of her shift she heard a call for help and went down the hall. She observed R#1 on her knees. CNA "D" stated she did not report the incident to anyone because both the LVN from the 6 p.m. to 10 p.m. shift and the charge nurse from the 10 p.m. to 6 a.m. shift had been in the room and she "assumed they had taken care of it."CNA " D " stated on 08/07/13 she noticed (R #1 made facial expressions, like hurting, when she was turned and changed. CNA " D " told her charge nurse (LVA " A " ), who then checked {R # 1). As the days went by CNA " D " continued to notice (R #1) making faces, and her right leg looked swollen, it was bigger than the other leg. CNA " D " said (LVN " A " ) would assess and say something like she didn ' t see nothing wrong with her (R #1) did not see any distress. I know I reported concern to my charge nurse (LVN " A " ) at least 4 times. On 09/04/13 at 1:40 a.m. CNA " E " was interviewed, CNA " E " stated on 08/07/13 she had just arrived for her 10 p.m. shift when she heard her charge nurse (LVN " A " ) call for her. She stated she went down the hall and found R3 1 on her knees on the floor. The CNA ' s from the 2-10 shift were trying to transfer a resident (R #1) from her bed to a shower chair to weigh her. The 3 CNA ' s (CNA " B " . " A " , and " C " ) were not able to transfer resident, they then called for help. The 3 CNA ' s claim to have placed (R #1) resident on the floor because she was too heavy to transfer. (CNA ' s " D " , " A " and " B " ) and I picked up (R #1) for any skin tears, bruises, extc, (sic) we did notice some swelling to right knee we did report to our nurse (LVN " A " ) and (LVN " B " ) as well. We (CNA " E " and " D " reported to our nurse (LVN " A " ) that (R #1} said " OW " , (LVN " A " ) said she always makes noises. I told the nurse about my concerns at least 4 times. She looked at (R #1) and she looked fine, she told us no one else reports it just us (CNA " E " and CNA " D " ). After about one week, when (CNA " D " ) and myself turned back the sheets for (R #1} we observed her right leg was twisted. We reported it to our charge nurse (LVN " A " ) and she sent her out to the hospital. During an interview on 09/05/13 at 4:15 p.m., LVN "A" indicated R#1 was a two person assist and was unable to stand; therefore, they were required to use a mechanical lift to transfer R#1. LVN "A" stated she was present in the building on 08/07/13 at approximately 9:50 p.m. when she heard someone call for help. She went to assist and found R#1 on the floor on her knees. Three CNAs had attempted to transfer her from her bed to a shower chair, and were unable to complete the transfer. LVN "B" who had been the Charge Nurse for the 2:00 p.m. to 10:00 p.m. shift was already in R#1's room. LVN "A" stated she did not make any documentation regarding the incident until 08/15/13 when the DON interviewed her and R#1 had been sent to the hospital. LVN "A" stated she did not investigate or interview any staff regarding this incident on 08/07/13. LVN "A" said she did not contact the Physician or the Responsible Party. LVN "A" stated she did not know why the CNAs were not using the Hoyer lift (a mechanical lift). LVN "A" stated she could not say why she did not report the incident. LVN "A" stated she believed the 2:00 p.m. to 10:00 p.m. LVN (LVN "B") should have documented the incident as it had occurred on her shift, and should have contacted the Physician and Responsible Party (RP). During this same interview with LVN "A" she indicated it was not a normal practice to transfer a resident at 10:00 p.m. to be weighed but LVN "B" had assigned this task to be completed by the CNAs during their 2:00 p.m. to 10:00 p.m. shift. The CNAs were redirected to do so before leaving for the night and they took a short cut to get it done quickly. LVN "A" said weighing R#1 could have waited until the next day. LVN "A" stated she had assessed R#1 on 08/07/13 before she was lifted back to bed. During this interview she provided a drawing of the events and stated she was outside R#1's room and called for help. She could not explain how she assessed R#1 from outside the room. In an interview on 09/26/13 at 10:50 a.m., LVN "B" stated she was at the nurse ' s station on 08/07/13 at approximately 9:50 p.m. , when she heard CNAs yell for help. She went to R#1's room where she observed three CNAs (CNA "A", "B", and "C") in the room with R#1 on the floor on one knee. She stated the CNAs had attempted a two person transfer, from the bed to the shower chair. She stated the CNAs told her while transferring R#1 they realized the resident was too heavy and let her to the ground. She stated no mechanical lift was observed in the room. LVN "B" stated she asked the CNAs why no mechanical lift was used, they replied "we thought we could lift her." LVN "B" stated "the CNAs knew R#1 was a Hoyer lift. At this facility we are told if a patient is heavier than you, you should use a (mechanical lift)." One of the CNAs was very small, she questioned them again and the CNAs said they thought they could lift her. On 09/04/13 at 5:00 p.m. interview with CNA "A" revealed on 08/07/13 during her shift, at approximately 9:50 p.m. she and another CNA had atttempted to transfer R#1 from her bed to a shower chair for the purpose of obtaining a weight. CNA "A" stated R#1 was like dead weight, we didn't realize it until it was too late. CNA "A" said, she didn't fall, her legs, I can't explain, she was lowered to the floor. She had her right side of the hip and thigh on the floor, she had her knees bent, her knees went to the ground. I didn't think I had to report because my charge nurse (LVN " B " )was present. During an interview on 09/04/13 at 5:30 p.m., CNA "C" stated she did not utilize the gait belt when tranferring R#1 on 08/07/13 but she had the gait belt around her waist. In an interview on 09/05/13 at 5:50 p.m. with CNA "C" she stated on 08/07/13 she was in the room of R#1 with two other CNAs. She was holding the shower chair, and two other CNAs were trying to transfer R#1 from her bed to the shower chair. It was just prior to shift change. CNA "C" stated "I don't know what happened to her (R#1) that night we could usually do her." "I left her room, clocked out and left the building." CNA "C" stated she did not believe she had to report because her charge nurse (LVN " " B " ) was present and she believed she would report. She did not report until, 08/15/13 when the DON was conducting an investigation and asked her for a statement. CNA "C" stated "we held her, we did not let her go, she did not fall." LVN "A" documented on 08/15/13 at 1:20 a.m. "(CNAs "D" and "E") called me into (R#1's) room because her right knee was swollen. (R#1) complained of pain with touch. Physician called at 1:35 a.m. whom advised to send out to ER for X-Ray. Responsible Party called at 1:37 a.m. to notify. 911 called at 1:45 a.m. Two EMTs (Emergency Medical Technicians) in facility transferring Resident at 1:57 a.m." Director of Nurses (DON) documented on R#1's Nurses' Notes, dated 08/15/13, she was notified at 8:30 a.m. that R#1 was sent to the emergency room (ER) at approximately 2:00 a.m. for swollen right knee. The DON notified R#1's physician. She was informed by hospital staff R#1 would be admitted with right femur fracture. The DON notified R#1's Responsible Party (RP). The DON also notified R#1's RP that during her investigation she had learned of an incident that occurred on Thursday, 08/08/13. The DON explained her charge nurses said that on 08/08/13 the charge nurse for the 2:00 p.m. to 10:00 p.m. shift asked two CNAs to get a weight on R#1. The transfer was not completed and they eased resident to floor on her knees. Nurses checked R#1 and noted redness to knees before they assisted CNAs in putting R#1 back to bed. During an interview on 09/04/13 at 10:30 p.m., the DON stated upon arrival at the facility on 08/15/13 she was told R#1 had been sent to the nearest hospital. She was informed by hospital staff R#1 was admitted due to fractures. The DON stated she began the investigation. While interviewing staff she discovered R#1 had previously been involved in an incident on 08/07/13 or 08/08/13. The DON stated she found: - staff had not used a mechanical lift (Hoyer), - the incident had not been documented anywhere, - the physician had not been notified, and - the responsible party was not notified. During an interview with Physician " A " on 09/04/13 at 6:45 p.m., he stated he was not notified of (R #1) incurring a incident/fall until the Don called him after (R #1) was hosptalized on [DATE]. R#1's Clinical Chart did not contain any documentation in the Nurses' Notes from 08/07/13 until 08/15/13 at 1:20 a.m. regarding R#1's incident on 08/07/13. Radiology Report dated 08/15/13 of R#1's right femur indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphyseal region is identified. The distal fragment is displaced slightly posteriorly. The tibia (shin bone) follows the distal fragment. A vertically oriented fracture through the patella (knee-cap) is also noted." According to www.britanica.com on 10/04/13 comminuted means, the broken ends of the bone are jammed together by the force of the injury. Radiology Report dated 08/15/13 of R#1's right knee indicated "an impacted comminuted [MEDICAL CONDITION] femoral metaphysis is identified with anterior apex angulation.....A fracture through the posterior aspect of the patella is also identified. R#1's Hospital Discharge Record dictated by Physician "B" on 08/18/13 at 1:54 p.m. revealed: Admitting Diagnoses: [REDACTED]. Right Patellar fracture Dehydration [MEDICAL CONDITION] (increased sodium level) Acute [MEDICAL CONDITION] Urinary Tract Infection Chronic bedridden state Discharge Diagnoses: [REDACTED]. Right patellar fracture Dehydration [MEDICAL CONDITION], resolved Acute [MEDICAL CONDITION], resolved Chronic bedridden state Urinary tract infection "Hospital Course" "A [AGE] year old female from (facility) comes in after sustaining a right distal femur fracture and right patellar fracture, unknown etiology. However, this injury can only occur in a fall in a patient who is chronically bedridden and cannot ambulate. Nonetheless, the patient was brought here and was evaluated by Orthopedics. After a lengthy discussion with the family, it was concluded the patient would be a high surgical risk candidate because of her advanced age. As a result, the decision was made to not surgically repair the fracture. The patient was placed in a straight leg brace. Plan is to allow the fracture to heal spontaneously. Even if the leg heals in a deformed state, the patient will never use the leg. The patient's life expectancy is less than a year." "As a result of the fall, the patient presented with acute [MEDICAL CONDITION], hemoglobin of 8. She received several units of blood. Her hemoglobin is now 11 and she is more stable. She also presented with BUN (Blood Urea Nitrogen - blood test) of 111 and creatinine of 1.6 and serum sodium of 150. These labs were consistent with the patient who is acutely dehydrated from this acute traumatic event. The patient is fed via PEG (Percutaneous endoscopic gastrostomy - a tube inserted into stomach for nutrition, fluids, and medications) and receives water flushes. This is to suggest that this trauma occurred at least 3 days prior to presentation resulting in her body's response to the fluid shift that would occur with this kind of injury. The patient was given hypotonic fluids with the resolution of her [MEDICAL CONDITION] and significant improvement of her acute [MEDICAL CONDITION]. Additional laboratory date revealed a urine culture positive for Proteus mirabilis resistant to more than half of the antibiotic on antiobiotic panel, but the patient is sensitive to third generation cephalosporins such as [MEDICATION NAME] or the oral form which is [MEDICATION NAME]. The patient can be discharged back to the nursing home with the same medications as prior. Recommend an air mattress and/or hospital bed. Recommend decubitus precautions. Recommend increasing the PEG free water flushes to 400 ml (milliliters) q (every) 6 for the next 5 days. We will add [MEDICATION NAME] suspension (antibiotic) 300 mg PEG b.i.d. (twice daily) x 14 days. [MEDICATION NAME] (antibiotic used to treat bacterial infections of the eye) 1 to 2 drops b.i.d. to both eyes for 7 days. Follow up Orthopedics in 2 to 4 weeks to evaluate fracture healing. We will continue all previous home medications as outlined in the nursing home medication requisition sheet." During an interview on 09/06/13 at 3:35 p.m., the DON said this incident involving R#1 was investigated and substantiated as neglect by the LVNs involved. The DON stated she had not considered investigating possible neglect by the CNAs. The DON stated she had reported incidents of possible neglect in the past to the State. The facility's Resident-Data-Collection Form dated 08/19/13 indicate R#1 was readmitted to the facility on [DATE] at 18:30 (6:30 p.m.) with the [DIAGNOSES REDACTED]. Special treatments and procedures listed an imbolizer to knee. R#1's functional status indicated total assist. The facility's admission orders [REDACTED] Right distal Femoral Fracture, Right Patellar fracture, Dehydration, [MEDICAL CONDITION] (increased sodium level), Acute [MEDICAL CONDITION], and Urinary Tract Infection. R#1's admission orders [REDACTED]. R#1's chart contained no documentation of pain assessment. The MAR (Medication Administration Record) revealed two documentations for administration of Tylenol 325 mg x 2. It was administered on 09/04/13 and 09/05/13, while the investigation was in process. On 09/05/13, at 2:20 p.m. during wound care, Licensed Vocational Nurse (LVN) "M" stated R#1 at been administered Tylenol 325 mg x 2 at 1 p.m. During this observation, Resident # 1 was moaning and groaning. R#1's Physician's Telephone Orders dated 08/19/13 indicated keep knee immobilizer on at all times. Non weight bearing to right lower extremity. R#1's Care Plan dated 08/19/13 included the approaches: keep knee immobilizer on at all times to right leg, non-weight bearing, assess right leg for rednessw/[MEDICAL CONDITION], notify physician/family of any complications, medicate for pain as needed. R#1's Care Plan dated 08/26/13 stated, "Resident had a recent fall. hospitalized for [REDACTED]. Not a candidate for Surgery. Resident is to wear knee immobilizer at all times with no weight bearing. Good family support. Received blood transfusion at hospital stay. Requires assist X 2 CNAs for all transfers." R#1's Significant Change, MDS dated [DATE], indicated R#1 required physical assistance of two or more persons for transfers. The facility's undated "Change in a Resident's Condition or Status" policy revealed: Policy Statement, "Our facility shall promptly notify...his or her Attending Physician.....of changes in the resident's medical condition...." Policy Interpretation and Implementation, "#1....Charge Nurse will notify the resident's Attending Physician....when there has been: a. an accident or incident involving the resident; b. a discovery of injuries of unknown source....d. a significant change in the resident's physical/emotional/mental condition...." On 09/14/13 at 6:30 p.m. Physician "A" the treating physician for R#1, as well as the facility Medical Director, was interviewed. Physician "A" stated he had been contacted by the facility and told R#1 was being readmitted to the facility. The facility did not advise him of R#1's [DIAGNOSES REDACTED].#1's pain. Physician "A" stated "if they had I would have ordered something different. I will see her and review her record this evening." Physician "A" stated he had last seen resident on 07/31/13. Post interview with surveyor, Physician's Telephone Order dated 09/04/13 Physician "A" ordered R#1 [MEDICATION NAME] 50 mg one tablet via [DEVICE] (tube inserted into the stomach for provision of nutrition, fluids and medications)PRN (as needed) for pain Q6 hrs (every 6 hours). The facility's Centers for Medicare and Medicaid Services Resident Census and Conditions of Residents Form 672 documented 12 residents on pain management program. On 09/26/13 during the exit conference the Administrator and Director of Nurses were given the opportunity to provide additional information, regarding pain management. No additional information was provided.

Based on interview and record review, the facility failed to immediately consult with the physician for one of eight Residents (R #1) reviewed for a change in condition. The facility failed to consult with the physician for R #1 when the facility recognized that R #1 had a change in condition and exhibited signs of oxygen deprivation. -The resident was congested and expelled green/yellow mucus. -The resident's fingernails were cyanotic (lack of oxygen). -Staff did not assess the resident's oxygen level after staff recognized the signs/symptoms of lack of oxygen. -Staff administered oxygen and a nebulizer treatment, and then left the resident alone in his room during the treatment. -The resident was found without a pulse or respirations approximately five minutes later. Failure to notify the physician affected R #1 by denying the resident's physician the opportunity to provide guidance in R #1's care could place one resident receiving respiratory treatment at risk of not receiving possible orders for life sustaining medical care. Findings were: Review of R #1's Acknowledgement of Advance Care Planning dated [DATE] revealed, "Resident is a full code status" (measures taken to sustain life), signed by a family member and facility staff. Review of R #1's Face Sheet dated [DATE] revealed an admission date of [DATE]. Review of R #1's Care Plans dated [DATE] revealed the following: History of Pneumonia: Monitor R #1 for episodes of congestion and SOB (shortness of breath) and assess and notify MD (medical doctor) and family...O2 (oxygen) sats (saturations) readings; Full Code Status, and Cognitive Loss. Review of R #1's Physician order [REDACTED]. Review of R #1's Minimum Data Set ((MDS) dated [DATE] revealed R #1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R #1: required extensive assistance for bed mobility, transfers, toileting, and bathing; had a feeding tube for nutrition (a tube place into the abdomen to provide nutrition); had not received oxygen therapy in the facility in the past 14 days; had a moderately impaired cognition (cueing required); usually made self understood and usually understood others. On [DATE] at 3:15 p.m., Licensed Vocational Nurse (LVN) "A" said that on [DATE], he worked the hours of 2:00 p.m. to 10:00 p.m. and did not make rounds at the beginning of the shift. At 4:50 p.m., LVN "A" said he went to R #1's room to administer a routine medication. LVN "A" said he noticed that R #1 was congested and placed a paper towel under R #1's mouth so the resident could expel mucus. LVN "A" said the mucus was thick and yellowish-green, and that the resident was in no distress. LVN "A" said that the head of R #1's bed was elevated at a thirty degree angle. LVN "A" said that he began a "[MEDICATION NAME]" treatment (breathing treatment) to R #1, and then noticed that R #1's nailbeds were cyanotic. LVN "A" said that he did not use a Pulse Oximeter to obtain R #1's oxygen level because the Pulse Oximeter would not be able to get a reading due to R #1's cyanotic nailbeds. LVN "A" said the he put a nasal cannula (tubing applied into the nostrils that provided oxygen to the body) into R #1's nostrils at a rate of 3 liters per minute, and left the room to make a follow-up call to the physician of another resident. LVN "A" said that he was then called to another resident's room by staff to assist with an "aggressive" resident. LVN "A" said that after he assisted the staff, he then went to R #1's room at 4:55 p.m. and found R #1 without a pulse or respirations. LVN "A" said that he initiated CPR at that time. LVN "A" said he called for staff to assist him in giving R #1 CPR and to call 911. LVN "A" said the EMS arrived at approximately 5:05 p.m., and that he continued CPR until the resident was put into the ambulance. LVN "A" said that it was the facility's policy to make rounds at the change of shift and to observe a resident during medication administration, but that LVN "A" felt comfortable leaving R #1 alone during the "[MEDICATION NAME]" treatment because R #1 was cooperative. LVN "A" said that he should have called 911 when he observed congestion, green/yellow mucus, and cyanotic fingernails of R #1. Review of R #1's Nurses Notes dated [DATE], [DATE], [DATE] and [DATE] on all three shifts revealed no change in condition for R #1. Review of R #1's Nurses Notes dated [DATE] revealed no change in condition for R #1 on the 10:00 p.m. ([DATE]) to 6:00 a.m. ([DATE]) and 6:00 a.m. to 2:00 p.m. shifts. The nurses notes on [DATE] revealed the following: "4:50 p.m. Rt (resident) awake, alert, respirations low and nonlabored. Rt showing s/s (signs and symptoms) of congestion. [MEDICATION NAME] tx (treatment) administered as ordered. Nailbeds appeared cyanotic. O2 (oxygen) administered via n/c (nasal cannula) @ 3L/min (3 liters per minute). Will cont (continue) to monitor; 4:55 p.m. Visual check observed that resident had 0 (no) respirations, pulse checked 0 pulse found, CPR initiated 911 called; 5p.m. CPR cont'd (continued), ambulance arrived @ facility; 5:10 p.m. Rt out of facility; 5:20 p.m. Rts (resident's) (FM "2") notified because unable to notify Rts (FM "1"); 5:25 p.m. Rts (FM "1") returned call + (and) he was informed of the transfer of (R #1); 5:30 p.m. (MD "1") notified of transfer." Review of R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"B" initialed that R #1 received one dose of [MEDICATION NAME] on [DATE] on the 6:00 a.m. to 2:00 p.m. shift. The MAR for the month of [DATE] revealed no doses of [MEDICATION NAME] were documented or initialed as administered. Review of the facility's Change in Resident's Condition or Status Policy dated [DATE] revealed: "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:..d. A significant change in the resident's physical/emotional/mental condition;...i. Instructions to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status." On [DATE] at 2:30 p.m., the Director of Nurses (DON) stated that it was the facility's policy for staff to make rounds at the change of shift and to notify the physician of a change in condition immediately for an emergency, or to call 911 in an emergency. Record review of the facility's Form 672 dated [DATE] revealed one resident with respiratory treatment. On [DATE] at 6:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on interview and record review, the facility failed to implement their policy and procedures that prohibit neglect for one of eight Residents (R #1) reviewed for neglect. The facility failed to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment when the facility recognized that R #1 had a change in condition and exhibited signs of oxygen deprivation. -The resident was congested and expelled green/yellow mucus. -The resident's fingernails were cyanotic (lack of oxygen). -Staff did not assess the resident's oxygen level after staff recognized the signs/symptoms of lack of oxygen. -Staff administered oxygen and a nebulizer treatment, and then left the resident alone in his room during the treatment. -The resident was found without a pulse or respirations approximately five minutes later. Failure to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment affected R #1 by possibly denying him care and services to avoid physical harm and could place one remaining resident receiving respiratory treatment at risk for lack of services. Findings were: Review of R #1's Acknowledgement of Advance Care Planning dated [DATE] revealed, "Resident is a full code status" (measures taken to sustain life), signed by a family member and facility staff. Review of R #1's Face Sheet dated [DATE] revealed an admission date of [DATE]. Review of R #1's Care Plans dated [DATE] revealed the following: History of Pneumonia: Monitor R #1 for episodes of congestion and SOB (shortness of breath) and assess and notify MD (medical doctor) and family...O2 (oxygen) sats (saturations) readings; Full Code Status, and Cognitive Loss. Review of R #1's Physician order [REDACTED]. Review of R #1's Minimum Data Set ((MDS) dated [DATE] revealed R #1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R #1: required extensive assistance for bed mobility, transfers, toileting, and bathing; had a feeding tube for nutrition (a tube place into the abdomen to provide nutrition); had not received oxygen therapy in the facility in the past 14 days; had a moderately impaired cognition (cueing required); usually made self understood and usually understood others. On [DATE] at 3:15 p.m., Licensed Vocational Nurse (LVN) "A" said that on [DATE], he worked the hours of 2:00 p.m. to 10:00 p.m. and did not make rounds at the beginning of the shift. At 4:50 p.m., LVN "A" said he went to R #1's room to administer a routine medication. LVN "A" said he noticed that R #1 was congested and placed a paper towel under R #1's mouth so the resident could expel mucus. LVN "A" said the mucus was thick and yellowish-green, and that the resident was in no distress. LVN "A" said that the head of R #1's bed was elevated at a thirty degree angle. LVN "A" said that he began a "[MEDICATION NAME]" treatment (breathing treatment) to R #1, and then noticed that R #1's nailbeds were cyanotic. LVN "A" said that he did not use a Pulse Oximeter to obtain R #1's oxygen level because the Pulse Oximeter would not be able to get a reading due to R #1's cyanotic nailbeds. LVN "A" said the he put a nasal cannula (tubing applied into the nostrils that provided oxygen to the body) into R #1's nostrils at a rate of 3 liters per minute, and left the room to make a follow-up call to the physician of another resident. LVN "A" said that he was then called to another resident's room by staff to assist with an "aggressive" resident. LVN "A" said that after he assisted the staff, he then went to R #1's room at 4:55 p.m. and found R #1 without a pulse or respirations. LVN "A" said that he initiated CPR at that time. LVN "A" said he called for staff to assist him in giving R #1 CPR and to call 911. LVN "A" said the EMS arrived at approximately 5:05 p.m., and that he continued CPR until the resident was put into the ambulance. LVN "A" said that it was the facility's policy to observe a resident during medication administration, but that LVN "A" felt comfortable leaving R #1 alone during the "[MEDICATION NAME]" treatment because R #1 was cooperative. LVN "A" said that he only stayed with residents during breathing treatments if they did not leave the breathing treatment mask on their face. LVN "A" said that he should have called 911 when he observed congestion, green/yellow mucus, and cyanotic fingernails of R #1. Review of R #1's Nurses Notes dated [DATE], [DATE], [DATE] and [DATE] on all three shifts revealed no change in condition for R #1. Review of R #1's Nurses Notes dated [DATE] revealed no change in condition for R #1 on the 10:00 p.m. ([DATE]) to 6:00 a.m. ([DATE]) and 6:00 a.m. to 2:00 p.m. shifts. The nurses notes on [DATE] revealed the following: "4:50 p.m. Rt (resident) awake, alert, respirations low and nonlabored. Rt showing s/s (signs and symptoms) of congestion. [MEDICATION NAME] tx (treatment) administered as ordered. Nailbeds appeared cyanotic. O2 (oxygen) administered via n/c (nasal cannula) @ 3L/min (3 liters per minute). Will cont (continue) to monitor; 4:55 p.m. Visual check observed that resident had 0 (no) respirations, pulse checked 0 pulse found, CPR initiated 911 called; 5p.m. CPR cont'd (continued), ambulance arrived @ facility; 5:10 p.m. Rt out of facility; 5:20 p.m. Rts (resident's) (FM "2") notified because unable to notify Rts (FM "1"); 5:25 p.m. Rts (FM "1") returned call + (and) he was informed of the transfer of (R #1); 5:30 p.m. (MD "1") notified of transfer." Review of R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"B" initialed that R #1 received one dose of [MEDICATION NAME] on [DATE] on the 6:00 a.m. to 2:00 p.m. shift. The MAR for the month of [DATE] revealed no doses of [MEDICATION NAME] were documented or initialed as administered. Review of the facility's Change in Resident's Condition or Status Policy dated [DATE] revealed: "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:..d. A significant change in the resident's physical/emotional/mental condition;...i. Instructions to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status." On [DATE] at 3:40 p.m., the Director of Nurses (DON) said that it was the facility's policy for nurses to continuously monitor a resident who received a nebulizer treatment, until that treament was completed. On [DATE] at 5:50 p.m., Paramedic "A" said that on [DATE] at approximately 5:00 p.m., her ambulance service was dispatched to the facility to respond to a 911 call regarding R #1. Paramedic "A" said that when Emergency Medical Service (EMS) personnel assessed R #1, facility staff were providing CPR, R #1 was without a pulse or respirations, and an Automated External Defibrillator (AED) was applied to him. Paramedic "A" said the AED reading showed that it was unable to provide defibrillation to R #1, so staff continued to provide manual CPR to R #1, until R #1 was put into the ambulance. Paramedic "A" said EMS personnel continued CPR to R #1, and drove him to the helicopter pad in that town for transport to an out of town hospital. Paramedic "A" said EMS personnel were unable to revive R #1 after performing CPR for approximately 20 minutes, and a physician pronounced R #1 deceased at approximately 6:00 p.m. on [DATE] at the helicopter pad. Paramedic "A" said R #1 was then transported to a funeral home per family request. On [DATE] at 2:30 p.m., the Director of Nurses (DON) stated that it was the facility's policy for staff to make rounds at the change of shift and to notify the physician of a change in condition immediately for an emergency, or to call 911 in an emergency. Review of the facility's Medication Administration Nebulizers Policy dated ,[DATE] revealed: "13. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer." Review of the facility's undated Recognizing/Identifying Signs and Symptoms of Abuse Policy revealed:..."2. 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness; 3. The following are some examples of actual abuse/neglect...2. (bullet number 9) Leaving someone unattended who needs supervision." Record review of the facility's Form 672 dated [DATE] revealed one resident with respiratory treatment. On [DATE] at 6:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on interview and record review, the facility failed to implement their written policy and procedures that prohibit neglect for one of eight Residents (R #1) reviewed for neglect. The facility failed to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment when the facility recognized that R #1 had a change in condition and exhibited signs of oxygen deprivation. -The resident was congested and expelled green/yellow mucus. -The resident's fingernails were cyanotic (lack of oxygen). -Staff did not assess the resident's oxygen level after staff recognized the signs/symptoms of lack of oxygen. -Staff administered oxygen and a nebulizer treatment, and then left the resident alone in his room during the treatment. -The resident was found without a pulse or respirations approximately five minutes later. Failure to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment affected R #1 by possibly denying him care and services to avoid physical harm and could place one remaining resident receiving respiratory treatment at risk for lack of services. Findings were: Review of the facility's undated Recognizing/Identifying Signs and Symptoms of Abuse Policy revealed:..."2. 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness; 3. The following are some examples of actual abuse/neglect...2. (bullet number 9) Leaving someone unattended who needs supervision." Review of the facility's Medication Administration Nebulizers Policy dated ,[DATE] revealed: "13. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer." Review of the facility's Change in Resident's Condition or Status Policy dated [DATE] revealed: "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:..d. A significant change in the resident's physical/emotional/mental condition;...i. Instructions to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status." Review of R #1's Acknowledgement of Advance Care Planning dated [DATE] revealed, "Resident is a full code status" (measures taken to sustain life), signed by a family member and facility staff. Review of R #1's Face Sheet dated [DATE] revealed an admission date of [DATE]. Review of R #1's Care Plans dated [DATE] revealed the following: History of Pneumonia: Monitor R #1 for episodes of congestion and SOB (shortness of breath) and assess and notify MD (medical doctor) and family...O2 (oxygen) sats (saturations) readings; Full Code Status, and Cognitive Loss. Review of R #1's Physician order [REDACTED]. Review of R #1's Minimum Data Set ((MDS) dated [DATE] revealed R #1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R #1: required extensive assistance for bed mobility, transfers, toileting, and bathing; had a feeding tube for nutrition (a tube place into the abdomen to provide nutrition); had not received oxygen therapy in the facility in the past 14 days; had a moderately impaired cognition (cueing required); usually made self understood and usually understood others. On [DATE] at 3:15 p.m., Licensed Vocational Nurse (LVN) "A" said that on [DATE], he worked the hours of 2:00 p.m. to 10:00 p.m. and did not make rounds at the beginning of the shift. At 4:50 p.m., LVN "A" said he went to R #1's room to administer a routine medication. LVN "A" said he noticed that R #1 was congested and placed a paper towel under R #1's mouth so the resident could expel mucus. LVN "A" said the mucus was thick and yellowish-green, and that the resident was in no distress. LVN "A" said that the head of R #1's bed was elevated at a thirty degree angle. LVN "A" said that he began a "[MEDICATION NAME]" treatment (breathing treatment) to R #1, and then noticed that R #1's nailbeds were cyanotic. LVN "A" said that he did not use a Pulse Oximeter to obtain R #1's oxygen level because the Pulse Oximeter would not be able to get a reading due to R #1's cyanotic nailbeds. LVN "A" said the he put a nasal cannula (tubing applied into the nostrils that provided oxygen to the body) into R #1's nostrils at a rate of 3 liters per minute, and left the room to make a follow-up call to the physician of another resident. LVN "A" said that he was then called to another resident's room by staff to assist with an "aggressive" resident. LVN "A" said that after he assisted the staff, he then went to R #1's room at 4:55 p.m. and found R #1 without a pulse or respirations. LVN "A" said that he initiated CPR at that time. LVN "A" said he called for staff to assist him in giving R #1 CPR and to call 911. LVN "A" said the EMS arrived at approximately 5:05 p.m., and that he continued CPR until the resident was put into the ambulance. LVN "A" said that it was the facility's policy to observe a resident during medication administration, but that LVN "A" felt comfortable leaving R #1 alone during the "[MEDICATION NAME]" treatment because R #1 was cooperative. LVN "A" said that he only stayed with residents during breathing treatments if they did not leave the breathing treatment mask on their face. LVN "A" said that he should have called 911 when he observed congestion, green/yellow mucus, and cyanotic fingernails of R #1. Review of R #1's Nurses Notes dated [DATE], [DATE], [DATE] and [DATE] on all three shifts revealed no change in condition for R #1. Review of R #1's Nurses Notes dated [DATE] revealed no change in condition for R #1 on the 10:00 p.m. ([DATE]) to 6:00 a.m. ([DATE]) and 6:00 a.m. to 2:00 p.m. shifts. The nurses notes on [DATE] revealed the following: "4:50 p.m. Rt (resident) awake, alert, respirations low and nonlabored. Rt showing s/s (signs and symptoms) of congestion. [MEDICATION NAME] tx (treatment) administered as ordered. Nailbeds appeared cyanotic. O2 (oxygen) administered via n/c (nasal cannula) @ 3L/min (3 liters per minute). Will cont (continue) to monitor; 4:55 p.m. Visual check observed that resident had 0 (no) respirations, pulse checked 0 pulse found, CPR initiated 911 called; 5p.m. CPR cont'd (continued), ambulance arrived @ facility; 5:10 p.m. Rt out of facility; 5:20 p.m. Rts (resident's) (FM "2") notified because unable to notify Rts (FM "1"); 5:25 p.m. Rts (FM "1") returned call + (and) he was informed of the transfer of (R #1); 5:30 p.m. (MD "1") notified of transfer." Review of R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"B" initialed that R #1 received one dose of [MEDICATION NAME] on [DATE] on the 6:00 a.m. to 2:00 p.m. shift. The MAR for the month of [DATE] revealed no doses of [MEDICATION NAME] were documented or initialed as administered. On [DATE] at 3:40 p.m., the Director of Nurses (DON) said that it was the facility's policy for nurses to continuously monitor a resident who received a nebulizer treatment, until that treament was completed. On [DATE] at 5:50 p.m., Paramedic "A" said that on [DATE] at approximately 5:00 p.m., her ambulance service was dispatched to the facility to respond to a 911 call regarding R #1. Paramedic "A" said that when Emergency Medical Service (EMS) personnel assessed R #1, facility staff were providing CPR, R #1 was without a pulse or respirations, and an Automated External Defibrillator (AED) was applied to him. Paramedic "A" said the AED reading showed that it was unable to provide defibrillation to R #1, so staff continued to provide manual CPR to R #1, until R #1 was put into the ambulance. Paramedic "A" said EMS personnel continued CPR to R #1, and drove him to the helicopter pad in that town for transport to an out of town hospital. Paramedic "A" said EMS personnel were unable to revive R #1 after performing CPR for approximately 20 minutes, and a physician pronounced R #1 deceased at approximately 6:00 p.m. on [DATE] at the helicopter pad. Paramedic "A" said R #1 was then transported to a funeral home per family request. On [DATE] at 2:30 p.m., the Director of Nurses (DON) stated that it was the facility's policy for staff to make rounds at the change of shift and to notify the physician of a change in condition immediately for an emergency, or to call 911 in an emergency. Record review of the facility's Form 672 dated [DATE] revealed one resident with respiratory treatment. On [DATE] at 6:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.

Based on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of eight Residents (R #1) reviewed for quality of care. The facility failed to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment when the facility recognized that R #1 had a change in condition and exhibited signs of oxygen deprivation. -The resident was congested and expelled green/yellow mucus. -The resident's fingernails were cyanotic (lack of oxygen). -Staff did not assess the resident's oxygen level after staff recognized the signs/symptoms of lack of oxygen. -Staff administered oxygen and a nebulizer treatment, and then left the resident alone in his room. -The resident was found without a pulse or respirations approximately five minutes later. Failure to assess R #1's oxygen level, consult with R #1's physician, and remain with R #1 during a breathing treatment affected R #1 by possibly denying him care and services to avoid physical harm and could place one remaining resident receiving respiratory treatment at risk for lack of services. Findings were: The Texas Administrative Code Title 22, Part 11, Chapter 217, Rule 217.11 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; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (D) Accurately and completely report and document: (vi) contacts with other health care team members concerning significant events regarding client's status." Review of R #1's Acknowledgement of Advance Care Planning dated [DATE] revealed, "Resident is a full code status" (measures taken to sustain life), signed by a family member and facility staff. Review of R #1's Face Sheet dated [DATE] revealed an admission date of [DATE]. Review of R #1's Care Plans dated [DATE] revealed the following: History of Pneumonia: Monitor R #1 for episodes of congestion and SOB (shortness of breath) and assess and notify MD (medical doctor) and family...O2 (oxygen) sats (saturations) readings; Full Code Status, and Cognitive Loss. Review of R #1's Physician order [REDACTED]. Review of R #1's Minimum Data Set ((MDS) dated [DATE] revealed R #1's [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R #1: required extensive assistance for bed mobility, transfers, toileting, and bathing; had a feeding tube for nutrition (a tube place into the abdomen to provide nutrition); had not received oxygen therapy in the facility in the past 14 days; had a moderately impaired cognition (cueing required); usually made self understood and usually understood others. On [DATE] at 3:15 p.m., Licensed Vocational Nurse (LVN) "A" said that on [DATE], he worked the hours of 2:00 p.m. to 10:00 p.m. and did not make rounds at the beginning of the shift. At 4:50 p.m., LVN "A" said he went to R #1's room to administer a routine medication. LVN "A" said he noticed that R #1 was congested and placed a paper towel under R #1's mouth so the resident could expel mucus. LVN "A" said the mucus was thick and yellowish-green, and that the resident was in no distress. LVN "A" said that the head of R #1's bed was elevated at a thirty degree angle. LVN "A" said that he began a "[MEDICATION NAME]" treatment (breathing treatment) to R #1, and then noticed that R #1's nailbeds were cyanotic. LVN "A" said that he did not use a Pulse Oximeter to obtain R #1's oxygen level because the Pulse Oximeter would not be able to get a reading due to R #1's cyanotic nailbeds. LVN "A" said the he put a nasal cannula (tubing applied into the nostrils that provided oxygen to the body) into R #1's nostrils at a rate of 3 liters per minute, and left the room to make a follow-up call to the physician of another resident. LVN "A" said that he was then called to another resident's room by staff to assist with an "aggressive" resident. LVN "A" said that after he assisted the staff, he then went to R #1's room at 4:55 p.m. and found R #1 without a pulse or respirations. LVN "A" said that he initiated CPR at that time. LVN "A" said he called for staff to assist him in giving R #1 CPR and to call 911. LVN "A" said the EMS arrived at approximately 5:05 p.m., and that he continued CPR until the resident was put into the ambulance. LVN "A" said that it was the facility's policy to observe a resident during medication administration, but that LVN "A" felt comfortable leaving R #1 alone during the "[MEDICATION NAME]" treatment because R #1 was cooperative. LVN "A" said that he only stayed with residents during breathing treatments if they did not leave the breathing treatment mask on their face. LVN "A" said that he should have called 911 when he observed congestion, green/yellow mucus, and cyanotic fingernails of R #1. Review of R #1's Nurses Notes dated [DATE], [DATE], [DATE] and [DATE] on all three shifts revealed no change in condition for R #1. Review of R #1's Nurses Notes dated [DATE] revealed no change in condition for R #1 on the 10:00 p.m. ([DATE]) to 6:00 a.m. ([DATE]) and 6:00 a.m. to 2:00 p.m. shifts. The nurses notes on [DATE] revealed the following: "4:50 p.m. Rt (resident) awake, alert, respirations low and nonlabored. Rt showing s/s (signs and symptoms) of congestion. [MEDICATION NAME] tx (treatment) administered as ordered. Nailbeds appeared cyanotic. O2 (oxygen) administered via n/c (nasal cannula) @ 3L/min (3 liters per minute). Will cont (continue) to monitor; 4:55 p.m. Visual check observed that resident had 0 (no) respirations, pulse checked 0 pulse found, CPR initiated 911 called; 5p.m. CPR cont'd (continued), ambulance arrived @ facility; 5:10 p.m. Rt out of facility; 5:20 p.m. Rts (resident's) (FM "2") notified because unable to notify Rts (FM "1"); 5:25 p.m. Rts (FM "1") returned call + (and) he was informed of the transfer of (R #1); 5:30 p.m. (MD "1") notified of transfer." Review of R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"B" initialed that R #1 received one dose of [MEDICATION NAME] on [DATE] on the 6:00 a.m. to 2:00 p.m. shift. The MAR for the month of [DATE] revealed no doses of [MEDICATION NAME] were documented or initialed as administered. Review of the facility's Change in Resident's Condition or Status Policy dated [DATE] revealed: "1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been:..d. A significant change in the resident's physical/emotional/mental condition;...i. Instructions to notify the physician of changes in the resident's condition. 2. A 'significant change' of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; b. Impacts more than one area of the resident's health status...4. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status." On [DATE] at 3:40 p.m., the Director of Nurses (DON) said that it was the facility's policy for nurses to continuously monitor a resident who received a nebulizer treatment, until that treament was completed. Review on [DATE] of LVN "A"'s personnel record revealed a hire date of [DATE]. Review of the Discipline Records revealed no disciplinary actions taken since LVN "A" was hired. Review on [DATE] of LVN "A"'s personnel record revealed a disciplinary verbal counseling was given to LVN "A" on [DATE]: "Failed to follow proper policy and procedure of med (medication) administration" signed by the DON. On [DATE] at 5:50 p.m., Paramedic "A" said that on [DATE] at approximately 5:00 p.m., her ambulance service was dispatched to the facility to respond to a 911 call regarding R #1. Paramedic "A" said that when Emergency Medical Service (EMS) personnel assessed R #1, facility staff were providing CPR, R #1 was without a pulse or respirations, and an Automated External Defibrillator (AED) was applied to him. Paramedic "A" said the AED reading showed that it was unable to provide defibrillation to R #1, so staff continued to provide manual CPR to R #1, until R #1 was put into the ambulance. Paramedic "A" said EMS personnel continued CPR to R #1, and drove him to the helicopter pad in that town for transport to an out of town hospital. Paramedic "A" said EMS personnel were unable to revive R #1 after performing CPR for approximately 20 minutes, and a physician pronounced R #1 deceased at approximately 6:00 p.m. on [DATE] at the helicopter pad. Paramedic "A" said R #1 was then transported to a funeral home per family request. On [DATE] at 2:30 p.m., the Director of Nurses (DON) stated that it was the facility's policy for staff to make rounds at the change of shift and to notify the physician of a change in condition immediately for an emergency, or to call 911 in an emergency. Review of the facility's Medication Administration Nebulizers Policy dated ,[DATE] revealed: "13. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer." Review of the facility's undated Recognizing/Identifying Signs and Symptoms of Abuse Policy revealed:..."2. 'Neglect' is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, or mental illness; 3. The following are some examples of actual abuse/neglect...2. (bullet number 9) Leaving someone unattended who needs supervision." Record review of the facility's Form 672 dated [DATE] revealed one resident with respiratory treatment. On [DATE] at 6:20 p.m. during the exit conference, the DON and Administrator were given the opportunity to provide additional information. None was provided.