Every finding on record at New Mexico State Veterans Home

Based on record review and interview the facility failed to provide residents in writing a list of costs of services that a resident may or may not be charged upon admission for all 126 residents att he facility (residents were identified by the Resident Matrix provided by the Administrator on 08/11/26). If residents are unaware of the cost of services that they may or may not be charged for, then residents could experience anxiety and depression from worrying about payment. The findings are:A. Record review of the facility's admission Agreement, not dated, revealed the following:A list of services the facility does provide.Staff did not document the list of cost of the service the facility provides. B. On 08/11/26 at 10:17 am, during an interview with the Finance Director and Account Auditor Supervisor, they stated the following:1. They speak to residents upon admission to let them know what they would need to pay.2. They will let them know within 48 hours. 3. They do not save the documents from their discussion on the first day. C. On 08/11/26 at 11:12 am, during an interview, the Admissions Coordinator stated the following:1. The Admissions Agreement has list of services.2. The Agreement does not have a cost associated with it on the agreement.3. They have been needing to update the Agreement and will add the cost of services in the Agreement.

Based on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents) for 2 (R #1, and R #2) of 3 (R #1, R #2, R #3) residents sampled for involuntary seclusion, when staff failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement of R #1 and R #2 in the secured/locked area by R #1 and R #2's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect R #1 and R #2 and assure their health and safety. 3. The IDT consideration of the impact and reaction of R #1 and R #2, if any, regarding placement on the unit. 4. Ongoing review and revision of R #1 and R #2's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. 5. Develop clinical criteria for the placement of residents in the secured/locked area that ensures residents are not placed in the secured/locked area for the convenience of staff, discipline, or based on diagnosis alone. These deficient practices are likely to result in residents being placed in seclusion involuntarily causing anxiety and depression. The findings are: A. Record review of the Facility's Secured Unit Operations and Resident Management Policy dated 09/21/25 revealed the following:1. To ensure the safety, security, and well-being of residents in secured units and maintaining a least-restrictive environment that respects residents rights.II. Definitions:Secured Unit: A designated area with controlled access to prevent resident elopement or wondering, typically for residents with cognitive impairments or safety risks.Elopement Risk: A Resident who is prone to leaving the facility without supervision, potentially causing harm.Voluntary Placement: A resident choice to reside in a secure unit even if they do not meet the clinical criteria for mandatory secure care.Clinical Necessity: A documented medical or behavioral need that justifies placement in a secured unit.Least Restrictive: Care practices designed to protect residents' safety while maximizing autonomy and freedom of movement whenever possible.Badge Access: Security system functionally requiring staff or authorized personnel to use badges to enter or exit secured areas.III. Policy:Secure Placement:All secured unit doors require badge access for entry and exit.Doors are alarmed-protected to alert staff of unauthorized or unexpected exits.Doors include an emergency egress mechanism: if the bar is pressed for a designated time. The door will unlock to allow safe exit.Staff should monitor alarm notifications and respond immediately if a door is opened unexpectedly.Resident in secured units must be protected from elopement or harm.Voluntary Placement:Resident who voluntarily choose to reside in a secure unit may do so if they do not meet the clinical criteria, may do so when is supports. Safety, well-being, and quality of life, provided:Respects resident rights and autonomy are respected [sic] at all times.A documented care plan addresses supervision, access, and least restrictive measures.Placement is reviewed and approved by the Director of Nursing or Administrator.V. Procedures:A. admission & Assessment 1. Conduct a comprehensive clinical and safety assessment for residents admitted to secure units. 2. Update risk assessments at least quarterly or sooner is residents' condition changes. 3. For voluntary residents, perform a risk and safety assessment and document the residents' choice and rationale. 4. Obtain written acknowledgement from resident and/or responsible party confirming understanding of secured unit placement.C. Resident Movement 1. Resident may leave the secured unit under staff supervision. 2. Voluntary residents will be provided badge access to enter and exit units.VI. References:Federal and state regulations governing long-term care operations, resident rights, and quality of care. R #1B. Record review of R #1 admission Record, no date, revealed the following:1. R #1 was admitted to the facility on [DATE].2. R #1 had the following diagnoses: a. Cerebral infarction (a serious medical emergency that happens when a blocked blood vessel stops blood and oxygen from reaching part of the brain, causing brain tissue to die). b. Chronic obstructive pulmonary disease (a progressive lung condition that blocks airflow and makes breathing difficult). c. Frontotemporal neurocognitive disorder (a group of brain disorders that damages the frontal and temporal lobes, causing major changes in behavior, personality, and language). d. Epilepsy (chronic brain disorder defined by two or more recurring, unprovoked seizures caused by abnormal electrical activity in nerve cells). C. Record review of R #1's Facility's Autonomy and Consent Form for Secured Unit Placement form, dated 02/19/26, revealed the following: The purpose of this form is to acknowledge that the resident, residents, family or legal representative voluntarily chooses to reside in the secured unit, understands the associated risks and alternatives, and has been provided informed consent for their placement and movement within the unit.We recognize the importance of self-determination and wish to respect a resident's right to make choices about aspects of his or her life in the facility that are significant to them. The intent of this consent, and the conversation it facilitates, is to ensure each resident has the opportunity to exercise their autonomy regarding things that are important to his or her life with respect to their interests and preferences. Residents PreferenceI prefer to reside on the secure unit (was left blank).I understand that there is alternative housing (was checked).I retain the ability to enter and exit the unit (was checked).I retain the ability to participate in activities, socialization, and daily routines (was checked).I have been informed of:The nature and purpose of residing on the secured unit (was checked).I have the right to choose Alternatives [sic] housing, if available (was checked).Potential risks and benefits of residing on the secured unit (was checked).The fact that placement may be revised at my request (was checked). Resident Statement: I understand and voluntarily choose to reside on the secured/locked unit (was checked). I have been informed of my right to leave the unit and my options for placement (was checked). D. Record review of R #1's medical record, no date, revealed staff did not document the following:1. The clinical criteria met for R #1's placement in the secured/locked area by R #1 physician along with information provided by members of the interdisciplinary team. 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect R #1 and assure health and safety. 3. The IDT consideration of the impact and reaction of R #1, if any, regarding placement on the unit. 4. Ongoing review and revision of R #1 care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. E. Record review of R #1's Care Plan, dated 11/24/25, revealed the following: [Name of R #1] resides in the Annex Building on [Name of 100 Unit]. Door alarms will be monitored by staff, but resident is free to exit the unit under supervision if they desire. F. On 08/11/26 at 9:20 am, during an observation of the Annex building revealed all units needed a security badge access to enter and exit the 5 units. G. On 08/11/26 at 3:10 pm, during an interview R #1 in the courtyard area outside 100 Unit in Annex Building stated the following:He is not allowed to go off the unit by himself.Staff have to open the doors even to the enclosed courtyard area.He does not have a key to enter or exit the unit.He is only aware of having to ask staff to open the doors to exit. H. On 08/11/26 at 3:10 pm, during an observation of R #1 in the courtyard area outside 100 Unit in Annex Building, revealed the following:1. CNA #2 was out in the courtyard.2. Doors had be opened with a key card to enter and exit courtyard. R #2I. Record review of R #2 admission Record, no date, revealed the following:1. R #2 was admitted to the facility on [DATE].2. R #2 had the following diagnoses: a. Frontal lobe and executive function deficit (disrupt your brain's ability to control thoughts, emotions and behavior). b. Chronic embolism and thrombosis of unspecified deep vein left lower extremity (blood clots that reduce or block blood flow inside blood vessels in left leg). c. Hypertension (high blood pressure,). d. Spinal stenosis (a narrowing of the spaces within your spine that can put pressure on the spinal cord and nerves). e. Major depression. J. Record review of R #2's Facility's Autonomy and Consent Form for Secured Unit Placement form, dated 02/19/26, revealed the following: The purpose of this form is to acknowledge that the resident, residents, family or legal representative voluntarily chooses to reside in the secured unit, understands the associated risks and alternatives, and has been provided informed consent for their placement and movement within the unit. We recognize the importance of self-determination and wish to respect a resident's right to make choices about aspects of his or her life in the facility that are significant to them. The intent of this consent, and the conversation it facilitates, is to ensure each resident has the opportunity to exercise their autonomy regarding things that are important to his or her life with respect to their interests and preferences. Residents PreferenceI prefer to reside on the secure unit (was checked).I understand that there is alternative housing (was checked).I retain the ability to enter and exit the unit (was checked).I retain the ability to participate in activities, socialization, and daily routines (was checked).I have been informed of:The nature and purpose of residing on the secured unit (was checked).I have the right to choose Alternatives [sic] housing, if available (was checked).Potential risks and benefits of residing on the secured unit (was checked).The fact that placement may be revised at my request (was checked).Resident Statement:I understand and voluntarily choose to reside on the secured/locked unit (was checked). I have been informed of my right to leave the unit and my options for placement (was checked). K. Record review of R #2's medical record, not dated, revealed staff did not document the following:1. The clinical criteria met for R #2's placement in the secured/locked area by R #2's physician along with information provided by members of the interdisciplinary team. 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect R #2 and assure health and safety. 3. The IDT consideration of the impact and reaction of R #2, if any, regarding placement on the unit. 4. Ongoing review and revision of R #2's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the intervention continues to meet the needs of the resident. L. Record review of R #2's Care Plan, dated 10/16/25, revealed the following:1. Resident voluntarily resides in a secured unit. BIMS: 142. Staff will ensure resident understands unit rules and their voluntary placement in the secured unit.3. [Name of R #2] will continue to enjoy as much independence as possible.4. Door alarms will be monitored by staff, but resident is free to exit the unit undersupervision if they desire. M. On 08/13/26 at 3:29 pm, during an interview R #2 stated the following: I am not able to even go to the courtyard without an escort.There is no other way to leave the unit without staff. N. On 08/13/26 at 3:29 pm, during an observation of R #2 in the courtyard area outside 100 Unit in Annex Building, revealed the following:1. CNA #3 was out in the courtyard.2. Doors had to be open with key card to enter and exit courtyard. O. On 08/13/26 at 3:56 pm, during an interview CNA #3 stated the following:1. Every resident has to go with a staff escort off the unit if they wanted to leave.2. CNAs or Activities staff would escort them.3. Only the residents with key cards can leave on their own.4. The residents with the keycards were grandfathered in.5. New residents did not get a key card.6. R #1 and R #2 did not have key cards. P. On 08/13/26 at 2:12 pm, during an interview the DON stated the following:1. The annex is not considered a Secure Unit.2. It is a building where the Units have doors that lock.3. It has an emergency egress system whereby holding the door latch will sound the alarm. If held for a set time the lock will release.4. If the alarm sounds staff will check on the residents.5. If the residents wish to leave the Unit then they will be escorted by staff and cannot go alone.6. Staff escort is for resident safety.7. Since the annex is not a Secure Unit there is no criteria to be in the locked unit.8. All residents who reside in the annex have all signed the [Name of the facility] Autonomy and Consent Form for Secured Unit Placement form.9. There is no way to turn off the locked door system in the annex.10. There are only very limited number residents who have key cards and are free to enter and exit the Unit on their own accord.

Based on interview, observation, and record review the facility failed to ensure care plan revisions occurred for 3 (R #16, R #17, and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for falls, when staff failed to revise resident care plans with the most current interventions to prevent falls or injury. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are:A. Record review of the facility Fall Prevention and Management Policy, reviewed date 09/15/25, revealed the following: 1. Staff are to revise the care plan based on findings and incorporate new interventions. B. Record review of facility Interdisciplinary Team and Care Planning Policy, reviewed date 10/07/25, revealed the following: 1. The following events commonly require immediate assessment and may require a focused IDT review and care-plan revision. This list is not exhaustive: a. Fall, injury, elopement event, resident-to-resident incident, abuse concern, or other adverse event. 2. Care planning is an ongoing clinical process. Staff must respond to changes in condition, preferences, risks, or goals when identified and must not wait for the next scheduled conference or MDS assessment when immediate action is needed. R #16 C. Record review of R #16's admission Record, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Communication hydrocephalus (an abnormal accumulation of cerebrospinal fluid (CSF) in the brain's ventricles, caused by impaired fluid reabsorption or blocked flow after it exits the ventricles). b. Repeated falls. c. Dependence on wheelchair. d. Epidemic vertigo (a sudden, intense feeling of spinning typically caused by viral infections that inflame the inner ear's balance nerves). e. Unspecified abnormalities of gait and mobility (any unusual walking pattern or difficulty moving where a specific cause hasn't yet been diagnosed). D. Record review of the facility incidents list, dated 04/01/26 to 06/30/26, revealed R #16 fell on the following dates: 1. 04/2/26 2. Twice on 04/10/26 3. 04/11/26 4. 04/14/26 5. Twice on 04/15/26 6. 04/22/26 7. 05/06/26 8. 05/11/26 9. 05/16/26 10. 05/17/26 11. Twice on 05/20/26 12. 06/16/26 13. 06/24/26 E. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #16 fell on the following dates: 1. 07/07/26 2. 07/12/26 F. On 07/14/26 at 10:37 AM, during an observation and interview with R #16 the following was revealed: 1. Staff was pushing R #16 in his wheelchair into the common area of the unit. 2. A stop screen with Velcro (hook-and-loop type fastener) attachments was placed across R #16's door entryway and his door was closed. 3. R #16 stated he had just returned from therapy. 4. R #16 stated he fell about three days ago because he has vertigo. 5. R #16 stated he was not sure if he was supposed to get up by himself. G. On 07/14/26 at 10:43 AM, during an interview, CNA #16 stated the following: 1. R #16 was very unstable on his feet. 2. R #16 was supposed to ask for assistance whenever he wanted to get up from his bed, toilet, or get out of his wheelchair. 3. R #16 believed he could do tasks for himself. 4. He would not ring the call bell for assistance, which would result in R #16 falling. 5. Staff are to put a fall mat next to R #16's bed when he is in bed and place his bed in the lowest position. 6. Staff check on R #16 at least every two hours to see if he wants to go to the restroom or needs anything. 7. The stop screen on R #16's door is a reminder for him to notify staff that he is going into his room so staff can assist him. 8. They keep R #16 in the common area as much as possible to keep a close eye on him so he doesn't fall. H. On 07/14/26 at 10:45 AM, during an observation of R #16 in the common area the following was revealed: 1. R #16 was observed going to his room and removing the stop screen. 2. R #16 did not notify staff that he was going into his room. 3. Staff immediately followed R #16 and asked him if he needed the restroom or needed assistance. 4. Staff wheeled R #16 back to the common area. I. On 07/15/26 at 12:15 PM, during an interview, the DON stated the following: 1. R #16 has frequent falls due to his diagnosis of hydrocephalus. 2. Most of R #16's falls were in his room. R #16 wants to do things for himself and won't call for assistance. 3. Interventions in place to prevent R #16 from falling were: a. Device on his wheelchair to prevent it from rolling back on him. b. Bed in lowest position and fall mat when R #16 is in bed. c. Stop screen on door as a reminder for him to notify staff when he goes into his room so staff can assist him. d. Frequent checks and bathroom breaks for R #16. e. Keep R #16 in the common area as much as possible. f. Involve R #16 in activities as much as possible so he doesn't stay isolated in his room. J. Record review of R #16's care plan, dated 06/30/26, revealed the following: 1. Ensure assistive devices are within reach. 2. Frequent rounding. 3. Frequently remind resident to use call light. 4. Offer non-slip socks. 5. Prompt toileting. 6. R #16 had multiple falls and it was expected they would continue due to his impulsivity. 7. Ensure safety measures including bed in low position, fall mat, and frequent rounding to prevent injury. 8. Anti-roll back bars to wheelchair. 9. Anticipate needs. 10. Ensure call light is within reach. 11. R #16 had a tendency to lower himself to floor when he feels dizzy. 12. Staff did not revise R #16's care plan for the following: a. Stop screen as an intervention to prevent falls. b. Keeping R #16 in common area as much as possible as an intervention to prevent falls. c. Involving R #16 in as many activities as possible as an intervention to prevent falls. K. On 07/15/26 at 12:42 PM, during an interview, the DON confirmed the following: 1. Staff did not revise R #16's care plan to include the stop screen as an intervention that was being used to prevent falls. 2. Staff did not revise R #16's care plan to include keeping R #16 in the common area as much as possible to prevent falls. 3. Staff did not revise R #16's care plan to include involving R #16 in as many activities as possible to prevent falls. 4. Staff were expected to revise resident care plans with all interventions that were being implemented to prevent falls or injury from falls. R #17 L. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had the following diagnoses: a. Unspecified dementia. b. Cerebral infarction (occurs when a blood vessel in the brain is blocked by a clot or narrowed by plaque. This cuts off vital oxygen and nutrients, causing brain tissue to die). c. Mild neurocognitive disorder (characterized by a modest decline in cognitive abilities (such as memory, language, or attention) that is noticeable to others but does not interfere with a person's independence in daily life). d. History of falling. M. Record review of the facility incidents list, dated 04/01/26 to 06/30/26, revealed R #17 fell on the following dates: 1. 06/14/26 2. 06/15/26 3. 06/30/26 N. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #17 fell on [DATE]. O. On 07/14/26 at 10:59 AM, during an observation of R #17 in his room, the following was observed: 1. R #17 was laying in bed with his eyes closed. 2. R #17's bed was in a low position about eight inches from the floor. 3. There was a grey mat on the floor next to the right side of R #17's bed. P. On 07/14/26 at 1:28 PM, during an interview, CNA #17 stated the following: 1. R #17 had fallen before, she did not remember the dates of his falls. 2. The interventions in place to prevent R #17 from falling were: a. Place R #17's bed in the lowest position. b. Place a fall mat next to R #17's bed when he was in it. c. Frequent rounding. 3. She would check on R #17 at least every 30 minutes. Q. On 07/15/26 at 10:01 AM, during an interview, LPN #17 stated the following about R #17's fall interventions: 1. Place R #17's bed in the lowest position. 2. Place a fall mat next to R #17's bed when he is in the bed. 3. Round on resident frequently. R. Record review of R #17's care plan, revised 07/01/26, revealed the following interventions for falls: 1. Fall mat at bedside when in bed. 2. Purposeful rounding every hour. 3. Assist R #17 with ambulation and transfers. 4. Encourage the R #17 to use bell to call for assistance. 5. Staff did not revise R #17's care plan to include that his bed should be in the lowest position. S. On 07/15/26 at 1:20 PM, during an interview, the DON confirmed the following: 1. R #17's bed was supposed to be kept in the lowest position. 2. Staff did not revise R #17's care plan to include that his bed was to be kept in the lowest position to prevent injury from falls. 3. Staff were expected to update resident care plans with all interventions. R #18 T. Record review of R #18's admission Record, no date, revealed the following: 1. R #18 was admitted to the facility on [DATE]. 2. R #18 had the following diagnoses: a. Vertigo of central origin (a sensation of spinning caused by disease or injury in the brain-specifically the brainstem or cerebellum-rather than the inner ear). b. Dementia. U. Record review of the facility incidents list, dated 04/01/26 to 06/30/26, revealed R #18 fell on the following dates: 1. 05/14/26 2. 05/19/26 V. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #18 fell on [DATE]. W. On 07/14/26 at 1:22 PM, during an observation and interview with R #18 revealed the following: 1. R #18 was observed laying in his bed on his right side. 2. There was no fall mat next to his bed. 3. R #18 stated he fell about a month ago because he was dizzy. 4. R #18 stated he was not sure what interventions were in place to prevent him from falling or injuring himself. X. Record review of R #18's Fall Incident report, dated 07/05/26, revealed the following: 1. R #18 was found wrapped in his blanket on the floor next to his bed. 2. R #18 stated he rolled out of bed. 3. R #18 told staff he needed a bigger bed because he had rolled out of bed six times. Y. On 07/15/26 at 10:39 AM, during an interview, LPN #16 stated the following: 1. R #18 was supposed to use the call light when he wanted to get up. 2. R #18 received a new bed recently because he was rolling out of bed. Z. On 07/15/26 at 12:10 PM, during an interview, R #18 stated he received a new, wider, bed about a week ago because he kept falling out of bed. AA. Record review of R #18's work order, dated 07/01/26, revealed the following: 1. On 07/01/26 an order was placed for a bigger mattress for R #18. 2. On 07/06/26 staff documented that R #18's 36-inch mattress was exchanged for a 42-inch mattress. BB. Record review of R #18's care plan, revised 07/07/26, revealed staff did not revise R #18's care plan to include a 42-inch mattress was placed to prevent him from rolling out of bed. CC. On 07/15/26 at 12:26 PM, during an interview, the DON confirmed the following: 1. R #18's mattress was exchanged for a wider mattress because he rolled out of bed. 2. Staff did not revise R #18's care plan to include the intervention of a 42-inch mattress to prevent him from rolling out of bed. 3. Staff were expected to revise R #18's care plan to include the implementation of a wider, 42-inch mattress as an intervention to prevent R #18 from falling out of bed.

Based on record review, interview, and observation, the facility failed to ensure medical records were complete and accurate for 2 (R #17 and R #18) of 3 (R #16, R #17, and R #18) residents reviewed for falls when staff failed to: 1. Ensure staff documented who attended IDT meetings, what was discussed, and what decisions were made regarding R #17 and R #18's care after falls. 2. Accurately document placement of R #18's fall mat. These deficient practices could likely cause residents to not have the equipment needed to prevent injury and cause staff to not have the most accurate resident information adversely impacting the care staff provides. The findings are:A. Record review of facility Interdisciplinary Team and Care Planning Policy, reviewed date 10/07/25, revealed the following: 1. Care planning is an ongoing clinical process. Staff must respond to changes in condition, preferences, risks, or goals when identified and must not wait for the next scheduled conference or MDS assessment when immediate action is needed. 2. The resident record will identify the date and type of review; participants; professional role; method of participation; resident and representative attendance or input; notification attempts; and, when applicable, the reason participation was not practicable. 3. Documentation will summarize relevant assessment findings, resident goals and preferences, risks and benefits discussed, options and alternatives offered, refusals or informed choices, decisions made, care-plan revisions, provider input, new orders or referrals, and unresolved issues. IDT Meeting Documentation R #17 B. Record review of R #17's admission Record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had the following diagnoses: a. Unspecified dementia. b. Cerebral infarction (occurs when a blood vessel in the brain is blocked by a clot or narrowed by plaque. This cuts off vital oxygen and nutrients, causing brain tissue to die). c. Mild neurocognitive disorder (characterized by a modest decline in cognitive abilities (such as memory, language, or attention) that is noticeable to others but does not interfere with a person's independence in daily life). d. History of falling. C. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #17 fell on [DATE]. D. On 07/14/26 at 10:59 AM, during an observation of R #17 in his room, the following was observed: 1. R #17 was laying in bed with his eyes closed. 2. R #17's bed was in a low position about eight inches from the floor. 3. There was a grey mat on the floor next to the right side of R #17's bed. E. On 07/14/26 at 1:28 PM, during an interview, CNA #17 stated the following: 1. R #17 had fallen before, she did not remember the dates of his falls. 2. The interventions in place to prevent R #17 from falling were: a. Place R #17's bed in the lowest position. b. Place a fall mat next to R #17's bed when he was in it. c. Frequent rounding. 3. She would check on R #17 at least every 30 minutes. F. Record review of R #17's Incident Audit Report, dated 07/03/26, revealed the following: 1. R #17 was found on the floor next to the bed. 2. Staff assessed R #17 for injury. 3. Fall mat was in place and resident had slip resistant socks on. 4. Staff did not document a potential cause for R #17 fall. G. Record review of R #17's IDT progress note, dated 07/09/26, revealed the following: 1. Activity staff documented that R #17's fall on 07/03/26 was not related to activities. 2. Staff did not document who was in attendance at the IDT meeting. 3. Staff did document the cause of R #17's fall on 07/03/26. 4. Staff did not document what decisions were made or any interventions that the IDT planned to implement to prevent R #17 from falling again. H. On 07/15/26 at 1:20 PM, during an interview, the DON confirmed the following: 1. R #17 had a fall on 07/03/26. 2. The activities staff documented an IDT meeting on 07/09/26 for R #17's fall on 07/03/26. 3. She was unable to determine who attended the IDT meeting on 07/09/26, what the IDT discussed regarding R #17's fall on 07/03/26, or what interventions the IDT determined would be appropriate for R #17. 4. Staff from each discipline including nursing, social services, activities, and any other pertinent disciplines were expected to document an IDT note in the medical record regarding information related to the cause of the fall and interventions being implemented to prevent future falls or injury from falls. R #18 I. Record review of R #18's admission Record, no date, revealed the following: 1. R #18 was admitted to the facility on [DATE]. 2. R #18 had the following diagnoses: a. Vertigo of central origin (a sensation of spinning caused by disease or injury in the brain-specifically the brainstem or cerebellum-rather than the inner ear). b. Dementia. J. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #18 fell on [DATE]. K. On 07/14/26 at 1:22 PM, during an observation and interview with R #18 revealed the following: 1. R #18 was observed lying in his bed on his right side. 2. There was no fall mat next to his bed. 3. R #18 stated he fell about a month ago because he was dizzy. 4. R #18 stated he was not sure what interventions were in place to prevent him from falling or injuring himself. L. Record review of R #18's Fall Incident report, dated 07/05/26, revealed the following: 1. R #18 was found wrapped in his blanket on the floor next to his bed. 2. R #18 stated he rolled out of bed. 3. R #18 told staff he needed a bigger bed because he had rolled out of bed six times. M. Record review of R #18's IDT progress note, dated 07/10/26, revealed the following: 1. Activity staff documented that R #18's fall on 07/05/26 was not related to activities. 2. Staff did not document who was in attendance at the IDT meeting. 3. Staff did not document information related to what was the cause of R #18's fall on 07/05/26. 4. Staff did not document what decisions were made or any interventions that the IDT planned to implement to prevent R #18 from falling again. Accuracy of Documentation N. Record review of facility Documentation policy, reviewed date 10/19/25, revealed the following: 1. Accuracy and Completeness a. Record factual and objective information. 2. Responsibilities a. Nursing Staff: Ensure all documentation is complete, accurate, and timely. R #18 O. Record review of R #18's physician's order, dated 07/07/26, revealed an order for R #18 to have a fall mat next to his bed when he was in bed. P. Record review of R #18's care plan, revised 07/07/26, revealed staff revised R #18's care plan on 07/07/26 to include that R #18 was supposed to have a fall mat next to his bed when he was in bed. Q. On 07/15/26 at 10:34 AM, during an observation of R #18 in his room, the following was observed: 1. R #18 was lying on his right side with his eyes closed. 2. There was not a fall mat on the floor next to R #18's bed or in the room. R. On 07/15/26 at 10:36 AM, during an interview, CNA #16 stated the following: 1. She was not aware R #18 was supposed to have a fall mat next to his bed. 2. She confirmed R #18 was lying in bed and R #18 did not have a fall mat next to his bed or in his room. 3. She confirmed R #18's care plan had an intervention for R #18 to have a fall mat next to his bed when he was in bed. S. On 07/15/26 at 10:39 AM, during an interview, LPN #16 stated the following: 1. She was not aware that R #18 was supposed to have a fall mat next to his bed when he was in bed. 2. She confirmed there was an order for R #18 to have a fall mat when he was in bed. 3. She confirmed R #18's care plan indicated that he was supposed to have a fall mat next to his bed when he was in bed. T. On 07/15/26 at 12:10 PM, during an interview, R #18 stated he had never had a fall mat next to his bed. U. Record review of R #18's Administration Record, dated July 2026, revealed staff documented R #18 had a fall mat in place on the following dates and times: 1. 07/07/26 evening. 2. 07/08/26 morning and evening. 3. 07/09/26 morning and evening. 4. 07/10/26 morning and evening. 5. 07/11/26 morning and evening. 6. 07/12/26 evening. 7. 07/13/26 morning and evening. 8. 07/14/26 morning and evening. V. On 07/15/26 at 12:26 PM, during an interview, the DON confirmed the following: 1. R #18 had a fall on 07/05/26. 2. The activities staff documented an IDT meeting on 07/10/26 for R #18's fall on 07/05/26. 3. She was unable to determine who attended the IDT meeting on 07/10/26, what the IDT discussed regarding R #18's fall on 07/05/26. 4. R #18 had orders for a fall mat while in bed. 5. Staff documented on R #18's care plan that he was supposed to have a fall mat next to his bed when he was in bed. 6. Staff were expected to get a fall mat for residents as soon as the order was entered. 7. Staff were expected to ensure fall mats were in place for all residents who had orders and/or interventions on their care plan for a fall mat to be in place. 8. Staff documented that R #18 had a fall mat in place multiple times between 07/07/26 and 07/14/26. 9. Before documenting that a fall mat was in place, nurses were expected to check the resident's room for a fall mat. 10. Staff were expected to document factually regarding what they observed.

Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #18) of 3 (R #16, R #17, R #18) residents reviewed for falls, when staff failed to: 1. Implement a systems approach to evaluate fall hazards and identify interventions to prevent future falls for R #18. 2. Ensure R #18 had a fall mat next to his bed while R #18 was in bed as ordered by the provider. These deficient practices could likely result in an increased risk of residents falling or getting injured if they fall. The findings are: A. Record review of facility Interdisciplinary Team and Care Planning Policy, reviewed date 10/07/25, revealed the following: 1. Care planning is an ongoing clinical process. Staff must respond to changes in condition, preferences, risks, or goals when identified and must not wait for the next scheduled conference or MDS assessment when immediate action is needed. 2. The resident record will identify the date and type of review; participants; professional role; method of participation; resident and representative attendance or input; notification attempts; and, when applicable, the reason participation was not practicable. 3. Documentation will summarize relevant assessment findings, resident goals and preferences, risks and benefits discussed, options and alternatives offered, refusals or informed choices, decisions made, care-plan revisions, provider input, new orders or referrals, and unresolved issues. 4. Approved care-plan interventions will be implemented promptly. 5. The responsible nurse or discipline will communicate new or revised interventions to direct-care staff on all shifts before the next affected care activity whenever practicable. 6. The following events commonly require immediate assessment and may require a focused IDT review and care-plan revision. This list is not exhaustive: a. Fall, injury, elopement event, resident-to-resident incident, abuse concern, or other adverse event. B. Record review of R #18's admission Record, no date, revealed the following: 1. R #18 was admitted to the facility on [DATE]. 2. R #18 had the following diagnoses: a. Vertigo of central origin (a sensation of spinning caused by disease or injury in the brain-specifically the brainstem or cerebellum-rather than the inner ear). b. Dementia. C. Record review of the facility incidents list, dated 04/01/26 to 06/30/26, revealed R #18 fell on the following dates: 1. 05/14/26 2. 05/19/26 D. Record review of the facility incidents list, dated 07/01/26 to 07/14/26, revealed R #18 fell on [DATE]. E. On 07/14/26 at 1:22 PM, during an observation and interview with R #18 revealed the following: 1. R #18 was observed lying in his bed on his right side. 2. There was no fall mat next to his bed. 3. R #18 stated he fell about a month ago because he was dizzy. 4. R #18 stated he was not sure what interventions were in place to prevent him from falling or injuring himself. F. Record review of R #18's Fall Incident, dated 05/14/26, revealed the following: 1. R #18 was found on the floor in his room. 2. R #18 said that he fell when he was trying to get out of bed to smoke. G. Record review of R #18's Fall Incident, dated 05/19/26, revealed R #18 fell when trying to transfer himself from his wheelchair to bed. H. Record review of R #18's medical record, no date, revealed the following: 1. Staff did not document whether an IDT meeting occurred to discuss R #18's fall on 05/14/26 or what interventions the IDT planned to implement to prevent R #18 from falling. 2. Staff did not document whether an IDT meeting occurred to discuss R #18's fall on 05/19/26 or what interventions the IDT planned to implement to prevent R #18 from falling. I. Record review of R #18's physician's order, dated 07/07/26, revealed an order for R #18 to have a fall mat next to his bed when he was in bed. J. Record review of R #18's care plan, revised 07/07/26, revealed the following: 1. Staff did not revise R #18's care plan after his fall on 05/14/26. 2. Staff did not revise R #18's care plan after his fall on 05/19/26. 3. Staff revised R #18's care plan on 07/07/26 to include that R #18 was supposed to have a fall mat next to his bed when he was in bed. K. On 07/15/26 at 10:34 AM, during an observation of R #18 in his room, the following was observed: 1. R #18 was lying on his right side with his eyes closed. 2. There was not a fall mat on the floor next to R #18's bed or in his room. L. On 07/15/26 at 10:36 AM, during an interview, CNA #16 stated the following: 1. She was not aware R #18 was supposed to have a fall mat next to his bed. 2. She confirmed R #18 was lying in bed and R #18 did not have a fall mat next to his bed or in his room. 3. She confirmed R #18's care plan had an intervention for R #18 to have a fall mat next to his bed when he was in bed. M. On 07/15/26 at 10:39 AM, during an interview, LPN #16 stated the following: 1. She was not aware that R #18 was supposed to have a fall mat next to his bed when he was in bed. 2. She confirmed there was an order for R #18 to have a fall mat when he was in bed. 3. She confirmed R #18's care plan indicated that he was supposed to have a fall mat next to his bed when he was in bed. N. On 07/15/26 at 12:10 PM, during an interview, R #18 stated he had never had a fall mat next to his bed. O. On 07/15/26 at 12:26 PM, during an interview, the DON confirmed the following: 1. Staff were expected to have an IDT meeting after each fall to determine what interventions would be implemented to prevent future falls. 2. Staff were expected to revise the resident's care plan with any interventions the IDT determined were appropriate to prevent future falls or injury. 3. Staff did not document an IDT meeting after R #18's falls on 05/14/26 or 05/19/26. 4. Staff did not revise R #18's care plan after his falls on 05/14/26 and 05/19/26. 5. Since there were no notes regarding an IDT meeting and R #18's care plan did not have any revisions for falls around the time of R #18's falls, she was unable to determine if an IDT meeting was held regarding R #18's falls on 05/14/26 or 05/19/26. 6. R #18 had orders for a fall mat while in bed. 7. Staff documented on R #18's care plan that he was supposed to have a fall mat next to his bed when he was in bed. 8. Staff were expected to get a fall mat for residents as soon as the order was entered. 9. Staff were expected to ensure fall mats were in place for all residents who had orders and/or interventions on their care plan for a fall mat to be in place.

Based on record review and interview, the facility failed to ensure residents with diagnosed mental health disorders, psychosocial distress, and/or suicidal ideation received appropriate behavioral health treatment and services for 3 (R #5, R #89, and R #131) of 4 (R #5, R #9, R #89, and R #131) residents reviewed for behavioral-emotional health, when the facility failed to provide or obtain psychotherapy/counseling for R #5 and R #131; failed to notify the Psychiatric Mental Health Nurse Practitioner (PMHNP) of R #89's hallucinations; and failed to follow through with psychiatric referral/consultation for R #131.The facility's failure resulted in residents' identified mental health needs remaining unaddressed while residents continued to express psychosocial distress, depression, and suicidal ideation, and placed residents at risk for not attaining or maintaining their highest practicable mental and psychosocial well-being. The findings are:R #5 A. Record review of R #5's admission record, no date, revealed the following: 1. An admission date of 11/21/24. 2. The following diagnoses: a. Post traumatic stress disorder (PTSD; a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events). b. Major depressive disorder (a serious mental health condition characterized by persistent low mood, loss of interest, and fatigue which last at least two weeks). c. Anxiety disorder (excessive, persistent, and uncontrollable fear, worry, or dread that interferes with daily life). B. Record review of R #5's Psychotropic Evaluation, dated 10/23/25, revealed the non-pharmacologic care provided to R #5 was music and psychotherapy. The record did not contain any other psychotropic evaluations. C. Record review of R #5's care plan, revision date 01/06/26, revealed R #5 had a diagnosis of PSTD. R #5 had the potential to plan on ending his life because of the pain he was in. R #5 did not want to continue. Refer to psychiatry (the branch of medicine focused on diagnosing, treating, and preventing mental, emotional, and behavioral disorders) and or psychology as indicated. D. Record review of R #5's staff progress notes revealed the following: 1. Dated 01/06/26, R #5 stated he was struggling with pain and does not want to carry on. Staff will schedule an appointment with psych, so he can talk about his depression and suicidal thoughts. Staff will get him scheduled for a psych evaluation. 2. Dated 02/11/26, R #5 cried during a visit with the Chaplain, because he was tired of being in pain and in his bed. The Chaplain encouraged him to get out of bed more so he could enjoy life outside. The Chaplain prayed for R #5. E. On 04/16/26 at 9:07 AM, during an interview, R #5 stated he was very depressed and did not want to go on. R #5 stated staff offered counseling and he accepted. He stated no one ever showed up for the counseling sessions. R #5 stated the Chaplain occasionally visited with him, but the Chaplain was not qualified or useful for the help he needed. R #5 stated he needed help processing his life. R #5 stated he needed a good psychiatric therapist to help him process his feelings and what he has been through. R #5 stated he needed someone trained in PTSD. R #5 stated he has not had any counseling or therapy to help him. R #5 stated staff knew he was depressed, had suicidal thoughts and PTSD. F. On 04/16/26 at 9:16 AM, during an interview, the Chaplain stated he talked to R #5 for spiritual and emotional assistance. The Chaplain stated he tried to help the residents that were suicidal and supported them. The Chaplain stated R #5 reported to him that he had suicidal ideation. The Chaplain stated he believed there was a difference between not wanting to live and wanting to kill yourself. The Chaplain stated he believed R #5 did not want to live because of the pain he was in. The Chaplain stated if he knew a resident was suicidal, then he would report it to his Supervisor. The Chaplain stated he did not have a formal degree in mental health. The Chaplain stated he could diagnose mental health disorders or determine if a resident was considered suicidal. The Chaplain stated he took classes regarding PTSD, but he did not have any formal training for treating residents with PTSD. G. On 04/16/26 at 1:32 PM, during an interview, the Nurse Practitioner (NP) stated she was trained in psychiatric and mental health. The NP confirmed R #5 had depression, PTSD, and suicidal ideation. The NP stated she treated R #5 under the supervision of the Medical Director. The NP stated she and the provider reviewed R #5's medication and treatment when R #5 felt sad or suicidal. She stated they decided if R #5's treatment needed to be adjusted and what medications were best for the resident. The NP stated if R #5 needed therapy, then she provided it. The NP stated if R #5 did not complain of any issues, then she did not provide counseling. The NP stated residents knew how to contact her and could reach out if they needed. The NP stated she did not have consistent counseling sessions with R #5. The NP stated if a resident was suicidal, then they would send them out to the hospital. She stated they did not have the medication to help suicidal residents. The NP stated if she provided counseling services to a resident, then she documented it in the resident's medical record. The NP stated R #5's medical record did not contain any documentation to show she provided counseling to R #5. The NP stated if it was not documented, then it did not happen. H. On 04/16/26 at 2:44 PM, during an interview, R #5 stated the NP did not provide therapy or counseling for him. R #5 stated he needed consistent counseling, not just on bad days. R #5 stated they stayed on top of his antidepressants, but mental health was not just about medication. R #5 stated he needed counseling. I. On 04/16/26 at 4:38 PM, during an interview, R #5's wife stated R #5 used to be very active. R #5's wife stated he struggled with not being able to do what he used to do and with constant pain. R #5's wife stated the facility sent him out to the hospital when R #5 was suicidal. She stated the facility did not provide R #5 any therapy or counseling, other than visits with the Chaplain. R #5's wife thought the Chaplain was a social worker. R #5's wife stated if R #5 was the husband she knew before the stroke, that he would not want to live. J. On 04/21/26 at 1:05 PM, during an interview, the Administrator stated her expectation was for residents to receive therapy if they needed it. She stated therapy was a continuous need for residents and not just needed in crisis. The Administrator stated the NP was psychiatric and mental health trained, and they hired the NP to provide psych services for the residents. The Administrator stated facility residents did not receive crisis management, therapy, or counseling. The Administrator stated facility residents received a medication review for mental health. R #89 K. Record review of R #89's admission record, no date, revealed the following: 1. An admission date of 11/21/24. 2. Diagnosis of bipolar disorder (a chronic mental health condition characterized by intense, alternating mood swings between extreme highs (mania or hypomania) and lows). L. Record review of R #89's progress note, dated 02/19/26, revealed R #89 reported to his nurse there were moles in his room, and they get under his covers. The nurse listened to R #89 and acknowledged his concerns. R #89 told the nurse he let housekeeping know also. The nurse stated housekeeping confirmed and told her it was not the first time R #89 had seen moles. M. Record review of R #89's Psychotropic Evaluations, revealed an evaluation was completed on 01/30/25. The record did not contain any other psychotropic evaluations. N. Record review of R #89's comprehensive MDS, dated [DATE], revealed staff did not document hallucinations or delusions. O. Record review of R #89's care plan, dated 10/16/25, revealed staff did not document R #89 had hallucinations. P. Record review of R #89's medical record revealed there were not any referrals for a psychiatric consult. Q. On 04/14/26 at 9:11 AM, during an interview, R #89 stated there were moles in his bed, and they crawled up his bed to his face. R #89 stated he told staff, and they tried to get the moles out of his room. R #89 was fixated on the moles would not answer other questions. R. On 04/14/26 at 9:18 am, during an interview, CNA #8 stated she knew R #89 thought moles were in his room. She stated sometimes he thought they were squirrels. She stated housekeeping will go into R #89's room, shake his sheets, and tell him the moles are gone. She stated she let her nurse know that R #89 was seeing moles in his room. She stated that the resident had been seeing them for a couple of months but did not know the exact date. S. On 04/16/26 at 1:51 PM, during an interview, the NP stated she did rounds (a structured, daily process where healthcare teams visit inpatients to assess their progress, review care plans, and discuss updates) every Wednesday, and she was not aware R #89 saw moles. The NP stated she would have discussed R #89's medication with the provider if she was aware the resident saw moles. The NP stated they monitored R #89's medication and made changes, if needed. The NP stated she did not provided counseling for R #89, because he did not state he needed it. The NP stated a mental health assessment was done for R #89 on 01/31/26. She stated the assessment indicated R #89 was not satisfied with his life, he dropped many activities and interest, he was often bored, and he was not in good spirits most of the time. R #131 T. Record review of R #131's admission Record, no date, revealed R #131 was admitted to the facility on [DATE] and discharged from the facility on 02/03/26. R #131 had the following diagnoses: 1. Major depressive disorder (MDD, mood disorder that causes a persistent feeling of sadness and loss of interest). 2. Paranoid schizophrenia (a chronic mental health condition characterized by intense, irrational distrust (paranoia) and symptoms of psychosis, such as delusions and auditory hallucinations, often focusing on themes of persecution). 3. Unspecified dementia (a progressive syndrome caused by abnormal brain changes, resulting in cognitive decline (memory loss, language difficulties, poor reasoning) that interferes with daily life) without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. 4. Generalized anxiety disorder (GAD, a mental health condition characterized by persistent, excessive, and uncontrollable worry about various daily, routine, or future events for at least 6 months). 5. Suicidal ideations (SI, thinking about, considering, or planning suicide, ranging from fleeting thoughts to detailed plans). U. Record review of R #131's physician's orders revealed the following: 1. Order dated 07/08/25 to send to the emergency room (ER) per resident request. 2. Order dated 08/06/25 for a psychiatry consult. 3. Order dated 09/11/25 to send to ER for psychiatric evaluation. 4. Order dated 11/25/25 to send to local hospital to expedite transfer to psychiatric facility. 5. Order dated 01/28/26 to send to the ER for psychiatric treatment. V. Record review of R #131's nursing progress notes revealed the following: 1. Dated 07/08/25, R #131 called crisis hotline (a free, confidential 24/7 phone or text service providing immediate, trained counselor support for people experiencing acute mental health, emotional, or suicidal distress) stating he was depressed, the treatment at the facility was not working, and he wanted to go to another city to receive treatment. 2. Dated 07/08/25, R #131 called 911 and requested to be taken to the hospital due to his schizophrenia. 3. Dated 07/09/25, R #131 called the crisis hotline, and the Emergency Medical Transportation (EMT) arrived for R #131. R #131 refused to be transferred to the hospital. 4. Dated 07/11/25, R #131 called the crisis hotline multiple times, and staff talked to R #131 about this behavior. 5. Dated 07/27/25, R #131 told staff he was unhappy and wanted to transfer to another facility. 6. Dated 08/03/25, R #131 had increased anxiety, stated he wanted to transfer to another facility, and dreads waking up here. 7. Dated 08/15/25, R #131 stated the facility PMHNP was not a doctor. 8. Dated 08/18/25, R #131 called the crisis hotline and reported suicidal thoughts. EMTs arrived, and the resident refused to be transferred to the hospital. 9. Dated 08/28/25, the crisis hotline reported R #131 called the crisis hotline and reported suicidal ideation. When nursing staff talked to R #131, he stated, Not every crisis is about suicide. I just want to know when I'm going to see an actual psychiatrist. R #131 refused to go to the hospital and did not understand why everyone thought he was suicidal. 10. Dated 09/05/25, R #131 continued to request to leave the facility because he did not receive any psychiatric treatment. 11. Dated 09/09/25, R #131 left a voicemail stating, Something has to be done about my depression. It is getting unbearable, and I have been two or three suicide risk since I've been here and it's getting worse. 12. Dated 09/10/25, R #131 was seen by the Medical Director, PMHNP, and the RN. R #131 denied suicidal ideation. Requested to be transferred to a psychiatric facility in another state. R #131 was encouraged to attend music therapy. 13. Dated 09/11/25, R #131 was sent to the ER for suicidal ideation and requested more help for mental health issues. 14. Dated 09/12/25, R #131 was accepted to a behavioral health hospital for suicidal ideation. 15. Dated 10/10/25, R #131 returned to the facility from the behavioral health hospital. 16. Dated 10/22/25, R #131 refused all medications. R #131 demanded to be sent to a facility in another state. 17. Dated 10/23/25, R #131 refused all medications and said the medications were poison. 18. Dated 10/24/25, R #131 requested a psychiatrist. 19. Dated 11/01/25, R #131 repeatedly pressed call light and asked to speak to the Psychiatric Doctor. Staff told R #131 he talked to the PMHNP. 20. Dated 11/07/25, R #131 told staff he was not okay and felt like he could not go anywhere. 21. Dated 11/10/25, the crisis hotline notified nursing staff that R #131 had called the crisis hotline multiple times over the previous few days. R #131 told the crisis hotline staff he felt his mental health needs were not being met. He stated the crisis hotline was going to put in a referral for a Crisis Coordinator. 22. Dated 11/13/25, the Crisis Hotline notified the nurse R #131 called the crisis line three times. R #131 refused the answer the crisis lines questions about suicidal ideation. 23. Dated 11/18/25, the Crisis Hotline notified the nurse R #131 reported suicidal ideation. 24. Dated 11/19/25, R #131 refused care and had refused to change his clothes for a couple of days. 25. Dated 11/24/25, R #131 refused medications. 26. Dated 11/25/25 at 7:03 AM, the nurse and a police officer made a wellness check on R #131 due to him calling the Crisis Hotline. R #131 told them he had a schizophrenic brain and had been asking the SSW to get him out of the facility. 27. Dated 11/25/25 at 8:21 AM, R #131 refused to take his medications and told the nurse he needed to go to a mental health hospital. R #131 refused to go to the ER for evaluation. Staff explained to R #131 that if he wanted to go to a mental health hospital, then he would need to be evaluated at the local ER to get a referral. R #131 still refused. 28. Dated 12/09/25, R #131 refused his medications. 29. Dated 12/30/25, R #131 reported feeling depressed. 30. Dated 01/03/26 at 9:21 AM, staff documented the resident sat up in bed and told the nurse he had been looking for an alternative to suicide. 31. Dated 01/03/26 at 12:10 PM, the nurse was notified R #131 called the Crisis Hotline and mentioned suicide. R #131 said he did not trust anyone except two night nurses or the doctor. 32. Dated 01/05/26, R #131 said he did not want to live anymore. 33. Dated 01/26/26, R #131 told the nurse he wanted to die. 34. Dated 01/28/26, R #131 reported having a psychiatric dream and requested to be sent to the hospital. R #131 was sent to the hospital. W. Record review of R #131's Chaplain progress notes revealed the following: 1. Dated 07/10/25, R #131 stated he had depression and lack of sleep. 2. Dated 07/17/25, R #131 wanted to debate the difference between a psychiatrist and a Chaplain (provide spiritual and emotional support, focusing on meaning, faith, and crisis presence). 3. Dated 08/08/25, R #131 told the Chaplain he was lonely and needed someone to talk to about his illness. 4. Dated 08/20/25, R #131 wanted to talk to someone about his emotional and spiritual mind. 5. Dated 09/10/25, R #131 told the Chaplain he was depressed. 6. Dated 09/11/25, R #131 told the Chaplain he wanted to be free from his depression. 7. Dated 10/27/25, R #131 told the Chaplain he was lonely and wanted to talk with someone spiritually about his life. 8. Dated 10/28/25, R #131 was agitated about how things were for him at the facility. R #131 became irrational in his thoughts. 9. Dated 10/31/25, R #131 told the Chaplain he was depressed and felt God had left him. 10. Dated 11/13/25, R #131 told the Chaplain the facility was not good at handling psychiatry. 11. Dated 11/24/25, the Chaplain documented R #131 was declining more in his mental health. 12. Dated 12/02/25, the Chaplain documented R #131 was declining in his mental health. 13. Dated 12/09/25, R #131 talked to the Chaplain about his views on psychiatric care. The Chaplain documented R #131 was declining in his mental health and was confused. 14. Dated 12/18/25, R #131 told the Chaplain he wanted to see the psychologist (licensed doctoral-level mental health professionals who study cognitive, emotional, and social processes to diagnose and treat behavioral disorders through psychotherapy) to see if that could help him. The Chaplain documented R #131 was declining in his mental health. 15. Dated 12/29/25, R #131 called the Chaplain three times to discuss the decline in his mental health. R #131 told the Chaplain he wanted the staff to work with him in a more productive way. 16. Dated 12/31/25, R #131 told the Chaplain the facility should have more psychology-based programs for him. 17. Dated 01/05/26, R #131 told the Chaplain he was lonely, and it helped to be able to talk about what is going on in his mind. 18. Dated 01/07/26, R #131 talked to the Chaplain about wanting to go to a facility nearby town. 19. Dated 01/14/26, the Chaplain documented R #131 was lonely and needed someone to talk to. 20. Dated 01/30/26, R #131 told the Chaplain he wanted to be surrounded by a culture of behavioral health professionals. X. Record review of R #131's Social Services progress notes revealed the following: 1. Dated 08/07/25, R #131 said he would be better off dead. R #131's mood was all over the place. R #131 stated he wanted to go to a psychiatric facility. 2. Dated 08/27/25, R #131 requested to be transferred to a psychiatric facility in another state. Stated he felt he was not receiving the appropriate psychiatric care at the facility, and he was satisfied with the care he received at the facility he was requesting to transfer to. The Social Services Worker (SSW) told R #131 the facility could not transfer him to a psychiatric facility, and he would need to go to an acute care setting (Emergency Room) to get a referral to be admitted to a psychiatric facility. 3. Dated 09/04/25, R #131 called the SSW several times and left voice messages. The resident stated he wanted specialty psychiatric care and was convinced he had to go to a specific psychiatric facility in another state. The SSW told R #131 psychiatric hospitals were usually temporary, and R #131 said he thought he could live at a psychiatric facility permanently. The PMHNP saw R #131, but R #131 felt he needed inpatient psychiatric care to receive the appropriate services. 4. Dated 11/07/25, R #131 told the SSW he was depressed and felt like he needed to get out of the facility. R #131 stated he felt like he needed to go to the mental health hospital in [state name] since they understood his mental health problems. 5. Dated 11/10/25, the SSW documented, he stated that he was only existing and not living. R #131 told the SSW the mental health treatment he received at the facility was not working and his previous treatments involved therapy. R #131 requested to see a psychiatrist. 6. Dated 11/13/25 at 10:36 AM, R #131 appeared to be hallucinating about God. R #131 rocked side to side and stated he wanted to get out of the facility. 7. Dated 11/13/25 at 4:36 PM, R #131 told the SSW he was not happy at the facility, because he was not getting the psychiatric care he needed. 8. Dated 11/19/25, R #131 reported being isolated, lonely, and his socialization needs were not met. 9. Dated 01/26/26, R #131 told the SSW he felt he had nothing to live for, but he was not suicidal. Y. Record review of R #131's provider progress notes revealed the following: 1. Dated 07/09/25, the provider documented R #131 had worsening depression, had made suicidal ideation statements, and behavioral issues. R #131 requested to see psychiatry daily. The provider documented the plan for R #131 was to monitor his behaviors and redirect behavior issues appropriately. 2. Dated 08/06/25, the provider documented R #131 was depressed and was taking a lot of psychiatric medications. The plan was to have R #131 evaluated by a psychiatrist. 3. Dated 08/20/25, the provider documented R #131's depression was still present, R #131 did not take his medications as prescribed, and R #131 requested to be transferred to another state to see a psychiatrist. The provider documented the plan for R #131 was to refer him to a local psychiatrist and work on getting him transferred per R #131's wish. 4. Dated 09/10/25, the provider documented R #131 refused treatment and medications. The plan for R #131 was to redirect R #131 and reassure him. 5. Dated 09/19/25, the provider documented R #131 was transferred to the psychiatric hospital due to suicidal ideation. 6. On 10/15/25, the provider documented R #131 was seen and treated by the psychiatric hospital for suicidal ideation. The plan for R #131 was to prescribe new medications, monitor, and redirect R #131. 7. Dated 11/05/25, the provider documented a referral would be placed for R #131 to see VA psych. 8. Dated 11/19/25, the provider documented R #131 still needed to see a psychiatrist. 9. Dated 11/26/25, the provider documented R #131 refused medications, had behavior issues and altered mental status. The plan for R #131 was to consider Depot injectable (antipsychotic medication) for schizophrenia. The provider documented R #131 was on the list to see a psychiatrist. 10. Dated 01/21/26, the provider documented that staff were reporting R #131 had more behavior issues, was talking too much, and his behavior was worse. The plan for R #131 was to increase his psychotropic medication and redirect behavioral issues. 11. The provider did not document any additional progress notes related to R #131's psychiatric conditions. Z. Record review of R #131's PMHNP progress notes revealed the following: 1. Dated 08/07/25, R #131 was seen. Staff notified her that R #131 had suicidal ideation. R #131 stated 1980 was the last time he had a plan to kill himself. Recommended R #131 be sent out for evaluation and treatment. 2. Dated 08/28/25, R #131 expressed suicidal ideation but refused to be sent to the ER. Staff were instructed to monitor R #131 for safety and comfort. 3. The PMHNP did not document any other progress notes for R #131. AA. Record review of R #131's Psychotropic Evaluation, dated 08/28/25, revealed the non-pharmacological interventions for R #131 were constant redirection and psychotherapy (talk therapy, a collaborative treatment based on the relationship between an individual and a trained mental health professional). BB. Record review of R #131's Mental Health Assessments revealed the following: 1. Dated 07/10/25, staff documented R #131 was irritable, not cordial, angry, and his cognition (includes thinking, knowing, remembering, judging, and problem-solving) was mixed up. Staff documented the plan was to monitor R #131 for safety and comfort. 2. Dated 08/08/25, staff documented R #131 was depressed. Staff documented the plan was to monitor R #131 for safety and comfort. CC. Record review of R #131's behavioral health hospital discharge documents, dated 10/10/25, revealed if R #131 felt overwhelmed, unable to cope, extremely anxious, or had suicidal ideation or thoughts of wanting to harm someone else, then he was to call his psychiatrist or therapist immediately. DD. Record review of R #131's medical record, no date, revealed staff did not document R #131 was seen by a psychiatrist or psychotherapy notes. EE. On 04/16/26 at 11:23 AM, during an interview, the PMHNP stated the following: 1. She completed weekly rounds with the MD to discuss resident's needs and adjust medications if needed. 2. She did psychotherapy with residents if there was a need. 3. She documented psychotherapy notes in a paper progress note. 4. She would see R #131 if the nurses told her there was a concern or when he would escalate. 5. She did not meet with R #131 on a regular basis, only if an issue would come up. 6. If residents were calm and there were no safety issues, she would only see them for weekly rounds with the MD. 7. She stated there were no concerns with R #131 after he returned from the behavioral health hospital on [DATE]. FF. On 04/16/26 at 1:11 PM, during an interview, the Social Services Director stated the following: 1. He was not aware R #131 was not happy with the psychiatric services provided by the facility. 2. If residents were not happy with the psychiatric services at the facility, then they were able to go to [name of agency in another town]. 3. The facility did not have any social workers trained to do therapy. 4. The only person in the facility qualified to do psychotherapy was the PMHNP. 5. He confirmed R #131's medical record did not have any psychotherapy notes. GG. On 04/16/25 at 2:26 PM, during an interview, the ADON stated the following: 1. The PMHNP did psychotherapy with residents. 2. R #131 voiced not wanting to see the PMHNP and wanted to see a psychiatrist. 3. R #131 voiced not being happy with the psychiatric services he was being provided at the facility. 4. She was not aware the provider ordered for R #131 to be referred to a psychiatrist. 5. Staff documented psychotherapy was one of R #131's non-pharmacological interventions on R #131's psychotropic evaluation, dated 08/28/25. 6. Psychotherapy was expected to be performed on a regular basis. 7. R #131's medical record only had two progress notes from the PMHNP. 8. R #131's progress notes completed by the PMHNP appeared to be in response to R #131 having suicidal ideation. 9. R #131 was not seen by a psychiatrist. HH. On 04/16/26 at 3:18 PM, during an interview, the Administrator confirmed the following: 1. The facility did not have a psychiatrist. 2. R #131 did not want to see the PMHNP, because he wanted to see a psychiatrist. 3. R #131 voiced not being happy with his psychiatric care. 4.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 5 (R #7, R #9, R #10, R #58, and R #112) of 6 (R #7, R #9, R #10, R #58, R #112, and R #133) residents reviewed for accuracy of documentation, when staff failed to: 1. Ensure the Preadmission Screening and Resident Review (PASRR, a mandatory federal program requiring Medicaid-certified nursing facilities to screen all applicants for serious mental illness and intellectual/developmental disabilities) included all mental health diagnoses for R #7 and R #112. 2. Update R #9's diagnosis when the pressure wound (injuries to skin and underlying tissue caused by prolonged pressure, friction, or shear, typically occurring over bony prominences like the sacrum, heels, or hips) was documented by the doctor as a chronic stage (long-standing, severe pressure injury that has persisted for an extended period, often months or years, and involves full-thickness tissue loss with exposed bone, tendon, or muscle) four (4) pressure ulcer.3. Document attempts to apply lotion to R #58's dry feet.4. Document communication with provider regarding change in antibiotics from intravenous to oral route for R #133.These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records. The findings are: PASRR R #7 A. Record review of R #7's admission Record, no date, revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7 diagnoses include: a. Post-traumatic stress disorder (PTSD; mental health condition triggered by experiencing or witnessing a traumatic event, characterized by persistent distressing symptoms that interfere with daily life). b. Major depressive disorder (MDD; a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems). c. Anxiety disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life). B. Record review of R #7's PASRR dated 06/10/25 revealed that staff did not document R #7's diagnoses of PTSD, MDD, and anxiety disorder. R #112 C. Record review of R #112's admission Record, no date, revealed the following: 1. R #112 was admitted to the facility on [DATE]. 2. R #112 diagnoses include: a. PTSD. b. Anxiety disorder. D. Record review of R #112's PASRR dated 07/22/25 revealed that staff did not document R #112's diagnoses of PTSD and anxiety disorder. E. On 04/21/26 at 3:21 PM, during an interview the admission coordinator confirmed the following: 1. R # 7's diagnoses included PTSD, MDD, and anxiety disorder and the diagnoses should be included on the PASRR. 2. R #112's diagnoses included PTSD and anxiety disorder, and they should be included on the PASRR. Diagnosis R #9 F. Record review of R #9's wound care consultation progress note dated 11/21/25 revealed the following: 1. Chief Complaint: Follow-up evaluation of chronic stage four (4) sacral (region of the lower back located just above the tailbone) pressure injury with known osteomyelitis (an infection or inflammation of the bone, usually caused by bacteria which can lead to bone damage if untreated). G. Record review of R #9's Face sheet, no date, did not include the diagnosis of chronic stage 4 pressure ulcer. H. On 04/21/26 at 4:43 PM, during an interview with the MDS Coordinator, she confirmed the following: 1. The wound care doctor did document that R #9 had a stage 4 pressure ulcer on the visit note for 11/21/25. 2. Staff did not update R #9's diagnosis list to include stage 4 pressure ulcer. R #58 I. Record review of R #58's admission Record, no date, revealed R #58 was admitted to the facility on [DATE]. J. On 04/14/26 at 10:17 AM, during an observation and interview with R #58, the following was revealed: 1. R #58's feet appeared dry and flakey. 2. R #58 stated he had a cream for his feet but was not sure when the last time was that staff used it on his feet. K. Record review of R #58's skin evaluation, dated 03/23/26, revealed staff documented, Skin very dry and scaley on both feet. L. Record review of R #58's skin evaluation, dated 04/06/26, revealed staff documented, Both feet and lower legs very dry and flakey. M. Record review of R #58's progress note, dated 04/07/26, revealed staff documented applying cream on R #58's legs. R #58 had his personal cream that was irritating his legs. Staff advised R #58 to discontinue using that cream. Also, staff advised R #58 to try a different cream that the facility had. N. On 04/20/26 at 10:49 AM, during an interview, RN #16 stated the following: 1. R #58's feet were very dry. 2. She offers to put lotion on R #58's feet at least once a week when she completes her skin assessment. 3. R #58 refuses to allow her to put lotion on him. 4. She doesn't document R #58's refusal to allow her to put lotion on him. O. On 04/20/26 at 11:04 AM, during an interview, CNA #16 stated the following: 1. R #58's feet were very dry. 2. She offers to put lotion on R #58's feet when she gets him up. 3. Resident always refuses to put lotion and states he doesn't like it. 4. She does not document R #58's refusal to put lotion on. P. On 04/21/26 at 2:28 PM, during an interview, the Registered Nurse Associate Manager confirmed the following: 1. Staff did not document attempts to apply lotion to R #58's feet, or that R #58 refused to allow staff to apply lotion. 2. Staff were expected to document when they offered to put lotion on residents and they refused. R #133 Q. Record review of R #133's admission Record, no date, revealed the following: 1. R #133 was admitted on [DATE]. 2. Diagnosis include urinary tract infection. R. Record review of R #133's Physician's orders revealed the following: 1. Order dated 04/11/26: Levofloxacin intravenous solution (an antibiotic given through the vein that is used to treat various bacterial infections in many different parts of the body) give 750 milligrams intravenously one time a day for sepsis (a life-threatening condition caused by the body's extreme and dysregulated response to an infection, leading to organ dysfunction and potentially death) for 10 days. 2. Order dated 04/11/26: Levofloxacin oral tablet give 750 milligrams by mouth one time a day for urinary tract infection for 10 days. S. Record review of R #133's Nursing Progress Notes dated 04/11/26 through 04/20/26 revealed that staff did not document any communication with the provider regarding changing R #133's levofloxacin from IV to oral route. T. Record review of R #133's medical record revealed no Provider Progress Notes dated 04/11/26 through 04/20/26. U. On 04/21/25 at 4:48 PM, during an interview with the RN #1 he confirmed that staff did not document anything regarding changing R #133's levofloxacin in R #133's medical record.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 ( R #11, and R #78) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure antipsychotic medications (a class of psychotropic medication primarily used to manage psychosis, a mental health symptom involving a loss of contact with reality, characterized by hallucinations, delusions, and disorganized thinking) were prescribed to treat an appropriate psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior) for R #78. 2. Ensure a gradual dose reduction (GDR; stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was carried out for R #11, and R #78. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, undesirable, and often unexpected reactions to medication). The findings are: R #11 A. Record review of R #11's admission Record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following diagnoses: a. Major depressive disorder, recurrent, moderate (depressive episodes with periods of remission in between moderate severity indicates significant symptoms and functional impairment but not complete disruption of daily life) b. Unspecified psychosis not due to a substance or known physiological condition (is a psychiatric diagnosis used when a person exhibits psychotic symptoms—such as hallucinations, delusions, and disorganized thinking—but the cause cannot be attributed to substance use or a known medical condition). c. Post-traumatic stress disorder, unspecified (PTSD, a mental health condition triggered by experiencing or witnessing terrifying, life-threatening events). B. Record review of R #11's physician orders revealed the following: 1. An order dated 08/28/25 for bupropion (medication used to treat depression) oral tablet extended release 24 Hour give 300 mg by mouth one time a day related to major depressive disorder recurrent, moderate. 2. An order dated 10/25/25 for duloxetine (medication used to treat major depressive disorder and anxiety disorder) HCl oral capsule delayed release. Sprinkle 60 mg (Duloxetine HCl) Give 60 mg by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms. 3. An order dated 08/08/25 for quetiapine fumarate (medication used to treat major depressive disorder by balancing brain chemicals linked to mood and behavior) oral tablet 100 mg 1 tablet by mouth at bedtime related to unspecified psychosis. C. Record review of R #11's Medication Regimen Review, dated 03/30/26, revealed the following: 1. The pharmacist recommended a GDR for R #11's order for bupropion 300 mg xl one time a day. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote stable. He did not document a clinical rationale for why a GDR should not be completed for R #11's bupropion 300 mg. 2. The pharmacist recommended a GDR for R #11's order for quetiapine 100 mg 1 tablet at bedtime. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote resident is very depressed and unspecified psychosis. He did not document a clinical rationale for why a GDR should not be completed for R #11's quetiapine 100 mg. 3. The pharmacist recommended a GDR for R #11's order for duloxetine 60 mg two times a day. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote stable. He did not document a clinical rationale for why a GDR should not be completed for R #11's duloxetine 60 mg. D. Record review of R #11's medical record, no date, revealed: 1. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's bupropion 300 mg after the pharmacist's recommendation on 03/30/26. 2. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's quetiapine 100 mg after the pharmacist's recommendation on 03/30/26. 3. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's duloxetine 60 mg after the pharmacist's recommendation on 03/30/26. E. On 04/21/26 at 1:10 PM, during an interview, House Supervisor (HS) #24 stated the following: 1. The provider was expected to review all pharmacist recommendations. They are to sign the pharmacist recommendation forms for R #11. 2. HS #24 confirmed the provider did not agree with the pharmacist's recommendation. The provider was expected to document a clear clinical rationale for why they did not want to follow the recommendation for R #11's medications duloxetine, bupropion, and quetiapine. R #78 F. Record review of R #78's admission Record, no date, revealed the following: 1. R #78 was admitted to the facility on [DATE]. 2. R #78 had the following diagnoses: a. PTSD. b. Vascular dementia, unspecified severity, with other behavioral disturbance (involves cognitive decline caused by brain vascular damage (e.g., strokes), marked by sudden, stepwise changes in personality, mood, and conduct). c. Anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life, lasting at least six months). d. Sleep disorder (disturb normal sleep patterns, affecting sleep quality, timing, or duration and causing excessive daytime sleepiness or impairment). G. Record review of R #78's physician's orders revealed the following: 1. An order dated 09/17/25, for olanzapine (an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar 1 disorder) 2.5 mg in the morning for unspecified dementia with other behavioral disturbance. 2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the olanzapine 2.5 mg order in the Electronic Medical Record (EMR) system that stated Increased mortality in elderly patients with dementia-related psychosis. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. 3. An order dated 09/17/25, for olanzapine 5 mg at bedtime for dementia with other behavioral disturbance. 4. Another black box warning attached to the olanzapine 5 mg order in the EMR system. 5. An order dated 07/13/25, for trazadone (a serotonin antagonist and reuptake inhibitor ([NAME]) antidepressant primarily used off-label for insomnia due to its strong sedative properties) 50 mg at bedtime for sleep, related to sleep disorder. H. Record review of R #78's Medication Regimen Review, dated 01/20/26, revealed the following: 1. The pharmacist recommended a GDR for R #78's trazadone 50 mg. 2. The provider selected Disagree, please offer clinical rationale below. 3. The provider did not document a clinical rationale for why a GDR should not be attempted for R #78's order for trazadone 50 mg. I. Record review of R #78's medical record, no date, revealed the provider did not document a clinical rationale for why a GDR was not conducted for R #78's trazadone. J. On 04/21/26 at 2:07 PM, during an interview, the Registered Nurse Associate Manager confirmed the following: 1. R #78 was receiving the antipsychotic medication olanzapine. R #78 did not have a diagnosis that had symptoms of psychosis. 2. R #78 had been taking trazadone 50 mg since 07/13/25. 3. A GDR had not been attempted for R #78's trazadone 50 mg. 4. The provider did not document in R #78's medical record a clinical rationale for why a GDR was not implemented for R #78's trazadone 50 mg.

Based on record review and interview, the facility failed to ensure the MDS was accurate for 3 (R #1, R #9 and R #133) of 6 (R #1, R #7, R #9, R #112, R #132, and R #133) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #1 A. Record review of R #1's admission Record, no date, revealed he was admitted on [DATE]. B. Record review of R #1's nursing progress note, dated 01/25/26, revealed R #1 was transferred to the hospital due to altered mental status (AMS; a broad term describing any change in a person's awareness, cognition, or behavior from their usual baseline, ranging from mild confusion to complete unresponsiveness). C. Record review of R #1 Convalescent Care Orders (physician orders that authorize a person to receive short-term, skilled care in a nursing facility, or other approved setting while they recover from an illness or acute health event) dated 03/02/26 revealed the following: 1. R #1 diagnosis was urinary tract infection (UTI; infection in any part of the urinary systems which include the kidneys, bladder, ureters and urethra). 2. R #1 had an order for ertapenem (antibiotic used to treat severe infections caused by various bacteria) 1 gram to be given intravenously (given in the vein) once daily for 3 days for UTI. D. Record review of R #1's Significant Change MDS assessment dated [DATE] revealed that staff did not document R #1 had a diagnosis of UTI in the last 30 days. E. On 04/21/26 at 4:43 PM, during an interview, with RN #1 and the MDS Coordinator the following was confirmed: 1. R #1 was treated with antibiotics for a UTI when he returned to the facility on [DATE]. 2. R #1's Significant Change MDS dated [DATE] did not include R #1's UTI diagnosis. R #9 F. Record review of R #9's admission Record, no date, revealed she was readmitted on [DATE]. G. Record review of R #9's wound care consultation progress note dated 11/21/25 revealed the following: 1. Chief Complaint: Follow-up evaluation of chronic stage four (4) (long-standing, severe pressure injury that has persisted for an extended period, often months or years, and involves full-thickness tissue loss with exposed bone, tendon, or muscle) sacral (region of the lower back located just above the tailbone) pressure injury with known osteomyelitis (an infection or inflammation of the bone, usually caused by bacteria which can lead to bone damage if untreated). 2. Assessments (clinician's professional evaluation of a patient's condition, synthesizing symptoms and findings into a diagnosis or clinical impression): Pressure ulcer of sacral region, stage 4. H. Record review of R #9's Significant Change MDS dated [DATE] revealed that staff did not document that R #1 had a diagnosis of a stage 4 pressure ulcer. I. On 04/21/26 at 4:43 PM, during an interview with the MDS Coordinator, she confirmed the following: 1. The wound care doctor did document that R #9 had a stage 4 pressure ulcer on the visit note for 11/21/25. 2. Staff did not include R #9's stage 4 pressure ulcer under the active diagnosis section of R #9's Significant Change MDS dated [DATE]. 3. R #9 does have an active diagnosis of a stage 4 pressure ulcer that should be included on the MDS. R #133 J. Record review of R #133's admission Record, no date, revealed the following: 1. R #133 was admitted on [DATE]. 2. Diagnosis of UTI. K. Record review of R #133's progress notes revealed the following: 1. Provider progress noted dated 02/25/26, revealed the following: Urinalysis (routine examination of the urine for bacteria and chemicals that suggest various illnesses, including infection and kidney disease) reviewed. It showed moderate leukocytes (presence of white blood cells, often signaling an infection or inflammation in the urinary tract) and positive nitrites (strong indicator of bacterial infection, most commonly UTI). Patient has been falling lately. Pending culture and sensitivity (laboratory test that identifies bacteria or fungi in a sample and determines which antibiotics or antifungal medications are effective in treating the infection). I will start empiric antibiotics (prescribed before the exact cause of an infection is identified). Ciprofloxacin (Cipro; antibiotic used to treat a wide range of bacterial infections including urinary tract infections) 500 mg twice a day for 7 days. Review once we have culture results. 2. Nursing progress note dated 02/26/26: Resident started on Cipro 500 mg twice a day this shift for UTI. 3. Nursing progress note dated 02/27/26: Continues on oral antibiotics for UTI until 03/05/26. 4. Nursing progress note dated 02/28/26: Resident continues antibiotics for UTI. 5. Nursing progress note dated 03/02/26: Resident continues on Cipro 500 mg twice daily for UTI. L. Record review of R #133's Physician's orders revealed an order dated 02/26/26: Ciprofloxacin oral tablet 500 mg, give 1 tablet by mouth two times a day for UTI. M. Record review of R #133's Quarterly MDS assessment dated [DATE] revealed that staff did not document that R #133 had a diagnosis of UTI in the last 30 days. N. On 04/21/26 at 4:43 PM, during an interview with the MDS Coordinator the following was confirmed: 1. R #133 was treated with antibiotics for a UTI from 02/26/26 through 03/04/26. 2. R #133's Quarterly MDS dated [DATE] did not include R #133's UTI diagnosis.

Based on record review, and interview, the facility failed to ensure care plan revisions and care plan meeting requirements occurred for 9 (R #2, R #4, R #5, R #11, R #18, R #28, R #29, R #92, and R #124 ) of 9 (R #2, R #4, R #5, R #11, R #18, R #28, R #29, R #92, and R #124) residents reviewed for care plans, when the staff failed to: 1. Ensure the required IDT members attend the care plan meeting, and staff did not document any input from the physician or the CNA who provided care for R #2, R #4, R #5, R #11, R #18, R #28, R #29, and R #92. 2. Ensure the care plan meeting was held within 7 days from the completion of the MDS assessment when creating or revising the care plan for R #4, R #28, and R #29. 3. Revise the care plan with the most current resident information for R #1, R #2, R #5, and R #124. These deficient practices could likely result in care plans not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care being provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: IDT Members and Timing R #2 A. Record review of R #2's admission Record, no date, revealed an admission date of 01/29/26. B. Record review of R #2's care plan meeting note dated 03/19/26 revealed the following: 1. The IDT did not include the physician and the CNA in the meeting. 2. Staff did not document that they received input from the physician or the CNA who provided care to R #2. C. On 04/15/26 of 3:23 PM, during an interview with the Senior Social Worker (SSW) confirmed the following: 1. R #2 had a care conference on 03/19/26. 2. The CNA, and physician were not present in the meeting. 3. The CNA, and physician did not give input for R #2's care plan meeting. R #4 D. Record review of R #4's admission Record, no date, revealed an admission date of 03/21/24. E. Record review of R #4's annual MDS was completed on 02/18/26. F. Record review of R #4's care plan meeting note dated 02/26/26 revealed the following: 1. The interdisciplinary team did not include the physician and the CNA in the meeting. 2. Staff did not document that they received input from the physician or the CNA who provided care to R #4. 3. Care plan meeting was not done within seven (7) days after the completion of the annual MDS dated [DATE]. G. On 04/15/26 at 3:26 PM, during an interview with the SSW, confirmed the following: 1. The CNA and physician did not attend R #4's meeting. 2. They did not provide input on R #4's care. 3. R #4's care plan meeting was not done within seven days of completion of the MDS dated [DATE]. R #5 H. Record review of R #5's admission record, no date, revealed R #5 was admitted to the facility on [DATE]. I. Record review of R #5's progress notes revealed the following: 1. On 04/02/26 a care plan meeting was held for R #5. The provider and a CNA with responsibility for R #5's care did not attend the IDT care plan meeting. 2. Staff did not document that input was received from the provider or a CNA who provided care to R #5. R #11 J. Record review of R #11's admission Record, no date, revealed an admission date of 03/14/25. K. Record review of R #11's care plan meeting note dated 02/19/26 revealed the following: 1. The interdisciplinary team did not include the physician and the CNA in the meeting. 2. Staff did not document that they received input from the physician or the CNA who provided care to R #11. L. On 04/15/26 at 3:29 PM, during an interview with the SSW confirmed the following IDT members did not attend R #11's care plan meeting: 1. The MDS Nurse, 2. The physician, 3. The CNA. R #18 M. Record review of R #18's admission record, no date, revealed R #18 was admitted to the facility on [DATE]. N. Record review of R #18's care plan meeting note, dated 01/18/26, revealed the following: 1. The interdisciplinary team did not include the physician and the CNA in the meeting. 2. Staff did not document that they received input from the physician or the CNA who provided care to R #18. R #28 O. Record review of R #28's admission Record, no date, revealed R #28 was admitted to the facility on [DATE]. P. Record review of R #28's admission MDS, dated [DATE], revealed the MDS was completed on 02/25/26. Q. Record review of R #28's progress notes, dated 03/10/26, revealed the following: 1. The IDT held a care plan meeting on 03/10/26 (not within seven (7) days of the completion of the admission MDS on 02/25/26). 2. The IDT members present were Dietary, an RN, the MDS Coordinator, and two social services workers. 3. Staff did not document that input was received from the provider or a CNA who provided care to R #28. R. On 04/21/26 at 1:37 PM, during an interview with the Registered Nurse Associate Manager and the MDS Coordinator, they confirmed the following: 1. The IDT care plan meeting held for R #28 was not within seven (7) days after the completion of his MDS that was completed on 02/25/26. 2. The provider and a CNA with responsibility for R #28's care did not attend the IDT care plan meeting on 03/10/26. 3. Staff did not document if input was received from the provider or a CNA with responsibility for R #28's care prior to R #28's IDT care plan meeting on 03/10/26. 4. Staff do not contact the provider for input prior to the IDT care plan meetings. R #29 S. Record review of R #29's admission record, no date, revealed R #29 was admitted to the facility on [DATE]. T. Record review of R #29's quarterly MDS, dated [DATE], revealed the MDS was completed on 02/25/26. U. Record review of R #29's progress notes, dated 03/05/26, revealed the following: 1. The IDT held a care plan meeting on 03/05/26 (this was not within seven (7) days of the completion of the quarterly MDS on 02/25/26). 2. Staff did not document the IDT members that attended the care plan meeting. R #92 V. Record review of R #92's admission record, no date, revealed R #92 was admitted to the facility on [DATE]. W. Record review of R #92's progress notes, dated 02/19/26, revealed the following: 1. The interdisciplinary team did not include the physician and the CNA in the meeting. 2. Staff did not document that they received input from the physician or the CNA who provided care to R #92. Revision R #1 X. Record review of R #1's admission Record, no date, revealed R #1 was admitted to the facility on [DATE]. Y. Record review of R #1's Significant Change MDS dated [DATE], revealed R #1's Activities Assessment preferences were coded as follows: 1. Staff documented code 1 (very important) for R #1 to: a. Listen to music he likes. b. Be around animals such as pets. c. Keep up with the news. d. Go outside and get fresh air when the weather is good. 2. Staff documented code 2 (somewhat important) for R #1 to do his favorite activities. Z. Record review of R #1's Progress Notes revealed the following: 1. Nutrition/dietary note dated 03/04/26: .Resident has experienced 6.5% significant weight loss over the past 30 days. 2. Nursing note-skin issues dated 03/19/26: New skin issue, stage 2 pressure ulcer injury (open wound caused by excessive and sustained pressure on a particular part of the body that extends into the bottom layers of the skin but does not extend to the subcutaneous fat, muscle or bone) to sacrum (region of the lower back located just above the tailbone). AA. Record review of R #1's Nursing Restorative Plan of Care dated December 2025 revealed R #1 was discharged from the Restorative Nursing Program (RNP; a structured set of nursing interventions that focus on maximizing an optimal level of functioning, enabling residents to regain/retain their independence following the debilitating effects of illness or injury) on 12/11/25. BB. Record Review of R #1's care plan dated 09/16/24 revealed the following: 1. Revision 09/29/25: R #1 participates in RNP, Physical Therapy (PT; the treatment of disease, injury, or physical conditions by methods such as massage, heat treatment, and exercise rather than by drugs or surgery), and dining. 2. Staff did not revise R #1's care plan for his recent (03/04/26) weight loss of 6.5 % over the past 30 days. 3. Staff did not revise the activities section of the care plan to reflect R #1's current activity preferences after his SCSA MDS was completed. 4. Staff did not revise R #1's care plan to include that he had an actual stage 2 pressure ulcer. CC. On 04/21/26 at 4:40 PM, during an interview, RN #1 and LPN #1, the following was confirmed: 1. R #1 was discharged from the RNP on 12/11/25 and R #1's care plan was not revised. 2. The dietician documented that R #1 had significant weight loss of 6.5% on 03/04/26 and the care plan was not revised. 3. R #1's care plan was not revised to include his current activity preferences as documented on the Significant Change MDS dated [DATE]. 4. R #1's care plan has not been revised to include that R #1 has a stage 2 pressure ulcer. R #2 DD. Record review of R #2's Significant change MDS dated [DATE], revealed R #2's Activities Assessment preferences were coded 1-4 (1 not very important and 4 not important at all) as follows: 1. Staff documented code 2 (somewhat important) for R #2 to be around animals such as pets. 2. Staff documented code 1 (very important) for R #2 participate in religious services. EE. Record review of R #2's care plan revision date 02/17/26 revealed staff did not include #2 personal preferences from the Significant change MDS for the following: 1. R #2 to be around animals. 2. R #2 to participate in religious services. FF. On 04/16/26 at 1:49 PM, during an interview with the Activities Director (AD) stated the activity assessments and care plans should be based on each resident. The activity assessment of the residents' personal preferences should set a foundational goal. They should be included in the care plan. The AD confirmed that R #2's care plan was not client centered with R #2's personal preferences. R #5 GG. On 04/14/26 at 10:54 AM, during an interview, R #5 stated the following: 1.That it is difficult for him to go to group activities. 2. He was not provided with one-on-one activities. 3. They did not have one-on-one activities. 4. He is in his bed a lot and that he gets bored. HH. Record review of R #5's progress note dated 04/16/26 revealed during a visit with the Chaplin, R #5 stated he was bored and lonely. II. Record review of R #5's care plan, dated 12/19/25, revealed the following: 1. R #5 does not participate in group activities because he refuses. 2. Staff did not document R #5's preferences for activities or his need for one-on-one activities JJ. On 04/20/26 at 11:35 AM, during an interview, the AD confirmed that there is no documentation of one-on-one activities for R #5. The AD confirmed that R #5's staff did not document R #5's preferences for activities. R #124 KK. On 04/14/26 at 9:54 AM, during an interview R #124 revealed he had wax build up in his ear. R #124 stated staff have been putting drops in his ear and that he had been to an audiologist, but they can't get his ear unplugged. LL. Record review of R #124's care plan revealed staff did not document R #124's wax build up and interventions.

Based on observation, interview, and record review the facility failed to store food under sanitary conditions for all 127 residents who eat food from the kitchen (residents were identified by the resident Matrix provided by the Administrator on 04/20/26), when they failed to label and date food items in the receiving kitchen refrigerator. If the facility fails to store food under safe and sanitary conditions then this could likely lead to foodborne illnesses (Foodborne illness can occur if you eat foods that are contaminated with harmful pathogens such as bacteria, viruses, and fungi) in residents. The findings are: A. On 04/13/26 at 2:30 PM, during an observation of the receiving kitchen refrigerator, the walk-in refrigerator had a large container of Pace Picante sauce dated 03/12/26 opened, and the expiration date was 03/31/26. A Large Sour Cream container had no date when it was opened. B. On 04/13/26 at 2:30 PM, during an interview the Dietary Supervisor (DS) #25 stated staff are to mark the food items when they opened. Staff should also throw out expired food items. C. Record review of the facilities Dry Storage Policy reviewed date 12/18/15 revealed that food is to be labeled and dated on all storage containers.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (set of reasons or a logical basis for a course of action) for not following the consultant pharmacist's recommendation in a timely manner for 3 (R #6, R #11, R #78) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects and residents receiving medications that are no longer necessary. The findings are: R #6 A. Record review of R #6's admission Record, no date, revealed R #6 was admitted to the facility on [DATE]. B. Record review of R #6's physician's orders revealed the following: 1. An order dated 03/14/26, for gabapentin (anticonvulsant medication used to treat partial seizures in epilepsy and nerve pain) 100 mg twice a day. 2. An order dated 03/13/26, for risperidone (an atypical antipsychotic medication used to treat schizophrenia, bipolar disorder, and autism-related irritability) 0.5 mg once a day. 3. An order dated 03/14/26, for venlafaxine (a prescription serotonin-norepinephrine reuptake inhibitor (SNRI) used to treat major depressive disorder, generalized anxiety disorder, social anxiety disorder, and panic disorder) 75 mg once a day. 4. An order dated 03/14/26, for carvedilol (beta-blocker used to treat high blood pressure (hypertension) and heart failure) 12.5 mg twice a day. 5. An order dated 03/14/26, for losartan potassium-HCTZ 50-12.5 mg once a day. 6. An order dated 03/14/26, for melatonin 6 mg at bedtime. C. Record review of R #6's pharmacy review, dated 01/07/26, revealed the following: 1. R #6 had a recent fall. 2. The pharmacist documented that the following medications could contribute to falls: a. Gabapentin 100 mg twice a day. b. Risperidone 0.5 mg once a day. c. Venlafaxine 75 mg once a day. d. Carvedilol 12.5 mg twice a day. e. Losartan potassium-hydrochlorothiazide (a combination medication used to treat high blood pressure (hypertension) and reduce stroke risk) 50-12.5 mg once a day. f. Melatonin (a hormone produced by the brain to regulate sleep cycles) 6 mg at bedtime. 3. The pharmacist recommended R #6's medications be reviewed for changes. 4. The provider selected disagree. Please offer clinical rationale below. 5. The provider did not document a clinical rationale for why R #6's medications should not be changed. D. Record review of R #6's medical record, no date, revealed the provider did not document a clinical rationale for why R #6's medications should not be changed. E. On 04/21/26 at 2:02 PM, during an interview, the Registered Nurse Associate Manager confirmed the following: 1. On 01/07/26, the pharmacist recommended the provider review R #6's medications after a fall. 2. The provider did not document a clinical rationale for why R #78's medications should not be changed. 3. He was unsure of the process for ensuring the provider documents a clinical rationale for why he didn't follow the pharmacist's recommendations. R #11 F. Record review of R #11's admission Record, no date, revealed the following: 1. R #11 was admitted to the facility on [DATE]. 2. R #11 had the following diagnoses: a. Major depressive disorder, recurrent, moderate (depressive episodes with periods of remission in between moderate severity indicates significant symptoms and functional impairment but not complete disruption of daily life). b. Unspecified psychosis not due to a substance or known physiological condition (is a psychiatric diagnosis used when a person exhibits psychotic symptoms). c. Post-traumatic stress disorder, unspecified (is intrusive thoughts, avoidance behaviors, negative changes in mood and cognition, hyperarousal, and emotional numbing). G. Record review of R #11's physician's orders, revealed the following: 1. An order dated 08/28/25 for bupropion (medication used to treat depression) oral tablet extended release 24 Hour give 300 mg by mouth one time a day related to major depressive disorder recurrent, moderate. 2. An order dated 10/25/25 for duloxetine (medication used to treat major depressive disorder and anxiety disorder) HCl oral capsule delayed release. Sprinkle 60 mg (Duloxetine HCl) Give 60 mg by mouth two times a day related to major depressive disorder, recurrent, severe with psychotic symptoms. 3. An order dated 08/08/25 for quetiapine fumarate (medication used to treat major depressive disorder by balancing brain chemicals linked to mood and behavior) oral tablet 100 mg 1 tablet by mouth at bedtime related to unspecified psychosis not due to a substance or known physiological condition major depressive disorder, recurrent, severe with psychotic symptoms. H. Record review of R #11's Medication Regimen Review, dated 03/30/26, revealed the following: 1. The pharmacist recommended a GDR for R #11's order for bupropion 300 mg xl one time a day. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote stable he did not document a clinical rationale for why a GDR should not be completed for R #11's bupropion 300 mg. 2. The pharmacist recommended a GDR for R #11's order for quetiapine 100 mg 1 tablet at bedtime. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote resident is very depressed and unspecified psychosis he did not document a clinical rationale for why a GDR should not be completed for R #11's quetiapine 100 mg. 3. The pharmacist recommended a GDR for R #11's order for duloxetine 60 mg two times a day. a. The provider selected disagree. Please offer clinical rationale below. b. The provider wrote stable he did not document a clinical rationale for why a GDR should not be completed for R #11's duloxetine 60 mg. I. Record review of R #11's medical record, no date, revealed: 1. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's bupropion 300 mg after the pharmacist's recommendation on 03/30/26. 2. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's quetiapine 100 mg after the pharmacist's recommendation on 03/30/26. 3. The provider did not document a clinical rationale for why a GDR should not be completed for R #11's duloxetine 60 mg after the pharmacist's recommendation on 03/30/26. J. On 04/21/26 at 1:10 PM, during an interview, with Registered Nurse Manager (RNM) stated the following: 1. The provider was expected to review all pharmacist recommendations and sign the pharmacist recommendation forms for R #11. 2. RNM confirmed the provider did not agree with the pharmacist's recommendation. The provider was expected to document a clear clinical rationale for why they did not want to follow the recommendation for R #11's medications duloxetine, bupropion, and quetiapine. R #78 K. Record review of R #78's admission Record, no date, revealed the following: 1. R #78 was admitted to the facility on [DATE]. 2. R #78 had the following diagnoses: a. PTSD. b. Vascular dementia, unspecified severity, with other behavioral disturbance (involves cognitive decline caused by brain vascular damage (e.g., strokes), marked by sudden, stepwise changes in personality, mood, and conduct). c. Anxiety disorder (mental health conditions characterized by excessive, uncontrollable, and persistent fear or worry that interferes with daily life, lasting at least six months). d. Sleep disorder (disturb normal sleep patterns, affecting sleep quality, timing, or duration and causing excessive daytime sleepiness or impairment). L. Record review of R #78's physician's orders revealed the following: 1. An order dated 05/20/25, for oxycodone 5 mg every 6 hours as needed for pain. 2. An order dated 09/17/25, for olanzapine (an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar 1 disorder) 2.5 mg in the morning for unspecified dementia with other behavioral disturbance. 3. An order dated 09/17/25, for olanzapine 5 mg at bedtime for dementia with other behavioral disturbance. 4. An order dated 07/13/25, for trazadone (a serotonin antagonist and reuptake inhibitor ([NAME]) antidepressant primarily used off-label for insomnia due to its strong sedative properties) 50 mg at bedtime for sleep, related to sleep disorder. 5. An order dated 01/09/26, for amlodipine besylate 5 mg once a day for high blood pressure. M. Record review of R #78's pharmacy review, dated 01/06/26, revealed the following: 1. R #78 had a recent fall. 2. The pharmacist documented that the following medications could contribute to falls: a. Oxycodone 5 mg every 6 hours. b. Olanzapine 2.5 mg in the morning. c. Trazadone 50 mg at bedtime. d. Olanzapine 5 mg at bedtime. e. Amlodipine 5 mg once a day. 3. The pharmacist recommended R #78's medications be reviewed for changes. 4. The provider selected disagree. Please offer clinical rationale below. 5. The provider did not document a clinical rationale for why R #78's medications should not be changed. N. Record review of R #78's Medication Regimen Review, dated 01/20/26, revealed the following: 1. The pharmacist recommended a GDR for R #78's order for trazadone 50 mg at bedtime. 2. The provider selected disagree. Please offer clinical rationale below. 3. The provider did not document a clinical rationale for why a GDR should not be completed for R #78's trazadone 50 mg. O. Record review of R #78's Medication Regimen Review, dated 03/30/26, revealed the following: 1. The pharmacist recommended a GDR for R #78's order for olanzapine 2.5 mg in the morning. 2. The provider selected disagree. Please offer clinical rationale below. 3. The provider did not document a clinical rationale for why a GDR should not be completed for R #78's olanzapine 2.5 mg. P. Record review of R #78's medical record, no date, revealed: 1. The provider did not document a clinical rationale for why R #78's medications should not be changed due to falls after the pharmacist's recommendation on 01/06/26. 2. The provider did not document a clinical rationale for why a GDR should not be completed for R #78's trazadone 50 mg after the pharmacist's recommendation on 01/20/26. 3. The provider did not document a clinical rationale for why a GDR should not be completed for R #78's olanzapine 2.5 mg after the pharmacist's recommendation on 03/30/26. Q. On 04/21/26 at 2:07 PM, during an interview, the Registered Nurse Associate Manager confirmed the following: 1. On 01/06/26, the pharmacist recommended the provider review R #78's medications after a fall. 2. The provider did not document a clinical rationale for why R #78's medications should not be changed. 3. On 01/20/26, the pharmacist recommended a GDR for R #78's trazadone 50 mg. 4. The provider did not document a clinical rationale for why a GDR should not be performed for R #78's trazadone 50 mg. 5. On 03/30/26, the pharmacist recommended a GDR for R #78's olanzapine 2.5 mg. 6. The provider did not document a clinical rationale for why a GDR should not be performed for R #78's olanzapine 2.5 mg. 7. He was unsure of the process for the frequency of performing GDR's.

Based on record review and interview, the facility failed to complete and transmit a MDS assessment within 14 days of completion (sign off by RN) for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments. This deficient practice could lead to the facility not reporting information in a timely manner (within 14 days) to the federal agency. The findings are: A. Record review of R #10's Quarterly MDS revealed a completion date of 03/31/26. B. Record review of R #10's Quarterly MDS revealed the facility transmitted the MDS to the federal agency on 04/15/26. C. On 04/21/26 at 4:36 PM, during an interview, the MDS Coordinator confirmed staff did not transmit R #10's Quarterly assessment to the federal agency within 14 days of completion.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #2) of 5 (R #2, R #6, R #11, R #78, and R #124) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, this deficient practice could likely result in residents and/or their representatives not being able to make informed decisions regarding residents' care. The findings are: A. Record review of R #2's physician's orders revealed the following: 1. An order dated 04/06/26 for Sertraline (a psychotropic medication used to treat major depressive disorder) oral tablet 50 mg, give 1 tablet by mouth one time a day for major depressive disorder. B. Record review of R #2's medical record revealed staff did not document consent for Sertraline. C. On 04/21/26 at 1:22 PM, during an interview House Supervisor (HS) #24 confirmed R #2 had an order for Sertraline to treat depressive disorder. The HS #24 stated that there should be consents completed for psychotropic medications. R #2 did not have a consent for Sertraline in his record.

Based on record review and interview, the facility failed to provide the required transfer information for 1 (R #1) of 2 (R #1 and R #128) residents reviewed for hospitalizations when staff failed send a copy of the written notice of transfer to the Ombudsman. This deficient practice could likely result in the residents and/or their representatives not receiving assistance from the ombudsman in the transition from the nursing home. The findings are: A. Record review of R #1's admission Record, no date, revealed R #1 was admitted to the facility on [DATE]. B. Record review of R #1's nursing progress note, dated 02/25/26, revealed R #1 was transferred to the hospital due to altered mental status (AMS; a broad term describing any change in a person's awareness, cognition, or behavior from their usual baseline, ranging from mild confusion to complete unresponsiveness). C. Record review of R #1's medical record, no date, revealed staff did document a written transfer notice and bed hold notice for R #1's transfer to the hospital on [DATE]. D. On 04/21/26 at 4:43 PM, during an interview, RN #1 stated that the nursing staff complete the transfer notice at the time of transfer but was unsure if the notice is sent to the ombudsman. E. On 04/22/26 at 1:58 PM, during an interview, the ombudsman stated that the facility does not send her a copy of the written transfer notices.

Based on record review and interview, the facility failed to ensure that an MDS assessment was completed every three months for 1 (R #10) of 1 (R #10) residents reviewed for MDS assessments when they failed to complete a quarterly MDS assessment within 92 days of the previous assessment reference date (ARD; the specific end point for the look-back periods in the MDS assessment process, also called the observation or assessment period.). This deficient practice could result in residents' assessments being outdated and residents not receiving care and treatment that meets their current needs. The findings are: A. Record review of R #10's Significant Change MDS assessment revealed an ARD of 12/08/25. B. Record review of R #10's Quarterly MDS assessments revealed an ARD of 03/23/26 (105 days after 12/08/25). C. On 04/21/26 at 4:36 PM, during an interview, the MDS Coordinator confirmed staff did not complete R #10's MDS assessments within 92 days of R #10's Significant Change MDS.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #132) of 4 (R #1, R #9, R #132, R #133) residents reviewed for medical care, when staff failed to implement an order after a doctor visit. This deficient practice could likely lead to unnecessary discomfort, prolonged symptoms or worsening of medical conditions. The findings are: A. Record review of R #132's admission Record, no date, revealed R #132 was admitted to the facility on [DATE]. B. On 04/14/26 at 9:51 AM, during an interview, R #132 stated the following: 1. He has a cough with a lot of phlegm that has had for several weeks. 2. He was seen by the facility doctor approximately two weeks ago where he told the doctor he had a cough with phlegm. 3. R #1 stated the doctor told him he would prescribe cough syrup for him. 4. R #1 has not received any cough syrup yet. B. Record review of R #132's provider visit note dated 04/01/26 revealed the following: 1. R #1 has a cough with phlegm. 2. Will prescribe Robitussin cough syrup. C. Record review of R #132's physician's orders revealed staff did not document any orders for cough syrup. D. Record review of R #132's Nursing Progress Notes revealed a note written by the ADON dated 04/01/26: [name of facility doctor] in to see resident. New orders noted. E. On 04/21/26 at 4:29 PM, during an interview, RN #1 stated the following: 1. The ADON is not at the facility today (04/21/26). 2. The ADON goes with the facility doctor when he sees residents, and she enters any new orders that the doctor wants to implement for residents. 3. R #132 does not have an order for cough syrup.

Based on record review and interview, the facility failed to ensure a comprehensive MDS assessment was completed within 14 calendar days after admission for 1 (R #132) of 2 (R #28 and R #132) residents reviewed for MDS timing. This deficient practice could likely result in residents' needs not being met. The findings are: A. Record review of R #132's admission Record, no date, revealed R #132 was admitted to the facility on [DATE]. B. Record review of R #132's MDS assessments revealed staff did not complete his admission MDS assessment until 04/13/26. C. On 04/21/26 at 4:27 PM, during an interview, the MDS Coordinator confirmed staff did not complete R #132's admission MDS assessment within 14 days of admission to the facility.

Based on observation and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (R #124) of 1 (R #124) residents randomly sampled, when the staff failed to interact and explain to R #124 why they were in House 2. This deficient practice could likely result in residents feeling embarrassed, angry, and that their feelings are unimportant to the facility staff. The findings are: A. On 04/14/26 at 9:38 AM, during an interview, R #124 stated that staff sitting in the common area did not care about the residents. R #124 stated that they were two guard dogs just sitting around in the house. R #124 stated they were only there when the surveyors were there. R #124 stated when he asked them what they were doing, they did not respond to him. B. On 04/14/26 at 11:23 AM, during an observation of House 2 during lunch, it was observed that there were two staff sitting at the dining table eating lunch. They were interacting with each other but not with the residents. C. On 04/14/26 at 11:26 AM, during an interview, the DM stated the two staff members were medical record staff. The DM stated medical record staff aren't usually at the house. D. On 04/14/26 at 11:29 AM, during an interview, Medical Record Staff (MRS) #1 stated that she was at the house because she was told to be there. When asked if she is usually assigned to House 2, she stated that she goes where she is told to go. E. On 04/14/26 at 3:21 PM, during an interview with the Administrator, she stated she has directed staff to start going to the different units to get to know the residents. The Administrator stated that her expectation is they be engaged with the residents and not just sitting around. The Administrator stated she would expect them to answer a resident if they were asked why they were at the unit.

Based on record review, observation, and interview, the facility failed to provide an ongoing program of activities designed to meet the interests for 2 (R #2, and R #5) of 4 (R #1, R #2, R #5, and R #29) residents reviewed for activities by not providing meaningful individualized activities based upon residents' interests. If residents are not provided or encouraged to attend/participate in activities that meet their interests, then they are likely to experience an increase in boredom, isolation, and depression. The findings are: R #2 A. Record review of R #2's admission Record, no date, revealed R #2 was admitted to the facility on [DATE]. B. Record review of R #2's Significant change MDS dated [DATE], revealed R #2's Activities Assessment preferences were coded as follows: 1. Staff documented code 2 (somewhat important) for R #2 to be around animals such as pets. 2. Staff documented code 1 (very important) for R #2 participate in religious services. C. Record review of R #2's care plan revision date 02/17/26 revealed staff did not include #2 personal preferences for the following: 1. To be around animals. 2. To participate in religious services. D. Record review of R #2's Daily Participation Record, for February 2026, revealed staff did not document activities for R #2's personal preferences of being around animals or participating in religious services. E. Record review of R #2's Daily Participation Record, for March 2026, revealed staff did not document activities for R #2's personal preferences of being around animals or participating in religious services. F. On 04/16/26 at 1:49 PM, during an interview with the Activities Director (AD) stated the activity assessments and care plans should be based on each resident. The activity assessment of the residents' personal preferences should set a foundational goal and be included in the care plan. The AD confirmed that R #2's care plan was not client centered to include R #2's personal preferences. She stated that due to R #2's lack of participation R #2 should receive one-to-one activity in his activity program. R #5 G. Record review of R #5's admission record, no date, revealed R #5 was admitted to the facility on [DATE]. H. On 04/14/26 at 10:54 AM, during an interview, R #5 stated the following: 1. It is difficult for him to go to group activities. 2. Staff do not provide one-on-one activities. 3. He is in his bed a lot and that he gets bored. I. Record review of R #5's progress notes, dated 04/16/26, revealed during a visit with the Chaplin, R #5 stated he was bored and lonely. J. Record review of R #5's Significant Change MDS assessment dated [DATE] revealed R #5's personal preferences for activities revealed the following: 1. It was very important to listen to music. 2. It was very important to go outside to get fresh air when the weather is good. K. Record review of R #5's care plan, dated 12/19/25, revealed R #5 did not participate in group activities because he refuses. R #5's care plan did not include his personal preferences from the Significant Change MDS. L. Record review of R #5's medical record, no date, revealed staff did not document one-on-one activities or activities that meet R #5's interest. M. On 04/20/26 at 11:35 AM, during an interview, the AD stated that staff converse with residents and watch movies with them for one-on-one activities. The AD stated that staff try to do activities in the different homes and in the annex for the residents that don't go to the main building for activities. The AD confirmed that she did not see that any one-on-one activities had been offered to R #5. The AD confirmed R #5's preferences are not documented in his medical record. The AD confirmed that she did not know if R #5 enjoyed watching movies or conversing as an activity.

49313 Based on record review and interview, the facility failed to provide adequate mental health services for 2 (R #62 and R #70) of 2 (R #62 and R #70) residents reviewed for mental health. This deficient practice likely resulted increased depression, hopelessness and psychosocial distress for R #62 and R #70. The findings are: R #62 A. Record review of R #62's admission documents, no date, revealed the following: 1. R #62 was admitted to the facility on [DATE]. 2. R #62 had the following diagnoses: a. Bipolar Disorder (serious mental illness characterized by extreme mood swings, that can include extreme excitement episodes or extreme depressive feelings). b. Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). c. Dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities). d. Post-Traumatic Stress Disorder (PTSD, mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback, and avoidance of similar situations). B. On 11/19/24 at 10:12 AM, during an interview with R #62, he stated the following: 1. The facility has not done anything for his mental health diagnoses or history of trauma. 2. Prior to coming to the facility, he used to receive therapy for his mental health diagnoses. 3. He confirmed that he is currently not receiving any behavioral health services and he believed that he would benefit from behavioral health services for his mental health diagnoses. C. Record review of R #62's nursing progress note, dated 9/10/24, revealed the following: 1. R #62 stayed in bed throughout the day shift. 2. R #62 refused lunch and refused to get out of bed. 3. R #62 stated he was giving up. 4. R #62's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) was contacted to talk to R #62 since he was feeling alone. 5. R #62's POA was going to speak to family about requesting a psychiatric consultation (a meeting with a psychiatrist to evaluate a patient's mental health and provide a diagnosis and treatment recommendations) for R #62. 6. Staff did not document that they notified the provider about R #62's statements. D. Record review of R #62's social service progress note, dated 09/11/24, revealed the following: 1. The social worker (Chaplin) documented that he was notified that R #62 was depressed and done with life. 2. R #62 was not motivated and would barely talk to the social worker (Chaplin) the day before (09/10/24). 3. R #62 stated that he does not believe in God. 4. R #62 stated that he wanted to die. 5. Staff did not document that they notified the provider about R #62's statements. E. Record review of R #62's physician's order, dated 08/14/24, for Paroxetine (medication used to treat depression and other mental illnesses) 20 mg one time a day for depression/anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). F. Record review of R #62'd physician's orders, no date, revealed the following: 1. The physician did not order behavior monitoring for R #62's diagnoses of Bipolar Disorder, PTSD, or Depression. 2. The physician did not order monitoring for the effectiveness of Paroxetine for R #62. G. Record review of R #62's physician's progress note, dated 09/11/24, revealed the following: 1. The physician did not document that R #62 had a diagnosis of depression. 2. The physician did not document that R #62 was taking Paroxetine for his diagnosis of depression. 3. The physician documented that R #62 was feeling unwell with no specific symptoms. 4. The physician documented that the plan was to redirect behavioral issues appropriately. There were no new orders for an assessment or referral for mental health services. H. Record review of R #62's care plan, multiple dates, revealed the following: 1. On 06/25/24, staff documented R #62 served in the United States Military. The team will utilize the information obtained from Military Service Tool to identify stressors or combat related injuries that may impact the Veteran emotionally and/or physically and will determine the best approach for team members to deliver individualized care to [sic]. 2. On 08/19/24, staff documented an order for Paroxetine for depression/anxiety. a. Interventions included: i. Administer medication as ordered. ii. Educate R #62 about risks, benefits, and side effects of the medication. iii. Monitor for adverse reactions to the medication. 3. There was no intervention to monitor for symptoms of depression or refer resident to the social worker/chaplain or any psychological services. I. Record review of R #62's Care Plan Meeting note, dated 09/19/24, revealed R #62's POA requested an evaluation for R #62's diagnoses of bipolar disorder and dementia. J. Record review of R #62's entire medical record, no date, revealed: 1. R #62's medical record did not contain an order for a psychiatric consultation. 2. R #62's medical record did not contain any documentation that R #62 was evaluated by a psychiatric professional. 3. R #62's medical record did not contain any documentation that R #62 attended any behavioral health appointments or was seen by a behavioral health professional. K. On 12/02/24 at 11:49 AM, during an interview with LPN #16, the following was revealed: 1. R #62 seems depressed occasionally. 2. Staff try to get R #62 out of his room to keep him busy with activities. 3. R #62 seems most depressed when he is in pain and will refuse to get out of bed. 4. Staff provide R #62 pain medication. 5. When R #62 refuses to get out of bed, staff notify the provider. 6. Staff also notify the Chaplain to speak to R #62 when he appears depressed. 7. The facility does not have a psychiatric provider or counselor. 8. R #62 was not receiving any psychiatric or behavioral health services. 10. She confirmed that the only interventions in R #62's care plan for his diagnosis of depression were to provide medication and monitor for side effects of the medication. L. On 12/02/24 at 1:15 PM, during an interview with the DON, he confirmed the following: 1. R #62's mood fluctuated frequently. 2. The social worker and the chaplain see residents when they are having mental health concerns. 3. The facility does not have any counseling or psychiatric services other than the social services worker and the chaplain. 4. R #62's care plan did not include interventions for R #62's diagnoses of depression other than giving medication and monitoring for side effects. 5. R #62's care plan did not include his diagnoses of bipolar disorder order, PTSD, or any interventions in place for these diagnoses. 6. R #62 did not have a psychiatric referral. 7. R #62 had not been evaluated by a psychiatric professional. 8. R #62 was not receiving mental health services. 9. Since R #62 was not suicidal, he would not expect staff to have referred him for behavioral health services or a psychiatric evaluation. R #70 M. Record review of R #70's physician orders, dated 06/28/24, revealed R #70 was admitted to hospice. N. On 11/19/24 at 10:20 am, during an interview, R #70 was tearful. R #70 said he wished he was dead. R #70 said he had not spoken to a counselor. R #70 said he just talked to staff. O. On 11/21/24 at 11:23 am, during an interview, CNA #9 said R #70 was more emotional in the last week or two. CNA #9 said R #70 told her he wished he was dead. CNA #9 said she reported to the unit nurse that R #70 said he wished he was dead. P. On 11/21/24 at 11:34 am, during an interview, LPN #8 said staff had told her R #70 was more down lately. LPN #8 said she was told that R #70 doesn't seem right but has not been told R #70 wishes he were dead. LPN #8 said she told hospice that R #70 was more sad lately. Q. Record review of R #70's medical record revealed the record did not contain any documentation that R #70 told staff he wished he was dead or that he seemed to be more sad than usual. The record did not contain any documentation that the facility provided any social services to R #70. R. Record review of an email sent from the Administrator dated 12/03/24, stated the facility staff had a discussion with hospice, and hospice stated this was the natural emotional state of an individual during the disease process. The Administrator said the facility provides a Chaplin to help the Veterans to relieve themselves of the emotional [NAME] and weight they carry from their war experience, and to assist in relief of the burden of guilt that they carry through their last moment of life. S. Record review of R #70's progress note, dated 10/02/24, revealed the Chaplin visited with R #70 on 10/02/24. The progress notes did not contain any documentation that R #70 visited with the Chaplin on a regular basis. T. On 11/21/24 at 11:50 am, during an interview, the DON said the facility was responsible for R #70's day-to-day care. The DON said R #70 should be provided mental health care, even if he was on hospice. The DON confirmed that R #70 was not receiving mental health care. U. On 12/06/24 at 11:07 am (after surveyor interviewed staff regarding R #70's mental health), during an interview with Hospice Nurse #8 (HN #8), he said that he was told on 11/22/24 that R #70 was telling staff that he wished he would just die. HN #8 said that he talked to R #70 on 11/27/24 and R #70 refused a referral for a psychiatric evaluation and medication. HN #8 said that he prayed with R #70 and told him he would continue to pray for him. V. On 12/20/24 at 1:55 pm, during an interview, the Assistant Administrator said that Social Services (SS #1) does not have a social work degree. The Assistant Administrator said that the Chaplin does not have a degree in social work and is not a licensed clinician.

Based on observation, interview, and record review, the facility failed to ensure they maintained an Infection Prevention and Control Program (IPCP) when they failed to: 1. Provide process surveillance (techniques of observation and monitoring to evaluate infection control practices) for tracking the infections, 2. Repeated antibiotic use for R #66 without verification of effectiveness of the treatment before prescribing it again. 3. Follow contact precautions (used when patients have an infection that can be spread by contact with patient's skin including mucous membranes, vomit, urine, feces, and wound drainage) protocols when staff failed to use proper PPE [Personal Protective Equipment: gloves and gown for all interactions that may involve contact with the patient or the patient's environment] for R #66 who was on contact precautions, 4. Use the Hoyer lift only for R #66 who was on contact precautions, 5. Ensure that staff perform appropriate hand hygiene when: a. RN #21 touched her face mask, b. The Receptionist in between screening visitor's temperatures, c. RN #22 performed R #3's blood sugar check, and d. Before CMA #21 administered medication to R #3, 6. Ensure staff assist residents to perform proper hand hygiene prior to their meals, 7. Ensure that staff wear their face masks properly in patient care areas, 8. Ensure resident's Nebulizer masks (nebulizer is a device that turns the liquid medicine into a mist which is then inhaled through a mouthpiece or a mask) and Nasal cannulas (flexible tubing that sits inside the nostrils and delivers oxygen.) tubing were covered when not in use, 9. Ensure that staff are trained in infection control practices, 10. Did not have functional Infection Control Program, including assurance that the facility assessment was utilized as part of the infection control program and that reviews were conducted on an annual basis. 11. Ensure that Indwelling suprapubic Catheter (soft plastic or rubber tube that is inserted to the bladder through a small cut in the abdomen to drain the urine and is connected to a collecting bag) tubing was not touching the floor. This has the potential to affect all 66 residents on the facility (residents were identified by the Census list provided by the Administrator on 06/06/22). If the facility cannot determine the rate and spread of infection in the facility, and are not following infection control practices for residents with infections, then this could likely result in the spread of infections causing illness and death. The findings are: Resident's hand hygiene A. On 06/06/22 at 11:50 AM, during an observation of common area revealed staff did not offer hand hygiene to R #6, R #7, R #8, R #25, and R #46 prior to start their meal. B. On 06/06/22 at 12:30 PM, an observation of common area revealed staff did not offer hand hygiene to R #66 prior to her meal. C. On 06/06/22 at 12:30 PM, during an interview with CNA #21, when asked if staff should offer hand hygiene to R #66, she stated we did not wash her hands because she took a shower an hour ago and she did not move from this area, so we did not have to sanitize her hands anymore. D. On 06/09/22 at 12:58 PM, during an interview IP confirmed that staff should offer hand hygiene to all residents prior and after their meals. Face mask E. On 06/06/22 at 10:41 AM during an observation of common area RN #21 was observed with her face mask under her nose. F. On 06/06/22 at 10:42 AM, during an interview RN #21 confirmed she failed to wear her mask properly. G. On 06/06/22 at 2:07 PM, during an observation of common area, RN #21 observed with her mask under her nose, not covering her face. During an interview at that time, she confirmed her mask was not covering her face and was under her nose. H. On 06/09/22 at 12:58 PM, during an interview, IP confirmed that staff should wear their masks properly at all time Staff's hand hygiene I. On 06/06/22 at 2:07 PM, during an observation of medication administration, RN #21 was observed touching her face mask. She failed to perform hand hygiene before she offered the medication to the R #46. J. On 06/06/22 at 2:10 PM, during an interview, RN #21 confirmed she failed to perform hand hygiene after she touched her face mask and offered the medication to R #46. K. On 06/09/22 at 1:00 PM, during an interview, IP confirmed staff and nurses should perform hand hygiene after touching their masks and before administering medication to the residents. L. On 06/10/22 at 8:17 AM, during an observation of reception area revealed receptionist did not change his gloves between checking visitor's temperatures and failed to perform hand hygiene after he removed his gloves. M. On 06/10/22 at 8:20 AM, during an interview, receptionist confirmed he failed to change his gloves and perform hand hygiene between each temperature check. He stated, I was nervous. N. On 06/14/22 at 12:57 PM, during an interview, DON confirmed staff should change their gloves and perform hand hygiene between each visitor while they are checking their temperatures. O. On 06/14/22 at 11:08 AM, during an observation of R #3's blood sugar check, it was observed RN #22 failed to change her gloves and perform hand hygiene after she checked the resident's blood sugar. P. On 06/14/22 at 11:12 AM, during an interview, RN #22 stated, I did not have to change my gloves because they were not contaminated with blood. Q. On 06/14/22 at 11:20 AM, during an observation of medication administration, CMA #21 failed to perform hand hygiene before administering medication to R #3. During an interview at that time, she confirmed she did not sanitize her hands between each task. R. On 06/14/22 at 12:57 PM, during an interview, DON confirmed RN #22 failed to change her gloves and perform hand hygiene after blood sugar check. She stated, staff should perform hand hygiene between each task while performing medication administration. S. Record review of Handwashing/ Hand hygiene policy revision date 08/01/19 revealed the following: Policy interpretation and Implementation .1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/ hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 9. The use of gloves does not replace hand hygiene/ hand washing. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections. 10. Single -use disposable gloves should be used: C. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . Nebulizer R #3 T. On 06/07/22 at 01:30 PM during observation of R #3's room revealed his Nebulizer mask was uncovered. R #10 U. On 06/07/22 at 01:31 PM during observation of R #10's room revealed his Nebulizer mask was uncovered. R #11 V. On 06/07/22 at 01:32 PM during observation of R #11's room revealed his Nebulizer mask was uncovered. R #13 W. On 06/07/22 at 01:33 PM during observation of R #13's room revealed his Nebulizer mask and Nasal cannulas were uncovered. R #14 X. Record review of R #14's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Y. On 06/07/22 at 1:39 pm during an interview with R #14, R #14's nebulizer was observed to be placed face down on R #14's dresser and uncovered. R #14 stated, I use it [nebulizer] in the mornings and in the evenings. Z. On 06/07/22 at 1:44 pm during an interview with RN #5 she stated, It's [R #14's nebulizer] supposed to be in a bag with a date as well. It needs some protection. RN #5 confirmed R #14's nebulizer was not dated or stored appropriately. R #18 AA. On 06/07/22 at 1:26 PM during observation of R #18's room revealed his Nebulizer mask was uncovered. R #21 BB. On 06/07/22 at 1:27 PM during observation of R #21's room revealed his Nebulizer mask and Nasal cannulas were uncovered. R #24 CC. On 06/07/22 at 1:28 PM during observation of R #24's room revealed his Nebulizer mask and Nasal cannulas (flexible tubing that sits inside the nostrils and delivers oxygen.) tubing were uncovered. R #28 DD. On 06/07/22 at 1:29 PM during observation of R #28's room revealed his Nebulizer mask was uncovered. R #35 EE. On 06/07/22 at 1:40 PM during observation of R #35's room revealed his Nebulizer mask was uncovered. R #45 FF. On 06/07/22 at 1:47 PM during observation of R #45's room revealed his Nebulizer mask was uncovered. R #49 GG. Record review of R #49's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . HH. On 06/07/22 at 1:28 pm during an interview with R #49, R #49's nebulizer was observed to be uncovered and stored in R #49's top dresser drawer. R #49 stated, I use it [nebulizer] four times a day. II. On 06/07/22 at 1:48 pm during an interview with RN #5 she stated, We use a zip lock [plastic storage bag] that should be dated. There should be a [name of tissue paper company] for mucous as well. RN #5 confirmed R #49's nebulizer was not stored appropriately or dated. R #55 JJ. On 06/07/22 at 1:55 PM during observation of R #55's room revealed his Nebulizer mask was uncovered. KK. On 06/07/22 at 2:10 PM, during an interview, IP confirmed R #11, R #35, R #45, and R #55's Nebulizer masks were uncovered. R #56 LL. On 06/07/22 at 01:26 PM during observation of R #56's room revealed his Nebulizer mask was uncovered. R #60 MM. Record review of R #60's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . NN. On 06/07/22 at 1:26 pm during an interview with R #60, R #60's nebulizer mask observed to be uncovered and stored on R #60's dresser. R #60 stated, I use it [nebulizer] three times a day. OO. On 06/07/22 at 1:47 pm during an interview with RN #5, she confirmed R #60's nebulizer was not stored appropriately or dated. PP. On 06/09/22 at 12:59 pm during an interview with the IP, she stated, My understanding prior to this week was we [facility] were to rinse them [nebulizers] and dry them [nebulizers], but then we were to place them [nebulizers] in a bag. They [residents nebulizer and nebulizer tubing] should be dated and changed monthly. IP confirmed resident nebulizer masks should be stored in a sealed bag, dated, and not left on or in resident dressers. R #62 QQ. On 06/07/22 at 01:26 PM during observation of R #62's room revealed his Nebulizer mask was uncovered. R #167 RR. On 06/07/22 at 01:26 PM during observation of R #167's room revealed his Nebulizer mask was uncovered. SS. Record review of Departmental Respiratory Therapy- Prevention of Infection policy revision date 11/01/11 revealed the following: .Infection Control Considerations Related to Medication Nebulizers/Continues Aerosol: 7.Store the circuit in plastic bag, marked with date and resident's name, between uses . Training TT. On 06/14/22 at 2:38 PM, during an interview with the IP when asked if she has completed staff training on infection prevention she stated, Staff development does the general education and IP does the infection control ones for all staff. There has not been any specific training that applies to everyone, so we did not perform any infection control training (since the IP started). When new employees come in, we do new hire orientation and then annual training. We have some training paperwork from the previous IP, but I don't have anything from the time I started (April 2022). Infection control program UU. On 06/14/22 at 2:45 PM, during an interview with the Infection Preventionist she was asked the following: 1. If the facility assessment was used to help develop and implement the IPCP. She stated, I do not know. 2. The annual review of the infection control program. She stated, I do not know, I am sure they (facility administration) review the infection control program, but since I started this role, I have not done it. VV. On 06/14/22 at 3:00 PM, during an interview IP confirmed that facility currently has no functional Infection Control program in place, and she is in the process of establishing and completing one (since she started in April 2022). PPE/ Contact precaution for R #66 WW. Record review of R #66's H &P (History and Physical) dated 07/24/19 revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . XX. On 06/06/22 at 11:01 AM, an observation of R #66's room revealed a contact precautions sign was posted on the door. YY. On 06/06/22 at 11:10 AM, during an observation of R #66's room, it was observed staff coming in and out of the resident's room without wearing their PPE. ZZ. On 06/06/22 at 12:20 PM, during an interview with RN #21, when asked why R #66 was under contact precautions she stated, R #66 has chronic [CONDITION(S)] ([CONDITION(S)]) (bacteria that resist treatment with more than one antibiotic). She is under contact precaution for E. coli (bacteria commonly found in the gastrointestinal tract [stomach] that can cause infection in the urine) in her urine. AAA. On 06/06/22 at 12:21 PM, an observation of the common area revealed, R #66 was brought to the dining area without any PPE on to have lunch with other residents around the same table. During an interview at that time RN #21 was asked, If R #66 is under contact precaution, why is she out of her room without proper PPE, RN #21 stated her infection is in her urine, she has an incontinence brief (adult diapers) on. We are allowed to take her out of her room. The only time we are required to have PPEs on is when we perform incontinence care for her. R #66 doesn't have to use PPE because the infection is in her urine. RN #21 continued to state We only use full PPE when we perform peri-care (cleaning the private areas of the patient), changing the resident's soiled (linens dirtied from fluids from human body) clothes and her contaminated bedding. BBB. On 06/07/22 at 8:30 AM, an observation of R #66's room revealed staff left a Hoyer lift (an assistive device helps to transport residents) inside of the resident's bathroom. CCC. On 06/07/22 at 8:35 AM, during an interview with CNA #21 when asked about the Hoyer lift inside of the R #66's room, she stated That's our community lift, but we keep it inside of her room because she uses it more than others. Every time we need it for another resident, we take it out and clean it prior to use, then we take it back to her room after we are done. DDD. On 06/07/22 at 8:43 AM, during an interview RN #21 stated, Hoyer lift is specific for R#66 because she is under contact precautions, we should not remove that from her room. RN #21 did not confirm how many residents used the Hoyer lift, but stated I don't know why staff are using it for other residents. EEE. On 06/07/22 at 9:03 AM, during an interview with CNA #22 when asked about the Hoyer lift inside of the R #66's room, he stated That is our unit's Hoyer lift. We use it for every resident who needs it, but I usually use my belt instead of using the lift. FFF. On 06/07/22 at 8:45 AM, an observation of the common area revealed R #66 was sitting around the table eating her breakfast. GGG. On 06/07/22 at 8:50 AM, during an observation, CNA #21 was observed helping R #66 with removing her dignity cover and picked up her disposable breakfast plates and cup without proper Replace with what she actually was wearing PPE/gloves. She failed to disinfect the table after resident was done with her meal. Repeated antibiotic use for R #66 HHH. Record review of R #66's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 11/2/21: .[MEDICATION(S)] (antibiotics to treat infection) 1 gram intramuscularly, every day for 5 days. 2. 11/09/21: . [MEDICATION(S)] 100mg by mouth two times a day for 10 days for [CONDITION(S)], discontinue [MEDICATION(S)] . 3. 12/13/21: . [MEDICATION(S)] 100 mg by mouth, every 12 hours for 10 days to treat [CONDITION(S)] . 4. 01/1/22: .[MEDICATION(S)] 100 mg, take one capsule by mouth three times a day for 7 days to treat [CONDITION(S)] . 5. 02/27/22: .[MEDICATION(S)] 100 mg, take one capsule by mouth three times a day for 10 days to treat [CONDITION(S)] . 6. 4/5/22: .[MEDICATION(S)] 100 mg by mouth, every 12 hours for 10 days to treat [CONDITION(S)] . 7. 5/3/22 .[MEDICATION(S)] 100 mg by mouth, every 12 hours for 14 days to treat [CONDITION(S)] . 8. 06/01/22 .Contact precautions . 9. 06/03/21: [MEDICATION(S)] (antibiotic to treat infection in the urine) 100 mg by mouth, two times a day to treat [CONDITION(S)] . 10. 06/28/21: .[MEDICATION(S)] 100 mg by mouth, two times a day for 14 days to treat [CONDITION(S)] . III. Record review of R #66's Care Plan dated 08/06/19 revealed the following: 1.Observe for signs and symptoms of [CONDITION(S)]: cloudy, smelly urine, blood in urine, lower back, flank (side, between ribs and hip), or suprapubic pain (above the pubic bone), pain on urination, fever, chills, malaise (general discomfort), nausea, vomiting . JJJ. Record review of R #66's Urine Culture (test to check the bacteria in the urine) Result dated 12/18/21 revealed positive for E.coli. KKK. On 06/09/22 at 12:42 PM, during an interview with IP, she was asked the following: 1. When asked about repeated antibiotic use for R #66 with chronic [CONDITION(S)], with no change in type of antibiotic, she stated I talked to our Medical Director (MD) about this resident, but I did not document our conversations, I recently started working here and can't speak for the reason why DR. [Doctor] continuously giving the resident the same antibiotics. 2. The IP confirmed that treatment is complete by end of the medication regimen only. The IP also confirmed that a cutlure and sensitivty test is not conducted after each antibiotic use to confirm the infection is cleared. 3. When asked about the process of contact precaution for R #66, IP stated [Name of R #66] has [CONDITION(S)] and is under contact precaution. She can come out of her room, but she cannot eat with other residents around the same table and staff should be sanitizing her hands prior and after her meal and her table should be disinfected every time. 4.When IP was asked about the use of Hoyer lift, she stated Lift is only for R #66 because she is under contact precaution. Staff are not supposed to take it out of her room and use it for any other resident. LLL. 06/10/22 at 8:41 AM, during an interview with MD, he stated [Name of R #66] is chronically (persistent) colonized (germs gather in one part of the body) with MDRS (multi drug resistant strains) from Ecoli. Her urine culture (UA) shows [Name of R #66] responds well to [MEDICATION(S)], but I was unable to clear her infection yet. I tried to order UA and change the antibiotic, but the daughter refused and stated, absolutely not (due to her age and cognition). So we decided to keep her under the same medication over and over. We tried to isolate her but it's difficult, putting gown and gloves on her aggravates (increase the symptoms) her dementia. Her daughter is not agreeing with this decision and the nurses are refusing to follow the order. When asked about the process of contact precaution he stated, her issue is not an open wound, the infection is in her urine, we need to place her under universal precaution (are a standard set of guidelines to prevent the transmission of bloodborne pathogens from exposure to blood and other potentially infectious materials by means of the wearing of nonporous articles such as medical gloves) instead, but about the process of contact precaution you need to refer to our IP. MMM. On 06/14/22 at 9:55 AM, during an Interview with MD he confirmed urine culture was not done based upon the family's wishes [due to resident age and congnition] and that contact precaution were not being followed. He stated we do not perform urine culture after the course of antibiotics is over. I use the clinical condition of resident to judge the situation, but to evaluate the medication in 48 hours after start of the antibiotics is something we haven't done before. Indwelling suprapubic Catheter OOO. On 06/15/22 at 11:25 AM, during an observation of R #59's room revealed R #59's catheter bag and oxygen tube were on the floor. PPP. Record review of R #59's Face Sheet revealed the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . QQQ. Record review of R #59's Care Plan revision date 05/17/22 revealed .make sure catheter has privacy bag and tubing is not dragging on the floor . RRR. On 06/15/22 at 11:26 AM, during an interview, RN #24 confirmed that R #59's catheter bag and tubing was on the floor. SSS. On 06/15/22 at 12:58 PM, during an interview the DON confirmed that catheter bag and tubing should be off the floor. TTT. Record review of Catheter Care, Urinary policy revision date 10/01/10 revealed the following: . Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor . Process surveillance UUU. On 06/14/22 at 2:30 PM, during an interview with the Infection Preventionist when asked about the facility process surveillance (auditing and review of infection control practices) of the facility staff's infection control practices, she stated, I have not completed process surveillance since I started working here (April 2022). VVV. Record review of Infection Prevention policy revision date 06/09/17 revealed the following: Policy . It is the policy of the [name of the facility] that surveillance of infections will be done on a regular and ongoing basis for both the residents and employees of the facility . 1.Procedure .4. The infection Preventionist Nurse will present the monthly summaries, organisms identified, and graphs to infection prevention committee members at a monthly meeting or as often as practicable. C. Infection rates will be calculated monthly by the infection control coordinator, using percentages based on the average daily census for the month, and by using resident days. 1.Incidence rates reflect new cases if infection in the resident population in a month . WWW. Record review of Infection Prevention Assessment and Plan policy revision date 06/09/17 revealed the following: 1.Procedure .10. Infection prevention for [name of the facility] will include a Risk Assessment for our residents and Plan to address identified infection risks . XXX. Record review of Quality Improvement Plan for Infection Prevention policy revision date 04/11/17 revealed the following: Procedure .3. Monitor of resident and employee infections and communicable disease, and calculation of Nosocomial infection (acquired during the process of receiving health care that was not present during the time of admission) rates on a monthly basis and by using resident days. B. Information that is collected will be used for reports and will be filed in the Infection Prevention office. 1.Monthly reports will include Nosocomial Infection report, organism found, tally sheets, updated monthly chronic [CONDITION(S)] reports, graphs, Agendas, and minutes of infection prevention quarterly meetings. A running list of all resident [CONDITION(S)]'s and cultures will be updated monthly and distributed to staff to follow organisms, symptoms, procedures, criteria met for infection, and evaluation of outcomes of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficienct practices resulted in an Immediate Jeopardy that was identified on 06/08/22 at 4:46 pm. A final Plan of Removal was submitted and approved on 06/10/22 at 1:22 pm. Plan of Removal The new Infection Control Nurse located a tracking and trending form for Infection Control and Antibiotic Stewardship. The IC nurse began backfilling information form July 1, 2021, to present to begin the tracking and trending on 06/10/22 and should be completed by 06/11/22. Related to ABX (antibiotic) use: Administrator received permission from Power of Attorney [POA] on 06/10/22 to perform a straight catheterization (process of inserting a catheter into a body cavity) on resident for CNS (culture and sensitivity). Administrator and physician will discuss referral to Urologist with POA after results return form CNS, but POA resistant due to resident age, gave permission to give her telephone number to surveyors. Resident placed on Contact and Isolation Precautions, until results from CNS come back negative from lab. If results are positive will consult physician for further instruction. Resident provided her own lift with immediate training on cleaning and disinfection. New lift provided for all other residents on unit. Immediately Education for Contact Precaution PPE, Hand Hygiene for staff and residents, as well as proper cleaning and disinfection of equipment and surfaces on 06/09/22 with NOC (night shift) shift for this unit. Training will continue at start of each shift (prior to starting on floor) to ensure all staff trained properly. Training will be completed by 06/17/22 for all rotations and to ensure training completed for any staff out on vacation or leave. Training for all new hire will be completed on orientation.

Based on record review and interview the facility failed to provide quality of care for 1 (R #27) of 1 (R #27) resident reviewed for diabetes, when R #27 who is insulin dependent (a chronic condition in which the pancreas produces little or no insulin) went out on leave (out of the building) and was provided by the facility short acting insulin to self-administer but was not provided a glucometer to check his blood sugar levels. This deficient practice likely resulted in R #27 being admitted to the hospital for DKA (diabetic ketoacidosis: a serious complication of diabetes that can be life-threatening. DKA develops when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy) and likely puts other residents who need insulin but are unable to monitor their blood sugar levels and self administer insulin when they leave the facility in life threatening situations. The findings are: A. Record review of the R #27's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] (a long acting insulin) 100 UNIT/ML INJECT 40 UNITS SUB-Q (applied under the skin) DAILY AT BEDTIME FOR DIABETES MELLITUS 2. [MEDICATION(S)] INSULIN 100 UNIT/ML PEN INJECT SUB-Q BEFORE MEALS THREE TIMES DAILY . < (less than) 100 0U (unit) 101-160=4U 161-200=6U 221-280=8U 281-340=10U 341-400 =10U > (greater than) 401 call MD (medical doctor). 3. Blood Sugar Check BG (blood glucose) according to [MEDICATION(S)] sliding scale 15 to 20 mins before meals B. Record review of R #27 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 02/04/22 R #27 may go out of the facility with brother. 2. 02/14/22 Give am PO (by mouth) meds on 02-15-22 @ (at) 05:00 (5:00 am) prior to departure for appointment, also sliding scale with snack for am. 3. 03/08/22 Res (resident) may go out on pass (1) overnight. Give 20 units reg insulin now for bs >400 provide pill planner c [with] meds for pass. 4. 05/02/22 Resident may go with c (with) brother to Las [NAME] for day for son court date. Meds (medications) for day to go c (with) resident. Go am RTN (return) pm. 5. 05/10/22 Resident may go with brother to Las [NAME] for day leaves 5/10/22 to return 5/11/22. Current PO meds, insulin and wound care supply sent with resident. 6. 05/22/22 Ok to go out on pass 5.24.22 Tuesday and back 5.25.22. Rx (Prescriptions) ready, 2 days of meds to go c (with) resident. C. Record review of the Progress Notes for R #27 revealed the following: 1. Social Services (SS) 03/08/22 at 8:23 AM Resident left for appointment 3/8/2022 at 0800 . in [name of local city] and will stay (1) overnight with sister. There was no documentation of education to R #27 or his family regarding blood sugar checks or need for insulin. 2. Medical Doctor 03/10/22 at 3:29 pm, Type: Health Status Note Note Text: Called [name of R #27] . He has been out of the facility in [Name of local city] x 2 more days than he had told us therefore we expressed our concern about his wellbeing. We offered to go get him or send someone to check on him but he would not give us his address. He was asked if he was checking his glucose and he said it was low (he states he has a glucometer) but would not give me a number. He has no insulin at this time, therefore we will call insulins to [name of local pharmacy] and he promised to go pick it up tonight. I have told him that without insulin his health could suffer greatly, leading to death. He stated he would come back to us tomorrow. 4. Nursing 03/13/22 at 10:12, the facility documented receiving information from the local hospital after R #27 was admitted Resident was admitted in the hospital [03/12/22] . with admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] D. Record review of R #27 Hospital Records 03/12/22 to 03/15/22 revealed the following: .Upon presentation to the ER here, he was found to have an initial serum glucose greater than 600 however on lab work his glucose was 497 . E. On 06/07/22 at 1:23 PM, during an interview the Social Services Director confirmed that R #27 has gone out on pass (overnight away from the building) a few times this year. F. On 06/08/22 at 8:38 AM, during an interview, R #27 stated that when he goes out on leave from the facility, the facility does send him with medication (including his insulin). They pack you that much medication (for time he was expected to be out of the facility). R #27 confirmed that the facility they does not provide him a glucometer. R #27 stated I can't take insulin without knowing my blood sugar. And then they tell me 'you didn't take insulin'. They never send me with a meter (glucometer). I have told them I need a meter. I am not going to just take the insulin. I bottom out (blood sugar drops) real fast. Especially when I don't eat. They say I am noncompliant because I don't take the insulin but I don't take it when I don't eat. I am not doing it just to not take the insulin. I don't want to bottom out. When asked what staff's response to his request for a glucometer, R #27 stated They don't say anything just don't get a meter. R #27 was asked if the facility had ever evaluated him for self-administering his insulin or using a glucometer, he stated No. When asked about his leave on 03/08/22, R #27 stated he had to take care of his banking and that he was only suppose to be gone for (1) night. R #27 stated the facility dropped him off at his appointment and that family picked him up. R #27 stated that he was at the mercy of family and friends because they had the vehicles and was staying different places due to this. R #27 also stated that he did not have charger for his phone so when staff tried to call him, his phone was dead. R #27 reported that during this outing and after several days without his medication when he was preparing to return to the facility, he was instructed instead go to the hospital where he was admitted [from 03/12/22 to 03/15/22] for high blood sugar levels. G. On 06/08/22 at 11:18 AM, during an interview House Supervisor (HS) #3 was asked if the facility issues glucometers to diabetic residents going out on pass, she stated, No we don't release glucometers. HS #3 was asked if R #27 had been out of the building recently and she stated that R #27 went to an appointment that the facility had taken him to in [NAME] on 06/07/22 from 6:00 or 7:00 am to 3:00 pm [approximately 8 hours]. HS #3 was asked if R #27 was sent with his insulin and a glucometer, she stated that the facility had not sent him with insulin or a glucometer. The HS #3 stated that the facility would administer insulin before and after R #27 returned. HS #3 stated No one is available to check his blood sugar (on facility transport), they (transportation staff) don't carry a glucometer. I think we need to [provide staff glucometers during outings]. HS #3 was asked if R #27 had received insulin prior to his leaving on 06/07/22, HS #3 stated, No, [he] refused. H. On 06/08/22 at 12:06 PM, during an interview Transportation Worker (TW) confirmed that R #27 did go to an appointment on 06/07/22 for about 7 hours in [NAME] . TW also confirmed that staff do not take insulin or glucometers during transport because they are not qualified to administer insulin or conduct blood sugar checks. I. On 06/08/22 at 2:30 pm, during an interview, the DON confirmed that if residents go out of the facility on pass they take insulin with them but are not issued glucometers. The DON continued that it was her understanding that the Power of Attorney (POA) will have the glucometer. Usually, we talk to the POA and we will go over the medication. It should be documented talking education with the family. The DON was asked about resident who need insulin and go to appointments, if staff take insulin or glucometers, she confirmed that the facility does not, The transportation team are CNA not CMAs . When they (residents) get back, we will check their blood sugar. We have an instruction if they (residents) show any sign of hyper or [CONDITION(S)] (during transport or at appointments) to go to the nearest hospital. We have been doing that practice. J. Record review of R #27's Medical Record revealed no documentation of a conversation between the facility staff and R #27 or his family about ensuring that they (resident or family) have a glucometer when he goes out on pass. K. On 06/08/22 at 3:48 pm, during an interview the Medical Doctor (MD) confirmed that R #27 requires insulin to live. When asked if R #27 should have insulin and a glucometer when out of the building, the MD stated, He is supposed have blood sugar checks and insulin. He needs the glucometer [to check his blood sugar level and determine how much insulin is needed], or he should not administer [the Insulin]. The above findings resulted in an Immediate Jeopardy that was called on 06/08/22 at 4:46 pm. A final Plan of Removal was submitted and approved on 06/10/22 at 10:35 am. The facility was verified to have fully implemented this approved plan on 06/10/22 at 5:00 PM. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 06/10/22. Plan of Removal The resident identified in this citation was given self-administration assessment for proper use of glucometer and insulin administration on 6/9/2022 and passed all areas of assessment and return administration. New Protocols implemented 6/9/2022 Every resident with diabetes required to have blood glucose checks and insulin administration will have a glucometer and insulin available on every transport, with a nurse to provide administration while out of facility, unless resident is able to perform self-administration. Residents going out of facility on extended leave of absence who are dependent on insulin will be given instruction and assessed for self-administration to ensure resident is aware and able to give him/herself appropriate insulin doses and use glucometers. If resident is unable to perform glucose testing or insulin administration, facility will train family members or friend to perform assessment with return demonstration prior to taking them out of facility, to endure that a competent person is with resident and able to provide insulin administration safely. Transportation will still be instructed to go to nearest hospital if resident became critical. Training on new protocols began immediately on 6/9/2022, with transportation staff, nursing staff, and physician and will continue at start of each shift, to ensure all staff are trained as soon as possible, and expected to be completed by 6/17/2022 which will include any staff out on vacation or leave. All new staff will be trained on protocols during orientation.

Based on observation, interview and, record review the facility failed to ensure there was a functional system in place to ensure staff could initiate /not initiate CPR (Cardiopulmonary Resuscitation lifesaving technique, aims to blood and oxygen flowing through the body) during an emergency for all 66 residents (residents were identified by the Resident Matrix provided by the Administrator on [DATE]), when they failed to: 1) Monitor the accuracy of resident's living will (legal document that helps communicate patient's wishes about medical treatment when they are not available to make their own wishes known ), 2) System for staff to immediately recognize the resident's code status (type of emergency treatment a person would or would not receive if their heart or breathing were to stop) during an emergency. 3) Ensure there was complete and ready to use crash cart equipment available for use in case of an emergency. 4) Provide advanced directive (legal document that explains how you want medical decisions about you to be made if you cannot make the decisions yourself ) to Emergency Medical Services (EMS) personal at the time of transfer for R #318. This deficient practice could likely cause confusion among the nursing staff who may not be aware of which residents are Full-Code (if the person's heart stopped beating, or stopped breathing, all resuscitation procedures will be provided to keep them alive) and those residents who wish to be a DNR (Do Not Resuscitate) (No code, allow natural death), then residents are likely to not receive the prompt initiation of CPR (Cardio Pulmonary Resuscitation) (lifesaving technique, aims to blood and oxygen flowing through the body) during a cardiac/respiratory arrest (when heart and breathing stops) nor have the availbale equipment needed which could likely result in resident death. In addition, this deficient practice likely resulted in R #318 being intubated (insert a tube into the patient's throat for giving oxygen) against his DNR code status. The findings are: A. Record review of facility Resuscitation during Cardiopulmonary Arrest Policy revision date [DATE] revealed the following: Always determine code status or DNR status in advance, while the resident is medically stable. R #20 B. Record review of R #20's Face sheet revealed the admitted [DATE]. C. Record review of R #20's Physician Orders dated [DATE] revealed code status as Full Code. D. Record review of R #20's MOST form (Medical Order for Scope of Treatment) (voluntary end-of-life planning tool designed to give those who are ill or medically frail the opportunity to make their health care wishes known in the event they are unable to speak for themselves) dated [DATE], revealed code status as DNR. E. Record review of [name of the unit] DNR report dated [DATE] located inside of the crash cart's (code cart, set of shelves used for dispensing emergency medication/equipment at the site of an emergency) binder revealed R #20's code status as Full Code. F. Record review of R #20's current Care Plan initiated on [DATE] revealed no documentation for code status was found. G. On [DATE] at 9:08 AM, during an interview, CNA #24 stated We have a DNR report paper which shows us the code status of each resident. Medical records oversee and update any changes. I also can look at the electronic system (PCC) if I don't have access to the paper report. When asked if she has no access to the paper report or PCC what actions she can take during an emergency, she stated I refer to my charge nurse. During the same interview CNA #24 was asked about education and training regarding resident's code status, she stated We usually get an all-staff In-service, but since our staff development is new, we haven't had any training since she started her position. H. On [DATE] at 9:20 AM, during an interview about resident's code status, RN #25 stated We check the crash cart's binder for their code status. Our Medication Administration Records (MAR) and treatment books also have the code status of all our residents. We also can check it on the electronic system as well. When asked if she ever found any discrepancy with the resident's code status in medical records, she stated No, I never noticed that medical records update the system and the DNR report papers regularly for all the residents. I. On [DATE] at 9:30 AM, during an interview with RN #25, when asked about R #20's code status she stated Full Code after looking at the DNR report paper. When asked to compare the DNR report paper with electronic system and the actual MOST form signed by the resident, she confirmed that there was discrepancy between R #20's living will and the information accessible to the nursing staff. R #37 J. Record review of R #37's Face sheet revealed the admitted [DATE]. K. Record review of R #37's Physician Orders dated [DATE] revealed code status as DNR. L. Record review of R #37's MOST form dated [DATE], revealed code status as CPR. M. Record review of [name of the unit] DNR report dated [DATE] located inside of the crash cart's binder revealed R #37's code status as DNR. N. Record review of R #37's current Care Plan initiated on [DATE] revealed no documentation for code status was found. O. On [DATE] at 12:10 PM, during an interview with RN #26 when she was asked about education and training regarding resident's code status (How would she know what to do if she found a resident unresponsive) she stated, I just started working here, I have not had any training about the resident's code status yet. P. On [DATE] at 1:56 PM, during an interview CNA #26 stated, To find the resident's code status I usually check our electronic system, the computer is located inside our Nurse station, I do not have access to the nurse's office to look at the resident's paper charts. When asked if she has no access to the PCC what actions she can take during an emergency, she stated I do not know. Q. On [DATE] at 1:59 PM, during an interview about R #37 code status, RN #23 was not able to provide the most updated code status list (DNR report), he stated I guess medical records did not leave the most updated list for this unit, the one I have here inside of the crash cart was updated last on [DATE]. I would follow the code status list [on the crash cart]. R. On [DATE] at 2:10 PM, during an interview with RN #23, when asked about R #37's code status he stated DNR after looking at the outdated DNR report paper located inside of the crash cart. When asked to compare the DNR report paper with electronic system and the actual MOST form signed by the resident, he confirmed that there was discrepancy between R #37's living will and the information accessible to the nursing staff. S. On [DATE] at 9:50 AM, during an interview with the DON, when asked about the discrepancies between the most updated DNR report papers dated [DATE] and the MOST forms signed by resident/resident's representative, she stated medical records are in charge of updating the resident's code status, I do not know why it was not updated. She confirmed that the code status of R #20 and R #37 did not match with their living will. During the same interview, when asked about the issue with resident's incorrect code status and staff not having quick access to the most updated code status information, she stated delay to start the process of CPR can affects resident's life. Initiating the code process for a resident who is DNR is against his/her will. R #318 T. Record review of R #318's Face Sheet no date revealed the admitted [DATE]. U. Record review of R #318's Medication Administration Records (MAR) dated [DATE] revealed the code status as DNR. V. Record review of R #318's Medical Orders for Scope of Treatment (MOST) forms revealed the following: 1.[DATE] Do Not Resuscitate (do not attempt chest compression). W. Record review of [ name of the facility] Fall Incident Report revealed the following: 1.[DATE] at 4:40 AM .Resident was attempting to get up from bed unassisted (without help), he stated, my foot slip and I slide off bed onto my butt . X. Record review of R #318's Transfer to hospital summary revealed the following: 1. [DATE] at 8:37 AM .Responded to the resident's room at 8:00 AM, Resident in power chair (electric wheelchair) leaning to the left, unresponsive (not responding to stimulations). Nurse performing sternal rub (painful stimulation with knuckles of closed fist to the center of the chest) with no response. Right pupil (middle of the eye) dilated (open), both pupils unresponsive (not reacting to light). Unwitnessed fall (no one observed the fall) reported by night shift. Neuro checks were initiated (started) and had been with in normal range thus far. No apparent head injury at that time, no physical evidence of a head injury. Order to transfer resident to the emergency room for evaluation for sudden change in Level of conciseness (person's awareness and understanding). Resident transferred to the hospital at 0830 [8:30 am]. Y. Record review of the Hospital's Medical Records revealed the following: 1.[DATE] at 11:18 AM ' . R #318 found unresponsive, patient found sitting on the floor, stating he did not hit his head or any injuries. Staff put the patient back to bed, and at around 7:30 AM when they went to see the patient, he was not responsive. EMS (ambulance) was called, and the patient was intubated about an hour prior to arrival to the hospital [EMS intubated R #318 on the way from facility to the hospital] . Z. On [DATE] at 4:59 PM, during an interview DON stated, the facility has a list of documents to send with residents to the hospital and the advanced directive form is part of that list. She confirmed the facility failed to send R #318's advanced directive with the ambulance transported the resident to the hospital, as the result resident was intubated during transport to the hospital which is not consistent with R #318's DNR status identified on his advanced directive. Crash Carts AA. Record review of the facility Policy Resuscitation during Cardiopulmonary Arrest, revision date [DATE] revealed the following: .Equipment/supplies needed: b. This equipment will be on a red plastic bag marked Emergency Resuscitation Equipment. The bag will be sealed, and it contents verified weekly for proper function by the respiratory therapist, a white label with the date of inspection and initials will seal the bag. [Per DON/ and record review of Emergency Supplies Inspection Record, facility was performing inspection daily, two times a day instead of weekly]. c. Oxygen tanks and suction machines should be available at every nursing section and dining room. O2 (Oxygen) tank should have a minimum of 1500 PSI (unit of pressure) and verified weekly . BB. Record review of ACLS (Advanced Cardiac Life Support) website updated [DATE], revealed the following: .Any environment in which a patient may unexpectedly experience a medical emergency needs to have the equipment to deal with that emergency efficiently. That's the job of a crash cart. A crash cart contains the equipment and medications that would be required to treat a patient in the first thirty minutes or so of a medical emergency .Any facility that treats patients who have the potential to have a sudden deterioration (become progressively worse) in their condition should have a crash cart available. Nursing homes who provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Dining room CC. On [DATE] at 9:40 AM, an observation of Dining room's crash cart (no nurse station inside of dining room) revealed the following: 1. The oxygen tank was ,d+[DATE] full. 2. One open to air Nasal Canula (NC) (Exposure to elements). 3. One suction machine tubing (tube designed to remove small amounts of secretions from the mouth, nose, and throat), Four NC, two yankaer suctions (curved catheter used to prevent aspiration (chocking) and clear airway) and three suction catheters (tube use to prevent chocking) that were undated. 4. Oxygen Concentrator Machine (medical device that gives extra oxygen) last service date was [DATE]. DD. Record review of daily crash cart's inventory list review (process to check that all required supplies were available and functioning) for the month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. EE. On [DATE] at 9:50 AM, during an interview, DON confirmed that the Oxygen tank was not full, there was contaminated and undated supplies inside of the crash cart with an outdated Oxygen Concentrator Machine. She also confirmed that the crash cart's inventory list was not properly filled out on [DATE]. Secured Unit I FF. On [DATE] at 11:01 AM, an observation of Secured Unit #I's crash cart (crash cart located inside of the nurse manager's office) revealed the following: 1. One oxygen tubing, one suction and yankaer tubing and two [CONDITION(S)] masks (allows delivery of oxygen to patients with [CONDITION(S)] [open cut on the front of neck to create a direct airway for the patient]) that were open to the air. 2. One oxygen tubing, one face mask (mask to reserve oxygen and delivers it directly to patient), two oral airways (device to keep the airway open by stopping the tongue from closing it), two yankaer and three suction tubing that were undated. 3. There was no daily crash cart's inventory list review for the month of [DATE]. GG. On [DATE] at 11:09 AM, during an interview, RN #25 confirmed there was contaminated and undated supplies inside of the cart and no crash cart's inventory list was found. Secured Unit II HH. On [DATE] at 11:011 AM, an observation of Secured Unit #II's crash cart (crash cart located inside of the nurse manager's office) revealed the following: 1. Nonfunctional oxygen tank, unsealed tank (releasing oxygen with pressure). 2. One open to air [CONDITION(S)] mask. (Exposure to elements) 3. Three suction tubing, one face mask, four yankaers and three suction catheters that were undated. II. Record review of daily crash cart's inventory list for month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. JJ. On [DATE] at 11:20 AM, during an interview, RN #23 confirmed the oxygen tank was not functioning properly, it was releasing oxygen and was not safe to use. She also confirmed there was contaminated and undated supplies inside of the cart and the crash cart's inventory list was not properly filled out for [DATE]. Independent Unit KK. On [DATE] at 12:10 PM, an observation of Independent Unit's crash cart (located inside of day room) revealed the following: 1. The oxygen tank was ,d+[DATE] full. 2. One open to air face mask (Exposure to elements). 3. Three oxygen tubing, five suction tubing and four suction catheters were undated. LL. Record review of daily crash cart's inventory list for month of [DATE] revealed [DATE] was not documented as being reviewed. All other dates were identified that the crash cart had been reviewed and was complete. MM. On [DATE] at 12:15 PM, during an interview, RN #26 confirmed the oxygen tank was not full, there was contaminated and undated supplies inside of the cart and the crash cart's inventory list was not properly filled out and was missing multiple dates. These resulted in an Immediate Jeopardy identified on [DATE] at 4:46 pm. A final Plan of Removal was approved on [DATE] at 1:22 pm. The facility was verified to have fully implemented this approved plan on [DATE] at 5:00 PM. Plans of Removal related to Code Status 1.Resident # 37 and Resident # 20's records were reviewed, and the families/POA's for both were contacted to verify advanced directives by physician and verified by Social Services Department. Once verified, the orders in PCC were updated to reflect that the MOST Form information was correct and the most current information available for the resident. This was completed on [DATE]. A review of all remaining resident documentation and PCC orders for all residents began on [DATE], and audit will be completed by [DATE], and audit will be completed by [DATE], taking into account POA's not immediately available. Upon admission or change to MOST form, Social Services Department will receive a copy of the resident MOST form and verify that physician orders match MOST forms. Will contact physician if order is incorrect or missing. Nursing may enter this information if physician is absent. Quarterly, all MOST forms will be reviewed in Care Plans for updates, corrections, changes, verification that orders match Most Forms. An alphabetized folder will be maintained at each nurse's station with each resident's Code Status. This will prevent delay in looking in computer for information. A resident list with code status will also be maintained on the Crash Carts. When staff member comes upon a downed resident, will use radio system to call for nurse STAT Code Blue, responding nurse or CNA will go to nurses' station check for code status and relay information to CNA who is with resident to prevent delay in life saving efforts. In-Service training for Social Services, Physician, MDS Coordinator and Nursing Department began immediately on [DATE] and will continue at start of each shift, to ensure all staff are trained as soon as possible, and expected to be completed by [DATE] which will include any staff out on vacation or leave. Training will be completed with all new hires during orientation. Plan of Removal related to Crash Carts 2.All 5 crash carts/suction carts were reviewed on [DATE]. All oxygen tanks were examined and found to be working. On [DATE] the Oxygen Contractor [NAME] in Las [NAME], changed out all oxygen tanks on all carts, ADON and [NAME] Oxygen Technician verified that all O2 tanks were full, working, and ready to use. Nursing Department will inspect crash carts biweekly to verify oxygen tanks remain working and filled. All supplies on every cart were discarded and replaced and dated than placed in crash carts biweekly to verify oxygen tanks remain working and filled. All supplies on every cart were discarded and replaced and dated than placed in crash carts. To ensure this does not happen again, the facility will discard and replace all tubing and disposable products every 6 months to prevent contamination. Additionally, all supplies and equipment will be examined bi-weekly to ensure products remain non-contaminated. Nurses will maintain a log of inspections and items replaced, to ensure equipment is available for immediate use. Training began immediately on [DATE] and will continue at start of each shift (prior to starting on floor), to ensure all staff are trained as soon as possible, and expected to be completed by [DATE] which will include any staff out on vacation or leave. A current copy of code status will be kept on each cart and updated by Medical Records team weekly, with new admissions, with discharges or as status changes occur. DON/ADON will audit cart logs monthly to ensure ongoing compliance and report to OAPI. Surveyor: Bostinto, Bo

Based on observation, interview, and record review, the facility failed to ensure that residents received proper care and treatment to meet their needs for 1 ( R #30) of 1 (R #30) resident reviewed for behavioral health services, when the facility failed to offer pharmacological (treatment with medication) and nonpharmacological (treatment without medication) interventions to manage and control R #30's visual hallucinations (seeing something that was not actually there) and anxiety. This deficient practice could likely affect resident's physical, mental and psychosocial wellbeing. The findings are: A. Record review of R #30's Face Sheet no date revealed admitted [DATE]. B. On 06/06/22 at 11:10 AM, during an observation of R #30's room, he was observed talking about people in his room, pointing toward the wall and stating, look at that man on top of that huge screen. C. On 06/13/22 at 1:45 PM, during an observation R #30 observed having visual hallucination talking about fictitious people (non-existent) in his room stating, I am a writer, I write about all these people here, pointing to the empty chair. D. On 06/13/22 at 1:55 PM, during an interview, R #30 stated, I get very anxious and overwhelmed with noises around me due to my war experience. I keep my room dark with my door closed to help me calm down. E. Record review of R #30's Face Sheet and Order Summary Report dated 06/13/22 revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Record review of R #30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . G. Record review of R #30's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 05/01/22 .Monitor delusions Misidentification (false belief, patient misidentify familiar person, objects or self and believe they have been replaced) every shift . No order for treatment was found. H. Record review of R #30's Care Plan revealed the following: 1. No documentation for anxiety was found. 2. 06/01/22 .Focus: [name of the resident] has impaired thought processes. He has some disorganized thoughts. He can display delusions at times . 06/01/22 .Intervention: Redirect and provide gentle reality orientation. Reorient to person, place, time, situation as required . I. Record review of R #30's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The monitoring sheet only identifies that R #30 was being monitored by staff initials and identify that R #30 was having delusions with 0 and dashes. There was no medical treatment or interventions documented. J. Record review of R #30's Progress Notes dated 01/06/22 revealed the following: 1.[name of the resident] has a history of delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary ). Staff report he shows some paranoia (unrealistic distrust of a feeling of being persecuted) in that he believes someone is out to get him so he stays mostly in his room and staff deter (discourage) other residents from going into his room . K. On 06/14/22 at 10:15 AM, during an interview the DON stated, This is the first time I am hearing about this issue; I was not aware [name of R #30] is experiencing hallucination and anxiety. Upon reviewing the MAR, she confirmed that the facility was monitoring delusions but not treating R #30's visual hallucination and anxiety.

Based on observation, interview, and record review the facility failed to ensure residents were free from accident hazards for 5 (R #17, R #30, R #40, R #317 and R #318) of 5 (R #17, R #30, R #40, R #317 and R #318) residents, when they failed to: 1. Supervise R #17 out in the courtyard of the secure unit, 2. Provide adequate and comfortable light for R #30's room according to his preferences and remove the floor mat/fall hazard from his room. 3. Use appropriate number of staff members to assist R #40 while using a Sara Lift (sit to stand lift used to assist mobility patients when they are unable to transition from a sitting position to a standing position on their own). 4. Ensure R #317 is positioned to prevent falls and injury. 5. Implement interventions to prevent falls after R #318 had 12 falls in one year. These deficient practices could likely result in residents being at risk of serious harm or death. The findings are: R #17 A. Record review of R #17's Care Plan dated 07/07/20 revealed the following: o [Name of R #17] resides in the [name of secure unit] r/t (related to) He requires secure unit. o [Name of R #17] requires secure unit and will need to be accompanied by staff when off the unit. o Staff to make sure [Name of R #17] remains on the secure unit and to make sure door remains secure when leaving the unit. B. On 06/07/22 at 10:00 AM, during an observation of the Secure Unit #2 revealed R #17 was outside in the courtyard trying to come in, the door required a key card because the unit is secured. Staff did not notice R #17 trying to come in, surveyor reported to CNA #5 that R #17 was out in the courtyard trying to come in. No staff were outside with R #17. CNA #5 let R #17 in. C. On 06/07/22 at 10:04 AM, during an interview, the House Supervisor (HS) #2 was asked if R #17 could be outside in the courtyard unsupervised, HS #2 checked R #17's chart and confirmed that resident should have been supervised when out in the courtyard. HS #2 stated, They (staff) should be watching him. D. On 06/07/22 at 11:03 AM, during an interview R #17 confirmed that he was outside earlier without staff supervision. R #17 was asked how long he was out in the courtyard he stated an hour. R #17 was asked how he got outside, he stated The CNA let me out. E. On 06/07/22 at 11:05 AM, during an interview CNA #5 was asked if R #17 could be out in the courtyard unsupervised, she stated, We were told by our lead aide that he was allowed to be outside and smoke (unsupervised). We don't let that happen (smoke unsupervised), but we let him outside as long as we check on him every half hour. He was only out there for 20 min [minutes]. Normally he knocks on the door (to come in). I took him out there to smoke then I left him out there. F. On 06/14/22 at 10:45 AM, during an interview the ADON confirmed that R #17 shouldn't be outside unsupervised, He should be supervised when he is out there [courtyard]. R #30 G. On 06/06/22 at 11:46 AM, an observation of R #30's room revealed, the light was off, and the room was very dark with no other lighting accommodation with a brown floor mat right by resident's bed side. H. On 06/13/22 at 1:45 PM, an observation of R #30's room revealed, room was very dark, and resident had a hard time getting up to find his way. He tripped over the floor mat, but did not have a fall. I. On 06/13/22 at 1:46 PM, during an interview R #30 stated, I don't like to have bright light, but my room is too dark, sometimes I have a hard time getting up and finding my way. J. On 06/13/22 at 1:50 PM, during an interview with CNA #24, when asked why there is a floor mat by the resident's bed, she stated, I am not sure why he has a mat on the floor, he is not a high fall risk. K. Record review of R #30's Physician Orders revealed no order for floor mat was documented. L. Record review of R #30's Care Plan revealed the following: 1.04/15/19 . [name of the resident] needs a safe environment with: even floors free from spills and/or clutter (collection of things around the room or on the floor), adequate, glare-free light (gentle light), a working and reachable call light, personal items within reach. 2. No intervention for using the floor mat was documented. 3. No intervention for keeping the resident's room dark was documented. M. On 06/14/22 at 10:20 AM, during an interview with DON, when asked about the floor mat and the darkness in R #30's room she stated I don't know why we never thought about making accommodations for the darkness in R #30's room. The darkness with the mat on the floor can be a safety hazard. She confirmed there was no care plan or physician order to keep the floor mat by resident's bed side. Findings for R #40: N. Record review of R #40's care plan dated 05/09/22 revealed, Focus: [Name of R #40] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Impaired balance, Limited Mobility, Limited ROM [Range of Motion]. Interventions: TRANSFER: [Name of R #40] requires Mechanical Lift (Sara lift with 2 person assist during transfer). O. On 06/06/22 at 1:19 pm during an interview with R #40, R #40 was observed being assisted by one Certified Nursing Aide (CNA) with a Sara Lift to be placed on the toilet. P. On 06/06/22 at 1:19 pm during an interview with CNA #15, she stated, It's [Sara Lift being used to assist R #40] two person. My partner went to lunch. CNA #15 confirmed two people should be present to assist residents with a Sara Lift. CNA #15 proceeded to use the Sara Lift by herself with R #40. Q. On 06/08/22 at 11:59 am during an interview with CNA #16, she stated, It's [Sara Lift use] always two [CNA assist]. CNA #15 confirmed two people should operate the Sara Lift when assisting residents. R. On 06/08/22 at 12:29 pm during an interview with CNA #17, she stated, It's [Sara Lift] always two [person assist]. I have done it [used Sara Lift by herself]. She [R #40] needs to get up and go to the bathroom and what was I supposed to do? I don't do it [use Sara Lift alone] often, but I have before. CNA #17 confirmed [NAME] Lift should be used with two staff, but she has had to use Sara Lift alone due to staffing. S. On 06/13/22 at 1:02 pm during an interview with the DON, she stated, It's [Sara Lift use] a two person assist. It [Sara Lift use] should be two person [assist]. DON confirmed Sara Lift's should be used by two staff members and R #40 is a two person assist for all transfers. Findings for R #317: T. Record review of R #317's care plan dated 03/29/22 revealed, Focus: [Name of R #317] is a High risk for falls r/t [related to] Confusion, Deconditioning, Gait/balance problems, Incontinence, Unaware of safety needs, Vision/hearing problems. Interventions: [Name of R #317] needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position, grey mat at night as ordered; handrails on walls, personal items within reach. V. Record review of R #317's progress notes dated 04/17/22 at 5:39 pm revealed, Nurse stat called via radio to this [name of annex F unit], arrived on the unit and noted rsd [resident] was lying on the floor with staff present and she was bleeding from her head. Attending nurses caring for her and attending to her assessment and wounds. [ .] rsd is alert and responding to the staff. She is yelling out leave me alone. 911 was called to transport rsd to local ER [emergency room ] due to head injury. Rsd was not further assessed due to head injury. EMT [Emergency Medical Technicians]can further assess this rsd at ER. W. Record review of R #317's progress notes dated 04/17/22 at 8:37 pm revealed, I received a call from this RSDs son [Name of R #317's son]. He [R #317's son] was angry and asking me where his mother is. I said she [R #317] was sent to [name of local hospital]. He [R #317's son] said she's not there so I told him that I would find out. I spoke with the ER nurse to find out. She [ER nurse] told me that she [R #317] was at [name of out of state hospital] with a C-5 FX [fracture- C5 spinal vertebra fracture] and a concussion. X. On 06/10/22 at 9:49 am during an interview with CNA #10, she stated, We were catching up on everything. The Registered Nurse who was here came out and said 'Oh my God' and [Name of CNA #11] just came out of that room and they both came out running. Ever since she [R #317] came here, she would like her legs up, so he'd [CNA #11] lower the bed so she [R #317] could put her feet up. She [R #317] had been doing that [sitting in a wheel chair with her feet on the bed] for years. When I was in there [R #317's room], she [R #317] was face down on the floor with her butt up in the air like a sleeping baby and blood was coming around her face. 911 was called right away. Y. On 06/10/22 at 10:04 am during an interview with CNA #11, he stated, We were getting everything ready and I was watching the floor. She [R #317] was in her room watching her favorite show. She [R #317] likes her feet up on the edge of her bed when she's relaxing and the door was open. We heard a loud thud and ran to her [R #317] assistance. We found her [R #317] on the floor and she was face down on her arm. It [R #317's bed] was at the lowest setting for her and she's not known to self transfer. CNA #11 confirmed he positioned R #317's feet on her bed while she was sitting in her wheelchair. Z. On 06/10/22 at 12:49 pm during an interview with RN #13, she stated, She [R #317] was a patient on my unit. I was outside of her [R #317] room by the kitchenette area and I heard a thud and when I got there, I found her on the floor. He [CNA #11] had come back out and when I saw her [R #317], she was on the ground with her neck turned to the left and surrounded by a large pool of blood. I looked at her and there was another nurse behind me and I said don't move her [R #317] neck I'm calling for ambulance. I stopped the bleeding and I went to give the report to the hospital. The nurses had stopped the bleeding and stabilized her for the moment. [Name of CNA #11] said he put her [R #317] in there [R #317's room] facing the wall and he said she probably made an attempt to get out of the wheelchair. How she [R #317] got from the position from looking at the bed, she would have to tumble off the wheelchair and that's hard to do. If she sat on the bed and fell forward that would make sense and we don't do that. He [CNA #11] said he just brought her [R #317] in there [R #317's room] and he said she [R #317] likes her legs up. I never knew they [CNA's] did that [put R #317's legs up on the bed when R #317 was in her wheel chair] to her and that should not be done unless it's in a recliner chair that's supported. She [R #317] has atrophy [body tissue or organ waste away] of her muscles and no strength in her muscles and that's an inappropriate event for her. RN #13 confirmed R #317 should not have been placed with her feet on the bed while she sat in her wheelchair. AA. On 06/13/22 at 1:04 pm during an interview the DON, she stated, She [R #317] is doing transfer by herself when she's not supposed to be and she got a change of condition. For me, it's [keeping R #317's legs elevated on the bed while she sat in a wheelchair] not safe because she [R #317] can slide. She is very unpredictable. DON stated R #317 has not returned to the facility and DON believed R #317 was in a specialized facility after the fall. DON confirmed there was no documentation present that demonstrated R #317 preferred to have her legs up and R #317 should not have been positioned with her legs up on the bed while she was seated in a wheelchair. Findings for R #318: BB. Record review of R #318's Face Sheet no date revealed the admitted [DATE]. CC. Record review of R#318's MDS dated [DATE] revealed the following: .Section J. Health Conditions: history of repeated falls . DD. Record review of the Hospital's Medical Record for R #318 revealed the following: 1.04/19/22 at 11:18 AM . [name of R #318] found unresponsive, patient found sitting on the floor, stating he did not hit his head or any injuries. Staff put the patient back to bed, and at around 7:30 AM when they went to see the patient, he was not responsive. EMS (ambulance) was called and the patient transported from facility to the hospital] . 2. Diagnosis of .right hemispheric subdural hematoma (pool of blood between the brain and its outermost covering to the right side of the head), right to left midline shift (displacement of brain tissue across the center line of the brain) indication: Trauma (physical injury). EE. 04/21/22 at 9:28 AM .facility has been notified of [Name of R #318] passing away at the Hospital . FF. Record review of R #318's Resident Incident Report revealed resident had 12 repeated falls during 2021- 2022 in the following dates: 1. 01/05/21 at 5:10 AM . 2.01/05/21 at 9:45 PM . 3.01/06/21 at 8:32 AM . 4.04/21/21 at 4:40 PM . 5. 09/26/21 at 4:45 AM . 6.10/25/21 at 2:35 PM . 7.11/20/21 at 8:45 AM . 8.01/21/22 at 7:17 AM . 9.02/06/22 at 8:00 PM . 10.02/19/22 at 11:10 PM . 11.03/09/22 at 7:05 AM . 12.04/19/22 at 4:40 AM. GG. Record review of R #318's 72 hours Fall Follow up revealed the following after each falls: 1. 01/05/21 Ask for assistance if in doubt about transfer. 2. 01/05/21 Res [Resident] educated to call for assistance. 3. 01/06/21 Resident encouraged to ask staff for assistance with all transfers to prevent further incident or injury. 4. 04/21/21 Education with staff regarding need to assist resident with his shoes before transfer. Resident reminded to call for assistance with shoes when ready to transfer. 5. 09/26/21 Resident needs to call for assistance with transfers. Motorized chair does not need to be used for transfers. 6. 10/25/21 Ask for assistance with all transfers or urinal (container use by patient for voiding) use. 7. 11/20/21 Encouraged resident to call for assistance when necessary. 8. 01/21/22 take his time to transfer. He should also ask for help with transfers. Resident verbalized understanding. 9. 02/06/22 Use call light (device used by patient to communicate with staff and request help) for assistance with toileting and transfers. 10. 02/19/22 Use call light to request assistance. 11. 03/09/22 Encouraged to use call light and ask for assistance with all transfers. 12. 04/19/22 Educated on using call light before getting up and staff to show resident where call light was placed. HH. Record review of R #318's Fall Care Plan, last revision date 06/07/21, revealed the following: 1.Ensure that [name of the resident] clothing (day wear as well as sleep wear) do not cause tripping. 2.Ensure that [name of the resident] footwear is non-slip and securely on for [plan of care] use. 3.Facilitate [name of the resident] autonomy and decision making; adapt plan as needed. 4.Fall risk assessment quarterly [ever 3 months] and PRN (as needed) 5.[name of the resident] needs a safe environment with even floors free from spills and/or clutter (crowd), adequate, glare-free light (help with visibility) a working and reachable call light, handrails on walls and personal items within reach. 6.Encourage [name of the resident] to use his grabber stick when reaching to prevent falls. 7.Staff to assist [name of the resident] with all transfers and showers for safety. II. On 06/15/22 at 4:59 PM, during an interview DON confirmed that during 2021 to [AGE] year, R #318 had 12 repeated fall incidents, and facility did not revise his care plan after each fall and implement interventions other than using the call light and asking for help to prevent the fall from happening again. She also confirmed that R #318 had 8 fall incidents after the last care plan for falls had been revised with no new interventions implemented.

Based on record review and interview, the facility failed to keep residents free from neglect for 1 of (R #318) of 3 (R #19, R #317, and R #318) residents reviewed for abuse/neglect when they failed to assess R #318 including neurochecks (assessment of neurological functioning; motor, sensory response and level of consciousness) following an unwitnessed fall . This deficient practice likely resulted in a delay in identifying a change in condition for R #318. The findings are: A. Record review of [ name of the facility] Fall Incident Report revealed the following: 1. 04/19/22 at 4:40 AM .Resident was attempting to get up from bed unassisted (without help), he stated, my foot slip and I slide off bed onto my butt . B. Record review of R #318's Health Status Notes by night shift RN revealed the following: 1. 04/19/22 at 4:35 AM .R #318 was sitting on floor on gray mat beside bed. He stated, I was trying to get up and my foot slip and sled [sic] into floor on my butt. Action: Writer [ RN] evaluated the resident; he was able to move all extremities with no complaints of pain or discomfort. Neuro checks (examination of motor response, especially reflexes to determine if the nervous system is impaired) within normal range for resident. [ R #318] He was assisted up from floor with the help of 3 staff members and place back on bed, then was transfer to chair . 2. 04/19/22 at 4:52 AM .Writer educated R #318 on calling for help using call light (device use by patients to communicate with staff and ask for help) before getting up from bed. Call light was within reach, resident stated I didn't see it. Writer educated staff to place the call light where resident can see . C. Record review of R #318's Transfer to hospital summary revealed the following: 1. 04/19/22 at 8:37 AM .Responded to the resident's room at 8:00 AM, Resident in power chair (electric wheelchair) leaning to the left, unresponsive (not responding to stimulations). Nurse performing sternal rub (painful stimulation with knuckles of closed fist to the center of the chest) with no response. Right pupil (middle of the eye) dilated (open), both pupils unresponsive (not reacting to light). Unwitnessed fall (no one observed the fall) reported by night shift. Neuro checks were initiated (started) and had been with in normal range thus far. No apparent head injury at that time, no physical evidence of a head injury. Order to transfer resident to the emergency room for evaluation for sudden change in Level of conciseness (person's awareness and understanding). Resident transferred to the hospital at 0830 [8:30 am]. D. Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1.04/19/22 at 8:00 AM .Transfer to the [name of the hospital] via ambulance STAT (as soon as possible) for altered mental status . E. Record review of the Hospital's Medical Records revealed the following: 1.04/19/22 at 11:18 AM ' . R #318 found unresponsive, patient found sitting on the floor, stating he did not hit his head or any injuries. Staff put the patient back to bed, and at around 7:30 AM when they went to see the patient, he was not responsive. EMS (ambulance) was called and the patient transported from facility to the hospital] . 2. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . F. Record review of R #318' Physician 60 days Progress Notes revealed the following: 1. 04/19/22 at 11:51 AM .[Name of R #318] found at 8 AM this morning to have decreased alertness along with a left facial droop (damage to the nerves in the face, preventing the facial muscle from working properly) and dilated right pupil. I confirmed of the essence to be evaluated at the hospital level of care . G. 04/21/22 at 9:28 AM .facility has been notified of [Name of R #318] passing away at the Hospital . H. Record review of R #138's Discharge Summery by facility revealed the following: 05/02/22 .resident passed away on 4/22/22 due to a subdural hematoma . I. On 06/10/22 at 1:59 PM, during an interview with CNA #31, when asked about R #318's fall incident she stated, I found him on the floor around 4:40 AM, sitting up next to bed, talking to me. No altered mental status noted. No pain. He said I did not hit my head, I just slid from my bed . J. On 06/10/22 at 1:58 PM, during an interview, LPN #31 stated, I went to his room around 7:00 am to give medication to his roommate and I saw him going through his refrigerator, I did not see any altered mental status at that time, but roommate said, 'don't bother him, he is upset.' [Name of CNA #32] found the resident unresponsive, she found him when she was dropping off the breakfast trays. He was in his wheelchair, on one side and unresponsive. [Name of RN #31] did sternal rub, but resident did not respond. Roommate was present but she was very upset and did not talk to us . K. On 06/10/22 at 2:13 PM, during an interview with CNA #32, when asked about R #138 she stated He fell during night shift. When breakfast came, I [ CNA #32] went to take their breakfast tray and found him unresponsive. He was on the chair but to his left side. Resident and his partner always went to breakfast very early, but that day R #318's partner said, we are going to stay in our room to eat. L. On 06/10/22 at 2:22 PM, during an interview with R #318's partner, she stated, After he fell , he was okay. He was talking and responding, but after a while he told me his head was hurting and he was not in a good mood. That's why we did not go to the dining room for breakfast. M. On 06/15/22 at 4:34 PM, during an interview with MD he stated that R #318 had a mental status change related to possible stroke. I was assuming it was stroke [due to the way the resident presented]. Refer to finding F. N. Record review of Falling Resident-Emergency Care revealed the following: Procedure .B. Do not move the resident until after am assessment can be carried out by the house supervisor or determine if and what injuries have occurred. The resident will not be further injured by being left where she/he was found, but improper moving of the resident could compound injuries sustained in the fall. M. All resident falls shall result in the 72 Hour Fall Follow Up Assessment completed every shift. In addition, any resident with an unobserved fall, or unobserved fall where the head was struck (hit forcibly), will be started on the neurological watch protocol for 24 hours. O. Record review of [name of the facility] Investigation revealed the following: Summary of Evidence: 1.04/20/22 .investigations have determined through interview with staff and camera view, that house RN did not go into R #318's room to complete assessment after the fall, did not initiate neuro checks. Did not physically go to the resident's room at any time after the fall. It was voiced by staff that house RN was allegedly (apparently) sleeping . 2.House RN voiced that she did not go to R #318's room to complete her assessment and voiced she knew it was her responsibility to do so. Determination of Fact and Findings: 3.There is evidence to support an allegation of neglect, that house RN neglected to complete neuro checks and required assessments after R #318's fall. Camera review shows RN walked past the resident's room at 0502, and never entered his room. 4.CNA #32 glanced (brief look) into R #318's room from the hallway at 6:34 AM and did not enter his room until 7:52 AM with breakfast tray. 5.LPN #31 [day shift] enters and exits R #318's room at 6:47 -6:48 AM, she stated, she did not complete neuro checks on resident, she did not feel the urgency as it was reported he slid out of bed and voiced she was not as diligent (showing care) as she should have been. 6.CMA #31 arrives to R #318's doorway at 7:46 AM. Resident's partner told her, R #318 was not feeling good and needed to lay down, after preparing their medication, she went to the room and found him, slump over (to one side). P. Record review of [name of the facility] Complaint Narrative Investigation Report (5 day) revealed the following: 1.there is evidence to support allegation of abuse, neglect, or mistreatment. House RN did not complete neuro checks and required assessment for R #318 after his fall. She did report falsely that she assessed R #318, however investigation confirmed she did not enter the resident's room. 2.Allegation of Abuse/ Neglect/Exploitation: Substantiated (provide evidence and support or prove the truth of). Q. On 06/15/22 at 4:34 PM, during an interview Incident Management Director confirmed that facility's investigations supported the allegation of neglect. R. On 06/15/22 at 4:59 PM, during an interview DON confirmed the following: 1. House RN failed to assess R #318 after his fall. No neuro check assessment done by any RN approximately until 4 hours after his fall when he was found unresponsive. 2. LPN #31 and CNA #32 failed to observe and assess the patient upon start of their shift [day shift]. S. Record review of Resident Right Regarding Accidents, Injuries, Abuse, Neglect and Exploitation revision date 12/09/14 revealed the following: .residents have the right to be protected from unreasonable risks to their personal safety and welfare . T. Record review of Activation of Nurse Stat Due to Fall guideline revealed the flowing: 3. Resident can not be left unattended, cannot move until the House supervisor RN/ RN arrive to assess the resident. 5. If LPN is working in a unit with fall, the House supervisor RN or any RN will initiate the assessment. 7. House supervisor RN will start assessing the resident/ neuro assessment started and call medical provider to report the status or condition of the resident. 9. If the resident hit his head or unwitnessed fall and on Anticoagulation medication (medication to prevent blood clot), the resident must send to ER for evaluation post unwitnessed fall.

Based on record review and interview, the facility failed to ensure 1 (R #1) of 3 (R #1, R #2, & R #3) residents sampled for weight loss 1) was receiving the assistance required to maintained his weight and not lose a significant amount of weight; 2) that the Registered Dietician (RD) acknowledge the weight loss and implement interventions to prevent further weight loss; and 3) ensure R #1 received enough fluids to drink during the day to avoid being dehydrated. This deficient practice likely resulted in significant weight loss for R #1 starting in July 2020 through 09/09/20 and R #1 to have critical laboratory values on 09/08/20 due to dehydration likely resulting in the resident being placed on end-of-life care. The findings are: A. Record review of R #1's [DIAGNOSES REDACTED]. 1. Two long-term [DIAGNOSES REDACTED]. 2. Two new [DIAGNOSES REDACTED]. B. Record review of the 06/02/20 MDS revealed R #1 needed extensive assistance (facility staff performed the tasks more than 80% of the time without the resident performing the task) of one staff member. C. Record review of R #1's Care Plan revealed he is to be assisted with meals and to be given small bites and drinks, alternate solids and liquids, and encourage the resident to drink adequate amounts of fluids daily. D. Record review of R #1's weights between 06/12/20 and 09/10/20 revealed the following: 1. 5.9% weight loss between 07/02/20 and 07/30/20 (10 lbs) 2. 7.7% weight loss between 06/12/20 and 08/22/20 (13 lbs) 3. 9.5% weight loss between 06/12/20 and 08/29/20 (16 lbs) E. Record review of R #1's clinical record revealed the following: 1. No notes by the RD requesting a supplement or change in diet after 06/12/20 2. No changes of diet or new orders for supplements by the physician. 3. No meal or fluid intake values for July 2020 through September 2020. F. Record review of R #1's laboratory results on 09/08/20 from a local hospital revealed the following: 1. Sodium level was 161 mmol/L (millimoles per liter - the amount of a mineral in a liter of liquid) (The normal range is 137-145) 2. Chloride level was 126 mmol/L (The normal range is 98-107) 3. 09/08/20 at 3:14 PM - Critical values verified by repeat analysis and results called to (name of nurse) at (facility) . 4. Osmolality level was 325.21 (The normal range is between 280 through 295. High osmolality could indicate dehydration.) G. During an interview on 03/25/21 at 3:30 PM, R #1's physician confirmed the laboratory values could indicate poor meal and fluid intakes. H. During an interview on 03/26/21 at 11:40 AM, CNA #1 stated that she did work with R #1 on the F-Hall. She stated that it was hectic and she felt short-handed. During meals, there was 4 to 5 residents that needed to be fed while 4 other residents needed encouragement to eat and there would only be one aide to do all of this. She stated that R #1 could be very combative if the person taking care of his did not approach him in the correct manner. It was quite often it took more than one staff member to accomplish tasks with R #1. She remembered that R #1 needed to be fed and offered liquid. I. During an interview on 03/26/21 at 11:55 AM, CNA #2 stated that about 6 residents needed assistance with meals and liquids while R #1 was on F-Hall. She remembers times that she had to work the hallway with 24 residents by herself. She stated that R #1 had dementia and could easily become combative, hitting others. She further stated that he needed total assistance to eat and drink. She also remembers times that he was rushed to eat and drink because there was not enough staff. J. During an interview on 03/26/21 at 12:15 PM, CNA #3 stated R #1 would become combative when trying to feed him. This would lead to a 50% chance of him eating his meals. K. During an interview on 03/26/21 at 1:40 PM, House Supervisor #2 confirmed that a resident with those laboratory results was probably not being assisted with feeding and drinking by staff. L. Record review of R #1's clinical record revealed the following: 1. Administrator's Note dated 09/09/20 at 5:35 PM that indicated R #1 new status was end-of-life. 2. physician's orders [REDACTED]. 3. physician's orders [REDACTED].

Based on observation, record review and interview, the following was revealed: 1. Facility allowed a COVID-19 positive staff member with symptoms to continue providing care to COVID-19 positive and non-positive residents. 2. Facility failed to clearly communicate resident COVID-19 status to nursing staff. 3. Facility failed to provide a barrier between green zones (non COVID-19 area) and red zones (COVID-19 positive area) staff were observed passing between zones. 4. Facility staff failed to change PPE (Personal Protective Equipment) between red, yellow and green zones. 5. Facility failed to thoroughly clean a red zone (for covid positive residents) before converting that unit to a green zone (for covid negative residents). This resulted in Immediate Jeopardy being called on 12/09/20 at 1:04 pm. The Administrator (ADM) was notified at this time. A plan of removal was received on 12/09/20 at 2:20 pm. The plan of removal was accepted and implementaiton was verified. The ADM was notified. The plan of removal included: 1. Covid Positive employees will only be allowed to work if they are asymptomatic (without any symptoms) in a positive (red zone) area. Employees will not go from zone to zone without doffing and donning complete and appropriate PPE in the zone. 2. Positive results are clearly noted on the 24-hour report for all licensed staff members to be aware of current resident status. Form will be updated as results are received, and staff notified. 3. Zones have been identified and barrier has been placed between the red zone and green zone. 4. Staff must doff to exit one unit and don to enter the next by way of barriers. 5. All red zones converted to green zones will be terminally cleaned. 6. All areas will be terminally cleaned prior to any movement of residents into the area. 7. Staff will establish policy and procedures per CMS (The Centers for Medicare and Medicaid Services) Guidelines. Based on observation, record review, and interview, the facility failed to maintain infection prevention measures by: 1. Allowing a staff who was positive with COVID-19 and symptomatic (with symptoms) to care for residents that did not have COVID-19, 2. Staff failing to change PPE (personal protective unit, i.e. masks, gowns, gloves) between COVID-19 positive and negative units. 3. Not clearly identifying covid units and PPE required and communicating with staff. 4. Not thoroughly cleaning a red unit before converting it to a green unit. This deficient practice likely resulted in the spread of potentially deadly infectious diseases to other residents and staff. The findings are: A. On 12/09/20 at 10:11 am during an interview with the Administrator (ADM), she confirmed the facility has had 68 staff members test positive for COVID-19 and 104 residents test positive for COVID-19. Findings related Contingency staffing: B. Record review of Facility policies dated 04/20 revealed: Contingency Staffing Strategies, 3. Allowing asymptomatic staff who have been exposed to COVID-19 to continue working when: a. They report normal temperature and lack of symptoms every day before reporting to work. b. They wear a facemask at work for for 14 days after the exposure event and, c. They agree to stop any resident care activities, report to their supervisor, and leave the facility if (even mild) symptoms develop. C. Record review of Crisis Staffing approval reveals approval for two weeks starting 11/23/20 that allows asymptomatic positive COVID-19 staff to work with only positive COVID-19 residents and are not allowed to enter any other units in the facility. D. Record review of Certified Nursing Assistant (CNA) #1 COVID-19 test documentation revealed, CNA #1 tested positive for COVID-19 via rapid test on 11/27/20. CNA #1's symptoms included slight cough. E. On 12/07/20 at 4:02 pm during an interview with CNA #1 she stated that she came to work on 11/27/20 and didn't feel well and had a fever which prompted her to be tested for covid 19. She stated that she was instructed to continue working after testing positive for COVID-19 on 11/27/20. CNA #1 confirmed the she worked with both resident in the red zone (COVID-19 positive) and yellow zone (exposed residents, but not confirmed positive) while positive herself with COVID-19. CNA #1 confirmed that by the end of her shift on 11/27/20, she also had a sore and scratchy throat. F. On 12/07/20 at 4:37 pm during an interview with Infection Preventionist (IP), she stated CNA #1 tested positive with COVID-19 on 11/27/20 and continued to work. IP also confirmed CNA #1 should have been sent home because she (CNA #1) had tested positive and presented with symptoms, but due to staffing challenges, stayed working at the facility. G. On 12/07/20 at 5:42 pm during an interview with CNA #2, she stated she worked with CNA #1 on the D unit (yellow and red) on 11/27/20. CNA #2 confirmed CNA #1 assisted with passing out food trays and assisted with transferring residents from unit to unit, with both residents that were COVID-19 positive and residents that weren't COVID-19 positive. CNA #2 also stated that she had some concerns about CNA #1's hand hygiene and that CNA #1 did show signs of COVID-19 (sore throat and coughing) during the shift and she continued to work. H. Record review of CNA #2 COVID-19 test documentation revealed, CNA #2 tested positive for COVID-19 via rapid testing on 11/29/20. I. On 12/08/20 at 12:03 pm during an interview with the Pharmacist/ Pharmacist Clinician (P/PC), he stated the D-unit was a yellow zone with a small part of it a red zone on 11/27/20. P/PC also stated staff that have tested positive for COVID-19 and are permitted to work should not be working in a yellow zone. J. On 12/08/20 at 1:05 pm during an interview with the Lead Aide Supervisor (LAS), he stated CNA #1 worked the D Unit on 11/27/20 while experiencing a headache. LAS also confirmed CNA #1 worked with both red and yellow residents on 11/27/20. Findings related to zones and PPE: K. On 12/07/20 at 3:30 pm during an interview with a staff member who wanted to remain anonymous, they stated staff moves between COVID-19 positive units and non-COVID-19 positive units without changing PPE. They also confirmed the facility is constantly moving positive and negative residents around the facility. L. On 12/08/20 at 4:20 pm during an interview with Certified Medication Aide (CMA) #1, she stated she is very confused with the constant unit and zone changes. CMA #1 confirmed F- unit and half of the E-unit were red, but she was not sure about the other half of the E-unit and the D-unit due to nobody had informed her to any changes of the units. M. On 12/07/20, 12/08/20 and 12/09/20 during observation, there was no signage and no barriers were set up to identify units and PPE needed in each unit. N. On 12/08/20 at 4:24 pm during an interview with the Ward Clerk (WC), she stated there's a lack of communication between the administration and staff on units and zones. She also stated that due to staffing, CNA's are required to go between multiple units and should change PPE between units. O. On 12/08/20 at 4:37 pm during a random observation, staff working in the F unit (red zone) and E unit (red zone) were observed walking between units and to the D unit (green zone) without changing PPE. No barriers were placed between the units and staff were observed wearing the same PPE between red and green zones. P. On 12/08/20 at 5:11 pm during an observation of the (Name of E and D units) and interview with the Assistant Director of Nursing (ADON), staff was observed moving between zones without changing PPE. ADON confirmed staff from the E Unit (red zone) go to the D unit (green zone) without changing PPE. ADON also confirmed the status of each zone. Q. On 12/08/20 at 5:35 pm during an interview with a staff member who wanted to remain anonymous, they confirmed that staff is still providing care to both residents in the green zone and red zone without a barrier separating the green and red units. R. On 12/08/20 at 5:42 pm during observation of the D-unit entrance, the door was marked as a red zone and two residents were observed standing outside their rooms and one resident was observed to be in a wheelchair sitting out in the hallway. ADON confirmed the D-unit was still marked as a red zone, but it was just changed to a green zone. Findings related to cleaning a red unit: S. On 12/08/20 at 4:26 pm during an interview with the Risk Management Safety Director (RMSD), he stated the D-unit was transferred from a red zone to a green zone, and that was completed at 2:30 pm today (12/08/20). RMSD also stated the D-unit rooms were cleaned and sprayed with a cleaning solution, and the furniture from each room was moved out into the hallway as the D-unit rooms were being cleaned. RMSD confirmed after each D-unit room was cleaned, the furniture for each room was moved back into each room without cleaning the furniture again. T. On 12/08/20 at 4:33 pm during an interview with another staff member who wanted to remain anonymous, they stated that due to a lack of communication between the administration and staff, residents were moved from unit to unit too quickly and before rooms could not be adequately cleaned. They also confirmed the D unit was a red zone earlier today, but it was converted to a green zone with residents moved in before it was properly cleaned. U. On 12/08/20 at 4:57 pm during an interview with the RMSD, he confirmed the D unit was previously red and was just converted to green unit. RMSD also confirmed the rooms in the D unit were cleaned and stated, We cleaned everything we could possibly reach however she confirmed the hallways were not cleaned prior to moving residents into the D Unit. V. On 12/08/20 at 5:36 pm during an interview with CNA #1, she confirmed she was moving residents beds from the green zone into the red zone (back and forth) without changing PPE. CNA #1 also confirmed she had treated residents (this day) in both the green zones and red zones without changing her PPE. W. On 12/08/20 at 5:45 pm during an interview with the ADON, she stated that the facility had moved residents into the D-unit and she knows housekeeping cleaned D-unit before the residents were moved into that unit, but states she doesn't not know if D-unit was deep cleaned. She further stated that several residents from the B-unit that were moved into the D-unit had all passed there 14 day quarantine time and were considered covid negative.

Based on record review and interview, the following was revealed: On [DATE] R #83 was ordered to receive a SLP (Speech Language Pathology) screen (a screen of a persons ability to properly swallow foods and fluids) due to increased swallowing problems. On [DATE] R #83 was ordered to be referred to a local hospital for evaluation of pneumonia (an infection of the lungs). He was returned to the residence on [DATE] with the following orders: Aspiration Precautions (extra monitoring to prevent possible inhalation of solids or liquids), Pureed diet (a diet of foods that have been altered to a pudding like consistency), Nectar thick liquids (liquids that have been thickened to a honey like consistency). On [DATE] the following events occurred: At approximately 8:00 am R #83 was given his medication. He was provided a total of 8 whole pills and several liquid medications. Medication orders indicated (MONTH) crush. Shortly after, R #83 vomited and brought up his medications within the emesis (vomiting). Staff also noted that R #83 was missing his upper and lower partial dentures. The upper dentures were found in his bed and the lower dentures were never found. By 8:30 am, R #83 began to complain that it felt like there was a rock in his throat. He continued to make the same complaint and refused food or drink through out the morning. At approximately 2:45 pm, R #83 was transported to the local hospital for evaluation Dys(hagia after choking on pills. He was discharged from the emergency room at 3:50 pm with a [DIAGNOSES REDACTED]. By 5:00 pm R #86 was described as continued swallowing difficulties and continued complaint of a rock in his throat. At 7:55 pm orders were entered to return R #83 to the emergency room . At 8:00 pm R #83 was found to be unresponsive and not breathing. He was pronounced dead shortly thereafter. This resulted in Immediate Jeopardy being called on [DATE] at 6:07 pm. The facility Administrator (ADM) and Director of Nursing (DON) were notified at this time. A Plan of Removal was received and rejected on [DATE] at 7:53 pm and on [DATE] at 6:05 pm. A third plan of removal was approved and verified on [DATE] at 9:17 am. The scope and severity was reduced from Level 4, J to Level 3, H The Plan of Removal included: 1. Nursing department will identify all residents who are at risk of choking due to having partial dentures. Residents will be re-assessed, and interventions will be implemented to validate staff is assisting residents. On all new admissions, the P[NAME] (Point of Care-a portion of each resident electronic record) will be updated to reflect they have a partial dental appliance and random audits will be conducted by MDS (Minimum Data Set) coordinator and/or her designee to validate accuracy of information. P[NAME] was updated and completed [DATE]. Responsible party MDS Coordinator and/or designee. Monitor: that the P[NAME] is updated for 6 months or until stable. 2. Nurses' Aides will implement appliance list back into the daily Certified Nursing Assistant (CNA) Packets. The packet is their daily work packet which includes; daily planner, shift to shift report, denture and partial list, daily bath report, 2 q hour (every 2 hour) check sheet and assignment sheet (each CNA is assigned to a group with information for each resident.) CNA review their packets and Lead Aide's review each CNA's packet for completion. The lead aide is responsible for tracking the logs. The ADON (Assistant Director of Nursing) will ensure that a Lead Aide is tracking the logs. Responsible party ADON or designee. Monitor: That the dental and partial is updated upon admission and with any charges that occur for 6 months or until stable. 3. Upon return from hospital, nursing will assess resident and document status. This includes a head to toe assessment by House Supervisor or designee. Vital signs will be taken by the- House Supervisor will review the hospital discharge paperwork and contact Medical Director or designee for review of appropriate emergency department evaluation and assessment. The nurse will advocate for the resident if they deem the symptoms are not treated appropriately, by contacting the Medical Director or designee to address. If the unit nurse still has concerns they will notify the House Supervisor. If it is not resolved it will go to Nursing Administration up to the Administrator. Our internal process will be to empower the nurses to advocate for the residents. Responsible Party: DON (Director of Nursing) or designee will monitor the head to toe assessment, house supervisor review of discharge paperwork and that the Medical Director or designee was contacted at return from the hospital for 6 months or until stable. The Medical Director or designee will decide on how to proceed on next course of treatment. In the event the Medical Director or designee does not agree with course of treatment a call will be made to ER (emergency room ) physician to discuss. Responsible Party: Medical Director or designee. Monitor: Medical Director or designee review of progress note for 6 months or until stable. 4. (MONTH) crush medication terminology will be removed and will be replaced with crush. Nursing staff will be re-educated by Pharmacist on new order process. Initiated on [DATE]. On [DATE] at 2000 (8:00 pm) all residents reviewed only crush med no choice. Each med identified and completed [DATE]. Responsible Party: Pharmacist Monitoring Med (Medication) Administrator for following crushing of MEDICATION ORDERS FOR [REDACTED] 5. Re-education to all nursing staff about the importance of documenting proper denture storage implemented [DATE]. 6. MDS Coordinator began updating the Point of Care on [DATE] after investigation (internal investigation) was completed to notify nurses' aides of new documentation parameters which included the removal and storage of the dental appliance when resident was sleeping. Check off placed on nurses' aides of new documentation parameters which included the removal and storage of the dental appliance when resident was sleeping. Check off place on nurses' aides to document if they notified nurse of refusal to remove the dental appliance on [DATE]. Completion [DATE]. Responsible Party: MDS Coordinator or designee. Monitor that the CNA documentation in P[NAME] is completed. 7. Any residents who have significant change in conditions will be assessed by charge nurse, 911 called and patient transferred to hospital. Nursing staff will be educated on [DATE]. Based on record review and interview the facility failed to provide services for 1 (R #83) of 3 (R #83) residents reviewed for Activities of Daily Living (ADL's). This deficient practice likely resulted in R #83 experiencing a choking incident without appropriate intervention and his death. The findings are: Based on record review and interview, the facility failed to prevent verbal abuse and neglect for 3 (R #64, 70 and 83) of 3 (R #64, 70 and 83) residents by: 1. Not identifying that R #83 likely swallowed his partial dentures after complainign that there was a rock in his throat, when providing treatment and seeking hosiptal evaluation which likely resulted in his death. 2. Not ensuring that R #64 and 70 were free from verbal abuse. If the facility is not protecting residents from abuse, then abuse is likely to continue to occur, which could result in increase of depression, isolation and emotional distress. The findings are: Findings for R #83 [NAME] Record review of R #83's face sheet indicates that resident was admitted to the facility on [DATE]. B. Record review of care plan dated [DATE] reveals, Focus: The resident has ADL (activities of Daily Living) self-care performance deficit r/t (related to) Dementia, Fatigue, SOB (short of breath), impaired balance. Interventions/Tasks: Oral Care: The resident has a couple of his own teeth to the bottom with a partial denture and a full upper denture. C. Record review care plan dated [DATE] reveals the following Diagnosis: [REDACTED]. debility (weakness), Deficiency of other specified B group vitamins (lack of specific vitamins), Hypertensive Heart and [MEDICAL CONDITION] (gradual loss of kidney function), Hypertension (high blood pressure), Vitamin D Deficiency (lack of vitamin D), Megaloblastic [MEDICAL CONDITION]'s (condition in which the bone marrow produces unusually large structurally abnormal, immature red blood cells), Disruptive Mood Dysregulation Disorder (Mental disorder), Type 2 Diabetes Mellitus (high blood sugar). D. Record review of Physicians orders revealed: 1. [DATE]: SLP (Speech-language pathologist) Screen request: increased swallowing problems. 2. [DATE]: (MONTH) crush meds (Medication) (poor swallow). E. Record review of Medication Treatment Sheet dated [DATE] reveals, Strict Aspiration precautions, (MONTH) Crush Meds. F. Record review of Nursing notes revealed: 1. [DATE] at 8:46 am reveals Charge nurse call me to this rsd (R #83) room with c/o (complaint of) having a rock stuck in this throat. Rsd is has (sic) audible rales (abnormal rattling sounds heard when examining lungs with a stethoscope) noted and cough present skin warm to touch, his spo2 (estimation of oxygen in the blood) sat (saturation) is 88% (percent) on 2 lit (liters) per NC (nasal canula) rsd (resident) when he speaks he has lots of mucus. Called (Name of Medical Doctor (MD)) and he said to provide rsd with some suction and a [MEDICATION NAME] (medication used to treat shortness of breath) med (medication) neb (nebulizer) rsd o2 (oxygen) sat was maintain at 88%. 2. [DATE] at 9:27 am reveals: (Name of MD) in to see this rsd (R #83) and assessed him. Dr. request the nurse to provide rsd with percussion and cough and spit up secretions. (MONTH) suction if needed. continue with [MEDICATION NAME] med nebs q (every) 2 hrs (hours) continue to observe rsd with changes. 3. [DATE] at 10:00 am reveals Late entry note. Order received and noted as follows. Strict aspiration precaution. Hold oral meds. NPO (Nothing by mouth) until further assessment. Encourage cough often and assist with suctioning. Chest percussion Q ,[DATE] hours and encourage to cough. SLP (Speech and Language Pathologist) screen in AM (morning) ([DATE]). 4XXX[DATE] at 11:52 am reveals Rsd went to D/R (dining room) for his noon meal refused to eat/drink at this time. cont. (continued) to c/o rock in his throat. 5. [DATE] at 1400 (2:00 pm) Order received and noted as follows: RSD may resume his current diet and thicken liquids, seating upright and with staff one on one. 6. [DATE] at 14:24 (2:24 pm) Staff tried to assist him with his diet due to being hungry rsd (R#83) was not able to swallow and continued to c/o rock in his throat, called (name of MD) back and reported the situation. (R #83) New orders obtained to send this rsd to (name of local hospital) via transport for eval (evaluation) of aspiration phemo., called (name of local hospital ER (emergency room )) and gave report to male nurse and called rsd listed POA (power of Attorney) to update him. POA will meet rsd at (name of local hospital). notified ADM (Administrator). 7. [DATE] at 15:25 (3:25 pm) reveals This writer tried to assist resident with breakfast and resident complain that his throat hurts.This writer and the CNA (Certified Nurse Aide) noticed that resident was not wearing his dentures. House RN (registered Nurse) and Medical provider was informed of the incident. Later on after a through search the upper denture was found. Orders were made and finally Medical provider decided to sent him to hospital. 8. [DATE] at 17:00 (5:00 pm) Late Entry: Staff note resident w/continued distress, swallowing difficulties, complaint of rock in throat. Resident sent to ER earlier in day with similar questionable aspiration complaint. Resident has ability to make swallow, clear sinus drainage noted on oral pharyngeal review, Lungs CTA on inspiration, [MEDICATION NAME] airway sounds on expiration sound clear, course rale notable in throat, resident capable of making swallow on request. Tickened liquid given and gargle and expectorate with same return of fluid. No color tinge change noted with thickened water, milk or chocolate ensure. No cough nor swallow difficulty noted. complaint persisted. Vitals remal stable, with o2 ,[DATE]. Discuss [MEDICATION NAME] gel order w/(name of MD) not ordered as no increased swallow difficulty from numbed throat wanted. Close observation, iteration of crushing meds and diet given, repeat cough and expiration instructions given. 9. [DATE] at 18:29 (6:29 pm) rsd returned from being at (name of local hospital and the return reports were no tests/EX rays were done and that he had dx of esophagitis. rsd is still no (sic) able to swallow food and or fluids very easily. staff seem to think this rsd may have swallowed his lower partial, it went missing today, called (name of MD) and left message with him about this concern. 10. [DATE] at 18:45 (6:45 pm) reveals This nurse arrived to find residnt experiencing a copious amount of sputum and gurgling sounds cominf from his throat. Med tech was asked to give him a breathing treatment because he was yelling for someone to help me this nurse was advised that resident had already received a breathing treatment. This nurse was also told that residents lower partial was missing since the morning and had not been found. This nurse was advised that resident had been complaining of sore throat and was saying he felt like a rock was stuck in his trhroat. This nurse asked was it possible that resident had swallowed his partial during the night thus possible reason(s) for the complaints. This nurse was then told resident was sent tot he ER for floolow up and that results were pending but to date, no new orders. This nurse went to house supervisor who was still in report with previous shift house nurse. this nurse shared possible concerns discussed in rounds regarding missing partial upon awakening and ytet to be found.complaints of having a sore throat, increased secretions, audible gurgling sounds and pain that felt like a rock was stuck in residents thrroat. AM house supervisor contacted provider to whic an order to hold the nightly [MEDICATION NAME], contine to provide pm suctioning, elevate hob (head of bed) supply health shake since meals were not ingested d/t pain and monitor until. Thursday morning. Proved concerned that if resident sent back to (name of local hospital) he would receive same treatment therefore keep resident at facility and evaluate in the morning. This nurse proceeded to residnets room to which he was laying in bed and yelling at the aides in playful manner. Vital taken and elevated HR (heart rate) of 107 and sats at 89 to 90% on 4 L of oxyen. Resident began to gurgle and produce more secretions help me, there is a rock in my throat. Resident continued to cough up large amounts of mucus. this nurse then called for the house superviosor to assess. Resident was suctioned frm the oral cavity and O2 rechecked for 68 to 70%. Provider was contacted again with concerns about oxygen level and possible swallowing of partial to which provider gave and order to have resident sent to the ER for further evaluation. 11. [DATE] at 18:52 (6:52 pm) reveals Medical (Name of Registered Pharmacist (RP)) was called and we are to continue to observe this rsd closely and new orders wre obtained to treat rsd tonight for comfort. 12. [DATE] at 18:56 (6:56) Order received as follows: Send rsd to (name of local hospatil ER) aspiration Pheno-choking episode this AM. 13. [DATE] at 19:12 (7:12 pm) reveals Resident was back from (Name of local hospital) at around 17:00 (5:00 pm) He verbalized he was hungry. Medical provider tried to give him chocolate drink, and residnet took a few sips. At dinner time he just took a few bites of his food and a few sips of his drink. He still complains that his throat hurts. 14. [DATE] at 19:54 (7:54 pm) Resident was sent to ER for aspiration evaluation earlier in the day and sent back this evening, upon start of shift, resident continues to have an increase in secretions and commented that he feels like I have a rock stuck in my throat. This nurse learned in report that rsidents partial was lost and not able to be found. bital taken and order to suction was done hovever sats continue to decline to 68% on 4 L of oxygen NC. Call to oncall provider with concerns that residnet may or may not have swallowed his partial. Current vitals BP ,[DATE], HR 107, T (Temperature) 97.6, R (respirations) 24. Order to send to ER for evaluation. 15. [DATE] at 20:00 (8:00 pm) CNA(s) run into nursing station (Name of R #83) is not breathing This nurse goes into residents room to find that he was unresponsive, this nurse called his name x (times) 4 and did stenum rub to which resident did not respond. This nurse then called for house supervisor stat for assistance. 15. [DATE] at 20:42 (8:42 pm) reveals Received report at the start of this shift about this resident that he was sent out during the day at the (sic) (Name of local hospital ER) for an evaluation due to choking episode but was sent back to this facility. At the start of shift resident was already complaining of a rock in my throat. SpO2 was 90%,BP=,[DATE] mmHg. T=97f, HR=71bpm. Assessed resident was awake and responsive on high fowler's position. Gurgling sounds noted on oral cavity. PRN (as needed) suction done by this nurse per doctor's order. Minimal oral secretions suctioned out. Noted SpO2=68 to 70%. Called (Name of MD), at 1918 (7:18 pm) no answer. Called (Name of RP)at 1922 (7:22 pm) and received order to send resident out. Notified ADON 1924 (7:24 pm) admin on cal at 1927 (7:27 pm) and Poa (Power of Attorney of 1931 (7:31 pm) All paper works prepared. Resident was also ready for send out. Around 2000 (8:00 pm), this nurse is about to call the (Name of local hospital ER) to report residents condition for send out per doctor's order, chen a Certified Nurse Aide {CNA} was running out of the resident's room calling a nurse stat (urgent, immediately). This nurse and the unit nurse went to the resident's room immediately. Resident was noted unresponsive. Assessed the resident's VS (vital Signs): BP=0, Caroid pulse absent; breath sounds not appreciated over lung fields per auscultation, no rise and fall of chest noted. Heart sounds absent per auscultation. Tried calling (Name of MD) but no answer. Notified (name of RP) at 2007 (8:07 pm) Received callback from (name of MD) at 2008 (8:08 pm) and cause of death [MEDICAL CONDITION] due to possible Aspiration Pneumonia. Notified ADON at 2011 (8:11 pm). Notified Admin on call at 2021 (8:21 pm). 16. [DATE] at 00:26 (12:06 am) reveals Received a call from (name of local hospital Er) nurse around 13:48 (11:48 pm) with the information that no xray was done at the hospital when resident was sent out earlier [DATE] at 0000. No personal effects/valuables on the body as withnessed by this nurse and the CNA's. G Record review of Physician's noted dated [DATE] reveals On [DATE] after the episode of apparent aspiration in the morning, (name of R #83) improved, coughed up aspiration contents and eventually appeared to clear his lungs/throat. He was placed NPO and closely observed as well as other measures, and in the early afternoon he (R #83) wanted to eat since he was hungry. I spoke with (name of RN #1) and we decided to try to cautiously let him eat a trial of thickened fluids and a soft mechanical consistency food. Shortly after this same nurse called me back and stated that it had failed and that he was not able to swallow, therefore I instructed her to send him to (name of local hospital). I also called the ER (emergency room ) physician, (Name of ER Physician), gave her a full report of why I was sending him to the ER, and she accepted the patient for further evaluation and management of possible dysphagia, aspiration and potential for [MEDICAL CONDITION]. Later that afternoon, I was informed that the resident had returned to us, this message was given to me by (Name of RN #1) and later by (Name of RP), with whom I discussed his status and management for the rest of the night. Later that night (at about 6:25PM) I was called by House RN, due to worsening [MEDICAL CONDITION], and I gave instruction to send to the ER, but shortly thereafter (7:19) I was called back by this RN that this resident had passed away. H. Record review of Discharge Summary from (Name of local Hospital) dated [DATE] at 15:50 (3:50 pm) reveals Discharge Diagnoses: [REDACTED].#83) is referred to emergency department with dysphasia after choking on pills. He complains of pain with swallowing and in the epigastric area. [MEDICATION NAME] and [MEDICATION NAME][MEDICATION NAME] were administered and the patient was able to tolerate oral fluids wel. There is no evidence of [MEDICAL CONDITION] obstruction with drooling or difficulty swallowing secretions. Patient has no fever no respirtatory distress and no [MEDICAL CONDITION] congestion. Respiratory effort was unlabored with good oxygenation. Oxygen level of 89% noted. Chemical pneumonitis may be contributing to his discomfort. No antibiotics are indicated for aspiration pneumonitis, however, patient may warrant further evaluation should symptoms of aspiration pneumonia develop. Chief complaint: Chocking, possible pneumonia. Patent to ER (emergency room ) from (Name of facility). Was given medications earlier today thata were whole, they are normally cut up in small pieces. Patient feels like he has something stuck in his throat. Medical Decision Making: Patient had painful [MEDICAL CONDITION] spasms that were evaluated with and EKG (Electrocardiogram). Patient had normal sinus rhythm with normal intervals no evidence of ischemia (Inadequate blood supply to an oragn or part of the body). Patient was observed in the emergency department was able to tolerate soft diet and fluids. After taking initial food challenge. Patient has clinical evidence of [MEDICAL CONDITION] spasm and esophagitis related to pill esophagitis. Patient may require esophoageal imaging with initial esophagram if his pain with swallowing persisits. There was no mention that resident had missing partial or may have swallowed his partial. I. On [DATE] at 3:34 pm during an interview with Certified Medication Aide (CMA) #1, she stated. I came into work about 4:30 am and gave him (R# 83) some meds about 5:00 am. He said he did not feel good I gave him meds and a neb (nebulizer treatment) and left him. I later returned and gave him his morning meds. I did not crush them. He later complained of a sore throat. He tooks his meds then about 15 minures later Registered Nurse (RN) #1 came in and stated he had spit up his pills. We checked the Medication Administration Record [REDACTED]. The Doctor was called and he instructed us not give him anything. Doctor said it was ok to give pureed food or thickened liquids. He was given his [MEDICATION NAME] acid (anticonvulsant medication) with pudding and could not swallow it. He was later sent to the ER and he retured later in the same state he was in before (not able to swallow and complaing of pain to his throat). He hollared and screamed. He continued to complain that there was a rock in his throat. He kept hollering. I later left, my shift was over. [NAME] On [DATE] at 3:47 pm during an interview with RN #1, she stated I was working in the dininig room that day, RN #2 called me and stated that R #83 had something in his throat and had an order for [REDACTED].#2 tried to get him to drink some juice, he spit it back into the cup. The Doctor was called again and we were told to suction and he ordered another Neb treatment and HOB (head of bed' upright. Neb helped somewhat but started sounding again. We called the Doctor again but he would not send him out. Resident status did not change during the day. He complained eat and continued to complain of a rock in his throat. Doctor was called again and was sent to the hospital, returned about an hour later. They (hospital) [MEDICATION NAME] his throat, he continued to complain when he got back about the rock in his throat. By 6:30 pm staff came in saying 'They thought he swallowed his partial' they had been looking for it all day and had not located it. The Doctor was called again and left message. There were no changes we were still doing mild suctioning. SAT's (saturations) were between ,[DATE]. K. On [DATE] at 12:59 pm during an interview with Certified Nurse Aide (CNA) #7, she stated I was with (Name of R #83) when he went to the hospital, they triaged him (R#83) he was very loud and he was told he probably had an esophogial abrasion. They (hospital) gave him [MEDICATION NAME] he was then given pudding as a test. Hospital called Charge Nurse (CN) #1 and gave report and sent the resident back to the facility. He was given an EKG and that was normal. The Doctor did not put her hands on the resident. They did no exam that was noticible. L. On [DATE] at 12:30 pm during an interview with MD, he stated CMA #1 told me he was getting uncrushed medications for several days and he had done fine prior to that time [DATE]. One of the RN's called me that morning and told me of his condition that they were not given medications- no order that he could remember to crush. At that time it seems to me that it was optional. He wasn't having any problems swallowing pills I think there was something else going on. I tried to evaluate him but he wouldn't let me. I came in and saw him. He had coughed up some tablets and something thickened and pinkish. He was upright and coughing. He did an assessment and we couldn't get him to swallow. We sent him out he returned about 5:00 pm and was checked by the pharmacist and they decided to watch him. At the hospital they thought he was doing ok. I did get a call that informed me he was missing his lower dentures. It is a possibility that he may have swallowed his dentures. I would expect him to have an exam (at the hospital). The lower partial have never been found. It is not common (to swallow partials) but it can happen. The first place they (partials) could lodge is in the esophogas. I asked when the last time was that the dentures had been seen. I got no response. I helped look all over for the denutures and they were not located. M. On [DATE] at 4:25 pm during an interview via telephone with CNA #8, she stated that sometime between 8 am and 10 am (on [DATE]) she was told that R #83's dentures were missing. He (R#83) didn't want to get up he wasn't feeling good and he said he had something in his throat. We got him up and got him ready. We found the upperdentures. I notified the nurse. He wasn't able to ear or drink he could not swallow. He was yelling and hollering tht he felt something stuck in his throat. The upper dentures were in the sheets, we stripped the bed but we could not find the bottoms (bottom partial). Throughout the day the patient (R #83) complained of is throat hurting). N. On [DATE] at 11:16 pm during an interview with R #70, he stated. (Name of R #83) was yelling he was telling them that he choked on his dentures, but staff would ignore him. He yelled all day, I know he had problems, but staff would just not listen to him. I later heard that he had choked on his dentures and died . Findings for R #64 and #70 O. Record review of R #64's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 06 (range 00 (not measurable)-15 (alert and oriented)). P. Record review of R #64's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 12. Q. Record review of Incident Report # dated [DATE] revealed, (Name of R #64) is very sensitive to sound and always request that we speak very quietly to him. When (name of R #64) asked (Name of RW #1) to talk more quietly (Name of RW #1) responded, I can talk like this or I CAN TALK LIKE THIS! When he uttered this sentence, (Name of RW #1) raised his voice to an almost shouting level. I was shocked into tears. R #64 has repeatedly asked all of us to speak softly. It was ourtageous that (Name of RW #1) would act with such disregard to a very vulnerable resident. Conclusion: There is credible evidence to support the allegation of verbal abuse as reported. (Name of Recreation Worker (RW) #1) did not deny making the statement only stated, 'does not recall making the statement.' Discipline action will be pursued per State of New Mexico Personnel Rules. The Administrator (ADM) signed and agreed with the conclusion on [DATE]. R. Record review of Resident Incident Report # 2093 dated [DATE] revealed: (Name of RW #1) went into (Name of R #64's) room I (this writer- RW #3) proceeded to walk in there (into R #64's room) and (Name of R #64) asked me to 'Take him out of my room' after talking trying to figure out what happened (name of RW #1) started clapping and talking loud and (Name of R #64) stated that (Name of RW #1) knows that hes (sic) (RW #1) being loud. (Name of RW #1) proceeded to call him 'Sir' (Name of R #64) fell to bed upset. Incident report further stated All 3 staff female staff members in recreation expressed fear of retaliation (from RW #1). S. Record review of the Investigative Report dated [DATE] revealed It is known by staff that (Name of R #64) does not like to be called sir. T. On [DATE] at 10:23 am during an interview with R #64, he stated that he is very sensitive to loud noises, and asked if I (surveyor) could speak softly to him. In addition, R #64 stated that he did not like to be called sir. U. On [DATE] at 11:09 am during an interview with Certified Nursing Assistant (CNA) #6, she stated, He (R #64) is more alert than some people here (in locked unit), but he is very confused and has Dementia. If he (R #64) doesn't like something that is happening, he will voice that right away. R #64 can voice when he is upset by something. V. On [DATE] at 11:44 am during a phone interview with Activities Technician (AT) #1, she stated, (Name of R #64) cannot take loud noises and you cannot talk loudly to him. (Regarding the [DATE] incident) I was sitting next to (name of R #64) and (name of RW #1) was standing right above him (R #64) and shouted 'Am I (RW #1) talking too loud for you (name of R #64)?!' AT #1 confirmed RW #1 was speaking loudly towards R #64 on purpose to upset R #64. W. On [DATE] at 3:24 pm during a phone interview with RW #2, she stated, (Name of R #64) has Dementia and really bad [MEDICAL CONDITION] (Post-Traumatic Stress Disorder). (Regarding the incident on [DATE]) (Name of RW #1) went in there (R #64's room) clapping his hands and yelling. He (RW #1) does things intentionally. RW #2 confirmed RW #1 was clapping his hands and yelling at R #64's intentionally to upset R #64. X. On [DATE] at 3:38 pm during an interview with RW #3, she stated, He's (RW #1) very loud and very hard to work with. I went to the room (R #64's room) to make sure everything was ok. When I walked in, (name of RW #1) was being loud and (name of R #64) told me to get him (RW #1) out of his (R #64) room. (Name of RW #1) started clapping very loudly and (name of R #64) does not like loud noises. (Name of R #64) looked visibly upset. RW #3 confirmed that the interaction bewteen RW #1 and R #64 was not joking and R #64 was visibly upset with RW #1. Findings for R #70: Y. Record review of R #70's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 13. Z. On [DATE] at 4:58 pm during an interview with R #70, he stated, I know there has been other complaints agains

Based on record review and interview, the facility failed to thoroughly investigate allegations of abuse and prevent further potential abuse while the investigation was in progress for 2 (R # 64 and R #70) of 2 (R # 64 and 70) residents reviewed for abuse. If the facility is not conducting thorough abuse investigations and ensuring that staff identified in the allegation are removed from resident interaction, then residents are likely to continue to be at risk of abuse. The findings are: Findings for R #64: [NAME] Record review of R #64's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated 07/12/19 revealed a BIMS (Brief Interview for Mental Status) score of 06 (range 00 (not measurable)-15 (alert and oriented)). B. Record review of R #64's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated 10/11/19 revealed a BIMS (Brief Interview for Mental Status) score of 12. C. Record review of Incident Report # dated 7/22/19 revealed, (Name of R #64) is very sensitive to sound and always request that we speak very quietly to him. When (name of R #64) asked (Name of RW #1) to talk more quietly (Name of RW #1) responded, 'I can talk like this or I CAN TALK LIKE THIS!' When he uttered this sentence, (Name of RW #1) raised his voice to an almost shouting level. I was shocked into tears. (Name of R #64) has repeatedly asked all of us to speak softly. It was outrageous that (Name of RW #1) would act with such disregard to a very vulnerable resident Conclusion: There is credible evidence to support the allegation of verbal abuse as reported. (Name of Recreation Worker (RW) #1) did not deny making the statement only stated, 'does not recall making the statement.' Maybe reinforcement education to the personnel involved to talk quietly and calmly. Discipline action will be pursued per State of New Mexico Personnel Rules. The Administrator (ADM) signed and agreed with the conclusion on 07/30/19. No corrective measures or disciplinary actions towards RW #1 was identified following this incident. D. Record review of Resident Incident Report # 2093 dated 12/08/19 revealed: (Name of RW #1) went into (Name of R #64's) room I (this writer- RW #3) proceeded to walk in there (into R #64's room) and (Name of R #64) asked me to 'Take him (RW #1) out of my room' after talking trying to figure out what happened (name of RW #1) started clapping and talking loud and (Name of R #64) stated that (Name of RW #1) knows that hes (sic) (RW #1) being loud. (Name of RW #1) proceeded to call him 'Sir' (Name of R #64) fell to bed upset. Incident report further stated All 3 staff female staff members in recreation expressed fear of retaliation (from RW #1). E. Record review of the Investigative Report dated 12/13/19 revealed It is known by staff that (Name of R #64) does not like to be called sir. The conclusion indicates that there is no credible evidence to support an allegation of abuse of mistreatment due to (Name of RW #1) and {Name of R #64) denied the allegation. No corrective measures or disciplinary actions towards RW #1 was identified following this incident. F. On 12/18/19 at 10:23 am during an interview with R #64, he stated that he is very sensitive to loud noises, and asked if I (surveyor) could speak softly to him. In addition, R #64 stated that he did not like to be called sir. [NAME] On 12/18/19 at 11:09 am during an interview with Certified Nursing Assistant (CNA) #6, she stated, He (R #64) is more alert than some people here (in locked unit), but he is very confused and has Dementia. If he (R #64) doesn't like something that is happening, he will voice that right away. R #64 can voice when he is upset by something. H. On 12/18/19 at 11:44 am during a phone interview with Activities Technician (AT) #1, she stated, (Name of R #64) cannot take loud noises and you cannot talk loudly to him. (Regarding the 07/22/19 incident) I was sitting next to (name of R #64) and (name of RW #1) was standing right above him (R #64) and shouted 'Am I (RW #1) talking too loud for you (name of R #64)?!' AT #1 confirmed RW #1 was speaking loudly towards R #64 on purpose to upset R #64. I. On 12/18/19 at 3:24 pm during a phone interview with RW #2, she stated, (Name of R #64) has Dementia and really bad [MEDICAL CONDITION] (Post-Traumatic Stress Disorder). (Regarding the incident on 12/08/19) (Name of RW #1) went in there (R #64's room) clapping his hands and yelling. He (RW #1) does things intentionally. RW #2 confirmed RW #1 was clapping his hands and yelling at R #64's intentionally to upset R #64. [NAME] On 12/18/19 at 3:38 pm during an interview with RW #3, she stated, He's (RW #1) very loud and very hard to work with. I went to the room (R #64's room) to make sure everything was ok. When I walked in, (name of RW #1) was being loud and (name of R #64) told me to get him (RW #1) out of his (R #64) room. (Name of RW #1) started clapping very loudly and (name of R #64) does not like loud noises. (Name of R #64) looked visibly upset. RW #3 confirmed that the interaction between RW #1 and R #64 was not joking and R #64 was visibly upset with RW #1. K. On 12/18/19 at 3:02 pm during an interview with the Investigator (INV), when asked, how did you substantiate the 07/22/19 incident and not the 12/08/19 incident, she stated. I would ask him (R #64) a question (about the incident) and he would answer it, but then go back to (talking about) his military days. I felt at the time (incident on 07/22/19), he wasn't able to answer (questions for the investigation), but during this time (incident on 12/08/19) he was able to answer all of the questions (for the investigation). I side on behalf of the residents and not staff. (Name of R #64) denied it (verbal abuse on 12/08/19) and so I didn't feel it was necessary to interview others (staff and/ or residents about allegation of abuse). Just based on my interaction with him (R #64) that day (date of investigation after incident on 12/08/19), I felt like he (R #64) was answering appropriately. INV confirmed she believed R #64 has become more alert and orientated since the incident on 07/22/19. INV also confirmed she did not interview anybody else besides R #64 for the incident on 12/08/19. INV confirmed she is the investigator for the facility and did no further investigation on the 12/08/19 incident. Findings for R #70 L. Record review of R #70's MDS (Minimum Data Sheet) Section C- Cognitive Patterns dated 10/18/19 revealed a BIMS (Brief Interview for Mental Status) score of 13. M. On 12/17/19 at 4:58 pm during an interview with R #70, he stated, I know there has been other complaints against him (RW #1) and nothing has gotten done. He's (RW #1) smart with me and sassy with me. R #70 confirmed he has had problems with how he is treated by RW #1. R #70 has also confirmed that he has reported his complaints about RW #1 to the facility. N. On 12/18/19 at 11:48 am during a phone interview with AT #1, she stated, It (incident between R #70 and RW #1) happened a couple of weeks ago in (name of R #70) room, he (R #70) was in tears and it was awful. I assigned (name of RW #1) to get opinions from the residents about this newsletter (facility newsletter created by R #70). He (RW #1) came back and told us (AT #1 and R #70) that not all of the residents enjoyed it (newsletter) and they said it (newsletter) was just awful. AT #1 confirmed that R #70 was mistreated by RW #1. AT #1 also confirmed that RW #1 was briefly assigned to the kitchen for two weeks after the incident (12/08/19), but returned back to working in recreation. O. On 12/18/19 at 9:30 am during an interview with R #70, he stated, I stay away from him (RW #1) and I don't want to be near him he continues to say inappropriate things, he is just not very nice to me or to others (staff and other residents). If he (RW #1) comes in to a place that I am at or a activity that I am attending, for a long period of time, I feel uncomfortable. I get up and leave. R #70 confirmed he will leave activities when RW #1 attends because RW #1 makes R #70 feel uncomfortable. P. On 12/18/19 at 3:10 pm during an interview with Certified Nursing Assistant (CNA) #5, she stated, We (CNA #5 and R #70) were walking down the hall, we went into his (R #70's) room and he broke down crying. He (R #70) said that he was sitting on his walker reading the newspaper, (name of RW #1) walked by and told him '(Name of AT #1) is gone and you're (R #70) next.' I went to my supervisor and told the Assistant Director of Nursing (ADON). CNA #5 confirmed she filed an incident report against RW #1. CNA #5 also stated that during Christmas time last year a family member and her family came in and (Name of RW #1) brought a cart to pass out gifts down the hallway with them and myself, family member did not make it down the hallway and came back crying saying This place is insane. I followed her outside and asked her what was wrong and she stated (RW #1) told her that her gifts were not needed here. The family member later stated that she called (name of RW #1's supervisor) and the Administrator. Q. On 12/18/19 at 3:27 pm during a phone interview with RW #2, she stated, I'm going to be very honest, (name of RW #1) doesn't interact with the residents that much and when he does, it's not good interactions. He does things intentionally and every time he (RW #1) see's (name of R #70), he (RW #1) always has something smart to say to him (R #70). A lot of our activities do not get done because (name of RW #1) does not do his job. The residents he (RW #1) does have contact with, have a sour taste in their mouth because of (name of RW #1). RW #2 confirmed she has witnessed RW #1 be verbally abusive towards R #70. R. On 12/18/19 at 3:45 pm during an interview with RW #3, he stated, (Name of R #70) is French and (name of RW #1) said he (RW #1) was half French and that he (RW #1) was half smarter than him (R #70). I was doing Bingo on Saturday and (name of RW #1) was upsetting (name of R #70) and the other residents. I should have wrote that (Bingo incident) up, but I didn't. He's (RW #1) supposed to be (working) in the kitchen, but he'll (RW #1) just leave (the kitchen) and he's (RW #1) supposed to be under supervision. He (RW #1) was going to different residents and laughing at them. RW #3 confirmed he has seen RW #1 intentionally upset R #70 before. S. Record review of Incident Report # Investigation conducted by the Investigator (INV) dated 11/04/19 revealed, Determination of Fact and Findings: There is credible evidence to support allegations of abuse, mistreatment or mental anguish as reported by (name of R #70). Incident Report was signed by the Administrator (ADM) and she also wrote, (Name of RW #1) needs to attend the next annual training specially (sic) Incident Report: Stress Reduction Respect and Dignity and Dealing W (with) Residents. T. Record review of the Investigative Report dated 11/14/19 revealed Corrective: At that time report was received, (Name of RW #1) was removed and reassigned to a different department pending investigation. U. On 12/18/19 at 4:40 pm during an interview with the ADM, she stated, When I see that somebody has a concern and we start an investigation, I will take them (employee under investigation) out of the area they work in and place them in the kitchen because it's (kitchen) away from the residents. After I put (staff) in there (working in kitchen) and it (investigation) is substantiated, but there's no harm to the resident, I'll put (staff) back (working in recreation). If there is actual harm, then we put them on administrative leave and they are out of this building. Actual harm is when they (staff) intentionally hurt someone, they verbally hurt someone, and they exploited that resident. If they (staff) use foul language, that is harm. If I substantiate something, that just means it happened. ADM confirmed she does not believe RW #1 was causing actual harm to R #70, even after her own definition of actual harm was stated. The ADM also confirmed that RW #1 was moved to the kitchen only after the incident involving R #70 on 11/04/19. V. Record review of the Dignity and respect post test revealed that it was completed by RW #1 on 12/13/19. W. Record review of the Acknowledgement of Training sheet for Incident Management/Abuse Prevention/Stress Reduction training Program was signed by RW #1 on 12/18/19.

Based on record review, interview, and observation, the facility failed to provide quality of care when they: 1) failed to prevent erosions of the penis for 3 (R #2, R #3, and R #4) of 5 (R#1, R #2, R #3, R #4, and R #5) sampled for neglect, secondary to having a Foley catheter, 2) failed to use standard infection control practices when observed for Foley catheter (a flexible tube used to drain urine from the bladder) care for 3 (R#2, R #4, and R #5) of 3 (R#2, R #4, and R #5) residents sampled for Foley catheter care, and 3) failed to prevent UTIs (urinary tract infections) for 3 (R #2, R #3, and R #4) of 3 (R #2, R #3, and R #4) residents sampled for UTIs. These deficient practices resulted in erosions of the penis resulting in deformity of the penis, pain, and risk of infection, regarding the lack of hand hygiene in foley care which places residents at risk for infections, and UTIs (urinary tract infections) with bacterial infections [MEDICAL CONDITION]. The findings are: EROSIONS R#2 A. On 03/13/18 at 10:31 am, during an interview, RN #2 (Nurse Supervisor) stated He (R #2) has some pretty significant erosion (at the tip of his penis) from his catheter (a flexible tube used to drain the bladder) and we've been trying to keep it from getting worse by positioning the catheter where it doesn't put more pressure on it. When asked if she (RN #2) knew when R #2's erosion had started; she stated, I'm not sure when it started, I'd have to check in the chart. B. On 03/13/18 at 10:34 am, while observing catheter care for R #2, it was noted that he had an erosion on the glans (the rounded part forming the end of the penis) of his penis where his indwelling foley catheter was inserted. C. Record review of R #2's Nursing Admission Assessment, dated 06/12/17, revealed that R #2 did have a Foley catheter on admission, but no penile glans (rounded end of the penis) erosion was documented at that time. D. Record review of R #2's Physician 60 Day Progress Note, dated 07/27/17 at 1:34 pm, revealed that R #2 did not have penile glans erosion documented at that time. E. Record review of R #2's physician progress notes [REDACTED]. No tingling or burning sensation. Nursing reported abundant purulence (pus) (sic) discharge. Culture taken and empirical Bactrim (a medication used to treat bacterial infections) started. Foley repositioning ordered and topical A&D ointment (a medication used as moisturizer to prevent minor skin irritations) to sooth (sic) and protect as possible. F. Record Review of R #2's care plan, dated 06/16/17 and revised on 02/19/18 revealed, The resident has Indwelling Catheter (sic); Interventions/Tasks: Staff to monitor for erosion to penis secondary to foley catheter. Revision of care plan dated 02/19/18 revealed, Resident (R #2) has the potential for impairment to skin integrity r/t (related to) fragile skin, erosion of foley cather site. Care plan entry dated 06/16/17 and revised on 02/22/18, revealed, The resident (R #2) had Indwelling Catheter, At risk for penile erosion and pressure injury; Goal: The resident will be/remain free from catheter-related trauma through review date. Care plan was not revised nor were interventions reassessed according to effectiveness until 02/19/18, despite the development of R #2's penile erosion on 08/29/17. G. Record review of R #2's physician progress notes [REDACTED].#2's penile glans erosion was a current issue. No changes were made to the care plan until 02/19/18 and interventions were not re-evaluated according to effectiveness until that date. H. On 03/14/18 at 10:23 am, during an interview, the MDS coordinator confirmed that R #2's care plan and interventions for his penile erosion had not been revised until 02/19/18. R #3 (This resident did not return back to the factilty after his transfer on 12/30/18.) I. Record review of local hospital ED (Emergency Department) records dated 12/30/18 revealed: ED Diagnosis: [REDACTED]. Pt (patient) with WBC (white blood count-a type of cell that fights infection) 30K (30,000) (normal range is 4,500 to 11,000), source most likely an open urethral lesion with Foley cath (a type of flexible tube used to drain urine from the bladder). It seems that the bulb (the balloon used to keep the tube in the bladder) traveled into the urethra (The tube that leads from the bladder and transports urine outside the body), possible with one of his falls, and cause erosion of the urethral (sic) so now it is open and purulent. This is not a new injury by look of the wound tissue. J. Record review from a (second) local acute care hospital records, dated 12/31/17, revealed, R #3 was admitted and treated for [REDACTED]. K. On 3/13/17 at 1:10 pm, during an interview, the DON stated, We have had a few penile erosions (for R #2, R #3, & R #4). We are using the Stat Loks (a device used to keep the catheter from putting tension on the insertion site) now to try and secure our catheters better. The erosions should have been recorded on the skin assessments. L. On 03/15/18 at 1:40 pm, during an interview with RN#1, after he reviewed the TAR (treatment administration record) for R #3, RN #1 said that he had done Foley care on R #3 many times. He stated, I don't know when it (the erosion) started on his penis. It could have started in December, maybe earlier, it was pretty old. We would do a skin sheet (record of skin integrity), I don't know if I did one. I don't see any note on the skin sheets at all. I'm sure we would typically record about an erosion, but I don't see any note. M. Record review of the facility weekly skin condition report for R #3, dated 12/16/17 revealed: Skin tears of right elbow and left forearm, groin area (bilateral - both sides) and head of penis skin is red. Will monitor. N. Record review of the facility weekly skin condition report for R #3, dated 12/23/17 revealed: Resident has Foley cath (catheter) intact and stable at this time The report lists bruises on the left and right iliac crest (a portion of the pelvis) and left flank (back area below the ribs). There is no mention of penile wounds or erosion. R #4 O. Record review of a physician progress for R #4, dated 12/19/17 at 10:55 (10:55 am) revealed: (Name of R #4) has had a Foley for several months due to [MEDICAL CONDITION] (an obstruction impeding the flow of urine from the bladder). Several unsuccessful attempts have been made to d/c (discontinue) the Foley. Current he has a ventral (pertaining to the front) glans (the round end of the penis) erosion (where tissue has been gradually destroyed) (attempts to reposition catheter have not helped to heal), peri-foley (around the catheter) leakage and frequent need to change catheter due to obstruction every two weeks. I will refer to (Agency Name) GU (specialist in genital urinary medicine) for consideration of a SP (suprapubic-a type of catheter inserted through the abdomen to drain the bladder). P. Record review of the care plan for R #4 dated 07/15/17 revealed: Focus: .has indwelling catheter r/t (related to) [MEDICAL CONDITION] (unable to urinate) Goal: .will remain free from catheter related trauma, revised 7/15/17 Intervention: Check tubing for kinks. Monitor for s/sx (signs/symptoms) due to discomfort due to catheter. Dated 07/15/17 Staff to monitor for erosion to penis with weekly skin assessments secondary to Foley catheter. Dated 02/19/18 (resident had penile erosion documented 12/19/17) There are no interventions to secure the catheter noted on the interventions to prevent tension on the meatus (opening of the penis). Q. Penile erosion, Journal of Wound Ostomy and Continence Nursing 2011 Sep-Oct;38(5):581-3. doi: 10.1097/WON.0b013e b3280. Urethral erosion: a case for prevention. Cipa-Tatum J1, Kelly-Signs M, Afsari K.PMID: 017 DOI: 10.1097/WON.0b013e b3280 Adverse outcomes of long-term urethral catheterization include urethral (the duct by which urine is conveyed out of the body from the bladder) erosion, ventral (the underside)penile erosion, meatal (opening to the urethra) erosion, and device-related necrosis (death of all or most of the cells) of adjacent tissues. Existing research suggests that negative outcomes associated with urethral and meatal erosions can be prevented by properly securing the indwelling catheter. Though this is one of the easiest and most effective practices, we found a low level of compliance with this preventive measure. Foley Care (R #3 had been transferred and was not available for observation of Foley catheter care.) R #2 R. On 03/13/18 at 10:34 am, while observing catheter care, RN #2 did not perform hand hygiene prior to putting on her gloves and touching R #2. She cleaned his catheter, took off her gloves, reached into her scrub pockets and pulled out a handful of gloves, and put them on top of R #2's bedside table and personal items. She did not perform hand hygiene before putting on a pair of the gloves she had placed on the bedside table before returning to clean R #2 and his catheter tubing. She then removed R #2's stat lock (a device used to hold catheter tubing in place to prevent tension) from his leg with alcohol wipes that she had taken out of the wrapper. She dropped the alcohol wipe wrappers on the floor, reached down to pick them up, and did not change her gloves and perform hand hygiene before touching R #2. S. On 03/13/18 at 11:01 am, during an interview, RN #2 confirmed that this is how she would normally perform catheter care. When asked if it is her normal practice to carry rubber gloves in her scrub top pocket and use them for catheter care, she stated Well I don't put anything that is dirty in my pockets and sometimes I do keep gloves in them for when I need them. She confirmed that she should have changed her gloves and performed hand hygiene after picking up the alcohol wrappers off of the floor and before touching R #2. R #4 T. On 03/13/18 at 1:49 pm, while observing catheter care, CNA #1 touched the sit to stand lift, R #4's wheelchair, and his clothing and outer surface of his disposable briefs with her gloves on and did not perform hand hygiene and/or change her gloves before touching R #4. After catheter care was completed she removed her gloves and did not perform hand hygiene. U. On 03/13/18 at 1:56 pm, during an interview, CNA #1 confirmed that this is how she would normally perform catheter care. She confirmed that she should have changed her gloves and performed hand hygiene after touching the sit to stand lift, R #4's wheelchair, and his clothing prior to touching R #4. R #5 V. On 03/13/18 at 3:45 pm, while observing catheter care, R #5's catheter bag and tubing were noted to be laying on the floor. RN #1 did not perform hand hygiene prior to putting on his gloves and touching R #5. RN #1 touched the trash bags that were laying on the floor next to R #5's bed, dropped his pen on the floor, picked it up with his gloves on and did not change his gloves and perform hand hygiene prior to touching R #5. RN #1 changed his gloves after cleaning catheter tubing, but did not perform hand hygiene before putting on a clean pair of gloves. RN #1 touched R #5's bedside table with gloves on, but did not change his gloves and perform hand hygiene before touching R #5. W. On 03/14/18 at 3:20 pm, during an interview, the DON confirmed that hand hygiene should have been performed before and after catheter care for R #2, R #4, and R #5. She confirmed that gloves should have been changed when going from a dirty surface to a clean surface while performing catheter care on R #2, R #4, and R#5, and that picking up items off the floor without changing gloves and performing hand hygiene was not correct procedure for catheter care. She also stated, I'm not sure about performing hand hygiene in between when they take their gloves off and put on a new pair of gloves, I will have to look that up. X. Record review of the facility's Employee Health DOM Handwashing Procedure Statement, dated 07/01/99, revised on 03/11/10, and reviewed on 07/11/17, revealed: It is imperative that hands be washed: . D. After removing gloves or other personal protective equipment. The Handwashing Procedure Statement also stated, The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. UTIs R #2 Y. Record review of R #2's Nursing progress notes dated 01/31/18 at 2:02 pm, revealed; New orders noted to give [MEDICATION NAME] (a medication used to treat infections caused by bacteria) one gram IM (intramuscular) 1% lido ([MEDICATION NAME], used at the injection site to reduce pain intensity) x 5 days Dx (diagnosis) UTI. Change Foley cath (a flexible tube inserted into the bladder for continuous urine drainage) (sic) today. Z. Record review of R #2's Physician 60 Day progress notes dated 02/1/18 at 2:54 pm, revealed; (Name of R #2) is being managed for UTI, diagnosed yesterday with some systemic manifestation, but today he seems to be improving, without fever and eating/drinking fluids well. Will follow labs tomorrow. AA. Record review of R #2's Infection Followup dated 02/01/18 at 5:47 pm, revealed; Infection date of onset 1/31/2018; functional decline/garbled speech; GI (gastrointestinal) tenderness; UTI symptoms: odor to urine, positive [MEDICATION NAME] (a finding that commonly means there are bacteria in the urine) on UA (urinalysis) and sediment in urine (microscopic gritty particles common in UTI's). BB. Record review of R #2's care plan dated 06/26/17 revealed two previous UTI's diagnosed on [DATE] and 12/04/17 were implemented in the care plan with interventions; however, no documentation was available to indicate that R #2's UTI diagnosed on [DATE] had been revised in the care plan and no interventions were documented. CC. On 03/15/18 at 10:45 am, during an interview, the DON she stated, His (R #2) temporary care plans were in the chart for his other UTI's, but I can't find anything for the one in (MONTH) (2018). R #3 DD. Record review of local hospital ED (Emergency Department) records for R #3 dated 12/30/18 revealed: 1. ED Diagnosis: [REDACTED]. Pt (patient) with WBC (white blood count-a type of cell that fights infection) 30K (30,000) (normal range is 4,500 to 11,000), source most likely an open urethral lesion with Foley cath (a type of flexible tube used to drain urine from the bladder). It seems that the bulb (the balloon used to keep the tube in the bladder) traveled into the urethra (The tube that leads from the bladder and transports and discharges urine outside the body), possible with one of his falls, and cause erosion of the urethral (sic) so now it is open and purulent (pus) . This is not a new injury by look of the wound tissue. 2. Record review from a local acute care hospital {second hospital} records, dated 12/31/17, revealed, R #3 was admitted and treated for [REDACTED]. R #4 EE. Record review of the urine culture and sensitivity (a laboratory test to determine what organisms are growing and which antibiotics are best for treatment) dated 01/05/18 revealed: greater than 100,000 cfu (colony forming units)/ml (per milliliter-a metric unit of volume) Proteus mirabilis (a multi-drug resistant organism). FF. Record review of physicians order for R #4, dated 02/05/18 revealed: UTI, start [MEDICATION NAME] (an antibiotic) 200 mg (milligram-a metric unit of measure) IM daily x 5 days. GG. Record review of a physician's orders [REDACTED]. HH. Record review of a physician's orders [REDACTED]. II. Record review of a physician's orders [REDACTED]. JJ. On 03/14/18 at 3:30 pm, during an interview, the DON confirmed that poor catheter care could have contributed to the UTIs that R #2, R #3, & R #4 were treated for [REDACTED].>

Based on record review and interview, the facility failed to assess for signs and symptoms of UTI (an infection that affects part of the urinary tract) for 1 (R #1) of 1 (R #1) sampled residents for UTIs. This failed practice led to an UTI with [MEDICAL CONDITION] and pneumonia. The findings are: A. On 03/13/18 at 2:25 pm, during an interview, RN #1 was asked if he assessed R #1 for a UTI. He stated that R #1's daughter reported concerns about her father's urine looking thick and cloudy on 01/20/18. RN #1 stated that he not assess R #1 prior to the daughter voicing her concerns. RN #1 then did a Urinalysis (dipstick) on R #1 on 01/20/18 which was positive for a UTI. When asked RN #1 who routinely performs/monitors Foley care for residents, he replied, Nurses do. B. Record review of physician's orders [REDACTED]. C. Record review of R #1 progress notes for dates 10/24/17 to 01/21/18 did not have documentation of his refusal for fluid intake or decline in urine output. D. Record review of (Name of Facility) Follow Up Question Report 01/01/18 to 01/31/18 for R #1's Urine Output revealed documentation of Not Applicable for urine output: 01/01/18, 01/02/18, 01/04/18, 01/05/18, 01/06/18, 01/07/18, 01/11/18, 01/12/18, 01/13/18, 01/18/18, 01/19/18, and 01/20/18. E. On 03/14/18 at 4:00 pm, during an interview, the DON confirmed that R #1 change in urine output was not reported nor documented. She further stated that this should have indicated to the nurses to do an assessment. F. On 03/15/18 at 2:57 pm, during an interview, the Physician reported that he was called on 01/21/18 at 3:40 pm regarding an aggravation to R #1's condition. He instructed the RN #1 to send R #1 to the hospital for [MEDICAL CONDITION]. (The resident did not return back to the facility.) G. Record review of R #1's Discharge summary from the local (first) hospital dated 01/21/18 revealed that R #1's inpatient [DIAGNOSES REDACTED]. to produce or respond to the hormone insulin is impaired),[MEDICAL CONDITION] (presence in tissues of harmful bacteria and their toxins, typically through infection), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), melena (dark sticky feces containing partly digested blood), acute urinary tract infection (a sudden inflammation of the bladder), and [MEDICAL CONDITION] ([MEDICAL CONDITION] does not make enough [MEDICAL CONDITION] hormone). H. Record review of R #1's Discharge summary from a local (second) acute care hospital dated 01/26/018 revealed Admitting [DIAGNOSES REDACTED]. R #1 also had a discharge [DIAGNOSES REDACTED].

Based on interview, observation, and record review, the facility failed to keep residents free from neglect for 2 (R #1 and R #3) of 2 (R #1 and R #3) residents when they: 1) failed to follow doctor's orders when they did not do a laboratory test to determine if the resident had harmful organisms in his sputum (fluid/mucus coughed up from the respiratory tract) C & S (culture and sensitivity - a laboratory test to determine what organisms are growing and which antibiotics will be effective to treat) for R #3, 2) failed to follow doctor's orders to do orthostatic vital signs (checking blood pressure and pulse while sitting, laying and standing to determine if the blood pressure lowers when standing which can lead to dizziness) for R #3, 3) failed to consistently provide interventions for a resident who fell 4 times in a month (resulting in a [MEDICAL CONDITION] and acetabulum (hip socket), and with another fall the open dislocation of a finger) for R #3, 4) failed to update care plan to address resident's reluctance to accept help and to address every fall for R#3, 5) failed to assess and/or failed to document an assessment for R #3 who became dizzy and had decreased oxygen in blood, 6) failed to document and intervene for an erosion (gradual destruction of tissue) of the penis that was acquired in the facility for 1 (R #3) of 1 (R #3) who was surveyed for a complaint of neglect , and 7) failed to assess for signs and symptoms of UTI (urinary tract infection) and pneumonia for R #1. These deficient practices resulted in the facility failing to provide assessments and interventions to avoid physical harm which led R #3 to [MEDICAL CONDITION] (the presence of harmful bacteria and their toxins) and further tested positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-a drug resistant bacteria) in the blood and urine and penile injury. Further, R #1 also [MEDICAL CONDITION]. The findings are: A. Record review of the medical record for R #3 revealed: admitted to the facility on [DATE]. Diagnoses: [REDACTED]. hypertension (high blood pressure), artheroscoerotic [MEDICAL CONDITION] of native coronary artery without [MEDICAL CONDITION] pectoris (hardening of the arteries that supply the heart with blood) without the chest pain, legally blind. B. Record review of the physician's progress note for R #3, dated 09/15/17 revealed the physician had discussed discontinuation of the Foley catheter (a type of flexible tube used to drain urine from the bladder) after the resident had been on [MEDICATION NAME]/[MEDICATION NAME] (medication used to treat an enlarged prostate gland that can impede urine flow), but R #3 declined to have it removed. TIME LINE for R #3 12/01/17 C. Record review of the incident note for R #3, dated 12/01/17 at 10:20 (10:20 am), revealed: Housekeeper reported he found (Name of resident) on the floor. Rsd (resident) assisted to sit back on his bed. Assessment done: no apparent harm/injury noted. D. Record review of the fall assessment for R #3, dated 12/01/17, revealed: 4. Resident's account of the Fall: He says he was trying to put on his pull up (disposable brief). Identify Immediate Cause(s): 4. What resident factors contributed on the fall: Rsd (resident) was looking of (sic) his footwear--he was sitting in the bed and bend (sic) over and lost his balance. (This shows a discrepancy between resident's statement as stated on the form and staff conclusion of cause as stated on the same form.) 12/07/17 E. Record review of the physician orders [REDACTED]. F. Record review of the MAR (Medication Administration Record) for (MONTH) (YEAR) shows the medication was added for use on an as needed basis but there are no entries that would indicate the medication was ever given. 12/14/17 G. Record review of the incident note for R #3, dated 12/14/17 at 18:25 (6:25 pm), revealed: Rsd (resident) states, 'my walker turned sideways and I fell .' fof (found on floor) sitting position, moving arms and legs easily but unable to bear weight to right leg. Assisted up to sitting walker (sic). Doctor notified and sent to ER (sic) (emergency room ) for evaluation. To ER at approx. (sic) (approximately) 1815 (6:15 pm). H. Record review of the facility health status note for R #3, dated 12/15/17 at 01:50 (1:50 am) revealed, Nurse from ER called at 0020 (12:20 am) that resident (R #3) has [DIAGNOSES REDACTED]. I. Record review from the discharge summary 12/14/17 from the local hospital Emergency Department for R #3 revealed: [MEDICAL CONDITION] (the large bony structure at the base of the spine to which the legs are attached), and [MEDICAL CONDITION] (the socket of the hip bone). J. Record review of the physician 60 day progress noted for R #3, dated 12/15/17 at 09:22 (9:22 am), revealed: Yesterday evening, 12/14/17, he (R #3) had a fall and found to have pelvic fracture between the right acetabulum and superior pubic ramus (part of the pelvis) at (Name of local hospital) ER, he has pain, but is otherwise OK. Plan: early mobilization (get the resident up and moving), no weight bearing (supporting the body weight on the lower extremities) until see by ortho (bone doctor), pain control as possible (he declines narcotics). Vital signs BP 127/77, (normal range is 120/80 to 90/60), pulse 98 (normal is 60 to 100 beats per minute), Respirations 25/min (per minute) (normal rate is 12 to 18 per minute), Temperature 99.4 (temporal artery-refers to site/method that temperature was taken) (normal range is 97.8°F (Fahrenheit-a scale of temperature) to 99.1°F /average 98.6°F), oxygen saturation 94.0% (normal oxygen saturation is 95 to 100%), pain scale 0 (scale where 0 is no pain and 10 is the worst imaginable) (resident denied having any pain when asked). 12/15/17 K. Record review of physician's orders [REDACTED]. L. Record review of R #3's clinical record revealed no documentation of a cough or any other reason for the lab order. M. On 03/14/17 at 5:00 pm, during an interview, the DON was asked what the results were from a C & S ordered on [DATE], she stated, 'We did not find results of the C & S that was ordered on [DATE]. They (staff) must not have ever gotten it (collected). I don't know why it was ordered, or why the cough medicine ([MEDICATION NAME]) (see order from 12/05/17) was ordered. The sputum C & S are usually ordered if the resident has an on going cough, I don't see it documented. N. Record review of the therapy evaluation for R #3, dated 12/15/17, revealed: (Name of orthopedic physician) ordered NWB (no weight bearing) on RLE (right lower extremity) and no surgical intervention at this time. Requires maximum assist to get in and out of bed, toileting and transfers. Goal: To progress from NWB (non weight bearing) to WBAT (weight bearing as tolerated) to FWB (full weight bearing) on his RLE (right lower extremity). O. Record review of the vital signs record for R #3, on 12/15/17, revealed: 1. On 12/15/17: at (YEAR) (8:15 pm) oxygen saturation 92%, Temperature 98.9 temporal, at 2050(8:50 pm) BP - 102/62, pulse 98/min at 0104 (1:04 am) Temp 99.4 temporal 12/22/17 P. Record review revealed a physician's orders [REDACTED].#3 for orthostatic vital signs (checking blood pressure and pulse while sitting, laying and standing to determine if the blood pressure lowers when standing which can lead to dizziness) x 2 (for 2 days). Q. Record review of R #3 MAR (medication administration record) for (MONTH) (YEAR) revealed: Orthostatic B/P (blood pressure) x 2 days, 12/22/17. The days 12/22/17 and 12/23/17 are marked to indicate these are the dates to enter the data, but the dates are blank. R. On 03/13/18 at 4:32 pm, during an interview with the DON after she saw the order for R #3 dated 12/22/17, she stated, I see the order for the orthostatic vital signs. The secretary saw it (the order) because it was put on the TAR (Treatment Administration Record), but I don't see a nurse actually noted the order (indicating that the nurse saw the order and signed the order in acknowledgement). We missed it. 12/24/18 (date on facility incident top right is 12/24/18, all other dates on the form and electronic record of incidnet show date of 12/25/18 S. Record review of the facility incident note for 12/24/18 for R #3 at 20:29 (8:29 pm) revealed: CNA (CNA #6) called me to resident's room where he was sitting on the floor. CNA (CNA #6) and resident confirmed that after his shower, the CNA (CNA #6) was assisting resident in transferring from the shower chair to his wheelchair when the resident lost his balance and the CNA (CNA #6) assisted him to the floor. He has no new bruises or skin issues and no c/o pain. T. Record review of the facility fall report for R #3, dated 12/25/17 for a fall on 12/24/17 revealed: 2. Describe exactly what happened, I (CNA #6) was assisting (Name of R #3) to transfer him to his wheelchair after shower about 19:30 (7:30 pm). He was up and grabbed the safety bar and I had him on the right side then he started going down to the floor. I just could go down to the floor. I just could go just go down with him and had him on legs (sic) to the floor. 12/27/17 U. Record review of the progress notes for R #3 dated 12/27/17 at 15:27 (3:27 pm), written by a PTA (Physical Therapy Assistant), revealed R #3 was complaining he was dizzy and found to have an oxygen saturation (shows the amount of oxygen in the blood) of 80% (normal oxygen saturation is 95 to 100%). The progress notes stated, (Name of RN #1) said he would write an order. V. On 03/15/19 at 1:40 pm, during an interview with RN #1 regarding the 12/27/17 progress note identifying the resident as dizzy with an oxygen saturation of 80%, he stated, I don't know if he (R #3) was assessed (if a nurse examined the resident, spoke with the resident, listened to the resident's lungs, etc.) for that (episode). I do not recall. That progress note says I will write the order for oxygen. I don't recall that. Typically we can write an order for [REDACTED]. W. Record review of R #3 vital signs record: oxygen saturation revealed oxygen saturation was checked on 02/27/17 at 21:38 (9:38 pm) and was 96% (6 hours after the resident was discovered to have an 80% oxygen saturation). X. Record review of 12/28/17 at 01:21 (1:21 am) order note revealed: O2 (oxygen) at 2L (Litre-a metric unit of measure)/min (per minute) via nasal cannula (tube that delivers oxygen to the nose) PRN (as needed) for dypsnea (difficulty breathing). Vital signs x (for) 2 days. Y. On 03/14/17 at 4:00 pm, during an interview, the DON was asked if she expected staff to have assessed R #3 after being told he was dizzy and his oxygen saturation was 80%. She said would would have expected a full assessment at that time and that staff would continue to monitor the resident. The DON said, I am not seeing any assessment. I don't know if the physician was notified; I did not find any physician note about this as a follow up. The DON confirmed that the interval between the first oxygen saturation (80% at 3:27 pm) and the next one recorded (96% done at 9:38 pm) was unacceptably long to wait to see if the resident's oxygen was returning to normal. Z. On 03/15/18 at 4:30 pm, during an interview with LPN #1 regarding R #3 having a low oxygen level and experiencing dizziness on 12/17/18; LPN #1 stated, I don't recall anything about that. I did work nights that night, but I just don't recall. If I was doing a 24 hour audit on the chart, I might have entered the order if oxygen was given and we had no order written, or if the doctor said, but if the doctor said (to give the oxygen) I would have written 'noted by' and then my name. I don't recall if he had symptoms or if he was assessed. 12/30/17 AA. Progress note 12/30/17 revealed: Rsd. (resident) fof (found on floor). Lying on left side .Left 4th and 5th digits appear fx (fracture) complaining of pain to right hip area. Clinician notified and Rsd. sent to (Name of local hospital). (R #3 did not return to this facility after this transfer.) BB. Record review of vital signs for R #3 on 12/30/17 at 12:47 pm revealed: 1. Temp 98.8 Auxiliary (an auxiliary temp is 2 degrees lower than an oral (by mouth) temperature and 2 degrees would be added to give an oral equivalent=100.8 F). 2. Blood Pressure 121/80, heart rate 82/min, respiratory rate was 26 breaths/minute CC. Record review of local hospital ED (Emergency Department) {first hospital} records for R #3 dated 12/30/18 revealed: 1. ED Diagnosis: [REDACTED]. 2. Pt (patient) with WBC (white blood count-a type of cell that fights infection) 30K (30,000 - normal range is 4,500 to 11,000), source most likely an open urethral lesion with foley cath (a type of flexible tube used to drain urine from the bladder). It seems that the bulb (the balloon used to keep the tube in the bladder) traveled into the urethra (The tube that leads from the bladder and transports and discharges urine outside the body), possible with one of his falls, and cause erosion of the urethral (sic) so now it is open and purulent (pus). This is not a new injury by look of the wound tissue. DD. Record review from the a local acute care hospital records {the first hospital sent R #3 to a second hospital}, dated 12/31/17, revealed, R #3 was admitted and treated for [REDACTED]. Care Planning for R #3 EE. Record review of the facility form Nursing Technician Care Plan (for the CNAs) dated 06/13/17 revealed: Potential for falls, requires assist for transfers. There is an undated, handwritten note in red that says 2 person assist. There is a note under special instructions dated 06/14/17 that says: needs one person assist for transfers. FF. Record review of the facility care plan dated 06/30/17 revealed: 1. Focus: High risk for falls r/t (related to) gait/balance problems, vision/hearing problems. There are handwritten entries noting falls on 07/18/17, 11/15/17, 12/01/17, 12/15/17, 12/24/17, and 12/30/17. Interventions: a. Anticipate resident's needs (initiated 06/30/17), b. Facilitate the resident's autonomy an decisions making: adapt plan as needed (initiated on 06/30/17), c. Reminder for resident to use call bell (initiated on 06/30/17), the same intervention was repeated on 07/20/17, repeated again on 11/05/17, and entered a fourth time (undated, hand written entry), d. PT (Physical Therapy) for early mobilization, dated 12/15/17 2. Focus: (Name of R #3) has a desire to maintain his independence as much as possible and may refuse assistance from staff. Date Initiated 06/30/17 and revised 12/30/17 Goal: will accept physical limitations as evidenced by requesting staff assistance with difficult maneuvers. Will cooperate with care Revised 12/30/17 Interventions: Allow resident to make decisions about treatment, provide sense of control. Document refusal of treatment .Staff to encourage (Name of R #3) to ask for assistance when he feels he is not able to do something on is own. Initiated 07/21/17 (There have been no additions to, or modifications noted on any interventions and tasks for refusing assistance since 07/21/17.) GG. On 03/13/17 at 1:10 pm, during an interview with the DON, when asked if the care plan for R #3 reflected appropriate and timely interventions, she responded, No the care plans do not. She further stated the interventions should have been reviwed and revised before the last fall. Penile Erosion (where tissue has been gradually destroyed) HH. On 03/13/17 at 1:10 pm, during an interview, the DON stated, We have had a few penile erosions. We are using the Stat Loks (a device used to hold catheter tubing in place to prevent tension) now to try and secure (prevent movement and tension) our catheters better. The erosions should have been recorded on the skin assessments (skin conditioning report). II. On 03/15/18 at 1:40 pm, during an interview with RN#1, after he reviewed the TAR (treatment administration record) for R #3, RN #1 said that he had done Foley care on R #3 many times. He stated, I don't know when it (the erosion) started on his penis. It could have started in December, maybe earlier, it was pretty old. We would do a skin sheet (record of skin integrity), I don't know if I did one. I don't see any note on the skin sheets at all. I'm sure we would typically record about an erosion, but I don't see any note. JJ. Record review of the facility weekly skin condition report for R #3, dated 12/16/17 revealed: Skin tears of right elbow and left forearm, groin area (bilateral (both sides) and head of penis skin is red. Will monitor. There is no mention of penile wounds or erosion. KK. Record review of the facility weekly skin condition report for R #3, dated 12/23/17 revealed: Resident has Foley cath (catheter) intact and stable at this time The report lists bruises on the left and right iliac crest (a portion of the pelvis) and left flank (back area below the ribs). There is no mention of penile wounds or erosion. LL. Review of resources: JJ. Penile erosion, Journal of Wound Ostomy and Continence Nursing 2011 Sep-Oct;38(5):581-3. doi: 10.1097/WON.0b013e b3280. Urethral erosion: a case for prevention. Cipa-Tatum J1, Kelly-Signs M, Afsari K.PMID: 017 DOI: 10.1097/WON.0b013e b3280 Adverse outcomes of long-term urethral catheterization include urethral erosion, ventral (the underside) penile erosion, meatal (opening to the urethra) erosion, and device-related necrosis (death of all or most of the cells) of adjacent tissues. Existing research suggests that negative outcomes associated with urethral and meatal (opening to the urethra) erosions can be prevented by properly securing the indwelling catheter. Though this is one of the easiest and most effective practices, we found a low level of compliance with this preventive measure. R #1 MM. On 03/13/18 at 2:25 pm, during an interview, RN #1 was asked if he assessed R #1 for a UTI. He stated that R #1's daughter reported concerns about her father's urine looking thick and cloudy on 01/20/18. RN #1 stated that he not assess R #1 prior to the daughter voicing her concerns. RN #1 then did a Urinalysis (dipstick) on R #1 on 01/20/18 which was positive for a UTI. When asked RN #1 who routinely performs/monitors Foley care for residents, he replied, Nurses do. NN. Record review of (Name of Facility) Follow Up Question Report 01/01/18 to 01/31/18 for R #1's Urine Output revealed documentation of Not Applicable for urine output: 01/01/18, 01/02/18, 01/04/18, 01/05/18, 01/06/18, 01/07/18, 01/11/18, 01/12/18, 01/13/18, 01/18/18, 01/19/18, and 01/20/18. OO. On 03/14/18 at 10:10 am, during an interview, RN #3 stated that R #1 refused fluid intake on occasions and may become combative during his time at the facilty. PP. On 03/14/18 at 10:20 am, during an interview, CNA #3 stated that R #1's demeanor had declined (different) and urine was thicker with a change in color over the past month. QQ. Record review of R #1 progress notes dated from 10/24/17 to 01/21/18 revealed no documentation of R #1's refusal for fluid intake or urine output. RR. Record review of physician's orders [REDACTED]. SS. On 03/14/18 at 4:00 pm, during interview with DON, it was confirmed that R #1 change in urine output was not reported or documented. TT. On 03/15/18 at 2:57 pm, during an interview, the Physician reported that he was called on 01/21/18 at 3:40 pm regarding an aggravation to R #1's condition. He instructed the RN #1 to send R #1 to the hospital for [MEDICAL CONDITION]. UU. Record review of R #1's Discharge summary from a local hospital dated 01/21/18 revealed that R #1's inpatient [DIAGNOSES REDACTED]. to produce or respond to the hormone insulin is impaired),[MEDICAL CONDITION] (presence in tissues of harmful bacteria and their toxins, typically through infection), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), melena (dark sticky feces containing partly digested blood), acute urinary tract infection (a sudden inflammation of the bladder), and [MEDICAL CONDITION] ([MEDICAL CONDITION] does not make enough [MEDICAL CONDITION] hormone). VV. Record review of R #1's Discharge summary from a local acute care hospital dated 01/26/018 revealed Admitting [DIAGNOSES REDACTED]. R #1 also had a discharge [DIAGNOSES REDACTED]. Discharge Diagnosis: [REDACTED]. [MEDICAL CONDITION], resolved community-aquired pneumonia, UTI, [MEDICAL CONDITION] (A high blood sugar) with DKA (Diabetic ketoacidosis occurs when the body cannot produce enough insulin for glucose (blood sugar) to use for fuel), and acute kidney injury on [MEDICAL CONDITION].

Based on record review and interview, the following was discovered: 1. R #2 was found twice today (05/16/16) outside the facility - was placed on 15 minute checks. On 06/11/16 at 7:00 pm, R #2 was found by staff lying on ground in front of building on (name of R #2's) back, upper body on gravel and lower body on sidewalk, right leg bent at knee. Staff stabilizing head/neck. Denies striking head and no obvious signs of head injury. Wheelchair (w/c) upright, but left wheels in gravel. Rsd (resident) alert with clear speech and reports trying to get w/c out of the gravel and fell from the chair. 1925 (7:25 pm), rsd placed on stretcher and left facility grounds via ambulance. R #2 had a fracture of the right femoral neck (a flattened pyramidal process of bone, connecting the femoral head with the femoral shaft, and forming with the latter a wide angle opening medialward). from the incident and was transferred from the Critical Care Hospital to an Acute Care Hospital. 2. Review of R #2's Care plan dated revealed, (Name of R #2) is a wanderer related to curiosity. Rsd wanders aimlessly in w/c, has demonstrated impaired safety awareness by following a visitor outside that had a dog. Goal: Rsd will not leave facility unattended through the review date - date initiated 05/17/16 through 09/03/16. Interventions include, Wander alert: placed on the back of w/c, starting 05/17/16. Monitor location every 15 minutes when exhibiting wandering behavior. Document wandering behavior . 3. Review of R #2's clinical record revealed no documentation of 15 minutes check between 05/16/16 and her fall on 06/11/16. 4. The facility's investigation indicated that the person assigned to monitor R #2 every 15 minutes was On unit. Further review of the investigation revealed, Could we get wander alerts onto main facility doors? was hand written on the facility's Post Fall Team Huddle Report. 5. Review of Progress Notes for R #3 revealed a note dated 07/13/16 at 12:46 pm: Health Status Note: (Name of R #3) continues to try to elope facility. (Name of R #3) cannot comprehend his limitation and was found standing up in parking lot with O2 tubing (soft 1 cm tubing for delivery of oxygen to the nostrils) wrapped around him. A Note dated 07/14/16 at 9:43 am: Incident Note, late entry for 07/13/16 at 1245, (name of R #3) wandered outside x 3 today that we are aware of, last time being between facility and construction zone wrapped in tubing, standing beside w/c. 6. Review of Progress Notes for R #5 revealed on 08/09/16 the resident was found, down exit driveway towards main road going over the last speed bump in his w/c . Further review of the progress notes revealed on 09/28/16, R #5 was found outside in the parking lot on the west side of the building. Review of R #5's Nursing Technician Care Plan revealed, 06/22/16 - Wanderguard to w/c. 7. Interviews revealed the following: On 10/13/16 at 11:30 am, during an interview, kitchen staff (KS) stated, The Wander Guards do not go off at the door; they go off at the main exits. KS revealed there are power boxes at the speed bumps near the main road entrance to the building and if a rsd goes past that point, an alarm will sound inside. On 10/13/16 at 11:45 am, during an interview, CNA #1 stated, (Name of R #2) has a Wanderguard on (name of R #2) wheel chair. If (name of R #2) makes it outside, an alarm will go off. CNA #1 revealed that there are no alarms on the doors of the facility but boundaries outside that residents with wheel chairs can not cross without alarm going off. On 10/13/16 at 11:50 am, during an interview with Ward Clerk (WC), when asked how the Wander Guards work, WC stated, They (Wanderguards) are placed on the rsd's wheelchair or walker and there is a big box outside, there is a boundary, if the rsd crosses it, their number will show up on that (pointing to the marque on the ceiling). On 10/13/16 at 2:35 pm, during an interview with Administrator, when asked when a rsd has on a Wanderguard and exits the building, when do the alarms go off, the Administrator stated, Rsd has to actually walk past the barrier. Administrator had a map and pointed to the barriers located between two poles near the speed bumps on the driveway to the facility. This resulted in Immediate Jeopardy being called on 10/13/16 at 4:00 pm. The Administrator and DON were notified at this time. A Plan of Removal was received and approved on 10/14/16 at 1:00 pm, but not lifted. After the plan was noted to be implemented on 10/17/16 at 2:40 pm, the IJ was lifted. The scope and severity was decreased from a Level 4, K, to a Level 3 G. The Plan of Removal included: 1. Secure Units and Anti-Elopement Bracelet policy and procedure developed on 10/13/2016. 2. All Veterans/members identified as wandering risks were assessed utilizing the Risk Assessment Elopement Decision Tree with the clinical input of the primary care providers, social workers, nursing, and administrative staff. 10/13/2016 at 1930 (7:30 pm). 3. Of Fifteen identified Veteran's/Members, The Risk Assessment Elopement Tree identified five who did not need secure unit or anti-elopement bracelet. 10/13/2016 at 1930. 4. Then Veterans/Members were identified as needing secure unit and anti-elopement bracelets; 10/13/2016 at 1930. 5. Although two Veterans/Members triggered YES on the Risk Assessment Elopement Decision Tree, after careful review, the primary care provider determined secure placement to be inappropriate. Justification risk for significant medical and /or psycho-social consequences has been documented in the medical record. Anti-Elopement bracelets will continue for those two Veterans/Members. Individualized care plans have been developed to include line of sight monitoring when Veterans are outside the Home. 6. Only two Veterans are likely to wish to leave unit. 7. The identified five Veterans/Members are not requiring anti-elopement bracelets had their brackets removed; 10/13/2016 at 7:50 pm per MD. 8. E Unit identified as the location to house the 10 Veterans/Members. Careful consideration of appropriate placement (roommates/fall risk) completed on 10/13/2016. 9. Veterans/members requiring movement from Echo Unit evaluated for appropriate placement in the 18 bed available and assigned. 10. Deputy Secretary is actively pursing funds to install an anti-elopement system on the 13 exterior doors of the Home. Two quotes have been received for anti-elopement systems. Expected installation is within three months; by 01/14/17. Based on record review and interview, the facility failed to ensure that residents were safe from accidents by not providing appropriate supervision, when residents with Wanderguards are able to leave the building premises without staff awareness due to the Wanderguards boundary not at the outside doors, but on the roads leading to the street for 3 (R #2, R #3, and R #5) of 4 (R #2, R #3, R #4, and R #5) sampled resident for wandering and falls. On 06/11/16, R #2 was found outside after she had fallen out of the wheel chair and broke her right hip. On 07/13/16, R #3 was found outside in the construction area with his O2 tubing wrapped around himself. On 08/09/16, R #5 was found heading out towards the street in his wheel chair. On 09/28/16, R #5 was found in the north parking lot. This failed practice likely resulted in R #2's breaking her right hip outside of the facility and possible injury to other residents. The findings are: R # 2 A. Record review of Progress Notes in facility's electronic records for R #2 revealed the following: 1. Progress Note dated 05/16/16 at 13:30 (1:30 pm); Incident Note: Resident (rsd) found twice today outside the facility - was placed on 15 minute checks. 2. Progress Note dated 06/11/16 at 22:00 (10:00 pm): 1900 (7:00 pm) dietary staff found (name of R #2) lying on ground in front of building on (name of R #2's) back, upper body on gravel and lower body on sidewalk, right leg bent at knee. Staff stabilizing head/neck. Denies striking head and no obvious signs of head injury. Wheelchair (w/c) upright, but left wheels in gravel. Rsd alert with clear speech and reports trying to get w/c out of the gravel and fell from the chair. 1925 (7:25 pm), rsd placed on stretcher and left facility grounds via ambulance. 3. Progress Note dated 06/11/16 at 21:09 (9:09 pm) states: (Name of hospital) notified this writer and family member, that rsd does indeed have fracture of right femoral neck and will be transferred to (a higher level of care) hospital. B. On 10/12/16 at 3:00 pm during an interview, facility investigator (FI) stated, I substantiated the investigation for neglect because (name of R #2's) care plan shows (name of R #2) is a wanderer and I wondered how (name of R #2) even got out of the building if (name of R #2) is supposed to be supervised. C. Record review of the facility's investigatigation dated 06/12/16 reviewed and conducted by FI revealed the following: 1) At 1900 (7:00 pm), (name of R #2) found by kitchen staff lying on ground in front of building, on (name of R #2's) back, upper body on grown (sic), lower body on sidewalk, unsafe wandering. 2) No one was with R #2 at the time of the incident, the assigned staff member at the time of the was fall was on unit. 3) R #2 was in a w/c and is a one person assist with transfers. 4) R #2 was transferred to local hospital per medical doctor's orders. 5) Page 22 of 34 of R #2 Care Plan revealed: Focus: High risk for falls, unaware of safety needs, confusion, poor communication/comprehension, psychoactive drug use, deconditioning, vision/hearing problems, gait/balance problems and incontinence. 6) A page from (name of local hospital) indicating R #2 was seen in theER on [DATE] at 19:37 (8:37 pm) for pain. The findings section stated, There is a comminuted displaced (when the bone breaks into several pieces) transverse subcaptial fracture (bone at right angles to the axis of the bone involved) of the right femoral neck (the ball of the ball-and-socket hip joint) with a slight superolateral (situated above and toward the side) displacement of the distal fragment with respect to the proximal fragment. 7) Could we get wander alerts onto main facility doors? was hand written on the facility's Post Fall Team Huddle Report. 8) Future preventative/corrective action for resident (s) health and safety: All rsds with risk of wandering will be taken to Day Care located on secure unit within the facility. D. Record review of Clinical Report-Physician's/Mid Levels for R #2 from (name of hospital)'s emergency room (ER) dated 06/11/16 at 20:06 (8:06 pm) reveals the following: Chief Complaint: FALL and PELVIS INJURY. RIGHT HIP INJURY. The injury occurred just prior to arrival. Occurred at nursing home. fell from a height off a chair and landed on a hard surface. Surgical repair was recommended. E. Record review of R #2's Care Plan dated 05/17/16 revealed, (Name of R #2) is a wanderer related to curiosity. Rsd wanders aimlessly in w/c, has demonstrated impaired safety awareness by following a visitor outside that had a dog. Goal: Rsd will not leave facility unattended through the review date - date initiated 5/17/16 through 9/3/16. Interventions include Wanderguard alert placed on the back of w/c starting 05/17/16. Monitor location every 15 minutes when exhibiting wandering behavior (bx). F. On 10/13/16 at 11:30 am, during an interview, kitchen staff (KS) stated that KS and co-worker were leaving the facility on 06/11/16 around 7:00 pm when they heard a seat belt alarm and looked and observed someone laying on the ground with w/c near by. KS stated, We stopped and got out of the car and observed (R #2) laying on her back, on the ground, in the rocks. (Name of R #2) said she was hurting and asked for help. When asked if R #2 had a Wanderguard, KS stated, (Name of R #2) did, but the Wanderguards do not go off at the door; they go off at the main exits. KS revealed there are power boxes at the speed bumps near the main road entrance to the building and if a rsd goes past that point, an alarm will sound inside. G. On 10/13/16 at 11:45 am, during an interview, CNA #1 stated, (Name of R #2) has a Wanderguard on her wheel chair. If (name of R #2) makes it outside, an alarm will go off. CNA #1 revealed that there are no alarms on the doors of the facility but boundaries outside that residents with Wanderguards can not cross without alarm going off. H. On 10/13/16 at 11:50 am, during an interview with Ward Clerk (WC), when asked how the Wanderguards work, WC stated, They (Wanderguards) are placed on the rsd's wheelchair or walker and there is a big box outside; there is a boundary, if the rsd crosses it, their number will show up on that (pointing to the marque on the ceiling). When asked about R #2 schedule, WC revealed R #2 goes to Day Care on C unit (locked unit) after breakfast until lunch and then back to R #2's room for nap or back to C. R #2 goes back to R #2's room after dinner. I. On 10/13/16 at 12:20 pm, during an interview with facility's receptionist, (who sits by the front door of the facility) when asked if an alarm goes off when rsds with Wanderguards leave through the door? Receptionist stated, No, they (rsds) have the Wanderguards on their wrists and if they go to the speed bumps (on the road near the entrance of the facility) an alarm will go off. There is a imaginary boundary rsds can not cross. Some rsds walk and have been caught out there. J. Record review of facility's Resident Monitoring Flow Sheet-Q (every)15 (RMFS-Q 15) minute form for R #2 revealed the following: 1) 15 minutes checks were initiated for high fall risk on 06/29/16 at 1400 (4:00 pm) and went through 07/07/16 at 2200 (10:00 pm). 2) 07/01/16 was missing. 3) Checks were not initiated by staff on 06/30/16 from 0115 (1:15 am) to 0530 (5:30 am), on 07/02/16 from 0015 (12:15 am) to 0545 (5:45 am), 1400 (2:00 pm) to 1430 (4:30 pm) and 1815 (6:15 pm) to 2345 (11:45 pm), on 07/03/16 from 2400 (12:00 am) to 0545 (5:45 am) and 1300 (1:00 pm) to 1330 (1:30 pm) and 1815 (6:15 pm) to 2345 11:45 pm), on 07/06/16 from 2400 (12:00 am) to 0545 (5:45 am) and 1815 (6:15 pm) to 2345 (11:45 pm), and on 07/07/16 from 2400 (12:00 am) to 0545 (5:45 am). K. On 10/13/16 at 2:20 pm, during an interview with Medical Records Director (MRD), MRD was shown R #2's medical chart and was asked how staff know when to start RMFS-Q 15, MRD stated, They should be on a Medication Administration Record (MAR) form ordered by a doctor or nurse. MRD was given R #2's chart and located R #2 RMFS-Q 15 form and MAR form and did not find either order. MRD located R #2's care plan and stated, It (RMFS-Q 15) started in care plan on 06/29/16. When shown the RMFS-Q 15 and asked what it meant due to the blanks spaces, he stated, That means they were not done. L. On 10/13/2016 at 3:44 pm, during an interview, RN #1 from D unit stated, Not everyone with a Wanderguard will go to C unit (locked unit). At 3 pm to 4 pm and later is when wander risks happen (increase). M. On 10/13/16 at 2:35 pm, during an interview with Administrator, when asked when a rsd has on a Wanderguard and exits the building, when do the alarms go off, the Administrator stated, Rsd has to actually walk past the barrier. Administrator had a map and pointed to the barriers located between two poles near the speed bumps on the driveway to the facility. N. On 10/13/16 at 3:45 pm, during an interview, Pharmacist stated, If a rsd gets in (goes to) C unit, they would have a doctor's order for that and they (rsds) are there intermittently (not continuously through out the day). O. On 10/13/16 at 3:47 pm, during an interview, CNA #2 stated, If they (rsds) can walk, a Wanderguard will go on their wrist or ankle. If not, it would be placed on their w/c . There is a barrier on the bridge and in the road (in front of the building) . If someone goes out past there, it will come up on the board. P. On 10/17/16 at 1:50 pm during an interview with the DON, she was shown R #2's RMFS-Q 15 forms starting on 06/29/16 through 07/07/16. When asked what the blanks meant, she stated, They should have been filled it. Staff forgot to check on them (the residents). R #3 Q. Record review of R #3's Care Plan entry dated 07/15/16 revealed: Focus: Resident is an elopement risk/wanderer resident has been found outside unattended. R. Record review of Progress Notes for R #3 revealed the following: 1) On 07/07/16 at 11:48 am: Health Status Note: At 0845 (8:45 am) resident noted to show signs of agitation, seeking exit. He went outside D unit parking area. Wanderguard (sic) place in his wheelchair for potential elopement and safety. 2) On 07/13/16 at 12:46 pm: Health Status Note: (Name of R #3) continues to try to elope (from the) facility. (Name of R #3) cannot comprehend his limitation and was found standing up in parking lot with O2 tubing wrapped around him. 3) On 07/14/16 at 9:43 am: Incident Note, late entry for 07/13/16 at 1245, (name of R #3) wandered outside (of the facility) 3 today that we are aware of, last time being between facility and construction zone wrapped in tubing standing beside w/c. He also wandered throughout facility throughout day become more and more agitated and harming self by punching items. 4) On 07/14/16 at 9:51 am: Incident Note: Pt (patient) wandered out of facility x 1 then was missing and search initiated. S. Record review of facility's RMFS-Q 15 forms for R # 3 started on 09/02/16 after a fall and completed on 09/19/16 revealed the following checks were not initialized by staff: 1) On 09/02/16 from 2400 (12:00 am) through 1745 (5:45 pm) 2) On 09/04/16 from 1415 (4:15 pm) through 1745 (5:45 pm) 3) On 09/05/16 from 0615 (6:15 am) through 0700 (7:00 am), from 0815 (8:15 am) through 0830 (8:30 am), and from 1000 (10:00 am) through 1130 (11:30 am) 4) On 09/11/16 from 2400 (12:00 am) through 0615 (6:15 am) and from 1645 (4:45 pm) through 1745 (5:45 pm). T. On 10/17/16 at 1:50 pm during an interview with DON, she was shown R #3's RMFS-Q 15 forms from 09/02/16 through 09/19/16. When asked what the blanks meant, she stated, They should have been filled it. Staff forgot to check on them (the residents). R #5 U. Record review of R #5's Progress Notes dated 08/09/16 revealed R #5 was found, down exit driveway towards main road going over the last speed bump in his w/c . V. Record review of Progress Notes dated 09/28/16 revealed R #5 was found outside in the parking lot on the west side of the building. W. Record review of of R #5's Nursing Technician Care Plan revealed, 06/22/16 - Wanderguard to w/c. X. On 10/18/16 at 11:35 am, during an interview, CNA #1 stated that R #5 was friends with another resident. That resident had outside appointments and R #5 wanted to leave with him. This is what happened in August. In September, he wanted to check in on his wife. CNA #1 explained that R #5 likes to visit with people and does not like to stay in one small place.

Based on record review and interviews, the facility failed to keep resident free from injury and neglect, for 1 (#1) of 5 (R #1, R #2, R #3, R #4, R #5) sampled residents reviewed for neglect by not providing adequate supervision. This deficient practice likely resulted in R #1 experiencing 1st [MEDICAL CONDITION](superficial burn or wound), 2nd [MEDICAL CONDITION](a burn, to the skin, that penetrates to the second layer of the skin, blisters develop, the first layer of skin falls away, exposing the raw cell nerves and are the most painful burn), and dehydration, when he was left outside in the sun, unattended. The findings are: A. Record review of the facility Freedom from Accident, Injury, Abuse, Neglect, and Exploitation Investigation Policy and Procedure, Revised and reviewed on 12/09/14, revealed Purpose: To establish policies and procedures that prohibit abuse, neglect, exploitation .for all residents .will promote an environment that is free of abuse, neglect or exploitation.will ensure all staff are aware of their responsibilities and can demonstrate competency in identifying, responding to, reporting accidents, injuries, abuse, neglect, exploitation . B. Record review of the facility Resident Rights regarding Accidents, Injuries, Abuse, Neglect and Exploitation: Resident Incident Reports: Policy and Procedures, Revised and reviewed on 04/14/15 revealed PURPOSE: It is the purpose of this policy to establish a policy regarding accents, injuries, abuse, neglect and exploitation of residents; inform persons employed or otherwise affiliated with the (Name of the facility) . C. Record review of Department of Health Incident Report dated 07/07/15 indicated, that on 07/04/15, R #1 was sent to the emergency room at (Name of the City) for elevated cardiac enzymes and blisters to his arms and legs for apparently sitting in the sun too long. According to the History and Physical, he was sitting out in the sun and has blisters on his thighs, arms and hands. He has dementia, hypertension, Diabetes Mellitus, possible [MEDICAL CONDITION] and coronary disease. Wound care has been consulted for the burn and he is requiring the use of [MEDICATION NAME] (sic) for those same burns. D. Record review of the facility's videos (no audio available) with specific snapshots on 07/03/15 revealed the following: 1. Camera Group: Multipurpose Room view looking south: At 12:51 pm, R #1 is exiting the dining room. Propels self with his wheelchair and enters the MP (multipurpose room). In the MP, R #6 pushes the door pad to open the door and R #1 goes out into the courtyard. R #6 remains in the MP. 2. Camera Name: Courtyard # 1 a. At 12:58 pm, R #1 is sitting in his wheelchair under a tree in the Courtyard under some shade provided by a tree. His arms are visible and appear to be resting on his lap. b. At 2:01 pm, R #1 is still in the courtyard, but the sun has moved and he is no longer shaded by the tree. c. At 2:59 pm, Recreational Worker #1 walks up to the R #1 who is still in the courtyard. d. At 3:00 pm, Recreational Worker #1 wheels R #1 into the facility's multipurpose room. e. At 3:07 pm, R #1 is in wheelchair and staff is taking him to the unit where his room is. E. Record review of U.S. Climate Data records the high temperature for the town in which the facility resides as being 102.9 degrees Fahrenheit. F. On 07/09/15 at 4:18 pm, during an interview with the Pharmacist (in the facility at the time of the incident), reported that he had been called in to R #1's room to assist the staff with the resident. The Pharmacist recalls that R #1's top left thigh was red, like a sunburn with a 1 (inch) by 1 to 1 1/2 x 3/4 abrasion above the knee. The right thigh had a 3/4 by 2 fluid filled shallow, blister above the knee. Both arms were red from the top of the hands to the just below the elbow. The following morning (07/04/15), the Pharmacist reported that he checked R #1. Staff indicated that R #1 was more lethargic than usual. Registered Nurse #3 (RN, who is also the wound care nurse), removed R #1's bandages and the Pharmacist also stated that he saw multiple small blisters had developed on the R #1's left arm and [MEDICAL CONDITION] was accumulating around the elbow area. The Pharmacist also noticed increased blistering to the left thigh and the fluid filled area on the right thigh expanded to doubled, maybe tripled in size. Labs were ordered (at 9:30 am) and results indicated renal function decline, dehydration, low sodium, and an increase in potassium. The Pharmacist reviewed the situation with the Facility's Medical Director, and sent R #1 to the local Hospital's emergency room . G. On 07/09/15 at 4:45 pm during an interview with Recreational Worker (RW) #1, he recalled that at 2 pm, on 07/03/15, he had started an activity of popcorn and movies with the residents in the dining room. During hydration time (between 3:10 pm to 3:15 pm) he noticed that R#1 was sitting out in the courtyard. He approached R #1 and called him by name. R #1 did not respond. He noticed that the R #1's arms were real red. His shirt was wet from sweat and slobber and the wheelchair was hot to the touch. He brought R #1 inside, again attempted to get a response from the resident. RW #1 called for help over his radio. According to Recreational Worker #1, Some CNAs (unidentifed) responded immediately, as well as RN #3. H. On 07/14/15 at 12:00 pm, during interview, The Facility Investigator (FI) stated R #6 opened the door for R #1 to go out in the court yard. R #1 propelled himself to a tree by the entrance to the courtyard, where there was shade at that time. R #1 appeared to have fallen asleep and was there by the tree for two hours. During that time the sun had shifted exposing R #1 to the sun. At about 3:00 pm, RW #1 notice R #1 out in the courtyard. When RW #1 approached R #1 he was unresponsive. RW #1 wheeled R #1 into the multi-purpose room and called for assistance. CNAs #1 and #3 responded. They immediately called for the nurse. RN #3 and Lead Aid #1 assisted R #1 to his room and began treatment. Staff are supposed to do hourly checks on all residents and R #1 was out there for 2 hours. CNA #2 had marked on the computer that she had done her hourly checks, but she had marked on the wrong resident. The investigation suggests neglect due to no performing hourly checks. I. Record review of the Point of Care Audit form dated 07/03/15, revealed that at 11:43 am, Certified Nursing Assistant (CNA) #1 documented that she had conducted hourly checks on R #1 at 10:00 am, 11:00 am, and 12:00 pm. At 2:30 pm, CNA #2 documented that she had conducted hourly checks on R #1 at 1:00 pm and 2:00pm. CNA #1 documented at 2:31 pm that she had conducted the 3:00 pm check on R #1. J. On 07/14/15 at 3:42 pm, during interview, CNA #3 stated that R #1 was assigned to CNA #2. She further stated that all residents are on hourly checks and that the hourly checks are documented on the computer. K. On 07/14/15 at 3:46 pm, during interview, CNA #1 revealed that she and CNA #3 were walking out of a resident's room when RW #1 called for help. They went to the multi-purpose room to help. When they got to R #1, he was sitting down in his wheelchair with his head down. He had saliva running down his shirt and he was not responsive. Red from elbow to top of hands mid-thigh to knee. We were going to start to wheel down to his room, but the nurse and lead aid meet us and took him to his room. CNA #1 left the resident with RN #3 and Lead Aid #1. When she returned, they were getting R #1 undressed and trying to give him fluids. L. On 07/14/15 at 4:00 pm, during interview, CNA #2 stated she was helping with R #2 (R #1 roommate) when I looked over and thought it was strange he (R #1) was not there because he usually takes a nap after lunch. When asked about documenting the hourly checks for R #1, she responded that all residents are on hourly checks and added I don't think it (the hourly check marked on the electronic chart) was for the right resident. I honestly do not know. We were really busy that day. M. Record Review of the 07/03/15 at 07:57 pm revealed the following 1510 called STAT (immediately) to (location). (Name of R #1) in w/c (wheelchair), not responding to verbal stimuli. Recreation worker had gone into (name of) Courtyard to offer him fluids and found him unresponsive, very red and with rapid breathing and so brought him indoors. Arms/hands and bilateral anterior (front) thighs are red, hot to touch. Blood sugar 321. VS (vital signs) 98.6 (temperature)-92 (heart Rate)-18 (respiratory)-81/54 (blood Pressure). Clinician in house (Dr.of Pharmacy) and called to room to assess. Thin layer of skin peeling above left knee. Skin pulled back together and [MEDICATION NAME] applied per noted orders--to apply generously to all areas of redness . (Name of RN #3) N. Record Review of the 07/04/15 Progress Note at 1:15 am revealed the following COMMUNICATION - with Family/NOK/POA Son called, informed of . Resident s/p sunburn through clothing this afternoon. L. knee lesion appears as abrasion less than 2 sq (square) inches. R knee lesion blister formed did not break as of yet, approximately 2 sq inches in size. At time resident discovered in sun, clothes removed and cold compress applied . (name of Pharmacist) O. Record Review of the Progress Notes dated 07/04/15 at 1:31 pm revealed the following: Health Status Note . (Name of resident #1) more lethargic this day . Clinician in this a.m. and order for CBC (complete blood count) and CMP (comprehensive metabolic panel test for bodies overall chemical balance and metabolism) obtained, noted. Drawn and sent to lab at 9:30 am. Results reviewed by clinician. WBC (white blood count) 15 (low 3.8; high 10.4), Na (sodium) 128 (low 136; high 145), K+ (potassium) 5.4 (low 3.5; high 5.1) with multiple other abnormals. Output via Foley catheter is decreased, 200ml on noc (night) shift and less than 100 so far today. Refusing fluids at 1100. Wound care done to anterior (front) thighs and upper extremities, measurements taken. Multiple blistered areas on thighs and left upper extremity . Order received and noted to send to (name of hospital) for eval via ambulance, [MEDICAL CONDITION] metabolic status . (name of R #1) left facility via stretcher at 1300 . (name of RN #3) P. Record review of the Report from (name of hospital) emergency room [DATE] at 1:42 pm, revealed the following Burn from Sun Exposure. Not alert. In distress.[MEDICAL CONDITION] screen is positive, infection was suspected . Physical Assessment . Right forearm: 1st degree burn, tenderness, swelling and [DIAGNOSES REDACTED] (reddening of the skin). Left forearm: 1st degree superficial burn . Right thigh: Large 2nd degree partial thickness burn to anterior (front) aspect of the right thigh . Left thigh: 2nd degree partial thickness burn the anterior aspect of the left thigh . Right knee: 2nd degree partial thickness burn . Left knee: 2nd degree partial thickness burn . Skin: . He has multiple blisters (intact) located on the right forearm, right wrist and right hand, right thigh and right knee and left forearm, left wrist and left hand and thigh and left knee (sic) . Q. Record review of the Laboratory - Comparative Report (done at local hospital) dated 07/04/15 at 2:01 pm revealed that R #1's BUN (Blood Urea Nitrogen an indicator of dehydration) was 39 (low 7; high 18). R. Record Review of the facility's Progress Notes dated 07/04/15 at 4:38 pm revealed the following Health Status Note . Resident w/ (with) increased lethargy today, lab to eval (evaluate) metabolic status s/p (status [REDACTED]. L (left) arm with [MEDICAL CONDITION], minimal blisters with minimal thickness able to be assessed totaling less than 2inches. R (right) arm with no blistering present, decreased reddened areas. R thigh above knee blister has expanded minimal thickness also measured 9 x 14 cm (centimeters). Surrounding tissue appears stable. L knee open area static w/ yesterday approximately 2 inches, significant blisters surrounding open area . (Name of RN #1) S. Record review of the facility investigation Dated 07/10/15 revealed the following: 1. During interview, CNA #1 stated when she was assisting another resident in (name of R #1's) room she noticed he was not in his room on his bed around 12:30 to 1:00 and went to look for him. She added that this was odd because he usually returns to his room to go to bed . 2. Administrative Summary: . resident sustained [REDACTED]. Based on the information gathered, staff appeared to have failed to complete a one-hour check while resident was outside in the (hot)weather. There is a discrepancy in the charting and the actual occurrence of checks. Investigation status: Based on all information present, it is more than likely that neglect did occur . Signed (name of Aministrator)

Based on record review and interviews, the facility failed to implement written policies and procedures to keep resident free from injury and neglect, for 1 (#1) of 5 (R #1, R #2, R #3, R #4, R #5) sampled residents reviewed for neglect by not providing adequate supervision. This deficient practice likely resulted in R #1 experiencing 1st [MEDICAL CONDITION](superficial burn or wound), 2nd [MEDICAL CONDITION](a burn, to the skin, that penetrates to the second layer of the skin, blisters develop, the first layer of skin falls away, exposing the raw cell nerves and are the most painful burn), and dehydration, when he was left outside in the sun, unattended. The findings are: A. Record review of the facility Freedom from Accident, Injury, Abuse, Neglect, and Exploitation Investigation Policy and Procedure, Revised and reviewed on 12/09/14, revealed Purpose: To establish policies and procedures that prohibit abuse, neglect, exploitation .for all residents .will promote an environment that is free of abuse, neglect or exploitation.will ensure all staff are aware of their responsibilities and can demonstrate competency in identifying, responding to, reporting accidents, injuries, abuse, neglect, exploitation . B. Record review of the facility Resident Rights regarding Accidents, Injuries, Abuse, Neglect and Exploitation: Resident Incident Reports: Policy and Procedures, Revised and reviewed on 04/14/15 revealed PURPOSE: It is the purpose of this policy to establish a policy regarding accents, injuries, abuse, neglect and exploitation of residents; inform persons employed or otherwise affiliated with the (Name of the facility) . C. Record review of Department of Health Incident Report dated 07/07/15 indicated, that on 07/04/15, R #1 was sent to the emergency room at (Name of the City) for elevated cardiac enzymes and blisters to his arms and legs for apparently sitting in the sun too long. According to the History and Physical, he was sitting out in the sun and has blisters on his thighs, arms and hands. He has dementia, hypertension, Diabetes Mellitus, possible [MEDICAL CONDITION] and coronary disease. Wound care has been consulted for the burn and he is requiring the use of [MEDICATION NAME] (sic) for those same burns. D. Record review of the facility's videos (no audio available) with specific snapshots on 07/03/15 revealed the following: 1. Camera Group: Multipurpose Room view looking south: At 12:51 pm, R #1 is exiting the dining room. Propels self with his wheelchair and enters the MP (multipurpose room). In the MP, R #6 pushes the door pad to open the door and R #1 goes out into the courtyard. R #6 remains in the MP. 2. Camera Name: Courtyard # 1 a. At 12:58 pm, R #1 is sitting in his wheelchair under a tree in the Courtyard under some shade provided by a tree. His arms are visible and appear to be resting on his lap. b. At 2:01 pm, R #1 is still in the courtyard, but the sun has moved and he is no longer shaded by the tree. c. At 2:59 pm, Recreational Worker #1 walks up to the R #1 who is still in the courtyard. d. At 3:00 pm, Recreational Worker #1 wheels R #1 into the facility's multipurpose room. e. At 3:07 pm, R #1 is in wheelchair and staff is taking him to the unit where his room is. E. Record review of U.S. Climate Data records the high temperature the town in which the facility resides as being 102.9 degrees Fahrenheit. F. On 07/09/15 at 4:18 pm, during an interview with the Pharmacist (in the facility at the time of the incident), reported that he had been called in to R #1's room to assist the staff with the resident. The Pharmacist recalls that R #1's top left thigh was red, like a sunburn with a 1 (inch) by 1 to 1 1/2 x 3/4 abrasion above the knee. The right thigh had a 3/4 by 2 fluid filled shallow, blister above the knee. Both arms were red from the top of the hands to the just below the elbow. The following morning, 07/04/15, the Pharmacist reported that he checked R #1. Staff indicated that R #1 was more lethargic than usual. Registered Nurse #3 (RN, who is also the wound care nurse), removed R #1's bandages and the Pharmacist also stated that he saw multiple small blisters had developed on the R #1's left arm and [MEDICAL CONDITION] was accumulating around the elbow area. The Pharmacist also noticed increased blistering to the left thigh and the fluid filled area on the right thigh expanded to doubled, maybe tripled in size. Labs were ordered (at 9:30 am) and results indicated renal function decline, dehydration, low sodium, and an increase in potassium. The Pharmacist reviewed the situation with the Facility's Medical Director, and sent R #1 to the local Hospital's emergency room . G. On 07/09/15 at 4:45 pm during an interview with Recreational Worker (RW) #1, he recalled that at 2 pm, on 07/03/15, he had started an activity of popcorn and movies with the residents in the dining room. During hydration time (between 3:10 pm to 3:15 pm) he noticed that R#1 was sitting out in the courtyard. He approached R #1 and called him by name. R #1 did not respond. He noticed that the R #1's arms were real red. His shirt was wet from sweat and slobber and the wheelchair was hot to the touch. He brought R #1 inside, again attempted to get a response from the resident. RW #1 called for help over his radio. According to Recreational Worker #1, Some CNAs (unidentifed) responded immediately, as well as RN #3. H. On 07/14/15 at 12:00 pm, during interview, The Facility Investigator (FI) stated R #6 opened the door for R #1 to go out in the court yard. R #1 propelled himself to a tree by the entrance to the courtyard, where there was shade at that time. R #1 appeared to have fallen asleep and was there by the tree for two hours. During that time the sun had shifted exposing R #1 to the sun. At about 3:00 pm, RW #1 notice R #1 out in the courtyard. When RW #1 approached R #1 he was unresponsive. RW #1 wheeled R #1 into the multi-purpose room and called for assistance. CNAs #1 and #3 responded. They immediately called for the nurse. RN #3 and Lead Aid #1 assisted R #1 to his room and began treatment. Staff are supposed to do hourly checks on all residents and R #1 was out there for 2 hours. CNA #2 had marked on the computer that she had done her hourly checks, but she had marked on the wrong resident. The investigation suggests neglect due to no performing hourly checks. I. Record review of the Point of Care Audit form dated 07/03/15, revealed that at 11:43 am, Certified Nursing Assistant (CNA) #1 documented that she had conducted hourly checks on R #1 at 10:00 am, 11:00 am, and 12:00 pm. At 2:30 pm, CNA #2 documented that she had conducted hourly checks on R #1 at 1:00 pm and 2:00pm. CNA #1 documented that she had conducted the 3:00 pm check on R #1 and documented it at 2:31 pm. J. On 07/14/15 at 3:42 pm, during interview, CNA #3 stated that R #1 was assigned to CNA #2. She further stated that all residents are on hourly checks and that the hourly checks are documented on the computer. K. On 07/14/15 at 3:46 pm, during interview, CNA #1 revealed that she and CNA #3 were walking out of a resident's room when RW #1 called for help. They went to the multi-purpose room to help. When they got to R #1, he was sitting down in his wheelchair with his head down. He had saliva running down his shirt and he was not responsive. Red from elbow to top of hands mid-thigh to knee. We were going to start to wheel down to his room, but the nurse and lead aid meet us and took him to his room. CNA #1 left the resident with RN #3 and Lead Aid #1. When she returned, they were getting R #1 undressed and trying to give him fluids. L. On 07/14/15 at 4:00 pm, during interview, CNA #2 stated she was helping with R #2 (R #1 roommate) when I looked over and thought it was strange he (R #1) was not there because he usually takes a nap after lunch. When asked about documenting the hourly checks for R #1, she responded that all residents are on hourly checks and added I don't think it (the hourly check marked on the electronic chart) was for the right resident. I honestly do not know. We were really busy that day. M. Record Review of the 07/03/15 at 07:57 pm revealed the following 1510 called STAT (immediately) to (location). (Name of R #1) in w/c (wheelchair), not responding to verbal stimuli. Recreation worker had gone into (name of) Courtyard to offer him fluids and found him unresponsive, very red and with rapid breathing and so brought him indoors. Arms/hands and bilateral anterior (front) thighs are red, hot to touch. Blood sugar 321. VS (vital signs) 98.6 (temperature)-92 (heart Rate)-18 (respiratory)-81/54 (blood Pressure). Clinician in house (Dr.of Pharmacy) and called to room to assess. Thin layer of skin peeling above left knee. Skin pulled back together and [MEDICATION NAME] applied per noted orders--to apply generously to all areas of redness . (Name of RN #3) N. Record Review of the 07/04/15 Progress Note at 1:15 am revealed the following COMMUNICATION - with Family/NOK/POA Son called, informed of . Resident s/p sunburn through clothing this afternoon. L. knee lesion appears as abrasion less than 2 sq (square) inches. R knee lesion blister formed did not break as of yet, approximately 2 sq inches in size. At time resident discovered in sun, clothes removed and cold compress applied . (name of Pharmacist) O. Record Review of the Progress Notes dated 07/04/15 at 1:31 pm revealed the following: Health Status Note . (Name of resident #1) more lethargic this day . Clinician in this a.m. and order for CBC (complete blood count) and CMP (comprehensive metabolic panel test for bodies overall chemical balance and metabolism) obtained, noted. Drawn and sent to lab at 9:30 am. Results reviewed by clinician. WBC (white blood count) 15 (low 3.8; high 10.4), Na (sodium) 128 (low 136; high 145), K+ (potassium) 5.4 (low 3.5; high 5.1) with multiple other abnormals. Output via Foley catheter is decreased, 200ml on noc (night) shift and less than 100 so far today. Refusing fluids at 1100. Wound care done to anterior (front) thighs and upper extremities, measurements taken. Multiple blistered areas on thighs and left upper extremity . Order received and noted to send to (name of hospital) for eval via ambulance, [MEDICAL CONDITION] metabolic status . (name of R #1) left facility via stretcher at 1300 . (name of RN #3) P. Record review of the Report from (name of hospital) emergency room [DATE] at 1:42 pm, revealed the following Burn from Sun Exposure. Not alert. In distress.[MEDICAL CONDITION] screen is positive, infection was suspected . Physical Assessment . Right forearm: 1st degree burn, tenderness, swelling and [DIAGNOSES REDACTED] (reddening of the skin). Left forearm: 1st degree superficial burn . Right thigh: Large 2nd degree partial thickness burn to anterior (front) aspect of the right thigh . Left thigh: 2nd degree partial thickness burn the anterior aspect of the left thigh . Right knee: 2nd degree partial thickness burn . Left knee: 2nd degree partial thickness burn . Skin: . He has multiple blisters (intact) located on the right forearm, right wrist and right hand, right thigh and right knee and left forearm, left wrist and left hand and thigh and left knee (sic) . Q. Record review of the Laboratory - Comparative Report (done at local hospital) dated 07/04/15 at 2:01 pm revealed that R #1's BUN (Blood Urea Nitrogen an indicator of dehydration) was 39 (low 7; high 18). R. Record Review of the facility's Progress Notes dated 07/04/15 at 4:38 pm revealed the following Health Status Note . Resident w/ (with) increased lethargy today, lab to eval (evaluate) metabolic status s/p (status [REDACTED]. L (left) arm with [MEDICAL CONDITION], minimal blisters with minimal thickness able to be assessed totaling less than 2inches. R (right) arm with no blistering present, decreased reddened areas. R thigh above knee blister has expanded minimal thickness also measured 9 x 14 cm (centimeters). Surrounding tissue appears stable. L knee open area static w/ yesterday approximately 2 inches, significant blisters surrounding open area . (Name of RN #1) S. Record review of the facility investigation Dated 07/10/15 revealed the following: 1. During interview, CNA #1 stated when she was assisting another resident in (name of R #1's) room she noticed he was not in his room on his bed around 12:30 to 1:00 and went to look for him. She added that this was odd because he usually returns to his room to go to bed . 2. Administrative Summary: . resident sustained [REDACTED]. Based on the information gathered, staff appeared to have failed to complete a one-hour check while resident was outside in the (hot)weather. There is a discrepancy in the charting and the actual occurrence of checks. Investigation status: Based on all information present, it is more than likely that neglect did occur . Signed (name of Aministrator)

Based on record review and interviews, the facility failed to ensure that resident were free from accidents for 1 (#1) of 5 (R #1, R #2, R #3, R #4, R #5) sampled residents reviewed for neglect, by not providing adequate supervision of a resident that fell asleep in an outside courtyard during a hot day while in the sun. This deficient practice likely resulted in R #1 experiencing 1st degree burns (superficial burn or wound), 2nd degree burns (a burn, to the skin, that penetrates to the second layer of the skin, blisters develop, the first layer of skin falls away, exposing the raw cell nerves and are the most painful burn), and dehydration, when he was left outside in the sun, unattended. The findings are: A. Record review of the facility Freedom from Accident, Injury, Abuse, Neglect, and Exploitation Investigation Policy and Procedure, Revised and reviewed on 12/09/14, revealed Purpose: To establish policies and procedures that prohibit abuse, neglect, exploitation .for all residents .will promote an environment that is free of abuse, neglect or exploitation.will ensure all staff are aware of their responsibilities and can demonstrate competency in identifying, responding to, reporting accidents, injuries, abuse, neglect, exploitation . B. Record review of the facility Resident Rights regarding Accidents, Injuries, Abuse, Neglect and Exploitation: Resident Incident Reports: Policy and Procedures, Revised and reviewed on 04/14/15 revealed PURPOSE: It is the purpose of this policy to establish a policy regarding accents, injuries, abuse, neglect and exploitation of residents; inform persons employed or otherwise affiliated with the (Name of the facility) . C. Record review of Department of Health Incident Report dated 07/07/15 indicated, that on 07/04/15, R #1 was sent to the emergency room at (Name of the City) for elevated cardiac enzymes and blisters to his arms and legs for apparently sitting in the sun too long. According to the History and Physical, he was sitting out in the sun and has blisters on his thighs, arms and hands. He has dementia, hypertension, Diabetes Mellitus, possible strokes and coronary disease. Wound care has been consulted for the burn and he is requiring the use of silvadene (sic) for those same burns. D. Record review of the facility's videos (no audio available) with specific snapshots on 07/03/15 revealed the following: 1. Camera Group: Multipurpose Room view looking south: At 12:51 pm, R #1 is exiting the dining room. Propels self with his wheelchair and enters the MP (multipurpose room). In the MP, R #6 pushes the door pad to open the door and R #1 goes out into the courtyard. R #6 remains in the MP. 2. Camera Name: Courtyard # 1 a. At 12:58 pm, R #1 is sitting in his wheelchair under a tree in the Courtyard under some shade provided by a tree. His arms are visible and appear to be resting on his lap. b. At 2:01 pm, R #1 is still in the courtyard, but the sun has moved and he is no longer shaded by the tree. c. At 2:59 pm, Recreational Worker #1 walks up to the R #1 who is still in the courtyard. d. At 3:00 pm, Recreational Worker #1 wheels R #1 into the facility's multipurpose room. e. At 3:07 pm, R #1 is in wheelchair and staff is taking him to the unit where his room is. E. Record review of U.S. Climate Data records the high temperature the town in which the facility resides as being 102.9 degrees Fahrenheit. F. On 07/09/15 at 4:18 pm, during an interview with the Pharmacist (in the facility at the time of the incident), reported that he had been called in to R #1's room to assist the staff with the resident. The Pharmacist recalls that R #1's top left thigh was red, like a sunburn with a 1 (inch) by 1 to 1 1/2 x 3/4 abrasion above the knee. The right thigh had a 3/4 by 2 fluid filled shallow, blister above the knee. Both arms were red from the top of the hands to the just below the elbow. The following morning, 07/04/15, the Pharmacist reported that he checked R #1. Staff indicated that R #1 was more lethargic than usual. Registered Nurse #3 (RN, who is also the wound care nurse), removed R #1's bandages and the Pharmacist also stated that he saw multiple small blisters had developed on the R #1's left arm and edema was accumulating around the elbow area. The Pharmacist also noticed increased blistering to the left thigh and the fluid filled area on the right thigh expanded to doubled, maybe tripled in size. Labs were ordered (at 9:30 am) and results indicated renal function decline, dehydration, low sodium, and an increase in potassium. The Pharmacist reviewed the situation with the Facility's Medical Director, and sent R #1 to the local Hospital's emergency room . G. On 07/09/15 at 4:45 pm during an interview with Recreational Worker (RW) #1, he recalled that at 2 pm, on 07/03/15, he had started an activity of popcorn and movies with the residents in the dining room. During hydration time (between 3:10 pm to 3:15 pm) he noticed that R#1 was sitting out in the courtyard. He approached R #1 and called him by name. R #1 did not respond. He noticed that the R #1's arms were real red. His shirt was wet from sweat and slobber and the wheelchair was hot to the touch. He brought R #1 inside, again attempted to get a response from the resident. RW #1 called for help over his radio. According to Recreational Worker #1, Some CNAs (unidentifed) responded immediately, as well as RN #3. H. On 07/14/15 at 12:00 pm, during interview, The Facility Investigator (FI) stated R #6 opened the door for R #1 to go out in the court yard. R #1 propelled himself to a tree by the entrance to the courtyard, where there was shade at that time. R #1 appeared to have fallen asleep and was there by the tree for two hours. During that time the sun had shifted exposing R #1 to the sun. At about 3:00 pm, RW #1 notice R #1 out in the courtyard. When RW #1 approached R #1 he was unresponsive. RW #1 wheeled R #1 into the multi-purpose room and called for assistance. CNAs #1 and #3 responded. They immediately called for the nurse. RN #3 and Lead Aid #1 assisted R #1 to his room and began treatment. Staff are supposed to do hourly checks on all residents and R #1 was out there for 2 hours. CNA #2 had marked on the computer that she had done her hourly checks, but she had marked on the wrong resident. The investigation suggests neglect due to no performing hourly checks. I. Record review of the Point of Care Audit form dated 07/03/15, revealed that at 11:43 am, Certified Nursing Assistant (CNA) #1 documented that she had conducted hourly checks on R #1 at 10:00 am, 11:00 am, and 12:00 pm. At 2:30 pm, CNA #2 documented that she had conducted hourly checks on R #1 at 1:00 pm and 2:00pm. CNA #1 documented that she had conducted the 3:00 pm check on R #1 and documented it at 2:31 pm. J. On 07/14/15 at 3:42 pm, during interview, CNA #3 stated that R #1 was assigned to CNA #2. She further stated that all residents are on hourly checks and that the hourly checks are documented on the computer. K. On 07/14/15 at 3:46 pm, during interview, CNA #1 revealed that she and CNA #3 were walking out of a resident's room when RW #1 called for help. They went to the multi-purpose room to help. When they got to R #1, he was sitting down in his wheelchair with his head down. He had saliva running down his shirt and he was not responsive. Red from elbow to top of hands mid-thigh to knee. We were going to start to wheel down to his room, but the nurse and lead aid meet us and took him to his room. CNA #1 left the resident with RN #3 and Lead Aid #1. When she returned, they were getting R #1 undressed and trying to give him fluids. L. On 07/14/15 at 4:00 pm, during interview, CNA #2 stated she was helping with R #2 (R #1 roommate) when I looked over and thought it was strange he (R #1) was not there because he usually takes a nap after lunch. When asked about documenting the hourly checks for R #1, she responded that all residents are on hourly checks and added I don't think it (the hourly check marked on the electronic chart) was for the right resident. I honestly do not know. We were really busy that day. M. Record Review of the 07/03/15 at 07:57 pm revealed the following 1510 called STAT (immediately) to (location). (Name of R #1) in w/c (wheelchair), not responding to verbal stimuli. Recreation worker had gone into (name of) Courtyard to offer him fluids and found him unresponsive, very red and with rapid breathing and so brought him indoors. Arms/hands and bilateral anterior (front) thighs are red, hot to touch. Blood sugar 321. VS (vital signs) 98.6 (temperature)-92 (heart Rate)-18 (respiratory)-81/54 (blood Pressure). Clinician in house (Dr.of Pharmacy) and called to room to assess. Thin layer of skin peeling above left knee. Skin pulled back together and Silvadene applied per noted orders--to apply generously to all areas of redness . (Name of RN #3) N. Record Review of the 07/04/15 Progress Note at 1:15 am revealed the following COMMUNICATION - with Family/NOK/POA Son called, informed of . Resident s/p sunburn through clothing this afternoon. L. knee lesion appears as abrasion less than 2 sq (square) inches. R knee lesion blister formed did not break as of yet, approximately 2 sq inches in size. At time resident discovered in sun, clothes removed and cold compress applied . (name of Pharmacist) O. Record Review of the Progress Notes dated 07/04/15 at 1:31 pm revealed the following: Health Status Note . (Name of resident #1) more lethargic this day . Clinician in this a.m. and order for CBC (complete blood count) and CMP (comprehensive metabolic panel test for bodies overall chemical balance and metabolism) obtained, noted. Drawn and sent to lab at 9:30 am. Results reviewed by clinician. WBC (white blood count) 15 (low 3.8; high 10.4), Na (sodium) 128 (low 136; high 145), K+ (potassium) 5.4 (low 3.5; high 5.1) with multiple other abnormals. Output via Foley catheter is decreased, 200ml on noc (night) shift and less than 100 so far today. Refusing fluids at 1100. Wound care done to anterior (front) thighs and upper extremities, measurements taken. Multiple blistered areas on thighs and left upper extremity . Order received and noted to send to (name of hospital) for eval via ambulance, Eval burns and metabolic status . (name of R #1) left facility via stretcher at 1300 . (name of RN #3) P. Record review of the Report from (name of hospital) emergency room [DATE] at 1:42 pm, revealed the following Burn from Sun Exposure. Not alert. In distress. Sepsis screen is positive, infection was suspected . Physical Assessment . Right forearm: 1st degree burn, tenderness, swelling and [DIAGNOSES REDACTED] (reddening of the skin). Left forearm: 1st degree superficial burn . Right thigh: Large 2nd degree partial thickness burn to anterior (front) aspect of the right thigh . Left thigh: 2nd degree partial thickness burn the anterior aspect of the left thigh . Right knee: 2nd degree partial thickness burn . Left knee: 2nd degree partial thickness burn . Skin: . He has multiple blisters (intact) located on the right forearm, right wrist and right hand, right thigh and right knee and left forearm, left wrist and left hand and thigh and left knee (sic) . Q. Record review of the Laboratory - Comparative Report (done at local hospital) dated 07/04/15 at 2:01 pm revealed that R #1's BUN (Blood Urea Nitrogen an indicator of dehydration) was 39 (low 7; high 18). R. Record Review of the facility's Progress Notes dated 07/04/15 at 4:38 pm revealed the following Health Status Note . Resident w/ (with) increased lethargy today, lab to eval (evaluate) metabolic status s/p (status [REDACTED]. L (left) arm with edema, minimal blisters with minimal thickness able to be assessed totaling less than 2inches. R (right) arm with no blistering present, decreased reddened areas. R thigh above knee blister has expanded minimal thickness also measured 9 x 14 cm (centimeters). Surrounding tissue appears stable. L knee open area static w/ yesterday approximately 2 inches, significant blisters surrounding open area . (Name of RN #1) S. Record review of the facility investigation Dated 07/10/15 revealed the following: 1. During interview, CNA #1 stated when she was assisting another resident in (name of R #1's) room she noticed he was not in his room on his bed around 12:30 to 1:00 and went to look for him. She added that this was odd because he usually returns to his room to go to bed . 2. Administrative Summary: . resident sustained [REDACTED]. Based on the information gathered, staff appeared to have failed to complete a one-hour check while resident was outside in the (hot)weather. There is a discrepancy in the charting and the actual occurrence of checks. Investigation status: Based on all information present, it is more than likely that neglect did occur . Signed (name of Aministrator)

Based on video observation, record review and interview, the facility failed to ensure that 1 (#1) of 10 (#'1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) sampled residents were provided the necessary care. Resident # 1 suffered a [MEDICAL CONDITION] and during the [MEDICAL CONDITION], fell to the floor head first from his wheel chair. Licensed Practical Nurse (LPN) #3 and the Registered Nurse (RN) Supervisor failed to perform an appropriate assessment on the resident and moved him from the floor to his wheel chair without any support given to the neck and spine. The resident was transferred to the Emergency Department (ED) of the local hospital where it was discovered that the resident had a crushed C1 vertebrae. This failed practice had the potential to result in residents having falls and not be assessed properly or at all for unseen injuries. The findings are: A. During an observation of the video clip recorded on the evening of [DATE] at 6:35 pm, it shows resident #1 in the multipurpose room sitting in his wheel chair. He was at the table next to the window facing out toward the turtle pond. The RA gave resident #1 a bag of popcorn and he begins to maneuver himself away from the table. The RA left the room and came back with a broom and sets the broom aside. She noticed that resident #1 was in his wheel chair and his left arm went out away from his body and his whole body began to twitch. She looked at him and walked out of the room. While she was out of the room resident #1 continued to seize and then fell head first out of the wheel chair to the floor. He landed on his left side. 1. The RA was viewed coming back up the hall toward the multipurpose room with the Charge Nurse LPN #3 of F unit for that night. When they arrived to the room, resident #1 was on the floor and continued to have [MEDICAL CONDITION] activity. LPN #3 was observed to go over to where resident #1's head was and put a hand on the resident's shoulder. He picked up the seat cushion from the floor and place the cushion under the resident's head. The RA began to sweep up the popcorn that had spilled on to the floor. LPN #3 left the room. 2. He returned to the room. The lead Certified Nursing Assistant (CNA) #9 came into the room shortly after the LPN. CNA #9 moved the wheel chair away from the resident. 3. The RN Supervisor arrived and CNA #10 shortly behind her. There was some conversation between the RN Supervisor and the LPN. They moved to different areas around resident #1. The RN Supervisor was observed to place the resident's Foley bag on the floor. She straightened out his legs and she lifted and swung the residents legs to the right of her. LPN #3 was positioned at the head. The RN Supervisor moved to the right side and behind the resident. Lead CNA #9 moved to the front of the resident. CNA #10 moved to behind the wheel chair and kept it in place. 4. The RN Supervisor was observed moving the resident's hips to place him in a sitting position. The resident was lifted into his wheel chair by the RN Supervisor and LPN #3 with their arms under the residents arm pits. There was no support observed given to the head or neck. 5. Once in the chair, resident #1's head was hung down. The RN Supervisor pulled out a pocket light from her pocket and looked at the resident's eyes. Resident #1 was wheeled to his room. 6. He was sent to the local hospital's ED where he died later that evening. B. Review of a copy of the Radiology Report from the hospital dated [DATE] read as follows: "There is an acute (having severe symptoms and a short course), mildly comminuted (broken or crushed into small pieces) and displaced [MEDICAL CONDITION] of C1(a ring of bone between the skull and the vertebrae column; first cervical vertebra) in the anterior ( situated before or toward the front) aspect of both sides of the midline and the bases of the posterior (situated behind) arch bilaterally (two sides). There is mild focal prevertebral [MEDICAL CONDITION] (soft tissue swelling). There is significant pannus (an [MEDICAL CONDITION] fluid overlying [DIAGNOSES REDACTED] cell) formation around the dens (a tooth like structure projecting upward from the body of the axis around which the atlas rotates) with dens erosion but no dens fracture. No other fractures are noted ...Impression: 1. Acute mildly comminuted and displaced Jefferson fracture (a fracture characterized by the bursting of the first cervical vertebra) involving the anterior and posterior aspects of the C1 ring." The physician's report from the ED dated [DATE] revealed that resident #1, " pronounced dead by me at approximately 2310 (11:10 pm). Impression: Cardiorespiratory arrest with death, contributing factors being urinary tract infection, C-spine fracture, probable [MEDICAL CONDITION]." C. Record review of resident #1's Record of admitted d [DATE], revealed that the resident was admitted to the facility on [DATE] with primary admitting [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. The discharge summery was also included on the admission form with a discharge date of [DATE] at 6:45 pm by ambulance because his condition had worsened. The primary [DIAGNOSES REDACTED]. D. On [DATE] at 2:45 pm, during an interview, the physician stated that he received a call from the nurse at 7:00 pm to 7:30 pm, "It was before sundown." He was asked if he had viewed the video and he responded, "Yes." The physician was asked if he noted if there had been an assessment. He said, "It is difficult to assess a resident while on the floor. You can observe them (staff) asking him (resident#1) questions. There was no assessment of bone placement." The physician was asked what he thought the cause of death to be and he stated, "The opinion is that he had [DIAGNOSES REDACTED] and continued [MEDICAL CONDITION] activity. Mortality is very high among people who are in continuos [MEDICAL CONDITION] activity. Cause of death was several contributing factors: #1. Lead to [DIAGNOSES REDACTED], melanoma in the brain metastasize. #2. C1 fracture caused by fall. There was severe [MEDICAL CONDITION] according to the x-ray." E. On [DATE] at 8:45 am, during an interview, LPN #4 stated that she had worked at the facility for 5 years as a charge nurse on F unit. She was asked how to perform an assessment. She stated, "You have to lay hands on to check skin integrity and range of motion. You have to call the RN Supervisor and do the assessment together." She stated the # 1 priority is to protect resident. "At no cost do you leave the resident. Screaming at top of lungs your lungs and hold on to the resident from behind." F. On [DATE] at 8:50 am, during an interview, LPN #5 stated that she had been at the facility for 5 years and worked on C unit. She was asked what to do in an emergency where a resident is in a chair and begins to have a [MEDICAL CONDITION]. She stated that you protect the resident. "Wrap your arms around the resident from behind and yell for help. When the RN Supervisor arrives then a hands on assessment needs to be done. Look at skin integrity and range of motion, bone placement." G. On [DATE] at 9:00 am, during an interview, the Director of Nursing (DON) stated that she was here the night of the incident. She did watch the video and stated she could not believe how the nurses and staff responded to the incident. She stated, "When someone is having a [MEDICAL CONDITION] you know they are going to be dead weight and hit the floor hard. The nurses surprised me. No hands on assessment. They looked like they were just having a conversation." She was asked how staff are trained to respond to residents who experience a [MEDICAL CONDITION]. She stated that the staff are trained to allow the resident to finish the [MEDICAL CONDITION]. "They should check the pulse, breathing, look for fractures." She stated that she expected both of the nurses to handle the situation a lot better than they did. She stated that she did not expect them to pick him up and have his head "bobble all over." The nurses should have done a hands on assessment and waited for the ambulance to pick him up where he was." H. On [DATE] at 9:53 am, during an interview, LPN #3 was asked what he remembered about the incident on [DATE]. "Activities care worker hollered down hall and I was doing the med (medication) pass. When I got to the multipurpose room, he was having grand mal [MEDICAL CONDITION]. I slide the cushion under his head. I did not lift his head." He was asked about the RA coming all the way up to him rather than yelling down the hall at him. He stated that she got mid way in the hall of F unit and was yelling something, but he was unable to hear her because "it gets very loud that time of night." He was asked if he had a radio. He said that he did not have a radio because there is "poor communication." He stated that the ones that he had were "staticy." He said that he does not carry a radio in the med room because of "poor reception." He went back to when he put the cushion under the resident's head. He stated that the VA (Veterans Administration) report stated that he lifted the head. He said, "I did not lift his head. I just slipped the cushion under his head because he was laying on his shoulder. I saw blood in his mouth. The resident was stiff and rigid, his whole arm was under him and it left enough space to slide the cushion under his head." He said that he went to get the house RN as per the facility rules. He stated, "The house RN that night had been there for [AGE] years and she comes and does the physical assessment. I told a tech (CNA) to go find the house RN. I went back to the residents side. Two other techs were off unit. The house RN came and assessed him. She wanted him rolled over and sat up she assessed for a broken hip." He was asked how she did the assessment. He said, "I don't know if she put hands on or not during her assessment. I can't remember if she touched him or not. You can do it visually to see if bones are in place. He stayed very rigid the whole time. When he was sat up, I noticed a light abrasion on his head. He was rigid even when we put him in the bed. He was not sitting well in the wheel chair. I lifted based on the house RN saying it was ok. LPN's don't do assessments. We always refer to the house RN. Three of us took him to his room, two staff were pushing and I was ahead and walking along side. No one had hands on the resident. I touched the resident two times, one time was from the floor to the wheel chair and one from the bed to the ambulance gurney." He was asked if he had ever seen this resident have a [MEDICAL CONDITION]. He replied, "I never seen him in a [MEDICAL CONDITION] before. I don't think he had a [DIAGNOSES REDACTED]. He stated that at 7:30 pm the ambulance arrived and the resident was still having a [MEDICAL CONDITION]. He said they placed an IV (intravenous) line and gave him medicine, that seemed to help. "He was still blowing (breathing heavy) real heavy." The LPN was asked if there was any other assessment done once in the room. He stated that they did do a blood pressure and he noticed a skin tear to the left elbow. He said that he noted three injuries, the skin tear to the left elbow, the blood in the mouth and the light abrasion to the head. He was asked if he had received any trainings prior to the incident. He stated that he had not had any trainings. He stated that when the ambulance took the resident away, "He was alive and kicking." I. On [DATE] at 10:30 am, during an interview, the RN Supervisor stated that she had been a nurse since 1984 and had been at the facility since 2008. She was asked what she recalled about the incident of [DATE]. She stated that at 6:45 pm she was called on the phone at the desk on E unit and was informed that there was a fall in the multipurpose room. She went to the multipurpose room and the LPN from F unit was already there. "He said the resident had had a [MEDICAL CONDITION]." She said that she assessed him and he looked like he was in post [MEDICAL CONDITION] status and had no apparent injury. She said that she asked the LPN and CNA to put him in his chair and take him back to his room. She said, "I checked neuro's (combing form denoting nerve, nerve tissue and nervous system) and he was fine." She said that once the resident was sat up, she noticed the skin tear. She said that she left to call the doctor. She said that the doctor said to transfer the resident to the local hospital. She said that she proceeded to get the paperwork ready for the ambulance. When asked how she assessed the resident she said that she looked at him. She said that she looked for deformities or abnormal positioning. She stated that she could not remember if she laid hands on the resident. She was asked where everyone was positioned when they lifted the resident to the wheel chair. She stated the LPN was on the left and the CNA was at the feet, she was on the right side. She said that she could not remember if anyone was at the head and shoulders. She was asked about when she checked his neuro's. She stated that she checked him when they got him in the wheelchair. "He was post [MEDICAL CONDITION] status and unresponsive and his pupils were sluggish (slow to respond) but responsive." She said that she noted that his range of motion was adequate. She was asked how she knew that without putting hands on the resident. She said, "By sitting him in the wheelchair, that movement seemed adequate." She then said that the LPN noticed a slight discoloration on the top of the forehead. She was asked if that was the first time she realized that he fell out of the wheelchair. She stated, "I don't know if that was there before the [MEDICAL CONDITION] or after. There was no redness or swelling." She said that she called the doctor and told him that the resident had a [MEDICAL CONDITION] and an apparent fall. She said that the staff got the blood pressure and it was elevated so she told the staff to take it again manually. Then she said she called the hospital and the resident's daughter. She said that the ambulance arrived, they started an IV and gave the resident some [MEDICATION NAME]. The resident stopped having a [MEDICAL CONDITION] once the [MEDICATION NAME] was given. She was asked if she had received any trainings in dealing with this type situation. She said that she had the basic protocol, try to keep the resident from injury. She said that you can't do much about the resident biting their tongue. She said that she had never witnessed the resident having a [MEDICAL CONDITION] and she did not know the characteristics. She said that she knew he had the [DIAGNOSES REDACTED]. She said that she did not know that the resident at been left alone at any time during the incident.

This is a repeat deficiency. Based on video observation , record review and interview, the facility failed to ensure that 1 (#1) of 10 (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) sampled residents was kept safe while having a seizure and then fell head first onto the floor. The resident was observed to be having a seizure in the multipurpose room while sitting in his wheelchair. The Recreation Aide (RA) observed the resident having a seizure. She left the multipurpose room leaving the resident alone. While she was out of the room, resident #1 fell head first onto the floor. This failed practice had the potential to result in residents being observed in a serious situation and being left alone and sustaining other injuries. The findings are: A. During an observation of the video clip recorded on the evening of 06/12/12 at 6:35 pm, revealed resident #1 in the multipurpose room sitting in his wheelchair. He was at the table next to the window facing out toward the turtle pond. The RA gave resident #1 a bag of popcorn and he begins to maneuver himself away from the table. The RA left the room and came back with a broom and sets the broom aside. She noticed that resident #1 was in his wheelchair and his left arm went out away from his body and his whole body began to twitch. She looked at him and walked out of the room. While she was out of the room resident #1 continued to seize and then fell head first out of the wheelchair to the floor. He landed on his left side. On a separate camera the RA was viewed going down the hall of F unit, she was seen to stop and pause looking back into the multipurpose room at the same time the resident fell out of his chair. She proceeded to walk up to somebody at the nurses' station which was in the middle of the unit. B. Review of a copy of the Radiology Report from the hospital dated 06/12/12 read as follows: "There is an acute (having severe symptoms and a short course), mildly comminuted (broken or crushed into small pieces) and displaced fracture of the ring of C1 (a ring of bone between the skull and the vertebrae column; first cervical vertebra) in the anterior ( situated before or toward the front) aspect of both sides of the midline and the bases of the posterior (situated behind) arch bilaterally (two sides). There is mild focal prevertebral edema (soft tissue swelling). There is significant pannus (an inflammatory fluid overlying [DIAGNOSES REDACTED] cell) formation around the dens (a tooth like structure projecting upward from the body of the axis around which the atlas rotates) with dens erosion but no dens fracture. No other fractures are noted ...Impression: 1. Acute mildly comminuted and displaced Jefferson fracture (a fracture characterized by the bursting of the first cervical vertebra) involving the anterior and posterior aspects of the C1 ring." The physician's report from the ED dated 06/13/12 revealed that resident #1, " pronounced dead by me at approximately 2310 (11:10 pm). Impression: Cardiorespiratory arrest with death, contributing factors being urinary tract infection, C-spine fracture, probable metastatic cancer." C. Record review of resident #1's Record of admitted d 09/29/09, revealed that the resident was admitted to the facility on [DATE] with primary admitting [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. The discharge summery was also included on the admission form with a discharge date of [DATE] at 6:45 pm by ambulance because his condition had worsened. The primary [DIAGNOSES REDACTED]. D. Review of the trainings for the staff involved in the incident revealed that the RA was also a Certified nursing Assistant (CNA) and was certificated since 03/09/11. She received in-service training in fall prevention on 11/15/11. E. On 06/25/12 at 245 pm, during an interview, the physician stated that he received a call from the nurse at 7:00 pm to 7:30 pm, "It was before sundown." He stated that he was told that the resident was postictal (occurring after a sudden attack or stroke, as an epileptic seizure...) in his bed. "He was apparently having residual seizure activity." He was told that the resident was unconscious. He said that he inquired as to what had happened. He was told that the resident had fallen out of his chair in the multipurpose room. "They stated that he had a grand mal seizure." The nurse reported that the resident had a bump or hematoma on the head. "They said pretty big. I told them to call 911 and send him to the hospital." The physician was asked if he had seen the video of the incident and he said yes. He was asked if the incident had been handled appropriately. He stated, "No, it was not handled well. The staff should have stayed by the patient and asked for help." He stated that while the resident was having a seizure they could not restrain him but they could have kept him from falling out of his chair. F. On 07/25/12 at 8:55 am, during an interview, CNA #1 stated that she had been a CNA at the facility for about 4 months and worked day shift. She was asked what to do if a resident is in a chair and starts to have a seizure. She stated that, "You wrap your arms around them and call out for a nurse. Do not leave them alone." She stated that she had just reasonably gone through a training. G. On 07/25/12 at 9:00 am, during an interview. Clerk #2 on D unit was asked what do the clerks do if there is a cry out for help. She stated, "You are to run and help as you can. Wait for staff to arrive and once they get there wait to get the word from the doctor or nurse to clear out. Go back to the desk and help from there by calling whoever they need." H. On 07/25/12 at 10:53 am, during an interview, CNA #7 on B unit stated that she had been a CNA at the facility for 2 years. She was asked what would she do if a resident were to have a seizure in a chair. She stated, "You stay with the resident and call out for a nurse. Yell out for a nurse. You try and hold on to them." When asked when her last training was, she stated that she had just gone through the training. I. On 07/25/12 at 2:08 pm, during an interview, Clerk #8 on the E unit stated that she came in one day after lunch and saw a resident start to fall out of his chair. She said she ran in and grabbed him and yelled out for a nurse "stat (immediately)." She was asked if she heard someone cry out for help what would she do. She stated that she would call overhead for help. She was asked when she went through her last training and she stated that she had just gone through all the trainings. J. On 07/25/12 at 4:11 pm, during an interview, the RA stated that she had been a RA for about a year. She also stated that she was a CNA. "It is required that you be a CNA before you become a Rec. Aide." She was asked what she remembered about the incident on the evening of 06/12/12. She stated that she had 6 to 8 residents watching the movie and she had sat down to watch the movie with them. She stated that one resident had spilt his popcorn and she went to get the broom and dust pan from the sports bar. When she returned, she noticed the resident was having a seizure. She said that she went to the F unit to get LPN #3. She stated when they came into the room together the resident was already on the floor. She said the RN (Registered Nurse) Supervisor came in with a CNA. She stated there were no staff present when the resident fell . She said that there was blood coming out of his mouth. She was asked about the training she had received prior to the incident. The RA stated that the training she received, "was to be sure that the resident was safe in their environment and if there is an incident get the RN." She was asked if she would do anything different and she said that she would have stayed with the resident. K. On 07/26/12 at 9:00 am, during an interview, CNA #6 stated that he has been a CNA at the facility for 21/2 years. Was asked what to do in the event of an emergency in the sports bar area. He stated that if he hears yelling in the sports bar he would tell the resident to stay where they and call for a nurse. "Protect the resident. When the nurse assesses and gives the ok, then I will help the resident up." He was asked if he sees a resident having a seizure in their room what would he do. "Yell for help and wrap arms around them from behind." L. On 07/26/12 at 9:00 am, during an interview, the Director of Nursing (DON) stated that she was here the night of the incident. She did watch the video and stated she could not believe how the nurses and staff responded to the incident. She stated, "when someone is having a seizure you know they are going to be dead weight and hit the floor hard. The one employee (RA) should have never left. She stated that the resident should never have been left alone. "She (RA) should have stayed with the resident and yelled out for help. That is the training."

Based on video observation, record review and interview the facility failed to ensure that the policies and procedures for neglect were implemented for 1 (#1) of 10 (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) sampled residents . Resident #1 was in the Multipurpose Room and when the resident began to have a [MEDICAL CONDITION], the Recreational Aide (RA) left him alone. While he was left alone, the resident fell on to the floor head first. The Registered Nurse (RN) Supervisor and the Charge Nurse, who was a License Practical Nurse (LPN) #3, proceeded to pick the resident up and place him back in his wheelchair without doing a full assessment or supporting his head and neck. The resident was taken to the Emergency Department (ED) at the local hospital where he later died that evening. The failed practice of this deficiency had the potential to effect residents by allowing resident to be neglected and go against the policy and procedure of the facility. The findings are: A. During an observation of the video clip recorded on the evening of [DATE] at 6:35 pm, revealed resident #1 in the multipurpose room sitting in his wheelchair. He was at the table next to the window facing out toward the turtle pond. The RA gave resident #1 a bag of popcorn and he begins to maneuver himself away from the table. The RA left the room and came back with a broom and sets the broom aside. She noticed that resident #1 was in his wheelchair and his left arm went out away from his body and his whole body began to twitch. She looked at him and walked out of the room. While she was out of the room resident #1 continued to seize and then fell head first out of the wheelchair to the floor. He landed on his left side. 1. On a separate camera the RA was viewed going down the hall of F unit, she was seen to stop and pause looking back into the multipurpose room at the same time the resident fell out of his chair. She proceeded to walk up to somebody at the nurses' station which was in the middle of the unit. 2. The RA was viewed coming back up the hall toward the multipurpose room with the Charge Nurse, LPN #3 of F unit for that night. When they arrived to the room, resident #1 was on the floor and continued to have [MEDICAL CONDITION] activity. LPN #3 was observed to go over to where resident #1's head was and put a hand on the resident's shoulder. He picked up the seat cushion from the floor and placed the cushion under the resident's head. The RA began to sweep up the popcorn that had spilled on to the floor. The LPN left the room. 3. He returned to the room. The lead Certified Nursing Assistant (CNA) #9 came into the room shortly after the LPN. CNA #9 moved the wheelchair away from the resident. 4. The RN Supervisor arrived and CNA #10 shortly behind her. There was some conversation between the RN Supervisor and LPN #3. They moved to different areas around resident #1. The RN Supervisor was observed to place the resident's Foley bag out on the floor. She straightened out his legs and she lifted and swung the residents legs to the right of her. The LPN was positioned at the head which became the left side of the resident when he was sat up. The RN Supervisor moved to the right side and behind the resident. Lead CNA #9 moved to the front of the resident. CNA #10 moved behind the wheelchair and held it in place. 5. The RN Supervisor was observed moving the resident's hips to place him in a sitting position. The resident was lifted into his wheelchair by the RN Supervisor and LPN #3 with their arms under the residents arm pits. There was no support observed given to the head or neck. 6. Once in the chair, resident #1's head was hung down. The RN Supervisor pulled out a pocket light from her pocket and looked at the resident's eyes. Resident #1 was wheeled to his room. 7. He was sent to the local hospital's ED where he died later that evening. B. Review of a copy of the Radiology Report from the hospital dated [DATE] read as follows: "There is an acute (having severe symptoms and a short course), mildly comminuted (broken or crushed into small pieces) and displaced [MEDICAL CONDITION] of C1 (a ring of bone between the skull and the vertebrae column; first cervical vertebra) in the anterior (situated before or toward the front) aspect of both sides of the midline and the bases of the posterior (situated behind) arch bilaterally (two sides). There is mild focal prevertebral [MEDICAL CONDITION] (soft tissue swelling). There is significant pannus (an [MEDICAL CONDITION] fluid overlying [DIAGNOSES REDACTED] cell) formation around the dens (a tooth like structure projecting upward from the body of the axis around which the atlas rotates) with dens erosion but no dens fracture. No other fractures are noted ...Impression: 1. Acute mildly comminuted and displaced Jefferson fracture (a fracture characterized by the bursting of the first cervical vertebra) involving the anterior and posterior aspects of the C1 ring." The physician's report from the ED dated [DATE] revealed that resident #1, "pronounced dead by me at approximately 2310 (11:10 pm). Impression: Cardiorespiratory arrest with death, contributing factors being urinary tract infection, C-spine fracture, probable [MEDICAL CONDITION]." C. Record review of resident #1's Record of admitted d [DATE], revealed that the resident was admitted to the facility on [DATE] with primary admitting [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. The discharge summery was also included on the admission form with a discharge date of [DATE] at 6:45 pm by ambulance because his condition had worsened. The primary [DIAGNOSES REDACTED]. D. Review of the facility's policies and procedures number ADM 01:016, Resident Rights: Freedom from Accident, Injury, Abuse, Neglect, and Exploitation Investigation dated [DATE] and a revision date of [DATE] revealed "...(name of facility) will ensure all staff are aware of their responsibility in identifying, responding to, reporting accidents, injuries, abuse, neglect and exploitation;... Neglect means...: 1. The failure to provide any treatment, service, care, medications or items that is necessary to maintain the health and safety of a resident; 2. The failure to take any reasonable precaution that is necessary to prevent harm to the health and safety of a resident, or; 3. The failure to carry out a duty to supervise properly or control the provision of any treatment, care, goods, service or medication necessary to maintain the health or safety of a resident." E. On [DATE] at 2:45 pm, during an interview, the physician stated that he received a call from the nurse at 7:00 pm to 7:30 pm, "It was before sundown." He stated that he was told that the resident was postictal (occurring after a sudden attack or stroke, as an epileptic [MEDICAL CONDITION]) in his bed. "He was apparently having residual [MEDICAL CONDITION] activity." He was told that the resident was unconscious. He said that he inquired as to what had happened. He was told that the resident had fallen out of his chair in the multipurpose room. "They stated that he had a grand mal [MEDICAL CONDITION]." The nurse reported that the resident had a bump or hematoma on the head. "They said pretty big. I told them to call 911 and send him to the hospital." The physician was asked if he had seen the video of the incident and he said yes. He was asked if the incident had been handled appropriately. He stated, "No, it was not handled well. The staff should have stayed by the patient and asked for help." He stated that while the resident was having a [MEDICAL CONDITION] they could not restrain him but they could have kept him from falling out of his chair. The physician was asked if he noted if there had been an assessment. He said, "It is difficult to assess a resident while on the floor. You can observe them (staff) asking him (resident#1) questions. There was no assessment of bone placement. The assessment occurred more when he was in bed." The physician was asked what he thought the cause of death to be and he stated, "The opinion is that he had [DIAGNOSES REDACTED] and continued [MEDICAL CONDITION] activity. Mortality is very high among people who are in continuos [MEDICAL CONDITION] activity. Cause of death was several contributing factors: #1. Lead to [DIAGNOSES REDACTED], melanoma in the brain metastasize. #2. C1 fracture caused by fall. There was severe [MEDICAL CONDITION] according to the x-ray." F. On [DATE] at 4:11 pm, during an interview, the RA stated that she had been a RA for about a year. She also stated that she was a CNA. "It is required that you be a CNA before you become a Rec. Aide." She was asked what she remembered about the incident on the evening of [DATE]. She stated that she had 6 to 8 residents watching the movie and she had sat down to watch the movie with them. She stated that one resident had spilt his popcorn and she went to get the broom and dust pan from the sports bar. When she returned, she noticed the resident was having a [MEDICAL CONDITION]. She said that she went to the F unit to get the LPN. She stated when they came into the room together the resident was already on the floor. Then she said the RN Supervisor came in and a CNA. She stated no staff was present when the resident fell . She said that there was blood coming out of his mouth. She said everyone looked at him for a few seconds and then picked him up and put him in his chair. She stated that they wheeled him back to his room. She said that she stayed in the multipurpose room. She said that she filled out the incident report. She stated that the training she received prior to the incident was to be sure that the resident was safe in their environment and and if there is an incident get the RN. She said that was about 2 years ago and that was all she remembered. She stated, "At the time I panicked. I was thinking about his safety but I guess I did not do the right thing." She was asked if there was something she could have done differently. She stated that the LPN put the pillow under his head. She said that his breathing sounded like snoring and thought he went to sleep while lying on the floor. She said that she had no training in CPR, falls or [MEDICAL CONDITION]. She also said that she was never assigned a radio and no one had ever told her to carry a radio with her. There were a couple of radios in the recreational department, but no one had told her to have one with her. She was asked if she would do anything different and she said that she would have stayed with the resident. G. On [DATE] at 9:53 am, during an interview, LPN #3 was asked what he remembered about the incident on [DATE]. "Activities care worker hollered down hall and I was doing the med (medication) pass. When I got to the multipurpose room, he was having grand mal [MEDICAL CONDITION]. I slide the cushion under his head. I did not lift his head." He was asked about the RA coming all the way up to him rather than yelling down the hall at him. He stated that she got mid way in the hall of F unit and was yelling something, but he was unable to hear her because "it gets very loud that time of night." He was asked if he had a radio. He said that he did not have a radio because there is "poor communication." He stated that the ones that he had were "staticy." He said that he does not carry a radio in the med room because of "poor reception." He went back to when he put the cushion under the resident's head. He stated that the VA (Veterans Administration) report stated that he lifted the head. He said, "I did not lift his head. I just slipped the cushion under his head because he was laying on his shoulder. I saw blood in his mouth. The resident was stiff and rigid, his whole arm was under him and it left enough space to slide the cushion under his head." He said that he went to get the RN as per the facility rules. He stated, "The RN that night had been there for [AGE] years and she comes and does the physical assessment. I told a tech (CNA) to go find the RN. I went back to the residents side. Two other techs were off unit. The RN came and assessed him. She wanted him rolled over and sat up she assessed for a broken hip." He was asked how she did the assessment. He said, "I don't know if she put hands on or not during her assessment. I can't remember if she touched him or not. You can do it visually to see if bones are in place. He stayed very rigid the whole time. When he was sat up, I noticed a light abrasion on his head. He was rigid even when we put him in the bed. He was not sitting well in the wheelchair. I lifted based on the RN saying it was ok. LPN's don't do assessments. We always refer to the RN. Three of us took him to his room, two staff were pushing and I was ahead and walking along side. No one had hands on the resident. I touched the resident two times, one time was from the floor to the wheelchair and one from the bed to the ambulance gurney." He was asked if he had ever seen this resident have a [MEDICAL CONDITION]. He replied, "I never seen him in a [MEDICAL CONDITION] before. I don't think he had a [DIAGNOSES REDACTED]. He stated that at 7:30 pm the ambulance arrived and the resident was still having a [MEDICAL CONDITION]. He said they placed an IV (intravenous) line and gave him medicine, that seemed to help. "He was still blowing (breathing heavy) real heavy." The LPN was asked if there was any other assessment done once in the room. He stated that they did do a blood pressure and he noticed a skin tear to the left elbow. He said that he noted three injuries, the skin tear to the left elbow, the blood in the mouth and the light abrasion to the head. He was asked if he had received any trainings prior to the incident. He stated that he had not had any trainings. He stated that when the ambulance took the resident away, "He was alive and kicking." H. On [DATE] at 10:30 am, during an interview, the RN Supervisor stated that she had been a nurse since 1984 and had been at the facility since 2008. She was asked what she recalled about the incident of [DATE]. She stated that at 6:45 pm she was called on the phone at the desk on E unit and was informed that there was a fall in the multipurpose room. She went to the multipurpose room and the LPN from F unit was already there. "He said the resident had had a [MEDICAL CONDITION]." She said that she assessed him and he looked like he was in post [MEDICAL CONDITION] status and had no apparent injury. She said that she asked the LPN and CNA to put him in his chair and take him back to his room. She said, "I checked neuro's (combing form denoting nerve, nerve tissue and nervous system) and he was fine." She said that once the resident was sat up, she noticed the skin tear. She said that she left to call the doctor. She said that the doctor said to transfer the resident to the local hospital. She said that she proceeded to get the paperwork ready for the ambulance. When asked how she assessed the resident, she said that she looked at him. She said that she looked for deformities or abnormal positioning. She stated that she could not remember if she laid hands on the resident. She was asked where everyone was positioned when they lifted the resident to the wheelchair. She stated the LPN was on the left and the CNA was at the feet, she was on the right side. She said that she could not remember if anyone was at the head and shoulders. She was asked about when she checked his neuro's. She stated that she checked him when they got him in the wheel chair. "He was post [MEDICAL CONDITION] status and unresponsive and his pupils were sluggish (slow to respond) but responsive." She said that she noted that his range of motion was adequate. She was asked how she knew that without putting hands on the resident. She said, "By sitting him in the wheel chair, that movement seemed adequate." She then said that the LPN noticed a slight discoloration on the top of the forehead. She was asked if that was the first time she realized that he fell out of the wheel chair. She stated, "I don't know if that was there before the [MEDICAL CONDITION] or after. There was no redness or swelling." She said that she called the doctor and told him that the resident had a [MEDICAL CONDITION] and an apparent fall. She said that the staff got the blood pressure and it was elevated so she told the staff to take it again manually. Then she said she called the hospital and the resident's daughter. She said that the ambulance arrived, they started an IV and gave the resident some [MEDICATION NAME]. The resident stopped having a [MEDICAL CONDITION] once the [MEDICATION NAME] was given. She was asked if she had received any trainings in dealing with this type situation. She said that she had the basic protocol, try to keep the resident from injury. She said that you can't do much about the resident biting their tongue. She said that she had never witnessed the resident having a [MEDICAL CONDITION] and she did not know the characteristics. She said that she knew he had the [DIAGNOSES REDACTED]. She said that she did not know that the resident had been left alone at any time during the incident. I. On [DATE] at 9:00 am, during an interview, the Director of Nursing (DON) stated that she was here the night of the incident. She did watch the video and stated she could not believe how the nurses and staff responded to the incident. She stated, "when someone is having a [MEDICAL CONDITION] you know they are going to be dead weight and hit the floor hard. The one employee (RA) should have never left. The nurses surprised me. No hands on assessment. They looked like they were just having a conversation." She was asked how staff are trained to respond to residents who experience a [MEDICAL CONDITION]. She stated that the staff are trained to allow the resident to finish the [MEDICAL CONDITION]. "They should check the pulse, breathing, look for fractures." She stated that she expected both of the nurses to handle the situation a lot better than they did. She stated that she did not expect them to pick him up and have his head "bobble all over." When asked if all RAs were expected to go through CNA training, she stated, "Yes. All Rec. Aides are to be CNAs except one and she has been here long before that was a rule." She was asked how should have responded to the incident. She stated that the resident should never have been left alone. "She (RA) should have stayed with the resident and yelled out for help. That is the training. The nurses should have done a hands on assessment and waited for the ambulance to pick him up where he was." She further stated that nurses and Certified Medication Aids are supposed to carry radios and the nurse should have been carrying one that night also.

Based on video observation, record review and interview the facility failed to ensure that 1 (#1) resident of 10 (#'s 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) sampled residents remained free of neglect. Resident #1 was in the Multipurpose Room and when the resident began to have a [MEDICAL CONDITION], the Recreational Aide (RA) left him alone. While he was left alone, the resident fell on to the floor head first. The Registered Nurse (RN) Supervisor and the Charge Nurse, who was a Licensed Practical Nurse (LPN) #3, proceeded to pick the resident up and place him back in his wheelchair without doing a full assessment or supporting his head and neck. The resident was taken to the Emergency Department (ED) at the local hospital where he later died that evening. This failed practice had the potential to result in other residents with a [DIAGNOSES REDACTED]. The findings are: A. During an observation of the video clip recorded on the evening of [DATE] at 6:35 pm, revealed resident #1 in the multipurpose room sitting in his wheelchair. He was at the table next to the window facing out toward the turtle pond. The RA gave resident #1 a bag of popcorn and he begins to maneuver himself away from the table. The RA left the room and came back with a broom and sets the broom aside. She noticed that resident #1 was in his wheelchair and his left arm went out away from his body and his whole body began to twitch. She looked at him and walked out of the room. While she was out of the room resident #1 continued to seize and then fell head first out of the wheelchair to the floor. He landed on his left side. 1. On a separate camera the RA was viewed going down the hall of F unit, she was seen to stop and pause looking back into the multipurpose room at the same time the resident fell out of his chair. She proceeded to walk up to somebody at the nurses' station which was in the middle of the unit. 2. The RA was viewed coming back up the hall toward the multipurpose room with the Charge Nurse, LPN #3 of F unit for that night. When they arrived to the room, resident #1 was on the floor and continued to have [MEDICAL CONDITION] activity. LPN #3 was observed to go over to where resident #1's head was and put a hand on the resident's shoulder. He picked up the seat cushion from the floor and placed the cushion under the resident's head. The RA began to sweep up the popcorn that had spilled on to the floor. The LPN left the room. 3. He returned to the room. The lead Certified Nursing Assistant (CNA) #9 came into the room shortly after the LPN. CNA #9 moved the wheelchair away from the resident. 4. The RN Supervisor arrived and CNA #10 shortly behind her. There was some conversation between the RN Supervisor and LPN #3. They moved to different areas around resident #1. The RN Supervisor was observed to place the resident's Foley bag out on the floor. She straightened out his legs and she lifted and swung the residents legs to the right of her. The LPN was positioned at the head which became the left side of the resident when he was sat up. The RN Supervisor moved to the right side and behind the resident. Lead CNA #9 moved to the front of the resident. CNA #10 moved behind the wheelchair and held it in place. 5. The RN Supervisor was observed moving the resident's hips to place him in a sitting position. The resident was lifted into his wheelchair by the RN Supervisor and LPN #3 with their arms under the residents arm pits. There was no support observed given to the head or neck. 6. Once in the chair, resident #1's head was hung down. The RN Supervisor pulled out a pocket light from her pocket and looked at the resident's eyes. Resident #1 was wheeled to his room. 7. He was sent to the local hospital's ED where he died later that evening. B. Review of a copy of the Radiology Report from the hospital dated [DATE] read as follows: "There is an acute (having severe symptoms and a short course), mildly comminuted (broken or crushed into small pieces) and displaced [MEDICAL CONDITION] of C1 (a ring of bone between the skull and the vertebrae column; first cervical vertebra) in the anterior (situated before or toward the front) aspect of both sides of the midline and the bases of the posterior (situated behind) arch bilaterally (two sides). There is mild focal prevertebral [MEDICAL CONDITION] (soft tissue swelling). There is significant pannus (an [MEDICAL CONDITION] fluid overlying [DIAGNOSES REDACTED] cell) formation around the dens (a tooth like structure projecting upward from the body of the axis around which the atlas rotates) with dens erosion but no dens fracture. No other fractures are noted ...Impression: 1. Acute mildly comminuted and displaced Jefferson fracture (a fracture characterized by the bursting of the first cervical vertebra) involving the anterior and posterior aspects of the C1 ring." The physician's report from the ED dated [DATE] revealed that resident #1, "pronounced dead by me at approximately 2310 (11:10 pm). Impression: Cardiorespiratory arrest with death, contributing factors being urinary tract infection, C-spine fracture, probable [MEDICAL CONDITION]." C. Record review of resident #1's Record of admitted d [DATE], revealed that the resident was admitted to the facility on [DATE] with primary admitting [DIAGNOSES REDACTED]. Secondary admitting [DIAGNOSES REDACTED]. The discharge summary was also included on the admission form with a discharge date of [DATE] at 6:45 pm by ambulance because his condition had worsened. The primary [DIAGNOSES REDACTED]. D. Review of the trainings for the staff involved in the incident revealed that the RA was also a CNA and was certificated since [DATE]. She received in-service training in fall prevention on [DATE], emergency preparedness on [DATE], incident management/ prevention of abuse on [DATE] and basic cardiac life support/cardiopulmonary resuscitation (BCLS/CPR) was good until [DATE]. 1. LPN #3 received in-service training for emergency preparedness on [DATE] with a retraining date of [DATE], fall prevention on [DATE] with a retraining date of [DATE], incident management/prevention of abuse on [DATE] with a retraining date of [DATE], and BCLS/CPR was good until [DATE]. 2. The RN Supervisor received in-service trainings for BCLS/CPR and was good for [DATE]. E. Review of the facility's policies and procedures number ADM 01:016, Resident Rights: Freedom from Accident, Injury, Abuse, Neglect, and Exploitation Investigation dated [DATE] and a revision date of [DATE] revealed "...(name of facility) will ensure all staff are aware of their responsibility in identifying, responding to, reporting accidents, injuries, abuse, neglect and exploitation;... Neglect means...: 1. The failure to provide any treatment, service, care, medications or items that is necessary to maintain the health and safety of a resident; 2. The failure to take any reasonable precaution that is necessary to prevent harm to the health and safety of a resident, or; 3. The failure to carry out a duty to supervise properly or control the provision of any treatment, care, goods, service or medication necessary to maintain the health or safety of a resident." F. On [DATE] at 2:45 pm, during an interview, the physician stated that he received a call from the nurse at 7:00 pm to 7:30 pm, "It was before sundown." He stated that he was told that the resident was postictal (occurring after a sudden attack or stroke, as an epileptic [MEDICAL CONDITION]) in his bed. "He was apparently having residual [MEDICAL CONDITION] activity." He was told that the resident was unconscious. He said that he inquired as to what had happened. He was told that the resident had fallen out of his chair in the multipurpose room. "They stated that he had a grand mal [MEDICAL CONDITION]." The nurse reported that the resident had a bump or hematoma on the head. "They said pretty big. I told them to call 911 and send him to the hospital." The physician was asked if he had seen the video of the incident and he said yes. He was asked if the incident had been handled appropriately. He stated, "No, it was not handled well. The staff should have stayed by the patient and asked for help." He stated that while the resident was having a [MEDICAL CONDITION] they could not restrain him but they could have kept him from falling out of his chair. The physician was asked if he noted if there had been an assessment. He said, "It is difficult to assess a resident while on the floor. You can observe them (staff) asking him (resident#1) questions. There was no assessment of bone placement. The assessment occurred more when he was in bed." The physician was asked what he thought the cause of death to be and he stated, "The opinion is that he had [DIAGNOSES REDACTED] and continued [MEDICAL CONDITION] activity. Mortality is very high among people who are in continuos [MEDICAL CONDITION] activity. Cause of death was several contributing factors: #1. Lead to [DIAGNOSES REDACTED], melanoma in the brain metastasize. #2. C1 fracture caused by fall. There was severe [MEDICAL CONDITION] according to the x-ray." G. On [DATE] at 4:11 pm, during an interview, the RA stated that she had been a RA for about a year. She also stated that she was a CNA. "It is required that you be a CNA before you become a Rec. Aide." She was asked what she remembered about the incident on the evening of [DATE]. She stated that she had 6 to 8 residents watching the movie and she had sat down to watch the movie with them. She stated that one resident had spilt his popcorn and she went to get the broom and dust pan from the sports bar. When she returned, she noticed the resident was having a [MEDICAL CONDITION]. She said that she went to the F unit to get the LPN. She stated when they came into the room together the resident was already on the floor. Then she said the RN Supervisor came in and a CNA. She stated no staff was present when the resident fell . She said that there was blood coming out of his mouth. She said everyone looked at him for a few seconds and then picked him up and put him in his chair. She stated that they wheeled him back to his room. She said that she stayed in the multipurpose room. She said that she filled out the incident report. She stated that the training she received prior to the incident was to be sure that the resident was safe in their environment and and if there is an incident get the RN. She said that was about 2 years ago and that was all she remembered. She stated, "At the time I panicked. I was thinking about his safety but I guess I did not do the right thing." She was asked if there was something she could have done differently. She stated that the LPN put the pillow under his head. She said that his breathing sounded like snoring and thought he went to sleep while lying on the floor. She said that she had no training in CPR, falls or [MEDICAL CONDITION]. She also said that she was never assigned a radio and no one had ever told her to carry a radio with her. There were a couple of radios in the recreational department, but no one had told her to have one with her. She was asked if she would do anything different and she said that she would have stayed with the resident. H. On [DATE] at 9:53 am, during an interview, LPN #3 was asked what he remembered about the incident on [DATE]. "Activities care worker hollered down hall and I was doing the med (medication) pass. When I got to the multipurpose room, he was having grand mal [MEDICAL CONDITION]. I slide the cushion under his head. I did not lift his head." He was asked about the RA coming all the way up to him rather than yelling down the hall at him. He stated that she got mid way in the hall of F unit and was yelling something, but he was unable to hear her because "it gets very loud that time of night." He was asked if he had a radio. He said that he did not have a radio because there is "poor communication." He stated that the ones that he had were "staticy." He said that he does not carry a radio in the med room because of "poor reception." He went back to when he put the cushion under the resident's head. He stated that the VA (Veterans Administration) report stated that he lifted the head. He said, "I did not lift his head. I just slipped the cushion under his head because he was laying on his shoulder. I saw blood in his mouth. The resident was stiff and rigid, his whole arm was under him and it left enough space to slide the cushion under his head." He said that he went to get the RN as per the facility rules. He stated, "The RN that night had been there for [AGE] years and she comes and does the physical assessment. I told a tech (CNA) to go find the RN. I went back to the residents side. Two other techs were off unit. The RN came and assessed him. She wanted him rolled over and sat up she assessed for a broken hip." He was asked how she did the assessment. He said, "I don't know if she put hands on or not during her assessment. I can't remember if she touched him or not. You can do it visually to see if bones are in place. He stayed very rigid the whole time. When he was sat up, I noticed a light abrasion on his head. He was rigid even when we put him in the bed. He was not sitting well in the wheel chair. I lifted based on the RN saying it was ok. LPN's don't do assessments. We always refer to the RN. Three of us took him to his room, two staff were pushing and I was ahead and walking along side. No one had hands on the resident. I touched the resident two times, one time was from the floor to the wheelchair and one from the bed to the ambulance gurney." He was asked if he had ever seen this resident have a [MEDICAL CONDITION]. He replied, "I never seen him in a [MEDICAL CONDITION] before. I don't think he had a [DIAGNOSES REDACTED]. He stated that at 7:30 pm the ambulance arrived and the resident was still having a [MEDICAL CONDITION]. He said they placed an IV (intravenous) line and gave him medicine, that seemed to help. "He was still blowing (breathing heavy) real heavy." The LPN was asked if there was any other assessment done once in the room. He stated that they did do a blood pressure and he noticed a skin tear to the left elbow. He said that he noted three injuries, the skin tear to the left elbow, the blood in the mouth and the light abrasion to the head. He was asked if he had received any trainings prior to the incident. He stated that he had not had any trainings. He stated that when the ambulance took the resident away, "He was alive and kicking." I. On [DATE] at 10:30 am, during an interview, the RN Supervisor stated that she had been a nurse since 1984 and had been at the facility since 2008. She was asked what she recalled about the incident of [DATE]. She stated that at 6:45 pm she was called on the phone at the desk on E unit and was informed that there was a fall in the multipurpose room. She went to the multipurpose room and the LPN from F unit was already there. "He said the resident had had a [MEDICAL CONDITION]." She said that she assessed him and he looked like he was in post [MEDICAL CONDITION] status and had no apparent injury. She said that she asked the LPN and CNA to put him in his chair and take him back to his room. She said, "I checked neuro's (combing form denoting nerve, nerve tissue and nervous system) and he was fine." She said that once the resident was sat up, she noticed the skin tear. She said that she left to call the doctor. She said that the doctor said to transfer the resident to the local hospital. She said that she proceeded to get the paperwork ready for the ambulance. When asked how she assessed the resident, she said that she looked at him. She said that she looked for deformities or abnormal positioning. She stated that she could not remember if she laid hands on the resident. She was asked where everyone was positioned when they lifted the resident to the wheelchair. She stated the LPN was on the left and the CNA was at the feet, she was on the right side. She said that she could not remember if anyone was at the head and shoulders. She was asked about when she checked his neuro's. She stated that she checked him when they got him in the wheelchair. "He was post [MEDICAL CONDITION] status and unresponsive and his pupils were sluggish (slow to respond) but responsive." She said that she noted that his range of motion was adequate. She was asked how she knew that without putting hands on the resident. She said, "By sitting him in the wheelchair, that movement seemed adequate." She then said that the LPN noticed a slight discoloration on the top of the forehead. She was asked if that was the first time she realized that he fell out of the wheelchair. She stated, "I don't know if that was there before the [MEDICAL CONDITION] or after. There was no redness or swelling." She said that she called the doctor and told him that the resident had a [MEDICAL CONDITION] and an apparent fall. She said that the staff got the blood pressure and it was elevated so she told the staff to take it again manually. Then she said she called the hospital and the resident's daughter. She said that the ambulance arrived, they started an IV and gave the resident some [MEDICATION NAME]. The resident stopped having a [MEDICAL CONDITION] once the [MEDICATION NAME] was given. She was asked if she had received any trainings in dealing with this type situation. She said that she had the basic protocol, try to keep the resident from injury. She said that you can't do much about the resident biting their tongue. She said that she had never witnessed the resident having a [MEDICAL CONDITION] and she did not know the characteristics. She said that she knew he had the [DIAGNOSES REDACTED]. She said that she did not know that the resident had been left alone at any time during the incident. J. On [DATE] at 9:00 am, during an interview, the Director of Nursing (DON) stated that she was here the night of the incident. She did watch the video and stated she could not believe how the nurses and staff responded to the incident. She stated, "when someone is having a [MEDICAL CONDITION] you know they are going to be dead weight and hit the floor hard. The one employee (RA) should have never left. The nurses surprised me. No hands on assessment. They looked like they were just having a conversation." She was asked how staff are trained to respond to residents who experience a [MEDICAL CONDITION]. She stated that the staff are trained to allow the resident to finish the [MEDICAL CONDITION]. "They should check the pulse, breathing, look for fractures." She stated that she expected both of the nurses to handle the situation a lot better than they did. She stated that she did not expect them to pick him up and have his head "bobble all over." When asked if all RAs were expected to go through CNA training, she stated, "Yes. All Rec. Aides are to be CNAs except one and she has been here long before that was a rule." She was asked how should have responded to the incident. She stated that the resident should never have been left alone. "She (RA) should have stayed with the resident and yelled out for help. That is the training. The nurses should have done a hands on assessment and waited for the ambulance to pick him up where he was." She further stated that nurses and Certified Medication Aids are supposed to carry radios and the nurse should have been carrying one that night also.

Based on record review and interview, the facility failed to implement procedures preventing neglect of residents for 1 (#37) of 6 (#16, 37, 71, 94, 111, 118) sampled residents evaluated for accident prevention, resulting in an injury to that resident. Resident # 37 sustained second [MEDICAL CONDITION] both knees after receiving a whirlpool bath in water exceeding safe temperatures. The facility procedure set a maximum safe temperature of 110 degrees Fahrenheit (F), but the facility hot water logs documented a temperature of 130 degrees F on the week of the incident. This failed practice likely caused burn injuries to Resident #37 and had the potential to [MEDICAL CONDITION] others who may use the whirlpool bath. The findings are: A. Review of facility policy, Resident Rights Regarding Accidents, Injuries, Abuse, Neglect and Exploitation, effective 07/01/99 and last revised 07/01/01, revealed the following: 1. Under Purpose, the policy documented, "It is the purpose of this policy to establish a policy regarding accidents, injuries, abuse, neglect and exploitation of residents ... Residents have a right to be protected from unreasonable risks to their personal safety and welfare." 2. Under Applicability, the policy documented, "This policy applies to all volunteers, residents, visitors ... and staff of (facility name)." 3. Under Definitions, the policy defined "neglect" as including, "The failure to take any reasonable precaution that is necessary to prevent harm to the health and safety of a resident." 4. Under Definitions, the policy defined "staff" as meaning, "Any person hired or appointed to any position at (facility name), whether a permanent, probationary, term, temporary, seasonal or part time status employee ..." B. Review of Resident #37's undated Record of Admission revealed the resident was admitted for long term care services on 11/29/06 with a [DIAGNOSES REDACTED]. C. Review of a Facility Emergency Resident Discharge/Transfer Form dated 06/05/12, for Resident #37, revealed the resident was transferred to Hospital #1 "per family request" on 06/05/12 at 1:45 pm. D. Review of Hospital #1's Emergency Medical Service (EMS) Report dated 06/05/12, for Resident #37, revealed the resident was received by the ambulance at 2:09 pm, transported to the hospital and received by the hospital at 2:23 pm. Under, "Narrative," the report documented, "per staff, pt (patient) has wounds on his lower legs that appeared yesterday morning. The staff member described them as 'blisters' ... Staff member also stated that from the last dressing change she did yesterday to the first one she did today the wounds appear to have worsened." E. Review of Hospital #1's physician progress notes [REDACTED]. 10% circumferential (extending around the circumference of the leg)[MEDICAL CONDITION] lower ext. (extremities) ~10% TBA (Total Burn Area) each leg for 20% TBA." F. Review of Hospital #1's Emergency Department report for 06/05/12, for Resident #37, revealed, "This is a [AGE] year old male that was transported to the Emergency Department at (name of Hospital #1) via Ground EMS with a history of possible burn wounds to both lower extremities. Reportedly, the patient was given hot water bath Sunday evening (06/03/12) and subsequently developed extensive burn wounds to the lower extremities and left forearm and anterior (front) chest. I did speak with (name of Physician #1) ... (name of Physician #1) said that he was also concerned that the patient's wounds were hot water burns, and he did do an investigation interviewing the attendant who gave the patient a bath; it can not be conclusively determined that these were hot [MEDICAL CONDITION](sic) wounds as opposed to an alternative etiology (cause) ... at any rate, (name of Physician #1) and I discussed the case and we felt that these were most likely burn wounds, presumptively accidental, ..." Under Diagnosis, the report documented, "Presumptive burn wounds to both lower extremities, left forearm and anterior chest." Under Plan, the report documented, "The case was also discussed with (name of Physician #3), (name of Hospital #2) Trauma Center and Burn Center on-call physician who accepted this case for transfer ... The patient was transferred to (name of Hospital #2) to care of (name of Physician #3)." G. Review of a Hospital #2 History and Physical (H&P) dated 06/05/12, for Resident #37, revealed, "The patient was transferred from (name of Hospital #1) on 06/05/12 ... due to the fact that he had sustained bilateral lower extremity circumferential [MEDICAL CONDITION] are likely deep partial thickness in nature. The injury was said to occur the evening of Sunday June 3rd." Under Skin, the H&P documented,"Had a bilateral lower extremity circumferential deep partial [MEDICAL CONDITION](sic). It had a moist base and reddish with areas of white appearance to the burned areas. [MEDICATION NAME] desquamation (peeling of the outermost layer of skin) was evident." Under Assessment, the H&P documented, "the case of a [AGE] year-old male transferred from (name of facility) to (name of Hospital #1) and then to (name of Hospital #2) for bilateral lower extremity circumferential [MEDICAL CONDITION] approximately 15% total body surface area and seemed to be deep partial thickness with a concomitant (accompanying or concurrent) finding of some systemic rash ..." H. During an interview on 06/06/12 at 11:45 am, the Facility Investigator was asked who else received whirlpool baths. She stated Resident #94 was also receiving whirlpool baths. I. During an interview with the Medical Director on 06/06/12 at 11:50 am, he stated, "At the time they took him out of the whirlpool, there was no redness. There was a redness on Monday with blisters to feet. On day two, redness had diminished but blistering had increased to upper torso. The blisters would pop and the tissue underneath looked healthy." He states,"redness and blistering wax (increase) and wane (decrease). On the first day,[DIAGNOSES REDACTED] (redness of the skin) was to arms and torso to about 10% of (sic) body. At first we were treating it as a burn. On the next day I thought it was something else because of the increasing of blisters." He stated, "I talked with family regarding what was going on and it was thought that something else was going on." The Medical Director stated that the resident had always been non-responsive and that the resident has advanced dementia. J. During an interview with Certified Nursing Assistant (CNA) #20 on 06/07/12 at 2:10 pm he stated, "With (name of Resident #37), after you give him a shower or whirlpool, his skin is always red." When asked how hot the water was, he stated, "The temperature of the water was probably 98 degrees (F); the gauge is next to the nozzle, so I looked at that". He also stated, "I have no idea how hot it can get. The hottest I've ever seen it go was maybe 102 (degrees F)." CNA #20 was asked, when he noticed the blisters on Resident #37. He responded, "(name of Resident #37) is so tall, when I get him out of bed I have to completely remove the covers, and at first glance I thought it (blister leakage) was urine at the foot of his bed. Monday morning is when I discovered the blisters; he had a bath the night before. When I saw the blisters I notified my house RN (Registered Nurse, RN #11)." K. During a follow-up interview with CNA #20 on 06/07/12 at 3:45 pm, when asked if the whirlpool was filled with water first or if Resident #37 was assisted into the tub first, CNA #20 stated, "I put him in the tub then started the water. I adjusted the valve with my foot, you have to adjust the water with the valve on the floor. The one that adjusts the hot and cold doesn't work and you have to adjust them from the floor." When asked what the temperature of the water was, CNA #20 stated, "When the water was filling up I tested it, it felt warm to the touch with the back of my hand. I did look at the thermometer and it read 98 degrees (F). (Name of Resident #37) was in the tub for no more than 30 minutes." He then stated, "The faucet is at the foot of the tub, when I turned the shower head on, the water was hot, so I had to readjust it." L. During an interview with CNA #21 on 06/07/12 at 2:31 pm, he stated, "I worked with him (Resident #37) the following morning on Monday. It was brought to my attention when (name of CNA #20) came and got me to go to his bedside, he and (name of RN #10) were getting ready to get him (Resident #37) up out of bed. That's when I saw the blisters for the first time on his feet and ankles. They were from the calf down, there were several blisters. Some were small and some were big water blisters, none on his torso." When asked how hot the whirlpool water normally is, he stated "I check the thermometer to see how hot the hot water is and it usually goes to 110." When asked if he had any in-service training on how to operate the whirlpool, he stated, "It was about 8 months ago, we're instructed to let the temp (temperature) go to no more than a 100 unless the resident specifies. You always ask them, 'does it feel ok, too cold? or too warm?' (name of Resident #37) is unable to communicate what's a comfortable temperature, so in that case we have a thermometer that hangs in the tub. So I'll stick my forearm in it because the hands will lie to us, they take a lower temp. So I'll rely on my forearm to see if its comfortable and that's usually around 96 (degrees F)." M. During an interview with RN #10 on 06/07/12 at 2:43 pm, she stated "When they went to get him up the next morning, Monday, to get him ready for breakfast, I hadn't noticed them (blisters) the night before. The previous night I didn't work with him. They (blisters) were located on the lower legs, some of them were large. He didn't have any other blisters besides the legs." When asked how often Resident #37 was receiving whirlpool baths, she stated "(name of Resident #37), was getting them 3 times a week, and before that he's never had blisters. The blisters didn't seem to be spreading." N. On 06/11/12 at 5:20 pm, observation of the facility Unit D whirlpool tub in the company of the facility Safety Officer revealed a whirlpool tub connected by a pair of flexible hoses to two water pipes coming up from the floor. The tub had two built-in control handles: one controlled the flow of water to the tub, the other controlled water to a separate hose with a shower-head. The handle controlling flow of water to the tub controlled flow rate only; there was no apparent way to increase or decrease the water temperature using the tub's controls. At the attachment of the tub's inlet hoses to the floor water pipes, the pipes from the floor each had a ball valve controlled by an on/off lever. Testing revealed it was possible to turn the levers by bumping them with a foot. O. Review of the whirlpool tub's service manual, dated 02/03/00, revealed that the tub was a Parker series 420 whirlpool tub. Review of the service manual revealed that the tub contained a built-in mixing valve which mixed hot water and cold water brought in by the flexible inlet hoses, delivering the water to pipes controlled by the two tub control handles. However, the unit contained no mechanism to block the flow of hot water if the cold water hose was not providing cold water; effective temperature control required that the unit receive a constant supply of both hot water and cold water to the mixing valve. P. Review of the facility maintenance investigation report, dated 06/05/12, revealed documentation of checks of temperatures at various locations around the facility along with the statement, "At this time (9:45 am) staff member name (name of CNA # 21) came in to the w/pool (whirlpool) room and asked what I was doing. I said checking the water temp. (Name of CNA # 21) then said if you want hot water you have to turn these on and off. He then went to proceed to turn off the ball valves on the floor." Q. Review of the Safety/Loss Control Procedure Statement, Water Temperature Procedure, dated 06/30/03, revealed the instruction, "General facility water temperatures shall be checked at least on a monthly basis to ensure water temperatures do not exceed 110 degrees Fahrenheit. Documentation shall be maintained by the Maintenance Department." R. On 06/12/12, review of the facility Equipment Room Inspection logs revealed water temperature entries for an "H-1 Dom (Domicile) Water Heater" and an "H-2 Dom Water Heater." On the form, the entries were preceded by the guidance, "Water Temp = 110 Deg. (degrees) F". Review of the hot water temperature entries for April 2012 revealed the following: 1. For April 2012, on "Week-1", the H-1 water heater was off, and the H-2 water heater was delivering at 127 degrees F. 2. For April 2012, on "Week-2", no water temperature was recorded. 3. For April 2012, on "Week-3", the H-1 water heater was off, and the H-2 water heater was delivering at 131 degrees F. 4. For April 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 132 degrees F. 5. For April 2012, on "Week-5", the H-1 water heater was off, and the H-2 water heater was delivering at 130 degrees F. 6. On the last sheet of the Equipment Room Inspection log for April 2012, a handwritten entry documented, "04-03-12 - Plant Storage Tank 127 @ 0800; A-upper 118; B-unit 118; C-unit 118; D-unit 117; E-unit 118; F-unit 117." S. On 06/12/12, review of the facility Equipment Room Inspection logs for May 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For May 2012, on "Week-1", the H-1 water heater was delivering at 136 degrees F., and the H-2 water heater was off. 2. For May 2012, on "Week-2", the H-1 water heater was off, and the H-2 water heater was delivering at 133 degrees F. 3. For May 2012, on "Week-3", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. 4. For May 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 125 degrees F. 5. For May 2012, on "Week-5", the H-1 water heater was delivering at 129 degrees F., and the H-2 water heater was off. T. On 06/12/12, review of the facility Equipment Room Inspection logs for June 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For June 2012, on "Week-1", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. A handwritten note above the temperature entry dated the entry as, "06-04". 2. For June 2012, on "Week-2", the H-1 water heater was delivering at 111 degrees F., and the H-2 water heater was off. U. On 06/12/12 at 9:00 am, during an interview with the facility Maintenance Director and Maintenance Supervisors #1 and #2, the Maintenance Director identified the "H-1" and "H-2 Dom Water Heater" entries on the Equipment Room Inspection logs as documenting the hot water temperatures for the water heaters serving the resident hot water system. He was asked to describe the facility hot water system; he stated that the facility had two water heaters, one of which was operating at any given time while the other was available as back-up. When asked how he set water temperatures for the facility resident fixtures, he stated, "It's what we set it at the plant (the facility hot water plant)." He stated that on 06/04/12, the H-1 water heater was operating; he identified the 130-degree temperature reading as the temperature of the H-1 water heater on that date. When asked about the temperatures at the resident hot water fixtures, Maintenance Supervisor #2 stated, "What we normally try to do is keep it (the hot water temperature) at 110 throughout the facility. To achieve that temp (temperature), we have to set it at 130 (degrees F) at the boiler (water heater)." When asked about the circuit of the hot water line through the facility, the Maintenance Director stated, "It goes to A upper (the upstairs A-wing, an assisted living facility) , it goes to B (resident wing B), C (resident wing C), and then it goes through a booster pump to push it down D, E, and F (resident wings D, E, and F)." When asked about tracking of water temperatures, he stated, "The only regular temperatures that we monitor are at the tank. Those are inspected daily but not documented on the log. Weekly, they are documented on a log." When asked whether he documented temperatures at resident fixtures, he stated, "No. We do monthly rounds with safety (the facility safety officer), and we check random temps then, but we don't document it on the sheet." V. On 06/12/12 at 9:27 am, a test of the hot water temperature at various resident-accessible sinks, showers, and tubs was conducted by Maintenance Supervisors #1 and #2 with facility thermometers and in the presence of the surveyor to establish the degree of temperature drop between the water heater and the resident rooms and other resident-accessible hot water sources. The test revealed hot water temperatures dropped no more than 8 degrees between the hot water heaters and the various resident-accessible fixtures. 1. On 06/12/12 at 9:27 am, observation of the facility water heaters with Maintenance Supervisors #1 and #2 revealed the active hot water heater was delivering hot water at 110.8 degrees F. When asked about a mixing valve, Maintenance Supervisor #1 reported there was none; he stated that the temperature of the hot water heater was set directly. 2. At 9:32 am, test of the hot water temperature at the sink in resident room B9 revealed a temperature of 108 degrees F. 3. At 9:45 am, test of the hot water temperature at the sink in the resident public restroom serving the B-wing revealed a temperature of 104 degrees F. 4. At 9:50 am, test of the hot water temperature at the sink in the C-wing resident dining room revealed a temperature of 106 degrees F. 5. At 9:55 am, test of the hot water temperature at the sink in resident room C6 revealed a temperature of 106 degrees F. 6. At 10:00 am, test of the hot water temperature at the shower in the C-unit shower room revealed a temperature of 104 degrees F. 7. At 10:12 am, test of the hot water temperature at the sink in resident room D11 revealed a temperature of 102 degrees F. 8. At 10:15 am, test of the hot water temperature at the sink in resident room E2 revealed a temperature of 102 degrees F. 9. At 10:18 am, test of the hot water temperature at the sink in the resident public restroom serving the E-wing revealed a temperature of 102 degrees F. 10. At 10:23 am, repeat observation of the facility boilers with Maintenance Supervisors #1 and #2 revealed the active boiler was delivering hot water at 110.7 degrees F.

Based on record review and interview, the facility failed to provide an environment that was free from hazards that resulted in an injury to 1 (#37) of 6 (#16, 37, 71, 94, 111, 118) sampled residents evaluated for accident prevention. Resident # 37 sustained second degree burns below both knees after receiving a whirlpool bath in water exceeding safe temperatures. The facility procedure set a maximum safe temperature of 110 degrees Fahrenheit (F), but the facility hot water logs documented a temperature of 130 degrees F on the week of the incident. This failed practice likely caused burn injuries to Resident #37 and had the potential to cause burns to others who may use the whirlpool bath. The findings are: A. Review of Resident #37's undated Record of Admission revealed the resident was admitted for long term care services on 11/29/06 with a [DIAGNOSES REDACTED]. B. Review of a Facility Emergency Resident Discharge/Transfer Form dated 06/05/12, for Resident #37, revealed the resident was transferred to Hospital #1 "per family request" on 06/05/12 at 1:45 pm. C. Review of Hospital #1's Emergency Medical Service (EMS) Report dated 06/05/12, for Resident #37, revealed the resident was received by the ambulance at 2:09 pm, transported to the hospital and received by the hospital at 2:23 pm. Under, "Narrative," the report documented, "per staff, pt (patient) has wounds on his lower legs that appeared yesterday morning. The staff member described them as 'blisters' ... Staff member also stated that from the last dressing change she did yesterday to the first one she did today the wounds appear to have worsened." D. Review of Hospital #1's physician progress notes [REDACTED]. 10% circumferential (extending around the circumference of the leg) burns both lower ext. (extremities) ~10% TBA (Total Burn Area) each leg for 20% TBA." E. Review of Hospital #1's Emergency Department report for 06/05/12, for Resident #37, revealed, "This is a [AGE] year old male that was transported to the Emergency Department at (name of Hospital #1) via Ground EMS with a history of possible burn wounds to both lower extremities. Reportedly, the patient was given hot water bath Sunday evening (06/03/12) and subsequently developed extensive burn wounds to the lower extremities and left forearm and anterior (front) chest. I did speak with (name of Physician #1) ... (name of Physician #1) said that he was also concerned that the patient's wounds were hot water burns, and he did do an investigation interviewing the attendant who gave the patient a bath; it can not be conclusively determined that these were hot water burns (sic) wounds as opposed to an alternative etiology (cause) ... at any rate, (name of Physician #1) and I discussed the case and we felt that these were most likely burn wounds, presumptively accidental, ..." Under Diagnosis, the report documented, "Presumptive burn wounds to both lower extremities, left forearm and anterior chest." Under Plan, the report documented, "The case was also discussed with (name of Physician #3), (name of Hospital #2) Trauma Center and Burn Center on-call physician who accepted this case for transfer ... The patient was transferred to (name of Hospital #2) to care of (name of Physician #3)." F. Review of a Hospital #2 History and Physical (H&P) dated 06/05/12, for Resident #37, revealed, "The patient was transferred from (name of Hospital #1) on 06/05/12 ... due to the fact that he had sustained bilateral lower extremity circumferential scald burns which are likely deep partial thickness in nature. The injury was said to occur the evening of Sunday June 3rd." Under Skin, the H&P documented,"Had a bilateral lower extremity circumferential deep partial thickness burns (sic). It had a moist base and reddish with areas of white appearance to the burned areas. Epidermal desquamation (peeling of the outermost layer of skin) was evident." Under Assessment, the H&P documented, "the case of a [AGE] year-old male transferred from (name of facility) to (name of Hospital #1) and then to (name of Hospital #2) for bilateral lower extremity circumferential scald burns over approximately 15% total body surface area and seemed to be deep partial thickness with a concomitant (accompanying or concurrent) finding of some systemic rash ..." G. During an interview on 06/06/12 at 11:45 am, the Facility Investigator was asked who else received whirlpool baths. She stated Resident #94 was also receiving whirlpool baths. H. During an interview with the Medical Director on 06/06/12 at 11:50 am, he stated, "At the time they took him out of the whirlpool, there was no redness. There was a redness on Monday with blisters to feet. On day two, redness had diminished but blistering had increased to upper torso. The blisters would pop and the tissue underneath looked healthy." He states,"redness and blistering wax (increase) and wane (decrease). On the first day,[DIAGNOSES REDACTED] (redness of the skin) was to arms and torso to about 10% of (sic) body. At first we were treating it as a burn. On the next day I thought it was something else because of the increasing of blisters." He stated, "I talked with family regarding what was going on and it was thought that something else was going on." The Medical Director stated that the resident had always been non-responsive and that the resident has advanced dementia. I. During an interview with Certified Nursing Assistant (CNA) #20 on 06/07/12 at 2:10 pm he stated, "With (name of Resident #37), after you give him a shower or whirlpool, his skin is always red." When asked how hot the water was, he stated, "The temperature of the water was probably 98 degrees (F); the gauge is next to the nozzle, so I looked at that". He also stated, "I have no idea how hot it can get. The hottest I've ever seen it go was maybe 102 (degrees F)." CNA #20 was asked, when he noticed the blisters on Resident #37. He responded, "(name of Resident #37) is so tall, when I get him out of bed I have to completely remove the covers, and at first glance I thought it (blister leakage) was urine at the foot of his bed. Monday morning is when I discovered the blisters; he had a bath the night before. When I saw the blisters I notified my house RN (Registered Nurse, RN #11)." J. During a follow-up interview with CNA #20 on 06/07/12 at 3:45 pm, when asked if the whirlpool was filled with water first or if Resident #37 was assisted into the tub first, CNA #20 stated, "I put him in the tub then started the water. I adjusted the valve with my foot, you have to adjust the water with the valve on the floor. The one that adjusts the hot and cold doesn't work and you have to adjust them from the floor." When asked what the temperature of the water was, CNA #20 stated, "When the water was filling up I tested it, it felt warm to the touch with the back of my hand. I did look at the thermometer and it read 98 degrees (F). (Name of Resident #37) was in the tub for no more than 30 minutes." He then stated, "The faucet is at the foot of the tub, when I turned the shower head on, the water was hot, so I had to readjust it." K. During an interview with CNA #21 on 06/07/12 at 2:31 pm, he stated, "I worked with him (Resident #37) the following morning on Monday. It was brought to my attention when (name of CNA #20) came and got me to go to his bedside, he and (name of RN #10) were getting ready to get him (Resident #37) up out of bed. That's when I saw the blisters for the first time on his feet and ankles. They were from the calf down, there were several blisters. Some were small and some were big water blisters, none on his torso." When asked how hot the whirlpool water normally is, he stated "I check the thermometer to see how hot the hot water is and it usually goes to 110." When asked if he had any in-service training on how to operate the whirlpool, he stated, "It was about 8 months ago, we're instructed to let the temp (temperature) go to no more than a 100 unless the resident specifies. You always ask them, 'does it feel ok, too cold? or too warm?' (name of Resident #37) is unable to communicate what's a comfortable temperature, so in that case we have a thermometer that hangs in the tub. So I'll stick my forearm in it because the hands will lie to us, they take a lower temp. So I'll rely on my forearm to see if its comfortable and that's usually around 96 (degrees F)." L. During an interview with RN #10 on 06/07/12 at 2:43 pm, she stated "When they went to get him up the next morning, Monday, to get him ready for breakfast, I hadn't noticed them (blisters) the night before. The previous night I didn't work with him. They (blisters) were located on the lower legs, some of them were large. He didn't have any other blisters besides the legs." When asked how often Resident #37 was receiving whirlpool baths, she stated "(name of Resident #37), was getting them 3 times a week, and before that he's never had blisters. The blisters didn't seem to be spreading." M. On 06/11/12 at 5:20 pm, observation of the facility Unit D whirlpool tub in the company of the facility Safety Officer revealed a whirlpool tub connected by a pair of flexible hoses to two water pipes coming up from the floor. The tub had two built-in control handles: one controlled the flow of water to the tub, the other controlled water to a separate hose with a shower-head. The handle controlling flow of water to the tub controlled flow rate only; there was no apparent way to increase or decrease the water temperature using the tub's controls. At the attachment of the tub's inlet hoses to the floor water pipes, the pipes from the floor each had a ball valve controlled by an on/off lever. Testing revealed it was possible to turn the levers by bumping them with a foot. N. Review of the whirlpool tub's service manual, dated 02/03/00, revealed that the tub was a Parker series 420 whirlpool tub. Review of the service manual revealed that the tub contained a built-in mixing valve which mixed hot water and cold water brought in by the flexible inlet hoses, delivering the water to pipes controlled by the two tub control handles. However, the unit contained no mechanism to block the flow of hot water if the cold water hose was not providing cold water; effective temperature control required that the unit receive a constant supply of both hot water and cold water to the mixing valve. O. Review of the facility maintenance investigation report, dated 06/05/12, revealed documentation of checks of temperatures at various locations around the facility along with the statement, "At this time (9:45 am) staff member name (name of CNA # 21) came in to the w/pool (whirlpool) room and asked what I was doing. I said checking the water temp. (Name of CNA # 21) then said if you want hot water you have to turn these on and off. He then went to proceed to turn off the ball valves on the floor." P. Review of the Safety/Loss Control Procedure Statement, Water Temperature Procedure, dated 06/30/03, revealed the instruction, "General facility water temperatures shall be checked at least on a monthly basis to ensure water temperatures do not exceed 110 degrees Fahrenheit. Documentation shall be maintained by the Maintenance Department." Q. On 06/12/12, review of the facility Equipment Room Inspection logs revealed water temperature entries for an "H-1 Dom (Domicile) Water Heater" and an "H-2 Dom Water Heater." On the form, the entries were preceded by the guidance, "Water Temp = 110 Deg. (degrees) F". Review of the hot water temperature entries for April 2012 revealed the following: 1. For April 2012, on "Week-1", the H-1 water heater was off, and the H-2 water heater was delivering at 127 degrees F. 2. For April 2012, on "Week-2", no water temperature was recorded. 3. For April 2012, on "Week-3", the H-1 water heater was off, and the H-2 water heater was delivering at 131 degrees F. 4. For April 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 132 degrees F. 5. For April 2012, on "Week-5", the H-1 water heater was off, and the H-2 water heater was delivering at 130 degrees F. 6. On the last sheet of the Equipment Room Inspection log for April 2012, a handwritten entry documented, "04-03-12 - Plant Storage Tank 127 @ 0800; A-upper 118; B-unit 118; C-unit 118; D-unit 117; E-unit 118; F-unit 117." R. On 06/12/12, review of the facility Equipment Room Inspection logs for May 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For May 2012, on "Week-1", the H-1 water heater was delivering at 136 degrees F., and the H-2 water heater was off. 2. For May 2012, on "Week-2", the H-1 water heater was off, and the H-2 water heater was delivering at 133 degrees F. 3. For May 2012, on "Week-3", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. 4. For May 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 125 degrees F. 5. For May 2012, on "Week-5", the H-1 water heater was delivering at 129 degrees F., and the H-2 water heater was off. S. On 06/12/12, review of the facility Equipment Room Inspection logs for June 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For June 2012, on "Week-1", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. A handwritten note above the temperature entry dated the entry as, "06-04". 2. For June 2012, on "Week-2", the H-1 water heater was delivering at 111 degrees F., and the H-2 water heater was off. T. On 06/12/12 at 9:00 am, during an interview with the facility Maintenance Director and Maintenance Supervisors #1 and #2, the Maintenance Director identified the "H-1" and "H-2 Dom Water Heater" entries on the Equipment Room Inspection logs as documenting the hot water temperatures for the water heaters serving the resident hot water system. He was asked to describe the facility hot water system; he stated that the facility had two water heaters, one of which was operating at any given time while the other was available as back-up. When asked how he set water temperatures for the facility resident fixtures, he stated, "It's what we set it at the plant (the facility hot water plant)." He stated that on 06/04/12, the H-1 water heater was operating; he identified the 130-degree temperature reading as the temperature of the H-1 water heater on that date. When asked about the temperatures at the resident hot water fixtures, Maintenance Supervisor #2 stated, "What we normally try to do is keep it (the hot water temperature) at 110 throughout the facility. To achieve that temp (temperature), we have to set it at 130 (degrees F) at the boiler (water heater)." When asked about the circuit of the hot water line through the facility, the Maintenance Director stated, "It goes to A upper (the upstairs A-wing, an assisted living facility) , it goes to B (resident wing B), C (resident wing C), and then it goes through a booster pump to push it down D, E, and F (resident wings D, E, and F)." When asked about tracking of water temperatures, he stated, "The only regular temperatures that we monitor are at the tank. Those are inspected daily but not documented on the log. Weekly, they are documented on a log." When asked whether he documented temperatures at resident fixtures, he stated, "No. We do monthly rounds with safety (the facility safety officer), and we check random temps then, but we don't document it on the sheet." U. On 06/12/12 at 9:27 am, a test of the hot water temperature at various resident-accessible sinks, showers, and tubs was conducted by Maintenance Supervisors #1 and #2 with facility thermometers and in the presence of the surveyor to establish the degree of temperature drop between the water heater and the resident rooms and other resident-accessible hot water sources. The test revealed hot water temperatures dropped no more than 8 degrees between the hot water heaters and the various resident-accessible fixtures. 1. On 06/12/12 at 9:27 am, observation of the facility water heaters with Maintenance Supervisors #1 and #2 revealed the active hot water heater was delivering hot water at 110.8 degrees F. When asked about a mixing valve, Maintenance Supervisor #1 reported there was none; he stated that the temperature of the hot water heater was set directly. 2. At 9:32 am, test of the hot water temperature at the sink in resident room B9 revealed a temperature of 108 degrees F. 3. At 9:45 am, test of the hot water temperature at the sink in the resident public restroom serving the B-wing revealed a temperature of 104 degrees F. 4. At 9:50 am, test of the hot water temperature at the sink in the C-wing resident dining room revealed a temperature of 106 degrees F. 5. At 9:55 am, test of the hot water temperature at the sink in resident room C6 revealed a temperature of 106 degrees F. 6. At 10:00 am, test of the hot water temperature at the shower in the C-unit shower room revealed a temperature of 104 degrees F. 7. At 10:12 am, test of the hot water temperature at the sink in resident room D11 revealed a temperature of 102 degrees F. 8. At 10:15 am, test of the hot water temperature at the sink in resident room E2 revealed a temperature of 102 degrees F. 9. At 10:18 am, test of the hot water temperature at the sink in the resident public restroom serving the E-wing revealed a temperature of 102 degrees F. 10. At 10:23 am, repeat observation of the facility boilers with Maintenance Supervisors #1 and #2 revealed the active boiler was delivering hot water at 110.7 degrees F. Resident #71 Based on record review and interview, the facility failed to provide an environment that was free from hazards that placed 1 resident (#71) at risk of injury, out of 6 sampled residents ( #16, 37, 71, 94, 111, 118) evaluated for accident prevention. Resident #71 was provided a bed with bed rails large enough to allow her head between the bars, creating the potential for entrapment. Failure to provide a safe environment had the potential to place Resident #71 and others who might be assigned the bed at risk of strangulation from entrapment; the facility safety officer reported the bed was the only one of its type in the facility. The findings are: A. Review of the record of Resident #71 revealed an undated Record of Admission documenting admission to the facility on [DATE] with [DIAGNOSES REDACTED]. B. On 6/13/12 at 5:03 pm, observation in the room of Resident #71 revealed a bed with one raised full side-rail. The side-rail consisted of three horizontal bars, one top, one bottom, and one through the middle, with a vertical bar at each end. Measurement of the horizontal bars by standard ruler revealed they were spaced 7 1/2 inches apart. C. On 06/13/12 at 5:06 pm, during an interview, the facility Safety Officer observed the side-rails and agreed that the space between bars was wide enough to admit a person's head. When asked if he'd received any guidance or instructions regarding safety of side-rails, he stated he had not. D. Review of Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, a guidance to industry released 03/10/06 by the Center for Devices and Radiological Health, a division of the U.S. Food and Drug Administration, revealed, "Openings in the rail should be small enough to prevent the head from entering. A loosened bar or rail can change the size of the space. The HBSW (Hospital Bed Safety Workgroup) and IEC (International Electrotechnical Commission) recommend that the space be less than 120 mm (4 3/4 inches), representing head breadth." The guidance further documented, "Adverse events identified as occurring within the rail were reported in bed models where open spaces within the rail were greater than 120 mm (4 3/4 inches). Manufacturers' measurements of bed models representative of those identified in these incidents had spacing within the rail of between 177 mm (6.97 inches) and 190 mm (7.48 inches). The data suggest that nearly all of these entrapment events may have been prevented if the spaces within the rails had been less than 120 mm (4 3/4 inches), representing head breadth as described above."

Based on record review and interview, the facility failed to ensure that 1 (#37) of 6 (#16, 37, 71, 94, 111, 118) sampled residents was free from neglect by not maintaining safe water temperatures. Resident # 37 sustained second [MEDICAL CONDITION] both knees after receiving a whirlpool bath in water exceeding safe temperatures. The facility procedure set a maximum safe temperature of 110 degrees Fahrenheit (F), but the facility hot water logs documented a temperature of 130 degrees F on the week of the incident. This failed practice likely caused burn injuries to Resident #37 and had the potential to [MEDICAL CONDITION] others who may use the whirlpool bath. The findings are: A. Review of Resident #37's undated Record of Admission revealed the resident was admitted for long term care services on 11/29/06 with a [DIAGNOSES REDACTED]. B. Review of a Facility Emergency Resident Discharge/Transfer Form dated 06/05/12, for Resident #37, revealed the resident was transferred to Hospital #1 "per family request" on 06/05/12 at 1:45 pm. C. Review of Hospital #1's Emergency Medical Service (EMS) Report dated 06/05/12, for Resident #37, revealed the resident was received by the ambulance at 2:09 pm, transported to the hospital and received by the hospital at 2:23 pm. Under, "Narrative," the report documented, "per staff, pt (patient) has wounds on his lower legs that appeared yesterday morning. The staff member described them as 'blisters' ... Staff member also stated that from the last dressing change she did yesterday to the first one she did today the wounds appear to have worsened." D. Review of Hospital #1's physician progress notes [REDACTED]. 10% circumferential (extending around the circumference of the leg)[MEDICAL CONDITION] lower ext. (extremities) ~10% TBA (Total Burn Area) each leg for 20% TBA." E. Review of Hospital #1's Emergency Department report for 06/05/12, for Resident #37, revealed, "This is a [AGE] year old male that was transported to the Emergency Department at (name of Hospital #1) via Ground EMS with a history of possible burn wounds to both lower extremities. Reportedly, the patient was given hot water bath Sunday evening (06/03/12) and subsequently developed extensive burn wounds to the lower extremities and left forearm and anterior (front) chest. I did speak with (name of Physician #1) ... (name of Physician #1) said that he was also concerned that the patient's wounds were hot water burns, and he did do an investigation interviewing the attendant who gave the patient a bath; it can not be conclusively determined that these were hot [MEDICAL CONDITION](sic) wounds as opposed to an alternative etiology (cause) ... at any rate, (name of Physician #1) and I discussed the case and we felt that these were most likely burn wounds, presumptively accidental, ..." Under Diagnosis, the report documented, "Presumptive burn wounds to both lower extremities, left forearm and anterior chest." Under Plan, the report documented, "The case was also discussed with (name of Physician #3), (name of Hospital #2) Trauma Center and Burn Center on-call physician who accepted this case for transfer ... The patient was transferred to (name of Hospital #2) to care of (name of Physician #3)." F. Review of a Hospital #2 History and Physical (H&P) dated 06/05/12, for Resident #37, revealed, "The patient was transferred from (name of Hospital #1) on 06/05/12 ... due to the fact that he had sustained bilateral lower extremity circumferential [MEDICAL CONDITION] are likely deep partial thickness in nature. The injury was said to occur the evening of Sunday June 3rd." Under Skin, the H&P documented,"Had a bilateral lower extremity circumferential deep partial [MEDICAL CONDITION](sic). It had a moist base and reddish with areas of white appearance to the burned areas. [MEDICATION NAME] desquamation (peeling of the outermost layer of skin) was evident." Under Assessment, the H&P documented, "the case of a [AGE] year-old male transferred from (name of facility) to (name of Hospital #1) and then to (name of Hospital #2) for bilateral lower extremity circumferential [MEDICAL CONDITION] approximately 15% total body surface area and seemed to be deep partial thickness with a concomitant (accompanying or concurrent) finding of some systemic rash ..." G. During an interview on 06/06/12 at 11:45 am, the Facility Investigator was asked who else received whirlpool baths. She stated Resident #94 was also receiving whirlpool baths. H. During an interview with the Medical Director on 06/06/12 at 11:50 am, he stated, "At the time they took him out of the whirlpool, there was no redness. There was a redness on Monday with blisters to feet. On day two, redness had diminished but blistering had increased to upper torso. The blisters would pop and the tissue underneath looked healthy." He states,"redness and blistering wax (increase) and wane (decrease). On the first day,[DIAGNOSES REDACTED] (redness of the skin) was to arms and torso to about 10% of (sic) body. At first we were treating it as a burn. On the next day I thought it was something else because of the increasing of blisters." He stated, "I talked with family regarding what was going on and it was thought that something else was going on." The Medical Director stated that the resident had always been non-responsive and that the resident has advanced dementia. I. During an interview with Certified Nursing Assistant (CNA) #20 on 06/07/12 at 2:10 pm he stated, "With (name of Resident #37), after you give him a shower or whirlpool, his skin is always red." When asked how hot the water was, he stated, "The temperature of the water was probably 98 degrees (F); the gauge is next to the nozzle, so I looked at that". He also stated, "I have no idea how hot it can get. The hottest I've ever seen it go was maybe 102 (degrees F)." CNA #20 was asked, when he noticed the blisters on Resident #37. He responded, "(name of Resident #37) is so tall, when I get him out of bed I have to completely remove the covers, and at first glance I thought it (blister leakage) was urine at the foot of his bed. Monday morning is when I discovered the blisters; he had a bath the night before. When I saw the blisters I notified my house RN (Registered Nurse, RN #11)." J. During a follow-up interview with CNA #20 on 06/07/12 at 3:45 pm, when asked if the whirlpool was filled with water first or if Resident #37 was assisted into the tub first, CNA #20 stated, "I put him in the tub then started the water. I adjusted the valve with my foot, you have to adjust the water with the valve on the floor. The one that adjusts the hot and cold doesn't work and you have to adjust them from the floor." When asked what the temperature of the water was, CNA #20 stated, "When the water was filling up I tested it, it felt warm to the touch with the back of my hand. I did look at the thermometer and it read 98 degrees (F). (Name of Resident #37) was in the tub for no more than 30 minutes." He then stated, "The faucet is at the foot of the tub, when I turned the shower head on, the water was hot, so I had to readjust it." K. During an interview with CNA #21 on 06/07/12 at 2:31 pm, he stated, "I worked with him (Resident #37) the following morning on Monday. It was brought to my attention when (name of CNA #20) came and got me to go to his bedside, he and (name of RN #10) were getting ready to get him (Resident #37) up out of bed. That's when I saw the blisters for the first time on his feet and ankles. They were from the calf down, there were several blisters. Some were small and some were big water blisters, none on his torso." When asked how hot the whirlpool water normally is, he stated "I check the thermometer to see how hot the hot water is and it usually goes to 110." When asked if he had any in-service training on how to operate the whirlpool, he stated, "It was about 8 months ago, we're instructed to let the temp (temperature) go to no more than a 100 unless the resident specifies. You always ask them, 'does it feel ok, too cold? or too warm?' (name of Resident #37) is unable to communicate what's a comfortable temperature, so in that case we have a thermometer that hangs in the tub. So I'll stick my forearm in it because the hands will lie to us, they take a lower temp. So I'll rely on my forearm to see if its comfortable and that's usually around 96 (degrees F)." L. During an interview with RN #10 on 06/07/12 at 2:43 pm, she stated "When they went to get him up the next morning, Monday, to get him ready for breakfast, I hadn't noticed them (blisters) the night before. The previous night I didn't work with him. They (blisters) were located on the lower legs, some of them were large. He didn't have any other blisters besides the legs." When asked how often Resident #37 was receiving whirlpool baths, she stated "(name of Resident #37), was getting them 3 times a week, and before that he's never had blisters. The blisters didn't seem to be spreading." M. On 06/11/12 at 5:20 pm, observation of the facility Unit D whirlpool tub in the company of the facility Safety Officer revealed a whirlpool tub connected by a pair of flexible hoses to two water pipes coming up from the floor. The tub had two built-in control handles: one controlled the flow of water to the tub, the other controlled water to a separate hose with a shower-head. The handle controlling flow of water to the tub controlled flow rate only; there was no apparent way to increase or decrease the water temperature using the tub's controls. At the attachment of the tub's inlet hoses to the floor water pipes, the pipes from the floor each had a ball valve controlled by an on/off lever. Testing revealed it was possible to turn the levers by bumping them with a foot. N. Review of the whirlpool tub's service manual, dated 02/03/00, revealed that the tub was a Parker series 420 whirlpool tub. Review of the service manual revealed that the tub contained a built-in mixing valve which mixed hot water and cold water brought in by the flexible inlet hoses, delivering the water to pipes controlled by the two tub control handles. However, the unit contained no mechanism to block the flow of hot water if the cold water hose was not providing cold water; effective temperature control required that the unit receive a constant supply of both hot water and cold water to the mixing valve. O. Review of the facility maintenance investigation report, dated 06/05/12, revealed documentation of checks of temperatures at various locations around the facility along with the statement, "At this time (9:45 am) staff member name (name of CNA # 21) came in to the w/pool (whirlpool) room and asked what I was doing. I said checking the water temp. (Name of CNA # 21) then said if you want hot water you have to turn these on and off. He then went to proceed to turn off the ball valves on the floor." P. Review of the Safety/Loss Control Procedure Statement, Water Temperature Procedure, dated 06/30/03, revealed the instruction, "General facility water temperatures shall be checked at least on a monthly basis to ensure water temperatures do not exceed 110 degrees Fahrenheit. Documentation shall be maintained by the Maintenance Department." Q. On 06/12/12, review of the facility Equipment Room Inspection logs revealed water temperature entries for an "H-1 Dom (Domicile) Water Heater" and an "H-2 Dom Water Heater." On the form, the entries were preceded by the guidance, "Water Temp = 110 Deg. (degrees) F". Review of the hot water temperature entries for April 2012 revealed the following: 1. For April 2012, on "Week-1", the H-1 water heater was off, and the H-2 water heater was delivering at 127 degrees F. 2. For April 2012, on "Week-2", no water temperature was recorded. 3. For April 2012, on "Week-3", the H-1 water heater was off, and the H-2 water heater was delivering at 131 degrees F. 4. For April 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 132 degrees F. 5. For April 2012, on "Week-5", the H-1 water heater was off, and the H-2 water heater was delivering at 130 degrees F. 6. On the last sheet of the Equipment Room Inspection log for April 2012, a handwritten entry documented, "04-03-12 - Plant Storage Tank 127 @ 0800; A-upper 118; B-unit 118; C-unit 118; D-unit 117; E-unit 118; F-unit 117." R. On 06/12/12, review of the facility Equipment Room Inspection logs for May 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For May 2012, on "Week-1", the H-1 water heater was delivering at 136 degrees F., and the H-2 water heater was off. 2. For May 2012, on "Week-2", the H-1 water heater was off, and the H-2 water heater was delivering at 133 degrees F. 3. For May 2012, on "Week-3", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. 4. For May 2012, on "Week-4", the H-1 water heater was off, and the H-2 water heater was delivering at 125 degrees F. 5. For May 2012, on "Week-5", the H-1 water heater was delivering at 129 degrees F., and the H-2 water heater was off. S. On 06/12/12, review of the facility Equipment Room Inspection logs for June 2012 revealed the same guidance, "Water Temp = 110 Deg. F". Review of the hot water temperature entries revealed the following: 1. For June 2012, on "Week-1", the H-1 water heater was delivering at 130 degrees F., and the H-2 water heater was off. A handwritten note above the temperature entry dated the entry as, "06-04". 2. For June 2012, on "Week-2", the H-1 water heater was delivering at 111 degrees F., and the H-2 water heater was off. T. On 06/12/12 at 9:00 am, during an interview with the facility Maintenance Director and Maintenance Supervisors #1 and #2, the Maintenance Director identified the "H-1" and "H-2 Dom Water Heater" entries on the Equipment Room Inspection logs as documenting the hot water temperatures for the water heaters serving the resident hot water system. He was asked to describe the facility hot water system; he stated that the facility had two water heaters, one of which was operating at any given time while the other was available as back-up. When asked how he set water temperatures for the facility resident fixtures, he stated, "It's what we set it at the plant (the facility hot water plant)." He stated that on 06/04/12, the H-1 water heater was operating; he identified the 130-degree temperature reading as the temperature of the H-1 water heater on that date. When asked about the temperatures at the resident hot water fixtures, Maintenance Supervisor #2 stated, "What we normally try to do is keep it (the hot water temperature) at 110 throughout the facility. To achieve that temp (temperature), we have to set it at 130 (degrees F) at the boiler (water heater)." When asked about the circuit of the hot water line through the facility, the Maintenance Director stated, "It goes to A upper (the upstairs A-wing, an assisted living facility) , it goes to B (resident wing B), C (resident wing C), and then it goes through a booster pump to push it down D, E, and F (resident wings D, E, and F)." When asked about tracking of water temperatures, he stated, "The only regular temperatures that we monitor are at the tank. Those are inspected daily but not documented on the log. Weekly, they are documented on a log." When asked whether he documented temperatures at resident fixtures, he stated, "No. We do monthly rounds with safety (the facility safety officer), and we check random temps then, but we don't document it on the sheet." U. On 06/12/12 at 9:27 am, a test of the hot water temperature at various resident-accessible sinks, showers, and tubs was conducted by Maintenance Supervisors #1 and #2 with facility thermometers and in the presence of the surveyor to establish the degree of temperature drop between the water heater and the resident rooms and other resident-accessible hot water sources. The test revealed hot water temperatures dropped no more than 8 degrees between the hot water heaters and the various resident-accessible fixtures. 1. On 06/12/12 at 9:27 am, observation of the facility water heaters with Maintenance Supervisors #1 and #2 revealed the active hot water heater was delivering hot water at 110.8 degrees F. When asked about a mixing valve, Maintenance Supervisor #1 reported there was none; he stated that the temperature of the hot water heater was set directly. 2. At 9:32 am, test of the hot water temperature at the sink in resident room B9 revealed a temperature of 108 degrees F. 3. At 9:45 am, test of the hot water temperature at the sink in the resident public restroom serving the B-wing revealed a temperature of 104 degrees F. 4. At 9:50 am, test of the hot water temperature at the sink in the C-wing resident dining room revealed a temperature of 106 degrees F. 5. At 9:55 am, test of the hot water temperature at the sink in resident room C6 revealed a temperature of 106 degrees F. 6. At 10:00 am, test of the hot water temperature at the shower in the C-unit shower room revealed a temperature of 104 degrees F. 7. At 10:12 am, test of the hot water temperature at the sink in resident room D11 revealed a temperature of 102 degrees F. 8. At 10:15 am, test of the hot water temperature at the sink in resident room E2 revealed a temperature of 102 degrees F. 9. At 10:18 am, test of the hot water temperature at the sink in the resident public restroom serving the E-wing revealed a temperature of 102 degrees F. 10. At 10:23 am, repeat observation of the facility boilers with Maintenance Supervisors #1 and #2 revealed the active boiler was delivering hot water at 110.7 degrees F. V. Review of facility policy, Resident Rights Regarding Accidents, Injuries, Abuse, Neglect and Exploitation, effective 07/01/99 and last revised 07/01/01, revealed the following: 1. Under Purpose, the policy documented, "It is the purpose of this policy to establish a policy regarding accidents, injuries, abuse, neglect and exploitation of residents ... Residents have a right to be protected from unreasonable risks to their personal safety and welfare." 2. Under Applicability, the policy documented, "This policy applies to all volunteers, residents, visitors ... and staff of (facility name)." 3. Under Definitions, the policy defined "neglect" as including, "The failure to take any reasonable precaution that is necessary to prevent harm to the health and safety of a resident." 4. Under Definitions, the policy defined "staff" as meaning, "Any person hired or appointed to any position at (facility name), whether a permanent, probationary, term, temporary, seasonal or part time status employee ..."

The facility failed to ensure one resident (#139) of three (#14, 54, and 139) residents identified by the facility as smokers using portable oxygen (O2) tanks received an update to his unsafe smoking care plan to provide more effective interventions after evidence of accidental ignition of the resident's oxygen cannula. On 04/12/11 at 10:10 am, Resident #139 was observed seated in a wheelchair in the "Turtle" courtyard, smoking a lit cigarette. The resident was wearing his O2 cannula and inspection of his portable O2 tank revealed that it was full and running at 2.5 liters per minute (LPM). Review of the resident record revealed that the resident had a care plan dated 03/08/11 for unsafe smoking that called on staff to remind him to turn off his oxygen before smoking, but interviews with nursing staff revealed that they had no method to identify when he went outside to smoke. Review further revealed documentation of an incident on 03/15/11 in which the resident was found to have a burned O2 cannula; the facility had failed to take action to modify the resident care plan following the incident. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 04/12/11 at 4:40 pm. The facility Administrator was notified on 04/12/11 at 4:40 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included revision of the resident care plan to require staff to keep his smoking materials, to light the resident's cigarette for him after removing the resident's O2 cannula and turning off the resident's O2 tank, and to remain present with the resident until he finished smoking. The plan also included retraining of nurses and Certified Nursing Assistants (CNAs) in monitoring of smokers who have orders for oxygen use and in documenting observations of smokers found smoking while using oxygen. After facility staff discovered the resident was attempting to subvert the restrictions by going to other residents and asking for cigarettes, the facility amended the Plan of Removal by implementing a facility-wide policy of having the nursing staff maintain all residents' smoking materials. Based on the Plan of Removal and the information provided, the IJ was lifted on 04/14/11 at 4:00 pm. This resulted in the scope and severity being reduced from a level 4, scope I to level 2, scope E. Based on observation, interview, and record review, the facility failed to update the resident care plan of 1 (#139) of 3 (#14, 54, and 139) residents identified by the facility as smokers using portable O2 tanks, following evidence of accidental ignition of the resident's O2 cannula. On 04/12/11, Resident #139 was twice observed smoking while wearing an O2 cannula with the O2 on: once at 10:10 am, and again at 3:10 pm. The resident had a care plan dated 03/08/11 instructing staff to remind him to turn off his oxygen before smoking, but nursing staff reported that they had no method to identify when he went outside to smoke, and the facility had failed to update the resident care plan to provide more effective interventions following a 03/15/11 incident in which the resident was found to have a burned O2 cannula. This deficient practice had the potential to cause a burn injury from accidental ignition of the O2 cannula in residents who smoke and use supplemental oxygen. The findings are: A. Review of the record of Resident #139 revealed a 03/01/11 Record of Admission documenting admission to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]." B. On 04/12/11 at 10:10 am, observation in the smoking area in the enclosed "Turtle" fountain courtyard revealed Resident #139 seated in a wheelchair, smoking a lit cigarette. The resident wore an O2 cannula on his face, the cannula plugged into a portable O2 canister on the back of the wheelchair. A cannula filter was in place on the cannula line close to the tank. Inspection of the O2 canister revealed that it was on and set to deliver oxygen at 2.5 LPM. A check of the O2 canister revealed that it was 1/4 full. C. On 04/12/11 at 10:11 am, during an interview, when asked if the facility staff had discussed the risks involved in smoking while using oxygen, the resident stated, "No, there's no reason to." D. Review of Resident #139's Physician Orders, dated 04/01/11, revealed orders for O2 at 2 to 4 LPM by nasal cannula for [MEDICAL CONDITION]. E. Review of Resident #139's Minimum Data Set (MDS) 3.0 Quarterly Assessment, dated 12/03/10, revealed the following information: 1. Under "Cognitive Patterns," the assessment documented a summary score of 14 out of 15 which indicated that the resident was able to "repeat 3 of 3 words, correctly state year, month, and day of week, and was able to recall 2 of the original 3 words independently and the third after a cue." 2. Under the "Functional Status" section, the assessment documented that the resident was "independent for transfer and locomotion on and off the unit, using a wheelchair." 3. Under the "Special Treatments, Procedures and Programs," section the assessment documented that the resident was receiving oxygen therapy. F. Review of Resident #139's care plan revealed a "Problem snap shot" for "Behavior/Mood/Well Being" dated 03/08/11. The plan identified, "Unsafe smoking: resident is at risk for injury to himself or others due to forgetting to turn off oxygen while smoking." Under the "Interventions" section the plan directed, "Filter to be placed on oxygen tubing; staff to remind resident to turn off oxygen while smoking." The plan had signatures dated 03/08/11 and 03/09/11. There were no more recent signatures or interventions dated after 03/09/11. G. Review of Resident #139's care plan revealed a "Problem snap shot" for "Special Care and Procedures " dated 03/08/11. The plan identified, "oxygen therapy, (496) Chr (chronic) Airway obstruct NEC (not elsewhere classified)." Under the "Interventions" section the plan directed, "Instruct/remind him/his visitors that oxygen is a fire hazard: No flammable substances, e.g. petroleum jelly, oils, or aerosols, and NO OPEN FLAMES OF ANY KIND e.g. lit cigarettes." (Capitalized as written.) The plan had signatures dated 03/08/11 and 03/09/11. There were no more recent signatures or interventions dated after 03/09/11. H. Review of Nursing Notes revealed an entry dated 03/16/11 at 2:26 am, documenting that the resident had been found with a burned O2 cannula, "2045 (8:45 pm) As CNA (Certified Nursing Assistant) was walking past the door to the turtle courtyard he smelled something burning. He looked down and noticed burn marks on the floor coming from the outside. At this time (name of Resident #139) was in his w/c (wheelchair) and was coming down the hallway to D unit. His O2 tubing was dragging on the floor behind his w/c. A portion of the tubing had been burned off and was found laying on the rug by the courtyard door. Rsd (resident) was asked what happened and was he smoking with his O2 on. He stated he didn't know what happened and denied that he was smoking although staff has passed thru the area and saw rsd smoking very shortly prior to this incident. Rsd stated that he had ran over his O2 tubing with the wheel of his w/c and that's why it caught on fire. Rsd states's (sic) he did not have his O2 on his face and was not burned. Skin assessed for injury, none noted." I. Review of facility Resident Incident Reports revealed a 03/15/11 report documenting the following information: 1. In the report, CNA #23 documented, "Was walking past door to the turtle courtyard when I noticed the smell of burring. I saw burn marks on floor coming from outside. Told nurse on unit, when they asked (name of Resident #139) what had happen (sic), he stated that it caught on fire on his wheel." 2. In the report, Licensed Practical nurse Licensed Practical Nurse (LPN) #12 documented, "(name of Resident #139) was coming down the hallway in his w/c. His O2 tubing was dragging on the floor behind his chair. A portion of the tubing had been burned off + was found laying on the rug by the door of the turtle courtyard. Rsd stated he didn't know what happened + denied smoking c (with) his O2 on. He stated that he had ran over his O2 tubing with the wheel of his w/c + that's when it caught on fire." 3. Under the "Measures taken to prevent occurrence or recurrence," section the report documented, "rsd counseled about the dangers of smoking c his O2 on." No other measures were documented. Review of the resident care plan and physician orders revealed no additional interventions. J. On 04/12/11 at 11:30 am, during an interview, Registered Nurse (RN) #10, the nurse serving Resident #139, stated, "He does have a problem with his lungs. He's on oxygen, we monitor him for that." When asked about the resident's care plan for unsafe smoking, he stated, "He has been in the past been caught smoking (with oxygen)." When asked how the facility monitored the resident's smoking behavior, he stated, "We try and monitor his smoking but he usually go outside and smokes. When he's outside in the courtyard, we kind of watch him a little bit to make sure he's ok. We remind him when he goes out to turn off his oxygen." When asked how they kept track of when he was going outside to smoke, he stated, "We don't, to be honest with you." K. On 04/12/11 at 11:40 am, during an interview, CNA #20 was asked about Resident #139's smoking care plan. She stated, "They said that we needed to monitor him during smoking. He's very independent, so its hard to know when he's going out to smoke." L. On 04/12/11 at 2:50 pm, during an interview, the facility Director of Nursing (DON) stated, "Usually he's pretty good about letting us know when he goes out, but once in a while he will wander out." Regarding the 12/08/10 Social Work entry documenting unsafe smoking, she stated, "I can't tell you. The only thing I heard about was when he caught the tubing on fire (the 03/15/11 incident)." She stated that she believed the resident might have been experiencing some confusion, saying, "He was in his room in his WC nude with his clothes tossed to the side. He said he was waiting on staff to help him change his clothes." M. On 04/12/11 at 3:10 pm, during an observation, Resident #139 was in the "Turtle" fountain courtyard smoking. Resident #139 was wearing his O2 nasal cannula and the canister was set at 3 LPM. A filter was observed in the tubing between the cannula and the canister. When asked if he was getting any oxygen through the cannula he stated that he was and moved the prongs from his nostrils to his forehead. When asked if he often smoked with his oxygen on, he said he smokes just a couple of times a day. He was asked if anyone had told him he should turn off his oxygen when he goes out to smoke, he said that he thought it was off and that he would put out his cigarette. He was observed to wheel himself to the other door, still smoking the cigarette. The resident tossed the cigarette as the Safety Coordinator approached him. N. On 04/12/11 at 3:20 pm, the Safety Coordinator went out and checked Resident #139's O2. When asked if he could confirm the resident's oxygen was on, he said it was on but that the resident did not have a cigarette. He was informed that the resident had just gotten rid of it. The Safety Coordinator said that the resident's oxygen had been turned off 3 times in the last hour because the resident had been found smoking. O. Review of the facility policy, "Smoking," effective date 07/01/99, revised 07/01/01, last reviewed 09/19/09, revealed the instructions, "Smoking shall be prohibited in any room, unit, or compartment where flammable liquids, combustible gases, or oxygen are used or stored and in any other hazardous location... Residents receiving supplements of oxygen will be assisted by staff, as needed, in closing the tank valve and removal of the nasal cannula from their face, before they light the cigarette in appropriate smoking area... Residents not using smoking materials safely... shall be referred to Care Plans for recommendations."

The facility failed to ensure that one (#139) of three (#14, 54, and 139) residents identified by the facility as smokers using portable oxygen (O2) tanks (#14, 54, and 139) received adequate supervision to prevent the resident from smoking while using oxygen. On 04/12/11 at 10:10 am, Resident #139 was observed seated in a wheelchair in the "Turtle" courtyard, smoking a lit cigarette. The resident was wearing his O2 cannula and inspection of his portable O2 tank revealed that it was full and running at 2.5 liters per minute (LPM). Review of the resident record revealed that the resident had a care plan dated 03/08/11 for unsafe smoking that called on staff to remind him to turn off his oxygen before smoking, but interviews with nursing staff revealed that they had no method to identify when he went outside to smoke. Review further revealed documentation of an incident on 03/15/11 in which the resident was found to have a burned O2 cannula; the facility had failed to take action to modify the resident care plan following the incident. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 04/12/11 at 4:40 pm. The facility Administrator was notified on 04/12/11 at 4:40 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included revision of the resident care plan to require staff to keep his smoking materials, to light the resident's cigarette for him after removing the resident's O2 cannula and turning off the resident's O2 tank, and to remain present with the resident until he finished smoking. The plan also included retraining of nurses and Certified Nursing Assistants (CNAs) in monitoring of smokers who have orders for oxygen use and in documenting observations of smokers found smoking while using oxygen. After facility staff discovered the resident was attempting to subvert the restrictions by going to other residents and asking for cigarettes, the facility amended the Plan of Removal by implementing a facility-wide policy of having the nursing staff maintain all residents' smoking materials. Based on the Plan of Removal and the information provided, the IJ was lifted on 04/14/11 at 4:00 pm. This resulted in the scope and severity being reduced from a level 4, scope I to level 2, scope E. Based on observation, interview, and record review, the facility failed to provide supervision to prevent 1 (#139) of 3 (#14, 54, and 139) residents from smoking while using oxygen, of three residents identified by the facility as smokers using portable O2 tanks, following evidence of an accidental ignition of the resident's O2 cannula. On 04/12/11, Resident #139 was twice observed smoking while wearing an O2 cannula with the O2 on: once at 10:10 am, and again at 3:10 pm. The resident had a care plan dated 03/08/11 instructing staff to remind him to turn off his oxygen before smoking, but nursing staff reported that they had no method to identify when he went outside to smoke, and the facility had failed to update the resident care plan to provide more effective interventions following a 03/15/11 incident in which the resident was found to have a burned O2 cannula. This deficient practice had the potential to cause a burn injury from accidental ignition of the O2 cannula in residents who smoke and use supplemental oxygen. The findings are: A. Review of the record of Resident #139 revealed a 03/01/11 Record of Admission documenting admission to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]." B. Review of the resident's Nursing Notes revealed a 02/24/10 note documenting that the resident had originally been admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. A 02/19/11 Nursing Note documented that the resident was transferred to a hospital for treatment of [REDACTED].#139 was a previous resident transferred to a hospital for treatment of [REDACTED]. C. On 04/12/11 at 10:10 am, observation in the smoking area in the enclosed "Turtle" fountain courtyard revealed Resident #139 seated in a wheelchair, smoking a lit cigarette. The resident wore an O2 cannula on his face, the cannula plugged into a portable O2 canister on the back of the wheelchair. A cannula filter was in place on the cannula line close to the tank. Inspection of the O2 canister revealed that it was on and set to deliver oxygen at 2.5 LPM. A check of the O2 canister revealed that it was 1/4 full. D. On 04/12/11 at 10:11 am, during an interview, when asked if the facility staff had discussed the risks involved in smoking while using oxygen, the resident stated, "No, there's no reason to." E. Review of Resident #139's Physician Orders, dated 04/01/11, revealed orders for O2 at 2 to 4 LPM by nasal cannula for COPD. F. Review of Resident #139's Minimum Data Set (MDS) 3.0 Quarterly Assessment, dated 12/03/10, revealed the following information: 1. Under "Cognitive Patterns," the assessment documented a summary score of 14 out of 15 which indicated that the resident was able to "repeat 3 of 3 words, correctly state year, month, and day of week, and was able to recall 2 of the original 3 words independently and the third after a cue." 2. Under the "Functional Status" section, the assessment documented that the resident was "independent for transfer and locomotion on and off the unit, using a wheelchair." 3. Under the "Special Treatments, Procedures and Programs," section the assessment documented that the resident was receiving oxygen therapy. G. Review of notes written by the Social Worker, revealed a 12/08/10 entry documenting, "We need to keep an eye on him when he goes out to smoke because he doesn't often turn off his O2. It has a line filter for his safety but it should still be turned off when he smokes." Review of the resident record revealed no nursing documentation of unsafe smoking incidents prior to 12/08/10. Review of the facility incident reports revealed no documented incidents of unsafe smoking on or prior to 12/08/10. 1. On 4/12/11 at 2:11 pm, during an interview, Social Worker #30 was asked about the 12/08/10 entry. She stated that she recalled being told about the resident's unsafe smoking but could not recall who had told her or when. She was asked regarding the lack of documentation of incidents prior to her note, she stated, "You don't always write an incident. If you see someone smoking with their oxygen on, you turn it off and you remind them. ... If it becomes extreme, you start writing incident reports, but if it's just an occasional incident, it's not an incident, it's a reminder." 2. On 4/12/11 at 3:50 pm, Certified Nursing Assistant (CNA) #21 stated that she observed the resident smoking with oxygen running on two occasions last year, once soon after his admission of 02/24/10 and the second "around spring time" of 2010. She stated that on both occasions she informed the nurse on duty. When asked if she'd documented the incidents, she stated she had not, saying, "I think the nurse does, we mostly document behaviors." H. Review of Nursing Notes revealed a 12/08/10 entry documenting, "Resident's quarterly care plan meeting was held today. ...During the meeting his sometimes unsafe smoking was discussed. He sometimes does not turn his oxygen off when he smokes, he does have a filter on his tubing. A new care plan problem was added for potential for injury due to unsafe smoking." I. Review of Resident #139's care plan revealed a "Problem snap shot" for "Behavior/Mood/Well Being" dated 03/08/11. The plan identified, "Unsafe smoking: resident is at risk for injury to himself or others due to forgetting to turn off oxygen while smoking." Under the "Interventions" section the plan directed, "Filter to be placed on oxygen tubing; staff to remind resident to turn off oxygen while smoking." The plan had signatures dated 03/08/11 and 03/09/11. There were no more recent signatures or interventions dated after 03/09/11. J. Review of the manufacturer guideline for the filter, a FireSafe Cannula Valve, revealed the following statements: 1. "Oxygen is not flammable but its presence will drastically increase the rate and severity of combustion. Things that will not burn in air may do so in an oxygen enriched environment. ... A lit cigarette can therefore easily ignite the tips of a nasal cannula delivering an oxygen enriched air mixture supplied by an oxygen concentrator ... The fire will then burn the PVC tube, effectively moving back up the tube towards the source of the oxygen ..." 2. "The Firesafe Cannula Valve provides no protection if a fire burns through the oxygen delivery tubing upstream of the device." K. Review of Resident #139's care plan revealed a "Problem snap shot" for "Special Care and Procedures " dated 03/08/11. The plan identified, "oxygen therapy, (496) Chr (chronic) Airway obstruct NEC (not elsewhere classified)." Under the "Interventions" section the plan directed, "Instruct/remind him/his visitors that oxygen is a fire hazard: No flammable substances, e.g. petroleum jelly, oils, or aerosols, and NO OPEN FLAMES OF ANY KIND e.g. lit cigarettes." (Capitalized as written.) The plan had signatures dated 03/08/11 and 03/09/11. There were no more recent signatures or interventions dated after 03/09/11. L. Review of Nursing Notes revealed an entry dated 03/16/11 at 2:26 am, documenting that the resident had been found with a burned O2 cannula, "2045 (8:45 pm) As CNA was walking past the door to the turtle courtyard he smelled something burning. He looked down and noticed burn marks on the floor coming from the outside. At this time (name of Resident #139) was in his w/c (wheelchair) and was coming down the hallway to D unit. His O2 tubing was dragging on the floor behind his w/c. A portion of the tubing had been burned off and was found laying on the rug by the courtyard door. Rsd (resident) was asked what happened and was he smoking with his O2 on. He stated he didn't know what happened and denied that he was smoking although staff has passed thru the area and saw rsd smoking very shortly prior to this incident. Rsd stated that he had ran over his O2 tubing with the wheel of his w/c and that's why it caught on fire. Rsd states's (sic) he did not have his O2 on his face and was not burned. Skin assessed for injury, none noted." M. Review of facility Resident Incident Reports revealed a 03/15/11 report documenting the following information: 1. In the report, CNA #23 documented, "Was walking past door to the turtle courtyard when I noticed the smell of burring. I saw burn marks on floor coming from outside. Told nurse on unit, when they asked (name of Resident #139) what had happen (sic), he stated that it caught on fire on his wheel." 2. In the report, Licensed Practical Nurse (LPN) #12 documented, "(name of Resident #139) was coming down the hallway in his w/c. His O2 tubing was dragging on the floor behind his chair. A portion of the tubing had been burned off + was found laying on the rug by the door of the turtle courtyard. Rsd stated he didn't know what happened + denied smoking c (with) his O2 on. He stated that he had ran over his O2 tubing with the wheel of his w/c + that's when it caught on fire." 3. Under the "Measures taken to prevent occurrence or recurrence," section the report documented, "rsd counseled about the dangers of smoking c his O2 on." No other measures were documented. Review of the resident care plan and physician orders revealed no additional interventions. N. On 04/12/11 at 11:30 am, during an interview, Registered Nurse (RN) #10, the nurse serving Resident #139, stated, "He does have a problem with his lungs. He's on oxygen, we monitor him for that." When asked about the resident's care plan for unsafe smoking, he stated, "He has been in the past been caught smoking (with oxygen)." When asked how the facility monitored the resident's smoking behavior, he stated, "We try and monitor his smoking but he usually go outside and smokes. When he's outside in the courtyard, we kind of watch him a little bit to make sure he's ok. We remind him when he goes out to turn off his oxygen." When asked how they kept track of when he was going outside to smoke, he stated, "We don't, to be honest with you." O. On 04/12/11 at 11:40 am, during an interview, CNA #20 was asked about Resident #139's smoking care plan. She stated, "They said that we needed to monitor him during smoking. He's very independent, so its hard to know when he's going out to smoke." P. On 04/12/11 at 2:50 pm, during an interview, the facility Director of Nursing (DON) stated, "Usually he's pretty good about letting us know when he goes out, but once in a while he will wander out." Regarding the 12/08/10 Social Work entry documenting unsafe smoking, she stated, "I can't tell you. The only thing I heard about was when he caught the tubing on fire (the 03/15/11 incident)." She stated that she believed the resident might have been experiencing some confusion, saying, "He was in his room in his WC nude with his clothes tossed to the side. He said he was waiting on staff to help him change his clothes." M. On 04/12/11 at 3:10 pm, during an observation, Resident #139 was in the "Turtle" fountain courtyard smoking. Resident #139 was wearing his O2 nasal cannula and the canister was set at 3 LPM. A filter was observed in the tubing between the cannula and the canister. When asked if he was getting any oxygen through the cannula he stated that he was and moved the prongs from his nostrils to his forehead. When asked if he often smoked with his oxygen on, he said he smokes just a couple of times a day. He was asked if anyone had told him he should turn off his oxygen when he goes out to smoke, he said that he thought it was off and that he would put out his cigarette. He was observed to wheel himself to the other door, still smoking the cigarette. The resident tossed the cigarette as the Safety Coordinator approached him. Q. On 04/12/11 at 3:10 pm, during an interview, the facility Incident Report Director reviewed her incident data base for the period of 02/01/10 through 04/12/11 and reported no other smoking related incidents except the incident of 03/15/11 involving Resident #139. When asked if she would expect to receive an incident report for residents found smoking with oxygen on, she stated, "Yes." R. On 04/12/11 at 3:10 pm, during an observation, resident #139 was in the "Turtle" fountain courtyard smoking. Resident #139 was wearing his O2 nasal cannula and the canister was set at 3 LPM. A filter was observed in the tubing between the cannula and the canister. When asked if he was getting any oxygen through the cannula he stated that he was and moved the prongs from his nostrils to his forehead. He was asked if he often smoked with his oxygen on; he said he smokes just a couple of times a day. He was asked if anyone had told him he should turn off his oxygen when he goes out to smoke; he said that he thought it was off and that he would put out his cigarette. He was observed to wheel himself to the other door, still smoking the cigarette. The resident tossed the cigarette as the Safety Coordinator approached him. S. On 04/12/11 at 3:20 pm, the Safety Coordinator went out and checked Resident #139's O2. When asked if he could confirm the resident's oxygen was on, he said it was on but that the resident did not have a cigarette. He was informed that the resident had just gotten rid of it. The Safety Coordinator said that the resident's oxygen had been turned off 3 times in the last hour because the resident had been found smoking. T. On 04/12/11 at 3:55 pm, during an interview, CNA #22 was asked if she had ever seen resident #139 smoking while using oxygen. She stated, "Yes, just today when he was out in the turtle courtyard. He was out in the courtyard, and I was coming back from the dining room. I think he had his oxygen on." When asked what time she had seen him, she stated it had been around 12:15 pm or 12:30 pm. When asked if she had checked his tank to see if it was on, she stated, "No. I just didn't think about checking the tank, 'cause he's not on this unit (B-unit) anymore." When asked if he'd been wearing his O2 cannula, she stated, "I believe so." When asked what she was supposed to do when observing a resident smoking with an O2 cannula in place, she stated, "You should check and make sure that the tank is off or that they don't have the oxygen on and smoking at the same time." When asked if she had done that for Resident #139, she stated, "No I didn't. I didn't even think about it at the time." U. Review of the facility policy, "Smoking," effective date 07/01/99, revised 07/01/01, last reviewed 09/19/09, revealed the instructions, "Smoking shall be prohibited in any room, unit, or compartment where flammable liquids, combustible gases, or oxygen are used or stored and in any other hazardous location... Residents receiving supplements of oxygen will be assisted by staff, as needed, in closing the tank valve and removal of the nasal cannula from their face, before they light the cigarette in appropriate smoking area... Residents not using smoking materials safely... shall be referred to Care Plans for recommendations." V. Review of the facility policy, "Resident Rights: Freedom from Accident, injury or Abuse. Resident Incident Report and Follow-up, effective date 12/15/95, revised 04/09, and last reviewed on 08/11/10, revealed the instructions, "Any staff member who has knowledge of an accident, injury... will document the incident on a Resident Incident Report Form immediately to assure immediate assessment of the resident. The employee may not leave the facility until the incident report has been written and turned over to the unit nurse."