Every finding on record at Nashville Center for Rehabilitation and Healing LL

Based on facility policy review, observation, and interview, the facility failed to maintain clean and sanitary equipment for 1 of 3 ice machines and 2 of 2 stove drip pans. The facility also failed to properly store refrigerated foods in 1 of 2 walk-in coolers. The findings include: Review of the facility's policy titled, Sanitization, revealed, .The food service area is maintained in a clean and sanitary manner .Ice chests and coolers used to store and transport ice are cleaned regularly . Review of the facility's policy, Ice Machines and Ice Storage Chests, revealed, .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Ice-making machines, ices storage chests/containers, and ice can all become contaminated by .unsanitary manipulation . Observation and interview in the kitchen on 3/13/2023 at 10:15 AM, revealed the small and large drip pans with large amounts of black, brown debris covering the width of pans. The Dietary Aide #2 confirmed the drip tray should be cleaned after every use. Observation and interview in the kitchen on 3/13/2023 at 10:20 AM, the Administrator confirmed the drip pans need to be cleaned immediately. Observation and interview of the walk-in cooler on 3/13/2023 at 10:30 AM, revealed sliced cheese wrapped in clear wrap with no label or date. The Dietary Aide #2 confirmed it should be labeled, dated, and the Dietary Aide #2 discarded the cheese. Observation and interview of the Kitchen ice machine on 3/13/2023 at 10:45 AM, revealed a carton (8 ounces) of liquid nutrition supplement was submerged down in the ice. The Dietary Aide #2 pulled the carton from the ice machine and stated, That should not be placed down in the ice chest.

Based on medical record review and interview, the facility failed to develop and implement an effective discharge planning process for 1 of 40 sampled residents (Resident #32) reviewed for potential discharge. The findings include: Review of the undated facility policy titled, Transfer or Discharge, Facility-Initiated, revealed, .A post-discharge plan is developed for each resident .This plan will be reviewed with the resident, and/or his or her family . Review of the medical record revealed Resident #32 admitted to facility on 9/21/2020 with diagnoses which included Atherosclerotic Heart Disease and Displaced Comminuted Fracture of Right Arm. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Review of the care plan revealed Resident #32 had a focus of resident expects to return to his previous living arrangement out in the community with an intervention to make arrangements with required community resources to support independence post-discharge. During an interview on 3/13/2022 at 1:20 AM, Resident #32 stated, I would like to discuss my care. I came to the facility because I broke my arm, been here two years and I would like to go back home. During an interview on 3/15/2023 at 9:37 AM, Social Service Director confirmed no documentation related to his wish to discharge. During an interview on 3/15/2023 at 11:06 AM, the Discharge planner stated, Discharge planning starts upon admission.

Based on facility policy review, medical record review, and interview the facility failed to have a declination form for Influenza and Pneumococcal Immunizations for 1 of 5 (Resident #8) sampled residents reviewed. The findings include: Review of the undated facility policy titled, Influenza Vaccine revealed .All residents and employees who have no medical contraindications to the vaccine will be offered the Influenza vaccine annually to encourage and promote the benefits associated with vaccinations aganist influenza .A resident's refusal of the vaccine shall be documented on the informed consent for Influenza vaccine and placed in the resident's medical record . Review of the undated facility policy titled, Pneumococcal Vaccine revealed .All residents are offered Pneumococcal vaccines to aid in preventing Pneumonia/Pneumococcal infections .Residents/representatives have the right to refuse vaccination. If, refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the Pneumococcal vaccination . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included COVID-19, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #8 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitve impairment. Review of the undated Influenza Immunization Informed Consent revealed the form was not signed for acceptance or decline of the immunization. Review of the undated Informed Consent for Pneumococcal Vaccine revealed the form was not signed for acceptance or decline of the immunization. During an interview on 3/15/2023 at 9:10 AM, Infection Preventionist confirmed the consent forms for Influenza and Pneumococcal are supposed to be filled out if refused.

44724 47127 Based on facility policy review, medical record review, and interviews, the facility failed to create and provide a baseline care plan for 5 of 40 (Residents #59, #62, #100, #216, and #358) sampled residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Care Plans Baseline, dated 11/30/2022, revealed, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment .The resident and/or record . Review of the medical record revealed Resident #34 was readmitted on [DATE] with diagnoses which included Altered Mental Status, End Stage Renal Disease, and Cerebral Infarction. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34's Brief Interview for Mental Status (BIMS) score of 8 indicated moderately impaired cognition. Review of the care plan history detail revealed the last review of the baseline care plan was completed on 1/21/2023. The baseline care plan was not reviewed after Resident #34's readmission. During an interview on 3/6/2023 at 9:25 AM, MDS Coordinator confirmed baseline care plans should be completed on admission by the admitting nurse. During an interview on 3/6/2023 at 9:35 AM, the Wound Care Nurse confirmed Resident #34's baseline care plan has not been reviewed since her readmission on 3/6/2023. During an interview on 3/6/2023 at 9:45 AM, Social Service Director (SSD) confirmed, I met with [Named Resident #34] on the day of admission within 24 hours. If a resident or family wanted a copy of the care plan, I think they would have to go through medical records to be able to obtain a copy. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] and readmitted to this facility on 2/10/2023 with diagnoses of Malignant Neoplasm of Prostate, Depression and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Quarterly MDS for Resident #59 dated 2/18/2023 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the baseline care plan for Resident #59 revealed the baseline care plan was not completed within 48 hours. Review of the medical record revealed Resident #62 was readmitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes and Atrial Flutter. Review of the Admission MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 15 indicating no cognitive impairment. During an interview on 3/13/2023 at 9:00 AM, Resident #62 confirmed the resident had not received a copy of the baseline care plan after admission to the facility. Review of the medical record revealed Resident #100 was admitted to this facility on 2/21/2023 with diagnoses of Infection and Inflammatory Reaction Due to Internal Left Hip Prosthesis, Subsequent Encounter. Review of the Comprehensive MDS for Resident #100 dated February 10, 2023 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 03/13/2023 at 11:15 AM, Resident #100 confirmed she had not received a copy of her baseline care plan. Review of the medical record revealed Resident #216 was admitted to the facility on [DATE] with diagnoses which included Abscess of Bursa Left Shoulder and Type 2 Diabetes Mellitus. During an interview on 3/13/2023 at 4:09 PM, Resident #216 confirmed he was not given a copy of his baseline care plan. Review of the medical records revealed Resident #358 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb, Type 2 Diabetes Mellitus without Complications. Continued review confirmed a baseline care plan was not initiated for Resident #358.

Based on facility policy, medical record review, and interview the facility failed to determine and perform a significant change Minimum Data Set (MDS) assessment for 1 of 40 sampled residents (Resident #16) reviewed. The findings include: Review of the facility MDS/Care Plan Coordinator Job Description revealed, .MDS/Care Plan Coordinator is an experienced health care provider who ensures an accurate assessment and up-to-date care plan for all residents . Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual revealed, .A significant change is a decline or improvement in a resident's status .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of medical record revealed Resident #16 admitted to facility on 8/16/2020 with diagnoses which included Metabolic Encephalopathy, Hepatic Failure, and Alcoholic Cirrhosis of Liver. Review of Resident #16's Nursing Progress Notes revealed, .12/14/2022 resident noted with IV [intravenous] fluids for hydration .responsive sluggishly to name, unable to safely swallow hs [hour of sleep] meds at present d/t [due to] cognition, resident not following verbal commands effectively HOB [head of bed] elevated for aspiration precaution .12/16/2023 resident noted with IV fluids for hydration .12/30/2022 .resident AMS [altered mental status] .start Rocephin [antibiotic] for Covid PNA [pneumonia] .would need midline placed .1/4/2023 resident presents overall weak .1/30/2023 Right Heel Unstageable wound with 100 % Eschar . Review of the Quarterly MDS dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status score of 11 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #16 experience no swallowing disorders and no unhealed pressure ulcers. Review of Resident #16's Nurse Practitioner Notes revealed, .1/06/2023 Covid f/u [follow up] .2/22/2023 Pt [patient] seen today for f/u per ST [Speech Therapy] .they think Pt's excess saliva and swallowing is due to esophagus issues .ST recommends PPI [proton pump inhibitors - medications that reduce the production of acid by the stomach] Omeprazole [PPI medication] ordered .3/14/2023 .IV fluids .ordered x 3 days .3/15/2023 CXR [chest xray] shows right basilar infiltrate . During an interview on 3/15/2023 at 11:26 AM, MDS coordinator confirmed a significant change MDS assessment would be completed if a new diagnoses, significant weight loss, or overall decline in a resident. The MDS coordinator confirmed the last MDS for Resident #16 was 12/26/2022 which was a Quarterly MDS assessment. During an interview on 3/16/2023 at 9:14 AM, Wound Care Nurse stated (Resident #16) had an overall decline that started in January. It started with Covid diagnose, her nutritional status decline, we had to assist her more with meals, and then the facility acquired unstageable pressure ulcer presented on 1/30/2023.

Based on facility policy review, medical record review, observation, and interview the facility failed to apply hubs to the end of an IJ (Internal Jugular Vein) Catheter external limbs and failed to apply a hub on the end of an IV (Intravenous) tubing and date the tubing for 1 of 17 (Resident #216) residents. The findings include: Review of the undated facility's policy titled, Administration Set/Tubing Changes revealed .Label tubing with date, time and initials. If a facility requires, label may include the date and time that tubing was initated and when tubing should be discontinued or changed .Place a sterile end cap on the primary and/or secondary intermittent tubing when it is disconnected from the catheter . Review of the medical record revealed Resident #216 was admitted to the facility on [DATE] with diagnosis which included Abscess of Bursa Left shoulder. Review of the Physician orders dated 3/8/2023 revealed .Vancomycin HCl Intravenous Solution Reconstituted 750 mg (milligrams) intravenously every 12 hours for L [left shoulder] Osteomyelitis . Observation and interview on 3/13/2023 at 11:22 AM revealed Resident #216 had an IJ on the right torso with three external limbs. Continued observation revealed each limb did not have a hub on the end. To the right of Resident #216 was a IV pole with a IV bag of Vancomycin with the tubing undated and no hub on the end. Resident #216 stated he admitted to the facility without hubs on the IJ. Observation and interview in Resident #216's room on 3/13/2023 at 11:34 AM, the Licensed Practical Nurse (LPN) #4 confirmed the IJ did not have hubs on the ends of the external limbs and they were supposed to be capped. Continued interview revealed the IV tubing was supposed to be dated and the end of the tubing should be capped when not in use. During an interview on 3/14/2023 at 9:39 AM, the Unit Manager for 100 hall confirmed she was aware the IJ external limbs were not capped, and the IV bag of Vancomycin tubing was undated and not capped at the end. During and interview on 3/16/2023 at 2:25 PM, the Director of Nursing (DON) stated she expected the central lines to have a hub on the ends when not in use, and the iv tubing should be dated with a hub on the end when not in use.

Based on facility record review and interview the facility failed to obtain State approval to open a Long Term Care (LTC) Hemodialysis Unit. The findings include: Review of the facility policy titled, Long-Term Care Facility Renal Dialysis Coordination Agreement, dated 11/17/2020 revealed, .agreement where by the three [3] hours per treatment, and is administered up to five [5] treatments per week, pursuant to a physician's order .to residents of the LTC facility .on the premises of the LTC facility through the Dialysis Facility's home program, including the provision of training services in the delivery of Renal Dialysis to Residents . Review of the facility email from Tennessee Department of Health dated 6/6/2022 revealed, .[Named Facility] this office received your plan (s) for the above referenced project for review and approval. This [We Concur] letter and stamp will serve as full documentation for approval and installation of nine station dialysis den as reflected on revised the attached .sketch. This letter, however, does not relieve the owner, architects, sprinkler contractors or any other subcontractors from legal and/or regulatory responsibilities associated with the documents . Review of the (named dialysis in-house clinic's) time log dated 3/17/2023 revealed 10 residents scheduled to receive hemodialysis at the LTC facility. During an interview on 3/16/2023 at 3:38 PM the Administrator stated, Our first day the facility started in-house hemodialysis was 9/20/2021. I thought that our dialysis clinic was approved. We have 10 residents receiving in house dialysis.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure 1 of 5 sampled residents (Resident #77's) enteral tube was labeled and dated. The findings include: Review of facility policy titled, Enteral Feedings-Safety dated 3/08/2023 revealed, .2. on the formula label document initial, date and time the formula was hung, and initial that the label was checked against the order . Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Acute Disseminated Encephalitis and Encephalomyelitis Unspecified, and Encephalopathy Unspecified. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 receives nutrition by enteral tube and no Brief Inteview for Mental Status (BIMS) score was documented. Review of the current Physician's Orders for Resident #77 revealed orders for the enteral tube. Observations in Resident #77's room on 3/14/2023 at 8:22 AM and 9:50 AM, revealed enteral tube was not labeled and dated. Observation and interview in Resident #77s room on 3/14/2023 at 9:53 AM, the Unit Manager confirmed that the enteral tube should be labeled and dated. During an interview on 3/14/2023 at 10:11 AM, the Director of Nursing (DON) confirmed Resident #77's enteral tube should be labeled and dated.

Based on medical record review and interview the facility failed to have a declination form for the COVID-19 vaccination for 1 of 5 (Resident #8) sampled residents reviewed. The findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included COVID 19, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #8 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitve impairment. Review of the undated COVID-19 Informed Consent Form revealed the form was not signed for acceptance or declination of the immunization. During an interview on 3/15/2023 at 9:10 AM, the Infection Preventionist confirmed the consent form for the COVID-19 vaccination was supposed to be filled out if they refuse.

Based on facility policy review, observation, and interview the facility failed to have 1 of 40 operable call lights. The findings include: Review of the undated facility policy titled, Answering the Call Light revealed .Be sure the call light is plugged in and functioning at all times . Observation and interview in Resident #62's room on 3/14/2023 at 9:22 AM, Resident #62 stated his call light was not working. Continued interview revealed I push the hell out of the button before it will come on. Observation and interview in Resident #62's room on 3/14/2023 at 9:35 AM, confirmed the Unit Manger pressed the call light and it was not working. The Unit Manager reset the call light button and the light lit up. Then she turned it off and pressed the button again and it did not work. During an interview on 3/14/2023 at 9:45 AM, the Director of Maintenance confirmed the call light cord was worn and had been dropped which caused it not to work.

Based on facility policy review, observation, and interview the facility failed to have adequate dining space for 3 of 3 rooms in the facility. The findings include: Review of the facility policy titled, TN COVID Communal Dining and Activity Programs, and Resident Outings revised 11/2022, revealed .Communal actvities and dining do not have to be paused during an outbreak, unless directed by the state or local health department . Observation in the 600 hall activties/dining room on 3/14/2023 at 7:55 AM revealed the door had a key pad which required a code before entering. There was a big TV (television) and various tables and chairs used for actvities. Contnued observation revealed games and activties stacked up aganist the wall on the shelves. Observation in the dining area for the 100, 200, 300, and 400 halls (Rehabilitation unit) on 3/15/2023 at 9:39 AM revealed one table with three chairs and two couches. Observation in the dining room on the 500 hall on 3/15/2023 at 9:55 AM revealed many items from different parts of the building stored in the room. The room had no space for communal dining. During an interview on 3/14/2023 at 8:48 AM, the Administrator stated the residents were having meals in their rooms at the time because of the construction which was currently happening at the facility. During an interview on 3/15/2023 at 9:42 AM, the Staffing Educator stated the Rehabilitation unit did not have communal dining area. During an interview on 3/15/2023 at 11:43 AM, the Activities Director confirmed the 600 hall dining room was a multipurpose room which held activities. The dining room held lunch club every day which was changed to movie time because many residents wanted to continue to watch TV or movies while eating. Continued interview revealed a dinner was held in the 600 hall dining room once a month. The residents who required assistance with their meals ate in their rooms. The Actvities Director stated it is not fine dining.

44724 Based on facility policy review, medical record review, observation, and interview, the facility failed to have quarterly care plan conference meetings with the resident or resident's representative for 11 out of 40 sampled residents (Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82). The findings include: Review of the undated facility policy, Care Plans, Comprehensive Person-Centered, revealed, .The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan is developed within seven [7] days of the completion of the required MDS [Minimum Data Set] [Admission, Annual or Significant Change in Status], and no more than 21 days after admission .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The IDT team reviews and updates the care plan .when there has been a significant change in the resident's condition .when the desired outcome is not me .when the resident has been readmitted to the facility from a hospital stay .at least quarterly, in conjunction with the required quarterly MDS assessment . Review of the undated facility policy, Care Planning-Interdisciplinary Team, revealed, The interdisciplinary team is responsible for the development of resident care plans .The IDT includes but is not limited to .resident's attending physician .a registered nurse .nursing assistant .member of the food and nutrition services staff .Care plan meetings scheduled at the best time of the day for the resident and family .if it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record . Review of the medical records revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Human Immunodeficiency Virus Disease, Unspecified Symptoms and Signs Involving Cognitive Functions following Cerebral Infarction, and Restless Leg Syndrome. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. Review of the medical records for Resident #19 revealed one Care Plan meeting on 3/24/2021 with family involvement. No further Care Plan meetings were noted. Review of the medical records revealed Resident #30 was admitted to the facility on [DATE]which included Alzheimer's Disease, Chronic Kidney Disease, and Unspecified Protein-Calorie Malnutrition. Review of the Significant change in status MDS dated [DATE] for Resident #30 revealed a BIMS score of 2 which indicated cognitive impairment. Review of the Care Plan for Resident #30 revealed one Care Plan meeting on 12/15/2021 with family involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident #32 was admitted to the facility on [DATE] with a readmission on 7/1/2022 with diagnoses of altered mental status, vascular dementia without behavioral disturbance, mood disturbance and anxiety. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated a severe cognitive impairment. Review of medical records revealed MDSs for Resident #32 were updated on 7/8/2022, 7/14/2022, 7/21/2022, 9/14/2022, 9/16/2022, 9/21/2022, 12/18/2022, 12/19/2022, 1/28/2023. Review of medical records revealed care plans for Resident #32 were completed on 2/26/2022, 7/27/2022, 9/20/2022, 11/2/2022, and 3/7/2023. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Chronic Kidney disease, and Cerebral Infarction. Review of the Significant change in status MDS dated [DATE] for Resident #49 revealed a staff assessment for mental status which revealed memory problems. Review of the medical record for Resident #49 revealed one Care Plan meeting on 8/25/2021 with family involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident # 57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Acute Respiratory Failure with Hypoxia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Metabolic Encephalopathy. Review of the Comprehensive MDS dated [DATE] revealed Resident #57 had no BIMS score present. MDS indicated BIMS should not be conducted and Resident #57 has short-term and long-term memory problems and was severely impaired. Review of the medical records revealed MDSs for Resident #57 were updated on 11/4/2021, 2/4/2022, significant change on 2/28/2022, 5/31/2022, 8/3/2022, 11/27/2022, 12/22/2022, and 2/16/2023. Review of the medical records revealed care plans for Resident #57 were completed on 4/17/2022, 8/3/2022, 9/20/2022 and 1/12/2023. Review of the medical records revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia Unspecified, Chronic Obstructive Pulmonary Disease Unspecified, and Mild Intellectual Disabilities. Review of the Quarterly MDS dated [DATE] for Resident #60 revealed a BIMS score of 12 which indicated moderately impaired cognition. Review of the medical records for Resident #60 revealed one Care Plan meeting on 11/20/2020 with resident involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident #69 was admitted to this facility on 3/12/2021 with diagnoses of Atrial Fibrillation, Essential Hypertension and Major Depressive Disorder. Review of the Quarterly MDS dated [DATE] revealed Resident #69 had a BIMS score of 15 which indicated no cognitive impairment. Review of the medical records revealed MDSs were updated on 9/10/2021, 12/10/2021, 3/15/2022, 5/22/2022, 8/24/2022, 10/24/2022, 12/23/2022, 1/5/2023 and 3/16/2023. Review of the medical records revealed the care plans for Resident #69 were completed on 10/1/2021, 1/7/2022, 4/23/2022, 8/3/2022 and 10/11/2022. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included Myoclonus, End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. Review of the Quarterly MDS dated [DATE] for Resident #76 revealed a BIMS score of 10 which indicated moderately impaired cognition. Review of the medical records for Resident #76 revealed no Care Plan Conferences had been held. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Acute Disseminated Encephalitis and Encephalomyelitis and Encephalopathy Unspecified. Review of the Comprehensive MDS dated [DATE] for Resident #77 revealed no BIMS score documented. Review of the medical records for Resident #77 revealed one Care Plan meeting on 4/13/2022 with resident and family involvement. No further Care Plan meetings were noted. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Other Orthopedic Aftercare, Pneumonia due to Coronavirus Disease 2019, and Displaced Intertrochanteric Fracture of the Left Femur Subsequent Encounter for Closed Fracture with Routine Healing. Review of the Comprehensive MDS dated [DATE] for Resident #81 revealed a BIMS score of 12. Review of the medical records for Resident #81 revealed one Care Plan meeting on 1/11/2022 with resident and family involvement. No further Care Plan meetings were noted. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Schizoaffective Disorder, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #82 revealed a BIMS score of 3 which indicated cognitive impairment. Review of the medical record for Resident #82 revealed one Care Plan meeting on 5/19/2022 with family involvement. No past Care Plan meetings were noted nor any family participation in the care planning process. During an interview on 3/15/2023 at 9:37 AM, the Social Service Director confirmed that she only does care plan conferences for long term care residents at the resident's or the family's request. She also confirmed that she has not done care conferences with Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82. During an interview on 3/15/2023 at 11:26 AM, the MDS Coordinator confirmed, The care plan should be reviewed and revised after each annual, Quarterly MDS assessment. Each department completes their part of the MDS, completes the CAAs (Care Area Assessments), and then the department would make the care plan decisions. Every department gets notified in Point Click Care (PPC-electronic computer system) that it is time to review and revise the care plan. If the care plan was reviewed or revised it would show under the care plan review of the PCC system. 46532

Based on facility policy review, medical record review, and interviews, the facility failed to report an allegation of abuse for 1 of 3 residents (Resident #1) reviewed. The findings include: Review of the facility's undated policy titled, Abuse Prevention Program, revealed, .Our residents have the right to be free from abuse, neglect, misappropriation or resident property, corporal punishment, and involuntary seclusion .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .d. The protection of residents during abuse investigations .f. Timely and thorough investigations of all reports and allegations of abuse .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . Review of the facility's undated policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, revealed, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect .the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult Protective Services .Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury .All allegations are thoroughly investigated .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Review of the facility's undated policy titled, Resident Rights, revealed, .Employees shall treat all residents with kindness, respect, and dignity .Residents are entitled to exercise their rights and privileges to the fullest extent possible . Review of Certified Nurse Assistant #1's employee file revealed date of hire as [DATE]. Continued review revealed an active CNA license #209088 with an expiration date of [DATE]. Continued review revealed he was educated on Resident Rights and the Abuse Policy on [DATE]. Continued review revealed a background check, including the Abuse Registry, was completed on [DATE]. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Colon, Intra-abdominal and Pelvic Swelling, Mass and Lump, and Chronic Pain Syndrome. Review of the Significant Change in Status Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed she felt down, depressed, or hopeless nearly everyday during the assessment period. Review of the Care Plan for Resident #1 revealed she had problems/assessments for weight decline, the use of antidepressant medications, anemia, colostomy, requires assistance with activities of daily living (ADL)s, use of antipsychotics, and comfort measures only. Appropriate goals and interventions were in place. Review of the Progress Notes for Resident #1 revealed was seen by the Nurse Practitioner (NP) for an acute mental status change on [DATE]. She was also seen by the NP on [DATE] due to having 2 falls the day before. The note stated, . pt [patient] not oriented to place or time, but states she fell and hit back of neck/head area .Per nursing staff, pt is more confused than normal. Pt refuses to go to hospital . Continued review revealed she expired on [DATE] at 11:50 PM. During a phone interview on [DATE] at 9:30 AM, Lab Technician (Lab Tech) #1 stated she has only been to this facility once, and it was on the day she claimed she saw Resident #1 not being cared for. She stated when she entered the room, the resident had one leg off the bed and was yelling, Don't let me fall. She stated the bed covers were off the resident and she was exposed up to her chest area. She stated the resident told her she was afraid because the male CNA slaps her and pulls her blanket up over her head. She stated she went and asked the male CNA to help her pull her up in bed. She stated the male CNA, whom the resident had accused of slapping her, came in the room to help. She stated she went to a male Medication Technician (Med Tech) on the first floor and told him what she had witnessed and what the resident had told her about the CNA slapping her and pulling the blanket over her head. She stated he told her to go to the front lobby and tell the lady behind the desk. She stated she did go and tell (Named employee) what had happened. She stated this employee stopped her and took her to a conference room where the Assistant Director of Nursing (ADON) came in and she stated she told her everything she had witnessed and heard. She stated the ADON did not appear interested in what she was saying and told her the resident has cancer and it has moved to her brain. She stated the ADON told her the resident refused care that morning and that's why she looked like she did. During an interview on [DATE] at 10:00 AM, Med Tech #1 stated on [DATE] a Lab Tech came to him and said she had concerns about a resident in room [ROOM NUMBER]. He stated she was visibly upset and told him the resident was being abused by the CNA. He stated he stopped her and told her to go tell [Named Unit Manager.] During an interview on [DATE] at 10:33 AM, UM #1 stated on [DATE] the Lab Tech came to her and told her she saw something she didn't like. She stopped her there, and told her she would get the ADON, which she stated she did right away. She stated the ADON came and talked to her from there. During an interview on [DATE] at 10:45 AM, the ADON stated the Lab Tech had voiced concerns about Resident 1's care. She stated the Lab Tech told her the resident was uncovered, dirty and her mouth was dry. During a phone interview on [DATE] at 12:20 PM, CNA #1 stated he had taken care of Resident #1 several times. He stated she was always very pleasant and didn't ask for much. He stated she had never accused him of being mean to her. He stated last Monday ([DATE]) she had declined and was not as responsive as she usually was. He stated the Lab Tech asked him to help her get her straightened back up in the bed. He stated they straightened her out and repositioned the linens under her. He stated she was not incontinent. He stated he has never been accused of being abusive and has never been written up for anything. He stated he has never slapped her nor pulled her blanket over her face. During an interview on [DATE] at 3:34 PM, the Administrator stated the ADON told him a Lab Tech complained to her about a care issue with Resident #1. He stated he was told the resident was not appropriately being cared for. He stated he was not told the resident had accused a CNA of slapping her or pulling the covers over her head. He stated he should have been notified immediately of the allegation and was not. He confirmed the Med Tech should have reported the allegation immediately to either himself, or to his manager, and he did not. He confirmed he should have reported the accusation to the State Agency and an immediate investigation should have been started.

Based on facility policy review, medical record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #1) reviewed. The findings include: Review of the facility's undated policy titled, Abuse Prevention Program, revealed, .Our residents have the right to be free from abuse, neglect, misappropriation or resident property, corporal punishment, and involuntary seclusion .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .d. The protection of residents during abuse investigations .f. Timely and thorough investigations of all reports and allegations of abuse .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . Review of the facility's undated policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, revealed, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect .the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult Protective Services .Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury .All allegations are thoroughly investigated .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Review of the facility's undated policy titled, Resident Rights, revealed, .Employees shall treat all residents with kindness, respect, and dignity .Residents are entitled to exercise their rights and privileges to the fullest extent possible . Review of Certified Nurse Assistant #1's employee file revealed date of hire as [DATE]. Continued review revealed an active CNA license #209088 with an expiration date of [DATE]. Continued review revealed he was educated on Resident Rights and the Abuse Policy on [DATE]. Continued review revealed a background check, including the Abuse Registry, was completed on [DATE]. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Colon, Intra-abdominal and Pelvic Swelling, Mass and Lump, and Chronic Pain Syndrome. Review of the Significant Change in Status Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed she felt down, depressed, or hopeless nearly everyday during the assessment period. Review of the Care Plan for Resident #1 revealed she had problems/assessments for weight decline, the use of antidepressant medications, anemia, colostomy, requires assistance with activities of daily living (ADL)s, use of antipsychotics, and comfort measures only. Appropriate goals and interventions were in place. Review of the Progress Notes for Resident #1 revealed was seen by the Nurse Practitioner (NP) for an acute mental status change on [DATE]. She was also seen by the NP on [DATE] due to having 2 falls the day before. The note stated, . pt [patient] not oriented to place or time, but states she fell and hit back of neck/head area .Per nursing staff, pt is more confused than normal. Pt refuses to go to hospital . Continued review revealed she expired on [DATE] at 11:50 PM. During a phone interview on [DATE] at 9:30 AM, Lab Technician (Lab Tech) #1 stated she has only been to this facility once, and it was on the day she claimed she saw Resident #1 not being cared for. She stated when she entered the room, the resident had one leg off the bed and was yelling, Don't let me fall. She stated the bed covers were off the resident and she was exposed up to her chest area. She stated the resident told her she was afraid because the male CNA slaps her and pulls her blanket up over her head. She stated she went and asked the male CNA to help her pull her up in bed. She stated the male CNA, whom the resident had accused of slapping her, came in the room to help. She stated she went to a male Medication Technician (Med Tech) on the first floor and told him what she had witnessed and what the resident had told her about the CNA slapping her and pulling the blanket over her head. She stated he told her to go to the front lobby and tell the lady behind the desk. She stated she did go and tell (Named employee) what had happened. She stated this employee stopped her and took her to a conference room where the Assistant Director of Nursing (ADON) came in and she stated she told her everything she had witnessed and heard. She stated the ADON did not appear interested in what she was saying and told her the resident has cancer and it has moved to her brain. She stated the ADON told her the resident refused care that morning and that's why she looked like she did. During an interview on [DATE] at 10:00 AM, Med Tech #1 stated on [DATE] a Lab Tech came to him and said she had concerns about a resident in room [ROOM NUMBER]. He stated she was visibly upset and told him the resident was being abused by the CNA. He stated he stopped her and told her to go tell [Named Unit Manager.] During an interview on [DATE] at 10:33 AM, UM #1 stated on [DATE] the Lab Tech came to her and told her she saw something she didn't like. She stopped her there, and told her she would get the ADON, which she stated she did right away. She stated the ADON came and talked to her from there. During an interview on [DATE] at 10:45 AM, the ADON stated the Lab Tech had voiced concerns about Resident 1's care. She stated the Lab Tech told her the resident was uncovered, dirty and her mouth was dry. During a phone interview on [DATE] at 12:20 PM, CNA #1 stated he had taken care of Resident #1 several times. He stated she was always very pleasant and didn't ask for much. He stated she had never accused him of being mean to her. He stated last Monday ([DATE]) she had declined and was not as responsive as she usually was. He stated the Lab Tech asked him to help her get her straightened back up in the bed. He stated they straightened her out and repositioned the linens under her. He stated she was not incontinent. He stated he has never been accused of being abusive and has never been written up for anything. He stated he has never slapped her nor pulled her blanket over her face. During an interview on [DATE] at 3:34 PM, the Administrator stated the ADON told him a Lab Tech complained to her about a care issue with Resident #1. He stated he was told the resident was not appropriately being cared for. He stated he was not told the resident had accused a CNA of slapping her or pulling the covers over her head. He stated he should have been notified immediately of the allegation and was not. He confirmed the Med Tech should have reported the allegation immediately to either himself, or to his manager, and he did not. He confirmed he should have reported the accusation to the State Agency and an immediate investigation should have been started.

Based on facility policy, record review, observation and interview, the facility failed to update care plans for 1 or 3 sampled residents (Resident # 2), which had the potential to result in unmet care needs. Review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, revealed, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .reflect treatment goals, timetables and objectives in measurable outcomes .the interdisciplinary team must review and update the care plan .when there has been a significant change in the resident's condition . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change MDS assessment dated [DATE] revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive decline. Continued review of the MDS (Minimum Data Set) revealed she required limited to extensive assistance for ADL (Activities of Daily Living) care. Resident #2 was able to walk with limited assistance of one person. Balance during transitions and walking revealed Resident #2 was not steady, only able to stabilize with staff assistance. Further review of the nutritional status for section K of the MDS revealed she had a significant weight loss over the past 6 months. Further review of the MDS revealed Resident #2 received a mechanically altered diet. Continued review of section M of MDS revealed she had an unhealed unstageable pressure ulcer and received a pressure reducing device for bed, nutrition interventions, and pressure ulcer care. Review of the Quarterly MDS assessment dated [DATE] also revealed in section M Resident #2 has an unhealed pressure ulcer. Review of the Care Plan dated 11/6/2021 revealed a plan of care to address skin integrity-actual pressure injury present upon admission related to decrease in mobility 11/6/21 right elbow-unstageable. Further review of the skin integrity Care Plan revealed only three interventions related to administer treatments, educate resident/family/caregivers as to cause of skin breakdown, and monitor for signs and symptoms of infection. During an interview with wound nurse on 12/9/2021 at 11:00 AM, this surveyor asked nurse to review Skin Integrity Care Plan for Resident #2. Wound Nurse reviewed the three interventions noted for the Care Plan. Wound Nurse was asked if Care Plan reflected all interventions used to treat the resident's pressure ulcer, she stated, No. Wound Nurse confirmed Care Plan was not updated to reflect the positioning pillows used, encouraging resident to get up from bed, wound order changes, or the supplements dietician ordered to help with healing. Wound nurse confirmed Care Plan was not updated to reflect needed interventions and changes with the wound.

Based on facility policy, record review, observation, and interview, the facility failed to ensure chemicals were out of Resident's reach for 1 of 3 sampled residents (Resident #2) which had the potential to harm 14 residents on 600 hall who wander. Review of the facility's undated policy titled, Accidents and Incidents-Investigating and Reporting, revealed, .All accidents or incidents involving residents, employees, visitors, vendors .occurring on our premises shall be investigated and reported to the Administrator .Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .the date and time the accident or incident took place .the nature of the injury/illness .the circumstances surrounding the accident or incident .where the accident or incident .the name of witnesses and their accounts of the accident or incident .the injured person's account of the accident or incident .the time the injured person's Attending Physician was notified .the date/time the injured person's family was notified and by whom .the condition of the injured person, including his/her vital signs .any corrective action taken .follow up information .The Nurse Supervisor/Charge Nurse and/or the department director of supervisor shall completed a Report of Incident/Accident form and submit the original to the Director of Nursing within 24 hours of the incident or accident .the director of nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence .Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities . Review of the safety data sheet for Odor Gone Concentrate, revealed, .odor gone concentrate .water-based alkali detergent .eye irritation - Category 2 .if in eyes : rinse cautiously with water for several minutes, remove contact lenses, if present and easy to do continue rinsing .if eye irritation persists get medical attention .warning may be harmful if swallowed .eye irritant .eyes: rinse cautiously with water for several minutes .skin: wash with plenty of soap and water .inhalation: remove person to fresh air and keep comfortable for breathing .call poison center or a doctor if you feel unwell .ingestion: may be harmful if swallowed .seek medical attention immediately .do not use of store near heat, sparks, or open flame .store in a cool, dry place .do not get in eyes, on skin or on clothing .keep out of reach of children . Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with a diagnoses which included Nondisplaced Fracture of Upper End of Right Humerus, Dementia, [CONDITION(S)], Chronic [CONDITION(S)], [CONDITION(S)], CKD stage 3, and Adult Failure to Thrive. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of 3 indicating severe cognitive decline. Continued review of the MDS revealed she required limited to extensive assistance for ADL care. Resident #2 was able to walk with limited assistance of one person. Balance during transitions and walking revealed Resident #2 was not steady, only able to stabilize with staff assistance. During an observation on 600 hall on 12/9/2021 at 11:38 AM Housekeeping was noted cleaning in Resident #2's room. When this surveyor saw housekeeping had left the room surveyor went to Resident #2's room for another interview. When arriving into room 606 B at 11:40 AM this surveyor noted Sani Chem Odor Gone solution sitting on the air conditioning unit next to window. Surveyor stayed at Resident #2's door way in view of Sani Chem Odor Gone solution awaiting to see if housekeeping would come back to pick up solution. The housekeeper noted to leave hall at 12:04 PM. Surveyor called LPN #2 to room 606 B. LPN #2 was asked if solution should be left in room and LPN #2 confirmed it is a safety concern for a confused resident. LPN #2 immediately removed solution at 12:06 PM and placed solution in a secured area. During interview with Housekeeper #1 on 12/9/2021 at 11:53 Surveyor # asked her about chemicals being in room 606 B. Housekeeper #1 stated, I did not mean to leave it in there, I normally keep it on my cart. Housekeeper #1 verified she had been trained that chemicals should not be left where accessible to the residents.

Based on facility policy, observations and staff interview, the facility failed to post the CMS (Center for Medicare Services) Daily Staffing Record on 73 of 290 days in 2021. The findings included: Review of facility policy dated 7/2016 titled, Posting Direct Care Daily Staffing, revealed, .Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of the shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . Observation of CMS Daily Staffing Record revealed the following days were missing: January 2021: 1st, 2nd, 3rd, 5th, 6th, 7th, 8th, 9th, 10th, 11th, 14th, 15th, 16th, 17th, 23rd, 24th, 28th, 30th, and 31st. March 2021: 5th. 6th. 7th, 9th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 25th, and 28th. April 2021: 1st, 3rd, 4th, 6th, 10th, 11th, 14th, 17th, 18th, 22nd, 24th, 25th, 27th, 28th, and 29th. May 2021: 1st, 2nd, 13th, 15th, 16th, 20th, 22nd, 23rd, 25th, 26th, 27th, 28th, and 29th. June 2021: 12th and 13th. July 2021: 28th and 29th. October 2021: 15th, 16th, and 17th. During an interview on 10/20/2021 at 8:36 AM with the Staffing Coordinator, she confirmed, There are holes in the daily staffing sheets and I am aware of it. I should have one for every day and I missed some.

Based on facility policy, medical record review, observations and interviews, the facility failed to protect 1 (Resident #4) of 10 residents reviewed from verbal abuse. The findings include: Review of the facility's policy dated 12/2016 titled Abuse Prevention Program revealed, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .Identify and assess all possible incidents of abuse .Investigate and report any allegations of abuse within timeframes as required by federal requirements .Protect residents during abuse investigations . Review of the facility investigation regarding the alleged verbal abuse, revealed an interview by the Administrator with Resident #4 in her room on 10/14/2021 (no time documented). In the interview, the resident stated the Unit Manager #4 made her feel embarrassed. The Administrator documented he felt Unit Manager #4 had spoken inappropriately and would require desciplinary action and education. Further review revealed an Employee Disciplinary Action Form for Unit Manager #4 dated 10/14/2021 documenting a Warning. The Plan for Improvement stated, Further concerns of this manner will result in suspension and investigation that could based on outcome lead to dismissal. Medical record review for Resident #4 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Further review of the MDS, Section E, Behaviors, revealed she had exhibited no behaviors. During an interview on 10/18/2021 at 2:57 PM with Resident #4 in her room, she stated, .[Named Unit Manager #4] busted in [CONDITION(S)] last week and yelled at me, 'Don't you ever ask anyone to do something without going through me.' It hurt my feelings and embarrassed me. During an interview on 10/18/2021 at 4:26 PM with the Administrator, he stated, [Named Resident #4] was embarrassed because she was talked to in front of others. During an interview on 10/18/2021 at 6:17 PM with Unit Manager #4, she stated Social Service Director #2 told her that Resident #4 had an [named transportation company] set up to leave facility. She stated she went to [CONDITION(S)] and Resident #4 was in the first chair. She stated she told Resident #4 that she could not set these things up without her knowing about it. She stated, With my mask on I have to raise my voice for her to hear me, but it was not in an elevation of anger. During an interview with the Administrator on 10/18/2021 at 4:26 PM, he confirmed he counseled with Unit Manager #4 and issued her a counseling form regarding the fact that she had embarrassed Resident #4 and it was inappropriate, and could be considered verbal abuse.

Based on facility policy, medical record review, observations and interviews, the facility failed to report an incident of verbal abuse for 1 (Resident #4) resident to the State Agency. The findings include: Review of the facility's policy dated 12/2016 titled Abuse Prevention Program revealed, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .Identify and assess all possible incidents of abuse .Investigate and report any allegations of abuse within timeframes as required by federal requirements .Protect residents during abuse investigations . Review of the facility investigation regarding the alleged verbal abuse, revealed an interview by the Administrator with Resident #4 in her room on 10/14/2021 (no time documented). In the interview, the resident stated the Unit Manager #4 made her feel embarrassed. The Administrator documented he felt Unit Manager #4 had spoken inappropriately and would require desciplinary action and education. Medical record review for Resident #4 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. During an interview on 10/18/2021 at 2:57 PM with Resident #4 in her room, she stated, .[Named Unit Manager #4] busted in [CONDITION(S)] last week and yelled at me, 'Don't you ever ask anyone to do something without going through me.' It hurt my feelings and embarrassed me. During an interview on 10/18/2021 at 4:26 PM with the Administrator, he stated, [Named Resident #4] was embarrassed because she was talked to in front of others. It was taken seriously and directed with [Named Unit Manager #4]. During an interview on 10/18/2021 at 6:18 PM with Unit Manager #4, she stated she went to [CONDITION(S)] and Resident #4 was in the first chair. She stated she told Resident #4 that she could not set these things up without her knowing about it. She stated, With my mask on I have to raise my voice for her to hear me, but it was not in an elevation of anger. During an interview with the Administrator on 10/18/2021 at 4:26 PM, he confirmed he had not reported the allegation of verbal abuse to the State Agency, and he should have.

Based on facility policy, medical record review, observations and interviews, the facility failed to prevent the potential for verbal abuse while the investigation is in progress for 1 (Resident #4) resident. The findings include: Review of the facility's policy dated 12/2016 titled Abuse Prevention Program revealed, .Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .Identify and assess all possible incidents of abuse .Investigate and report any allegations of abuse within timeframes as required by federal requirements .Protect residents during abuse investigations . Medical record review for Resident #4 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Review of the facility investigation regarding the alleged verbal abuse, revealed an interview by the Administrator with Resident #4 in her room on 10/14/2021 (no time documented). In the interview, the resident stated the Unit Manager #4 made her feel embarrassed. The Administrator documented he felt Unit Manager #4 had spoken inappropriately and would require desciplinary action and education. Further review revealed an Employee Disciplinary Action Form for Unit Manager #4 dated 10/14/2021 documenting a Warning. The Plan for Improvement stated, Further concerns of this manner will result in suspension and investigation that could based on outcome lead to dismissal. Further review of the faciliy's investigation revealed no residents had been interviewed regarding abuse or mistreatment until 10/18/2021, after the State Agency entered the building. During an interview on 10/18/2021 at 2:57 PM with Resident #4 in her room, she stated, .[Named Unit Manager #4] busted in [CONDITION(S)] last week and yelled at me, 'Don't you ever ask anyone to do something without going through me.' It hurt my feelings and embarrassed me. During an interview on 10/18/2021 at 4:26 PM with the Administrator, he stated, [Named Resident #4] was embarrassed because she was talked to in front of others. It was taken seriously and directed with [Named Unit Manager #4]. During an interview with the Administrator on 10/18/2021 at 4:26 PM, he confirmed he had not suspended Unit Manager #4 pending the completion of the investigation. He confirmed he should have suspended the Unit Manager, as per the facility policy.

Based on medical record review, review of hospital records, and staff interviews, the facility failed to ensure 1 of 8 residents (#10) had appropriate criteria to be discharged from the facility. Cognitively-impaired Resident #10 was discharged from the facility without documented overall improvement in the resident's cognition or functional status prior to her discharge home to live alone. The resident was unable to perform activities of daily living (ADLs) independently before she was discharged home. These failures resulted in Immediate Jeopardy when Resident #10 was admitted to the hospital 3 days after discharge from the facility. On 12/20/18 at 10:57 AM, the Administrator was notified verbally that Immediate Jeopardy began on 4/24/18, when Resident #10 was discharged home without proper indications for a facility-initiated discharge. Resident #10 had no improvement in her health including functional or cognitive status, was not a danger to herself or others, and the facility was capable of meeting her documented physical and emotional needs. Three days after discharge from the facility, Resident #10 was admitted to the hospital. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM. F-622 and F660. A partial extended survey was completed on 12/20/18. The findings include: Medical record review revealed Resident #10 was admitted to the facility on [DATE] from a local hospital with [DIAGNOSES REDACTED]. Continued review revealed the a sister as a contact with the facility. Review of a hospital General Medicine Discharge Summary dated 3/20/18 revealed Resident #10 was admitted to the hospital on [DATE] with Weakness and Altered Mental Status. The emergency department (ED) determined the resident had a Urinary Tract Infection [MEDICAL CONDITION] and began treatment with antibiotics. During the resident's hospitalization , she had a speech cognitive evaluation that revealed a low Montreal Cognitive Assessment (M[NAME]A) which is a screening tool to determine mild cognitive function. The results of the M[NAME]A were 5 out of 30 which indicated the resident had severe Dementia. Review of an admission Progress Note dated 3/20/18, revealed Resident #10 was admitted from a local hospital and presented to the facility with Generalized Weakness and Altered Mental Status. Continued review revealed the resident required extensive assistance with all ADLs and was incontinent of both bowel and bladder. Medical record review of the Care Plan initiated on 3/21/18 revealed Resident #10 was combative with staff, such as grabbing, slapping, and hitting them. The care plan identified the resident would wander into other resident rooms and would come out of her room naked. The interventions noted were to distract the resident with activities, to notify the physician of negative behaviors, redirect the resident, and for staff to approach the resident in a calm manner. Review of Physical Therapy (PT) Notes revealed on 3/21/18, Resident #10 had a friend who assisted the resident for years with transportation and documented the resident lived in an apartment alone. Review of Progress Notes on 3/26/18, revealed Resident #10 would yell and scream as loud as she could and would wander into other resident rooms and the resident had one-on-one monitoring during the day by staff. Review of a 14-day Admission Minimum Data Set (MDS) assessment for Resident #10 dated 3/27/18 revealed a Brief Interview for Mental Status (BIMS) score was a 3 of 15 and determined the resident was severely cognitively impaired. Continued review revealed the resident was normally understood by others and usually understood others. Further review revealed Resident #10 required extensive assistance with bed mobility and transfers with the assistance of 1 staff member, was noted to need limited assistance with eating with the assistance of 1 staff member, was able to move around in her room and the corridor, and required extensive assistance from 1 staff member. Medical record review of the Nursing Progress Notes dated 3/31/18 revealed Resident #10 was getting in and out of bed constantly, and exhibited behaviors such as kicking, yelling, spitting, going in to other resident rooms yelling and was difficult to redirect. Medical record review of a Nurse Practitioner (NP) note dated 4/6/18, revealed Resident #10 was sleeping better at night but remained agitated and combative with caregivers during the day. Medical record review of a Nurse Practitioner (NP) progress note dated 4/9/18 revealed .poor insight. Mental Status: confused and abnormal affect. Orientation: not oriented to time and place and to person. Memory: recent memory abnormal and remote memory abnormal . The NP noted the resident had a [DIAGNOSES REDACTED]. The NP also documeted Resident #10 was still agitated but there was some improvement noted. Review of a care plan initiated 4/9/18, revealed Resident #10 with cognitive impairment related to dementia. The goal noted the resident would be able to communicate basic needs daily. Review of a National Health Rehabilitation note written by a physician, noted to also be a Physiatrist (a physician who specializes in physical medicine and rehabilitation), wrote a note dated 4/10/18, documented Resident #10 required 1 on 1 supervision and that the resident was slightly less confused. The physician diagnosed the resident with failure to thrive while at home and she was appropriate for a secured dementia unit and could not participate meaningfully in therapy. The physician noted to continue physical and occupational therapy for conditioning. On 4/12/18, this same physician noted that he saw the resident on this date. The physician wrote the resident continued with a 1 on 1 sitter and would be appropriate for placement on a secured dementia unit. He noted a functional update in which the resident was able to ambulate .45 separate trials with contact guard assist and a rolling walker for 42 feet, 17 feet, 15 feet, 10 feet, and 84 feet. She performed sit to stand from her wheelchair to rolling walker with min (minimal) assist . The physician ordered to continue physical and occupational therapies for conditioning. On 4/17/18, the physician documented the resident's last therapy treatment was scheduled for 4/23/18 and her identified barriers were dementia, impulsivity, decreased safety awareness, and weakness. Review of the 30-day MDS assessment dated [DATE], revealed Resident #10 with no improvement in the BIMS score. The BIMS score was 3 out of 15 which determined the resident was severely cognitively impaired. Continued review revealed Functional Status identified the resident had improved; however, still required limited assistance of 1 staff member for bed mobility. For transfers, the resident required extensive assistance with 1 staff member. For walking in room and in corridor the resident required supervision with oversight and cueing by staff. For eating, the resident required set-up and 1 person assistance with meals. Record review of a NP progress note dated 4/19/18 revealed Psychiatric .poor insight. Mental Status: confused and abnormal affect. Orientation: not oriented to time, place or person. Memory: recent memory abnormal and remote memory abnormal . Continued medical record review of a progress note at 6:10 AM on 4/20/18, noted Resident #10 had not slept all night and needed to be redirected and offered activities. Medical record review of the progress notes dated 4/22/18, stated Resident #10 needed supervision with dressing, eating and drinking which included encouragement and cueing. Medical record review of the Progress Notes revealed Resident #10 was assessed by a Nurse Practitioner (NP) on 4/23/18, and documented the resident's insight was poor and that she was confused and not oriented to time, place, and person. Medical record review of the Physical Therapy Discharge Summary dated 4/23/18 revealed Resident #10's short and long-term goals were: required minimal assistance with bed mobility with 100 percent verbal cues; required functional transfers with minimal assistance with 100 percent verbal cues; would walk 20 feet with minimal assistance and 100 percent verbal cues; the resident's dynamic standing was fair with minimal assistance and was unable to shift her weight; and the resident was unable to follow commands. Record review of the Occupational Therapy Discharge Summary dated 4/23/18 revealed Resident #10's short and long-term goals were: to stand during activities of daily living (ADLs), the resident was fair to minimal assistance and unable to shift her weight. For lower body dressing, the resident was at maximum assistance with verbal cues at 50 percent. To manipulate fasteners, the resident was unable to perform this function and it was noted that this treatment was discontinued on 4/9/18. Bi-lateral upper body strength, the resident was able to move part through full range against gravity and moderate resistance. This note documented the resident reached potential achievement and her prognosis was to maintain current level of function since she had good strong family support. Review of a hospital Ethics Consult dated 4/30/18 compiled to address Resident #10's decision making and placement was written by a Registered Nurse Juris Doctor (RN/JD) revealed, .Likely patient will need a conservator for long term placement and management of her affairs since there really is no one else and she cannot return home alone. Of note .has been consulted to determine a decision maker and need for .conservator . Interview with the Director of Social Services and the Social Services Aide #148 in the Social Services office on 12/18/18 at 11:09 AM revealed the Director of Social Services stated she had a conference with the resident and a son (friend - residnet did not have a son). She said the son was the one who made the resident's decisions. Per Director of Social Services even though the resident had cognitive issues, she was able to give permission to speak with this person. She went on to state this person was the one who provided care for the resident and prepared her meals. The Director of Social Service was unable to provide the name and number of the man that Resident #10 was discharged home with and confirmed there was no information in the clinical record to support this information that she provided. She stated the facility wanted to keep the resident or place her on a dementia unit but could not provide a reason why the facility did not, other than the resident wanted to return home. Interview with Registered Nurse (RN) #23 who was also a Unit Manager in the conference room on 12/19/18 at 9:28 AM revealed RN #23 stated there was a young man who was identified as possibly living full-time with Resident #10. RN #23 stated the resident really wanted to return home. Per interview with the RN, the resident was adamant about going home. Interview with the Administrator on 12/19/18 at 1:02 PM in the conference room revealed he was recently hired in (MONTH) (YEAR). The Administrator stated prior to his arrival, there were issues. He continued to state, he had identified concerns around the discharge process and noticed the length of stay was short. Currently, he stated if there is a belief the resident needs long-term care, we need to reinforce this with the resident and their representative. A telephone interview was completed with Resident #10's friend on 12/19/18 at 1:27 PM in the conference room. He confirmed he had known the resident since the 1980's. He said that they were good friends and he did not live with the resident. He specifically stated she has her own place. The friend said he would only check on her. Interview with the Administrator, Director of Social Services, Rehabilitation Director #109, and PT #112 on 12/19/18 at 2:45 PM in the conference room revealed PT #112 stated Resident #10 had no improvement in her goals and her therapy levels would vary. The Director of Social Services stated there were multiple discussions with the resident's friend. The Administrator stated there was no documentation, in the record, that was specific to the friend. The staff stated that if there was a resident who did not meet their therapy goals, they would discharge them if there was stable support in the home. Interview with a night shift Licensed Practical Nurse (LPN) #40 on 12/20/18 at 9:40 AM revealed Resident #10's ADL status was up and down. There were some days the resident could help herself, but other days she could not and needed staff to assist her. LPN #40 stated the resident was alert, but could not say she was oriented. LPN #40 explained the resident would revert back and sundown (late evening confusion). The resident could feed herself, but sometimes she needed assistance because she would not eat. She said the resident's friend visited 2 to 3 times per week and would sit with her. Whenever he would sit with her, the resident was calm. When he left, she would become confused and combative. She stated the Resident #10's friend felt she could do more for herself whenever she was at home, but it was her belief the friend did not understand the resident's decline in status. She stated the resident could not cook for herself and she needed someone to be with her 24 hours a day. She did not believe the friend understood dementia, and the care the resident would need at home. She stated prior to the resident coming to the facility, this friend lived with her. She thought the friend was living in the resident's home while she was at the facility as well. It was her understanding that they would be living together again once she was discharged . The LPN #40 said the resident was not safe to be discharged home. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM when the facility implemented the following corrective actions: On 12/20/18, immediately after notification of the Immediate Jeopardy, the facility completed an audit on the residents due to be discharged from 12/19/18 through 12/20/18 for proper indications for discharge. The audit revealed no residents were scheduled to be discharged . On 12/20/18 at 11:48 AM, an in-service was provided to all administrative staff, regarding appropriate indications for discharge. One of the Policy/Training aide entitled Criteria Determining the Need for Resident or Discharge or Transfer (Phase I) dated 11/7/16, was provided to the staff for training. The document specifically stated .The facility must permit each resident to remain in the facility, and not transfer or discharge the resident unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered .The resident has failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the facility .The facility ceases to operate . The Administrator attached all educational materials and sign-in sheets provided to the staff during this period. An interview was conducted on 12/20/18 at 4:15 PM, with the Administrator. Also present was the interim DON #11, current DON #12, the Rehabilitation Director #109, a Regional Director, Registered Nurse/Unit Managers (RN) #23 and RN #22. The Administrator stated the staff present had completed re-education on the A[NAME]. The training was also provided during the morning meeting (12/20/18) and with all Unit Managers. All residents scheduled for discharge from the facility will be evaluated for potential barriers, such as unsafe discharge. If the facility determined an unsafe discharge, the physician, local police, and Adult Protective Services (APS) would be notified. The facility provided evidence that in-service training was provided to all administrative staff, to all staff included in discharge planning, and to the nursing staff. Social Services will begin to follow up with all discharged residents or responsible party within 24 hours, then 72 hours, 14 days, and finally after 28 days as part of the facility's action plan. Interview with DON #12 on 12/20/18, confirmed the discharge training was discussed and implemented in the morning meeting (12/20/18) and with all Unit Managers. The Administrator or designee will conduct audits 5 times a week for 8 weeks. The audit will then continue 3 times a week for 4 weeks, then weekly for 4 weeks. The results of the discharge audits will be discussed during the Clinical Start up meetings weekly and will be ongoing. Audits will be discussed in monthly Quality Assurance/Performance Improvement meetings for 6 months.

Based on medical record review, review of hospital and home health records, staff interviews and facility policy review, the facility failed to ensure 2 of 8 sampled residents (#10 and #18) had a safe and effective discharge. Cognitively-impaired Resident #10 was discharged from the facility after completion of skilled services. The resident was unable to perform activities of daily living (ADLs) independently, before she was discharged home. Resident #10 was not provided additional community resources, such as food, home and community-based services, and 24/7 caregiver support, to ensure Resident #10 was safe to be discharged back to the community. These failures resulted in Immediate Jeopardy when Resident #10 was admitted to the hospital 3 days after discharge from the facility and an additional resident (#18) was placed at risk for more than minimal harm that was not Immediate Jeopardy when the facility failed to provide clear discharge planning and referrals to community services. On 12/20/18 at 10:57 AM in the conference room, the Administrator was notified verbally that Immediate Jeopardy began on 4/24/18, when cognitively-impaired Resident #10 with a [DIAGNOSES REDACTED]. Three days later, the resident was transported from home to a local hospital due to an increase in confusion. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance on 12/20/18 at 5:13 PM when the facility implemented corrective actions and was effective from 4/24/18 - 12/20/18. A partial extended survey was completed on 12/20/18. The findings include: Review of the facility policy, Discharge Planning undated, noted .Residents of the facility will be evaluated for discharge potential and plans upon admission, and discharge planning will be initiated at that time. Discharge planning will be part of the comprehensive care plan and will be addressed during Interdisciplinary Care Plan Meetings, based on significant change in resident's medical condition, or at any other time requested by the resident/representative .Consideration will be given to care-giver support person's availability and capacity/capability to perform required care to ensure the safety of the resident .The resident/representative will be involved in discussion regarding the results of the evaluation . Medical record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Brief Interview for Mental Status (BIMS) on the 14 day Admission Mental Data Set (MDS) revealed a score of was 3 out of 15. During Resident #10's stay, she received skilled services such as physical and occupational therapies. Per review of the Progress and Skilled Therapy Notes, there was no indication the staff instructed the resident with medication management or the preparation of food in anticipation of her return home. There was no information a home visit was made by the therapy department as well to ensure a safe discharge home. Medical record review revealed there was no discharge plan identified in the medical records for Resident #10. There was no evidence the resident, or her family member were involved in the development of a discharge plan during her stay in the facility. There was no documented evidence that additional community services were set up to assist the resident in a successful transition back home. There was no evidence in the clinical record social services or the interdisciplinary team (which includes staff from skilled therapy) met with the resident and her representative to identify that she might be more appropriate for long-term care placement verses being discharged home alone. Review of the Physical Therapy .Progress Report dated 3/27/18 revealed a Physical Therapy Assistant (PTA) noted a discharge plan for Resident #10 was yet to be determined. Medical record review dated 4/3/18 revealed the Physical Therapist (PT) documented the anticipated discharge plan was unknown due to the cognitive decline Resident #10 experienced and there was a decrease in safety limiting her ability to return home alone. Medical record review revealed the Physical Therapist documented on 4/10/18 that the anticipated discharge plan for the resident was possible nursing home placement with psych services or a memory care unit. Medical record reveiw revealed the Physical Therapy Assistant documented on 4/17/18 the anticipated discharge plan for the resident was yet to be determined. Medical record review of a Physical Therapy note dated 4/23/18, by the Physical Therapist revealed the resident was to be discharged home with her boyfriend with 24 hour supervision and noted the prognosis to maintain her current level of functioning was good with .strong family support . Review of a Care Plan dated 4/11/18 identified Resident #10 with impaired mobility. The goal identified was for the resident improve in her ADL status. Further review revealed the resident's placement was indentified as short term, placement. The goal for Resident #10 was for her to be safely discharged with eligible community services/resources. The interventions included to assist the resident with application for community resources; to educate the resident and/or designated representative about community resources; to identify community support for the resident; to make appropriate referrals as needed, such as homecare; provide resident and/or designated representatives with teachings as needed such as medications, diet or adaptive equipment; and, social worker to meet with the resident and/or designated representative to identify needs for discharge. There was no evidence in the medical record interventions were established for the resident to be safely discharged to her own home. Review of a Transfer/Discharge Report dated 4/24/18 identified multiple medications were prescribed to Resident #10, including an antipsychotic for her [DIAGNOSES REDACTED].ambulates w/ (with) assist (assistance), ext (extensive) assist with ADLs . There was no staff name identified on this document. Medical record review of Resident #10's revealed the Home Health records dated 4/24/18 revealed the Registered Nurse who made the home visit documented, .NUTRITION .Probably inadequate - rarely eats a complete meal and generally eats only about ½ of any food offered .malnourished .impaired decision-making . Continued review of the Home Health records dated 4/26/18 revealed the PT who went to the resident's home noted, .She is referred to home health .There is a friend .who lives in the building and checks on her. Otherwise, she lives in her apartment by herself . Medcial record review of hopsital records revealed 3 days after discharge, Resident #10 was transported to the Emergency Department (ED). The ED notes dated 4/27/18 stated, This patient is an [AGE] year-old female past medical history of [REDACTED]. The patient is unable to give a history .It is unclear what the relationship was with a family member who dropped her off. All he told people in triage was that her nerves are bothering her .The patient's friend return (sic) to the emergency department. He states that she has been in a nursing home for the past 4 or 5 weeks. She was discharged from the nursing home to her home on Tuesday. He states that she lives alone. He states that she has been having difficulty walking and inability to take care of herself. He states that she does not make her feed (sic). He tried to bring her fever (sic) when he can. He states that she has had no complaints up until today and all she said is that she is nervous and needs to go see a doctor . Review of another ED note dated 4/27/18 revealed, .History is obtained from the chart given no family is present and the patient is unable to provide information. It appears that the patient was recently admitted ,[DATE]-[DATE] for acute [MEDICAL CONDITION] (abnormal levels of electrolytes, water, and vitamins that possibly affect brain function) which was thought to be secondary to a Urinary Tract Infection [MEDICAL CONDITION]. At that time, she had a Montreal Cognitive Assessment (M[NAME]A) which is a screening tool to determine mild cognitive function. The results of the M[NAME]A were 5 out of 30 which indicated the resident had severe dementia. She was discharged to a SNF (skilled nursing facility). Reportedly, she recently got back home on 4/24 to her house where she lives alone. The friend told the ED that she has had difficulty getting around the house, has not been eating, and is unable to care for herself . Interview with the Director of Social Services on 12/18/18 at 11:09 AM in the social service office with the Social Service Aide #148 revealed the Director of Social Services verified Resident #10's male friend (who was not the resident representative or next of kin) was the person who would prepare the resident meals and stayed with her occasionally. The Director of Social Services stated there was a meeting with the resident and the male friend. The Director of Social Services said the man would make decisions for the resident. The Director of Social Serives stated the resident did have cognitive issues, but she was able to give permission to speak with her friend. She confirmed she did not have information on the meeting that was held with the resident and her friend. Per Director of Social Services, she said the man said the resident (#10) was the one who cared for her and would prepare her meals and stay with her occasionally. The Director of Social Services was asked about discharge planning and stated there was no other information other than the baseline care plan. The Director of Social Services provided a typed, undated written document, which was not part of the electronic medical record. The information contained in this note revealed the resident was referred to a home health agency on 4/20/18 and the home health agency performed a home visit on 4/24/18. The note further stated home health discharged her since the resident was admitted to the hospital on [DATE]. This document was signed by the Director of Social Services. Interview with the Director of Social Services, the Physical Therapist #112 and the Rehabilitation Director #109 on 12/19/18 at 10:59 AM in the conference room the Utilization Review (UR) process and the Interdisciplinary (IDT) meets and goes over the entire case load and anticipates discharges and any anticipated needs. Per members in this interview, they said they discuss safe discharges. Rehabilitation Director #109 said that her staff did note the resident had cognitive impairments and identified the resident had a friend who stayed with her and both were adamant about returning home. Per Physical Therapist #112, the friend did not participate in caregiving training before the resident was discharged back home. Both Rehabilitation Director #109 and Physical Therapist #112 could not provide a reason why care giving training was not provided to the friend. All present during this interview said that if Resident #10 was left by herself there would be safety issues. They stated a home visit was not completed by therapy prior to the resident's discharge. Per Rehabilitation Director #109, the discharge was not safe based on the resident's cognition. An interview was conducted with the interim Director of Nursing (DON) #11 on 12/20/18 at 1:20 PM in the conference room revealed her expectation for the discharge process was all IDT members were all in agreement with the discharge. Review of the job description for the Director of Social Services, undated revealed there was no date identified on the document. The job description specifically stated, .assess all new residents upon admission and complete the social service initial admission notes, social history, social assessment, and discharge planning when appropriate .Coordinate discharge planning for appropriate residents .Document referral information and discharge disposition for the medical record .make referrals to other social service agencies such as home delivered meals and homemaker services as needed .create discharge packet with information for patients and families . Review of the job description for Physical Therapist, undated revealed there was no date noted on this document. The document specifically documented, .Recognizes and identifies patients' needs for imitations (sic) of services from other disciplines and consult with other professionals as needed .Provides advisory and consultative services to staff .Participates in patient care conferences and discharge planning . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Care Plan initiated on 10/4/18 for impaired skin integrity and another care plan developed on 10/8/18 for nutritional problem for Resident #18. A baseline care plan was initiated on 10/5/18 and noted the resident was to be discharged back home to live with his family. Review of a Social Services Evaluation completed on 10/9/18 noted Resident #18's Brief Interview for Mental Status score was 6 out of 15 which indicated he was severely cognitively impaired. Review of the Progress Notes dated 10/30/18, revealed the Director of Social Services entered the following information into the clinical record, Resident #18, .was admitted to the facility on [DATE] with dx (diagnosis) of Benign (sic) neoplasm of meninges, [MEDICAL CONDITION], weakness, difficult walking, dysphasia, aftercare following surgery on the nervous system, and [MEDICAL CONDITION]. He was discharged home with wife on 10/16/18. He was alert and fairly well oriented at the time of discharge .Resident was scheduled to see is PCP (primary care physician) on day of discharge .Wife visited daily and was very supportive . There was no documentation that showed the resident might need home health or additional services after discharge, or if the resident's wife was the sole caregiver in the home. Interview with the interim DON #11 on 12/19/18 at 9:10 AM revealed her expectation is social services was to anticipate residents' needs, set-up home health and to prepare the resident to go home. The DSS was interviewed on 12/20/18 at 4:11 PM in the social service office regarding Resident #18. The DSS stated that she did not remember if home health was set-up for him. She said the resident wanted to be discharged home earlier than planned and he had a doctor's appointment scheduled on the date of his discharge which was on 10/16/18. The DSS stated, I would anticipate that physician would set up those services. The Immediate Jeopardy was removed onsite after receipt of an acceptable Allegation of Compliance (A[NAME]) on 12/20/18 at 5:13 PM when the facility implemented the following corrective actions: On 12/20/18, immediately after notification of the Immediate Jeopardy, the facility completed an audit on the residents due to be discharged from 12/19/18 through 12/20/18 for proper indications for discharge. The audit revealed no residents were scheduled to be discharged . On 12/20/18 at 11:48 AM, an in-service was provided to all administrative staff, regarding appropriate indications for discharge. One of the documents/training aides Criteria Determining the Need for Resident or Discharge or Transfer (Phase I) dated as revised 11/7/16, was provided to the staff for training. The document specifically stated .The facility must permit each resident to remain in the facility, and not transfer or discharge the resident unless .The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility .The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The health of individuals in the facility would otherwise be endangered .The resident has failed, after reasonable and appropriate notice, to pay (or to have paid under Medicare or Medicaid) a stay at the facility .The facility ceases to operate . The Administrator attached all educational materials and sign-in sheets provided to the staff during this period. An interview was conducted on 12/20/18 at 4:15 PM, with the Administrator. Also present was the interim Director of Nursing (DON) #11, current DON #12, the Rehabilitation Director #109, a Regional Director, Registered Nurse/Unit Managers (RN) #23 and RN #22. The Administrator said the staff present had completed re-education on the A[NAME]. The training was also provided during the morning meeting (12/20/18) and with all Unit Managers. All residents scheduled for discharge would be evaluated for potential barriers, such as unsafe discharge. If the facility determined an unsafe discharge, the physician, local police, and Adult Protective Services (APS) would be notified. The facility provided evidence that in-service training was provided to all administrative staff, to all staff included in discharge planning, and to the nursing staff. Social Services would follow up with all discharged residents or responsible party within 24 hours, then 72 hours, 14 days, and finally after 28 days as part of the facility's philosophy. During interview with DON #12 on 12/20/18, she verified the discharge training was discussed and implemented in the morning meeting (12/20/18) and with all Unit Managers. The Administrator or designee will conduct audits five times a week for eight weeks. The audit will then continue three times a week for four weeks, then weekly for four weeks. The results of the discharge audits will be discussed during the Clinical Start up meetings weekly and will be ongoing. Audits will be discussed in monthly Quality Assurance Performance Improvement meetings for six months.

Based on facility policy review, medical record review, review of facility investigation and interview, the facility failed to ensure residents remained free from verbal abuse for 1 resident (#17) and neglect for 1 resident (#24) of 22 residents reviewed resulting in HARM for Resident #17 and #24. The findings included: Review of facility policy, Abuse, undated revealed the definition of abuse included it was a willful infliction of injury resulting in physical harm, pain or mental anguish. The abuse should be reported immediately to the charge nurse. The charge nurse was to assure the resident was safe and any needed medical interventions for the resident had been obtained, the charge nurse was to report the Administrator, the Director of Nursing, the physician and the family. Medical record review revealed Resident #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 9/5/17 Quarterly Minimum Data Set (MDS) revealed the Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating the resident was cognitively intact. Review of a facility investigation dated 9/5/17 revealed an allegation of a verbal confrontation between Resident #17 and Certified Nurse Aide (CNA) #7. Continued review revealed the resident overheard CNA #7 talking disrespectfully about the resident and confronted the CNA and an argument ensued. The CNA allegedly raised her voice, used profanity and spoke disrespectfully to the resident and reportedly attempted to relocate the patient to her room against her will. Further review of the facility investigation revealed the Director of Nursing (DON) was notified and CNA #7 was dismissed for conduct that was unprofessional and disrespectful. Review of a witness statement by Resident #17 dated 9/5/17 at 10:45 PM revealed the resident heard CNA #7 talking about her and the CNA and the resident started arguing. Continued review revealed the CNA grabbed the resident's wheelchair and started pushing her real hard and fast down the hall. The resident did not want to go down the hall and grabbed the wooden rail on the wall. Review of a witness statement by Registered Nurse (RN) #6 dated 9/5/17 revealed CNA #7 and Resident #17 were arguing in the hall. The CNA grabbed the resident's wheelchair and proceeded to push her to her room. The resident told CNA #7 to stop and not to touch her or the wheelchair. Continued review revealed the CNA went over to the nurse's station and was speaking about the resident using profanity. CNA #7 totally disrespected the resident. Review of a witness statement by CNA #9 dated 9/5/17 revealed CNA #7 was heard talking loudly to Resident #17 in the hall. She observed CNA #7 behind the resident's wheelchair while the resident was holding onto the railing on the wall to prevent CNA #7 from pushing her down the hall. Interview with Resident #17 on 9/26/17 at 11:30 AM on the 500 unit hall revealed the resident had an argument with CNA #7. She stated they yelled at each other, then the CNA pushed the resident's wheelchair down the hall against her will. Continued interview revealed the resident stated she held onto the rail on the wall. Resident #17 stated the CNA was fired. The resident stated all the other staff were respectful and accommodating. Interview with the Administrator on 9/26/17 at 12:45 PM in the DON office confirmed the staff to resident abuse on 9/5/17 for Resident #17 had occurred according to the resident and witness statements. The staff to resident abuse resulted in HARM for Resident #17. Medical record review of Resident #24 revealed the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed the resident required assistance with activities of daily living (ADLs), had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence. Further review revealed the resident was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage and occasional bowel incontinence. There was no skin breakdown included on the Care Plan and no specific interventions to address the resident's needs to prevent skin breakdown. Medical record review of the Quarterly MDS dated [DATE], revealed the BIMS score was 15 out of 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance to total dependence for ADL except for eating. Continued review revealed the resident was always incontinent of bowel and had a catheter for the bladder. The assessment indicated the resident had no skin integrity concerns. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. Continued interview with the resident revealed the CNAs had told her they could not get her up due to not enough staff and stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident, informed the resident she would only clean her up once during the night shift. Further interview with the resident revealed she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM on the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. Continued interview revealed there was a large amount of stool and urine that was almost the consistency of mud. The resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and that no one had checked or changed her since 10:00 PM the previous night. CNA #5 continued to state he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. He stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing)her up once during the night shift. Further interview with CNA #5 revealed the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. Interview with RN #4 on 9/26/17 at 10:35 AM on the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM this morning. Upon the request of the surveyor, the RN went to assess Resident #24's skin condition. Observation with RN #4 revealed an open area on the left upper thigh with some slough and the buttocks and thighs bilaterally were very red and unblanchable. Interview with RN #4 revealed the Wound Nurse took care of those type of things. Continued interview with RN #4 confirmed she was unaware the resident had any open areas or skin integrity issues and stated CNA #5 had reported the resident's condition to her at 8:00 AM, and she had not reported anything to anyone else .was going to report it, just not immediately. RN #4 confirmed she did not assess the resident until the surveyor's request. RN #4 confirmed the resident .did not get up in the chair because there was not enough staff .the staff were aware the indwelling urinary catheter consistently leaked. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 12:15 PM in the Director of Nursing's office revealed RN #4 reported the incident regarding Resident #24 at about 11:00 AM today. She confirmed RN #4 should have reported the incident immediately and that CNA #5 should have reported what CNA #8 said to the resident. Resident #24 did not receive care for 9 1/2 hours resulting in neglect and HARM

Based on review of facility policy, medical record review, and interview, the facility failed to ensure an allegation of abuse was reported immediately to the Administrator in accordance with facility policy for 1 resident (#24) of 22 sampled residents. Resident #24 was deprived care and threatened with the deprivation of care by a staff member when she was left in her own incontinence for 9.5 hours after being told she would only receive incontinence care once on the night shift and staff did not immediately report this to the Administrator. The deprivation of care resulted in HARM for Resident #24. The findings included: Review of facility policy, Abuse, revealed the definition of abuse included that it was a willful infliction of injury resulting in physical harm, pain or mental anguish. The abuse should be reported immediately to the charge nurse. The charge nurse was to assure the resident was safe and any needed medical interventions for the resident had been obtained, and the charge nurse was to report to the Administrator, the Director of Nursing, the physician and the family. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #24's Care Plan dated 4/19/17 revealed the resident required assistance with activities of daily living; had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence; was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage and occasional bowel incontinence. Further review revealed no skin breakdown was included on the Care Plan and no specific interventions to address the resident's needs to prevent skin breakdown. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was 15 out of 15 indicating the resident was cognitively intact. Continued review of the MDS revealed the resident required extensive assistance to total dependence for activities of daily living except for eating and was always incontinent of bowel and had an indwelling catheter. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. Continued interview revealed the Certified Nurse Aides (CNAs) had told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident informed her, she would only clean her up once during the night shift. The resident stated she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. Continued interview revealed the resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and no one had checked or changed her since 10:00 PM the previous night. CNA #5 stated he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. Further interview revealed he stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing) her up once during the night shift. CNA #5 stated the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. Interview with RN #4 on 9/26/17 at 10:35 AM in the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM that morning, and she had not reported anything to anyone else. She stated she was going to report it, just not immediately. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 12:15 PM in the Director of Nursing's office revealed RN #4 reported the incident regarding Resident #24 at about 11:00 AM today. The ADON confirmed the RN should have reported the incident immediately and CNA #5 should have reported what CNA #8 said to the resident. Interview with the Administrator on 9/26/17 at 12:30 PM in the DON's office confirmed he and the ADON were not notified by RN #4 about this abuse until 11:00 AM on this date.

Based on review of facility policy, medical record review, interview, and observation, the facility failed to ensure Care Plans were initiated and interventions implemented to address alterations in skin integrity and/or incontinence care for 4 residents ( #11, #13, #23, #24) of 22 sampled residents. The facility's failure contributed to the development of Resident #24's Stage III pressure ulcer and Resident #24 was deprived care and threatened with the deprivation of care by a staff member, when she was left in her own incontinence for 9.5 hours after being told she would only receive incontinence care once on the night shift resulting in HARM for Resident #24. The findings included: Review of facility policy, Bowel and Bladder Management, undated revealed .The facility would evaluate bowel and bladder status upon admission, readmission, significant change and quarterly .If the resident was incontinent, a baseline elimination status would be completed to assess the bowel and bladder patterns .The interdisciplinary team (IDT) would review bowel and bladder data to determine if retraining would be an option or a pattern had been identified .If retraining was indicated, the care plan would be updated to reflect the interventions .If a pattern was identified, the IDT would implement a voiding plan and the care plan updated. Medical record review revealed Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed Resident #24 required assistance with activities of daily living (ADL), had a suprapubic catheter due to [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], overactive bladder, and bowel incontinence. Continued review revealed the resident was at risk for developing skin breakdown related to impaired mobility, occasional suprapubic catheter leakage, and occasional bowel incontinence. The Care Plan did not include actual skin breakdown, there were no specific interventions to address the resident's needs to prevent skin breakdown, and there were no interventions that addressed the leaking catheter. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score was 15 out of 15 indicating the resident was cognitively intact. Continued reveiw revealed the resident required extensive assistance to total dependence for ADLs except for eating. Continued review revealed the resident was always incontinent of bowel and had an indwelling catheter for the bladder. Further review revealed the resident had no skin integrity concerns. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the Certified Nurse Aides (CNAs) told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Continued interview revealed the resident stated she did not get checked or changed until the dayshift CNA (#5) came in this morning at 7:30 AM when the CNA changed and repositioned her. Resident #24 stated CNA #5 told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. Continued interview revealed the resident told him that no one had checked or changed her since 10:00 PM last night. CNA #5 stated he changed and repositioned the resident then reported the resident's condition to Registered Nurse (RN) #4. Further interview with CNA #5 confirmed the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red, and there had been an open area on the back of her upper left thigh for a week. The deprivation of care resulted in HARM for Resident #24. Medical record review revealed Resident #11 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/25/17 revealed the resident was at risk for developing skin breakdown related to frequent incontinence, needed assistance for ADLs, and was frequently incontinent of bladder. There were no specific interventions addressing the incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed the BIMS score was 3 out of 15, indicating the resident was severely cognitively impaired. Further review revealed the resident required limited assistance to extensive assistance with ADLs and required extensive assistance with toilet use and was frequently incontinent of bladder and bowel. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Medical record review revealed Resident #13 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 10/31/16 Care Plan revealed the resident had impaired cognitive skills related to forgetfulness and required staff assistance with ADLs. Medical record review revealed there was no Care Plan addressing the resident's needs regarding bladder incontinence. Medical record review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, required extensive assistance to total dependence for activities of daily living and was always incontinent of bowel and bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there no Care Plan that addressed those needs. Medical record review revealed Resident #23 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 6/27/17 Care Plan revealed Resident #23 required staff assistance for ADLs had impaired cognitive/communicative skills and was at risk for the development of skin breakdown related to impaired mobility and bladder incontinence. Medical record review of the Quarterly MDS 9/18/17/revealed the BIMS score was 4 out of 15, indicating severe cognitive impairment, the resident required limited assistance with toileting and was occasionally incontinent of bladder. Medical record review revealed there was no Bladder Continence Assessment that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. Observation on 9/25/17 at 2:50 PM revealed a very strong urine odor was noted in the hall outside Resident #23's door. Certified Nurse Aide (CNA) #1 confirmed the odor at that time, but did not enter the resident's room. Resident #23 allowed the surveyor to enter her room. Interview with Resident #23 revealed she did not have to go to the bathroom. The resident eventually realized she was very wet with urine on her clothes and bedding and verbalized she was upset that it had happened. Interview with Licensed Practical Nurse (LPN) #1 on 9/25/17 at 2:55 PM in the 500 hall revealed the LPN thought Resident #23 went to the bathroom independently and stated she was unaware the resident was incontinent. Interview with the Corporate Care Consultant RN on 9/26/17 at 12:30 PM in the Director of Nursing (DON)'s office confirmed there were no assessments completed that resulted in an understanding of the resident's individual urinary continence needs and there was no Care Plan that addressed those needs. The DON confirmed there were no Care Plans that addressed the specific needs of the residents and there were no actions to be taken regarding incontinence care for Residents #11, #13. #23, or #24. The DON confirmed there was not a Care Plan that addressed the alterations in skin integrity for Resident #24.

Based on review of facility policy, medical record review, review of the Weekly Skin form, and interview, the facility failed to ensure appropriate care and services to prevent the development of pressure ulcers for 1 resident (#24) of 22 sampled residents. The failure contributed to the development of a Stage III pressure ulcer resulting in HARM for Resident #24. The findings included: Review of facility policy, The Skin Assessment and Evaluations, undated revealed the admission nurse would identify alteration in resident's skin integrity. The nurse would notify the Physician for a treatment order and document in the resident's record. The Admission Nurse would generate a skin Interim Care Plan. Weekly skin assessment would be documented. The Physician and family notification would be made with all newly identified alterations in resident skin integrity and documented in the medical record by the nurse identifying the new skin alteration. If a new alteration in resident skin integrity was identified, the CNA (Certified Nursing Assistant) would report it to the charge nurse. At the time a new alteration in skin integrity was identified, the resident's Care plan should be revised. All resident alterations in skin integrity would be tracked weekly. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 4/19/17 revealed the resident required assistance with Activities of Daily Living (ADLs) had a suprapubic catheter due to [MEDICAL CONDITION] Bladder, [MEDICAL CONDITION], Overactive Bladder, and Bowel Incontinence; was at risk for developing skin breakdown related to impaired mobility, and occasional suprapubic catheter leakage and occasional bowel incontinence. There was no skin breakdown included on the care plan and no specific interventions to address the resident's needs to prevent skin breakdown. There were no interventions that addressed the leaking catheter. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance to total dependence for activities of daily living except for eating, always incontinent of bowel and had an indwelling catheter for the bladder. Further review of the assessment revealed the resident had no skin integrity concerns. Medical record review of the Weekly Skin form dated 9/22/17 by Registerd Nurse (RN #4) revealed there was friction [MEDICAL CONDITION] on the resident's posterior left thigh, an abrasion on the coccyx, and an abrasion on the right thigh. Further review of the Weekly Skin form dated 9/26/17 at 6:13 AM revealed the same documentation as the 9/22/17 form. Interview with Resident #24 on 9/26/17 at 10:15 AM in her room revealed the staffing was low. She stated the Certified Nursing Assistants (CNAs) had told her they could not get her up due to not enough staff. She stated last night (9/25/17) at 10:00 PM she had been incontinent of stool and her indwelling urinary catheter had a large amount of leakage. Resident #24 stated CNA #8, while cleaning the resident, informed the resident she would only clean her up once during the night shift. The resident stated she did not get checked or changed until the dayshift when CNA #5 came in this morning at 7:30 AM and changed and repositioned her. Resident #24 stated the CNA told her she was still dirty on her buttocks. Interview with CNA #5 on 9/26/17 at 10:30 AM in the 500 unit hall revealed Resident #24 was drenched with urine and stool when he went to change her at 7:30 AM today. He stated there was a large amount of stool and urine that was almost the consistency of mud. The resident told him what CNA #8 had told her last night, about only clean(ing) her up once during the night shift, and that no one had checked or changed her since 10:00 PM the previous night. CNA #5 stated he changed and repositioned the resident, then reported the resident's condition to Registered Nurse (RN) #4. Continued interview revealed he stated he did not tell the RN what CNA #8 said to Resident #24, about only clean(ing) her up once during the night shift. CNA #5 stated the resident had an indwelling urinary catheter that consistently leaked urine, her buttocks and the back of her thighs were red and there had been an open area on the back of the upper left thigh for a week. The CNA stated the resident did not get up due to the lack of staff. Interview with RN #4 on 9/26/17 at 10:35 AM in the 500 unit hall revealed CNA #5 had reported the resident's condition at 8:00 AM this morning. Upon the request of the surveyor the RN went to assess Resident #24's skin condition. Observation with RN #4 revealed an open area on the left upper posterior thigh with some slough. The buttocks and thighs bilaterally were very red and unblanchable. RN #4 stated the wound nurse took care of those type of things. The RN confirmed she was unaware the resident had any open areas or skin integrity concerns. RN #4 stated CNA #5 had reported the resident's condition to her at 8:00 AM. She confirmed she did not assess the resident until the surveyor's request. Continued interview with RN #4 confirmed the resident did not get up into the chair because there were not enough staff. RN #4 confirmed the staff was aware the indwelling urinary catheter consistently leaked. Interview with the Licensed Practical Nurse (LPN) #13, who was the Wound Nurse, on 9/26/17 at 1:40 PM in the conference room revealed she was unaware of any open areas regarding Resident #24. She confirmed there was no documentation regarding any open areas and there was no documentation regarding the resident's skin integrity after 6:13 AM on 9/26/17. LPN #13 confirmed RN #4 did not enter any documentation (into the computer) regarding the observations made on 9/26/17 at 10:30 AM. She stated the expectation was the floor nurses would assess/evaluate, document, call the Physician and get orders when the Wound Nurse was not there. LPN #13 stated she looked in the computer for updates regarding skin issues. Interview with LPN #13 revealed she did not do wounds full time. Medical record review of a physician's orders [REDACTED].cleanse with normal saline and apply duoderm patch one a day and as needed . The order was received by RN #4. Medical record review of a Non Ulcer Skin Condition form dated 9/26/17 at 4:38 PM by LPN #13 revealed the left thigh wound was Friction [MEDICAL CONDITION] that measured 1.5 centimeters (cm) long, 0.8 cm wide and 0.1 cm deep. Interview with the Assistant Director of Nursing (ADON) on 9/26/17 at 5:30 PM in the Director of Nursing's office confirmed the documentation made by LPN #13. They confirmed RN #4 had not documented any observations regarding the wound. The ADON and LPN/Talent Manager revealed they would assess the wound and the reddened areas. Medical record review of an Initial Weekly Wound form dated 9/26/17 at 6:19 PM by the LPN/Talent Manager revealed a pressure ulcer on the left thigh that measured 1.5 cm long, 0.8 cm wide and no depth. The wound was documented as a Stage III pressure ulcer. Medical record review of the Physician order [REDACTED].cleanse with normal saline, apply Santyl (prescription ointment that cleans wounds to clear the way for healthy tissue) and a dry dressing each day and as needed . Interview with the ADON on 9/27/17 at 9:30 AM in the conference room confirmed Resident #24's Stage III pressure ulcer was not assessed or treated properly. She revealed the Physician was notified and new orders were received to treat the Stage III pressure ulcer. Continued interview confirmed the Stage III pressure ulcer was not documented per facility policy until surveyor intervention on 9/26/17. The failure to ensure care was provided to prenvent the development of a Stage III pressure ulcer resulted in HARM for Resident #24.