Every finding on record at NHC Healthcare, Murfreesboro

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide an environment free from physical restraints for 1 (Resident #3) of 3 sampled residents reviewed for restraints. The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated [DATE], revealed, .Abuse, Neglect .will not be tolerated by anyone, including staff .family members or legal guardians .The patient has the right to be free from abuse .This includes but is not limit to freedom from .any physical restraint .not required to treat the patients medical symptoms .All allegations of possible abuse .will be immediately assessed to determine the appropriate direction of the investigation . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Local infection of the skin and subcutaneous tissue, Acute Respiratory Failure with Hypoxia, Metabolic Encephalopathy, Muscle Wasting and Atrophy, Unspecified Dementia, Contusion of right lower leg, and History of falling. Resident #3 expired at the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Continued review revealed Resident #3 required extensive assistance of two plus person physical assistance for bed mobility, transfer, toileting, personal hygiene, and limited assistance of one person for dressing. Continued review revealed Resident #3 had limitation in range of motion with both lower extremities. Further review revealed Resident #3 had a fall in the last ,d+[DATE] months. Review of the facility Safety Events (Incident Reports), with dates ranging from ,d+[DATE] through ,d+[DATE], revealed Resident #3 had a total of 39 documented falls with various injuries, which included 2 major injuries that required hospital transfer for evaluation. (Refer to Tag F689) During an interview on [DATE] at 5:20 PM, Certified Nursing Assistant (CNA) K stated, .[Named Resident #3] had a lot of falls .when she came back from hospital, she was mainly in the bed .we mainly used a lift with her, and you always need 2 people when you use the lift .her bed was kept against the wall and she had a clip alarm to alert us if she was trying to get up . During a telephone interview on [DATE] at 1:54 PM, Family Member (FM) O stated, .the facility called me when she [Resident #3] had the fall [DATE] .he [Licensed Practical Nurse LPN I] just said I need you to go to the hospital .she had so many falls since she had been there .the Administrator called me the next day .she couldn't tell me how long she laid in the floor or what time for sure it happened .you know the staff would put chairs against the end of the bed to keep her restrained to the bed .I have pictures of it .we have walked in and the bed be against the wall and two chairs at the end of her bed . Review of the undated picture provided by FM O revealed Resident #3 in the bed with one side of the bed against the wall and two burgundy chairs sitting at the end of the bed below the half side rail. During a telephone interview on [DATE] at 2:00 PM, CNA P stated, .the staff was very aware of her [Resident #3] fall risk .I have found chairs next to her bed to keep her in the bed .I told the staff it's a restraint she could get hurt you can't do that .it was more than one time I found it that way . During a telephone interview on [DATE] at 2:27 PM, an Anonymous Registered Nurse (RN) stated, .I knew about the chairs sitting next to [Named Resident #3]'s bed .the staff said the family was doing it and staging it but the family said the staff was doing it .I have walked into the room when family had not been there and found two burgundy straight back chairs next to the bed and the other side of the bed against the wall .the daughter reported that the second shift was doing it .the Administrator was aware of it .I told the staff you can't do that . The RN was asked was an in-service given to the staff or any education given to the family about restraints. The Anonymous RN stated, No. During an interview on [DATE] at 4:30 PM, the Administrator was asked if she had been made aware of staff or family placing chairs against the side of Resident #3's bed to restrain her in the bed. The Administrator stated, .Not that I know of .you can't leave chairs next to a bed, that is a restraint . The Administrator reviewed the picture provided by FM O and identified the person in the photo was Resident #3 and confirmed the photo had been taken in Resident #3's room. The photo revealed Resident #3 lying in bed with one side of the bed pushed up against the wall and the other side had 2 chairs placed against the opposite side of the bed.

Based on facility policy, record review, and interview, the facility failed to ensure a discharge summary was completed that contained needed information of the residents stay to ensure a safe discharge for 1 of 3 (Resident #4) residents reviewed for discharge. The findings include: Review of the facility policy titled, TRANSFER/DISCHARGE, dated 2/2023 revealed, .A patient may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician .Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for the transfer .The center will assist in effecting a smooth transition . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] with diagnoses which included Dementia, moderate, with anxiety, Obsessive-compulsive disorder, Unspecified Psychosis, Depression, Alcohol Dependence with alcohol-induced persisting Dementia, Anxiety Disorder, and Pseudobulbar affect. Review of the Behavior Analysis Report revealed on 12/17/2022 Resident #4 was wandering hallway and attempting to enter other resident ' s room. Continued review revealed on 12/30/2022 Patient searching nurses' station for drinks/snacks and grabbing multiple supplements, attempted to redirect and pt stated, You can't tell me what to do. On 1/6/2022 resident repeatedly in and out of nurses' station stealing supplements/snacks, hiding items under shirt or in her purse. On 2/17/2023 Resident #4 smeared feces on curtain. Continued review revealed on 3/10/2023 Resident #4 with usual wandering behavior. On 3/13/2023, Resident #4 taking food (pudding) and supplement off med cart and med cart cooler and 3/14/2023 Resident #4 rummaging on top of med cart, cabinets, and cooler. Review of the comprehensive care plan for Resident #4 revealed a problem start date of 4/5/2022 at risk for alteration in behaviors related to diagnoses of Dementia, psychosis, anxiety, as evidenced by restlessness pacing and wandering. Continued review of the comprehensive care plan for Resident #4 revealed she likes to travel around the environment and may occasionally follow others into other rooms/areas and assist her back to common area as needed. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Continued review revealed Resident #4 had delusional behaviors and wandered daily over the last 7 days. Further review revealed the wandering impact placed the resident at significant risk of getting to a potentially dangerous place and wandering intrudes on the privacy of others. Review of the Behavior Analysis Report revealed on 4/8/2023 resident had been going to other residents' rooms, to nurses' station, trying to steal food and drinks, did not sleep much. Review of the Elopement Risk dated 5/27/2023 for Resident #4 revealed resident exhibited wandering or exit seeking behavior in the last 90 days. Continued review revealed Resident #4 was independently ambulatory. Review of the Quarterly MDS dated [DATE] revealed Resident #4 had a BIMS score of 4 which indicated severe cognitive impairment. Review of the Psychiatric Nurse Practitioner (NP) Progress Notes revealed, .6/9/2023 .PSYCHOTIC SYMPTOMS .Preoccupation with the bathroom/toilet and at times will smear feces due to confusion .Preoccupation with food and continues to take food items from nursing carts/others .Patient denies AH/VH [Auditory Hallucination/Visual Hallucination] but had been observed responding to internal stimuli and talking to self and has been talking to her daughter, when daughter is not present and has made some delusional thinking about someone 'being hit by a train' and that someone 'being molested'. Patient denies these things to writer today .Chronic pacing .Due to severity of cognitive deficits, her behaviors will most likely progress/worsen as her overall condition declines. Redirection or patient education is not effective due to her cognition and inability to recall information .Prognosis is guarded and she may eventually need placement in a memory care unit or a geriatric behavioral nursing facility . Review of the Behavior Analysis Report revealed on 6/16/2023, Resident #4 rummaging through roommate's clothes and trying to take food from tray rack (clean and dirty). Review of the Psychiatric Nurse Practitioner Progress Notes revealed, .7/10/2023 .Chronic pacing and asking for multiple things repetitively due to significant short-term memory impairment .Patient with progressing behaviors and has begun taking peer's clothes and putting soiled linens in peer's bed. She continues to respond to internal stimuli and has been having extended conversations with unseen people. Her hallucinations do not appear to be bothersome or distressing to her, however her behaviors towards her peers have been distressing to them. Will increase Seroquel [antipsychotic medication used to treat psychosis] .Will D/C [discontinue] Depakote [anticonvulsant medication used as a mood stabilizer] since she is taking a low dose .increasing Seroquel for psychosis/disorganization . Further review of the Psychiatric Nurse Practitioner Progress Notes revealed, .7/17/2023 .Chronic pacing in the afternoon/evening and asking for multiple things repetitively due to significant short term memory impairment .No history of inpatient psychiatric hospitalization . Review of the Care Conference Report for Resident #4 dated 7/20/2023 revealed, .Care Plan meeting held today. Present were Social Work, Nurse Manager, Dietician, and participating by telephone was patient's daughter .Care Plan, medications, and diet reviewed. Patient's behavior was discussed and nurse shared that there are memory care units that are designed for patients that wander and might be more helpful to her. Daughter agreed with referral being made . Review of the Progress Notes dated 7/26/2023 revealed, .SW (Social Worker) made referral to several long term care facilities that have Dementia and Memory Care units per daughter .agreement during recent care plan meeting .[Named Facility #2] has accepted .[Named Resident #4] as a patient and daughter is in agreement with her mother being transferred and admitted there. [Named Facility #2] to contact daughter and set up a date and time for admission and will inform SW . Review of the Progress Notes dated 7/27/2023 revealed, .[Named Facility #2] social worker called and stated they are able to admit [Named Resident #4] today .Van Service has been arranged to transport patient around 3:30 PM today . Review of the Department Notes from (Named Facility #2) dated 7/28/2023 8:26 AM, .Late Entry 7/27/23 [2023] .Resident up in the common area asking staff that walked by how to get out of here. Resident is also asking other residents how to get out of here. Unable to redirect. Snack offered and provided. Resident stated in a raised angry tone, 'I did not ask for a snack, if I want a snack I will get one myself' . Continued review of the Department Notes dated 7/28/2023 11:59 AM, .spoke with daughter, with daughter stating she thought her mom was going to a nursing home with a memory care unit .daughter did not realize facility does not have a memory care unit .daughter plans to come in on this date, will have further discussion of resident plan of care at that time . Continued review of the Department Notes dated 7/28/2023 3:33 PM revealed, .spoke with .daughter at bedside to review residents behaviors, resident has behaviors prior to admission to this facility .adjusted psychotropic medication in facility multiply [multiple] times stated by daughter .reviewed in patient psych stay at behavioral unit may benefit resident, daughter agreeable .4:07 PM New order received to initiate transfer .for eval and treat for possible inpatient psych stay, EMS [Emergency Management Service] notified of need for transport . Further review of the Department Notes from (Named Facility #2) dated 8/16/2023 revealed, .Late entry on 8/15/23 [2023] [Named Facility #3] called to inform this writer that they would accept resident as long term for memory care. Daughter contacted via phone to make aware that facility .has accepted resident for long term care. Daughter agreeable with facility to set up transportation . Review of the Transitions of Care/Discharge Summary dated 7/29/2024 (completed by Facility #1- 2 days after Resident #4's discharge) revealed, .Mood and Behavior Patterns .other behavioral symptoms directed toward others .Behavior of this type occurred 1 to 3 days .Care Plan Goals .Goal Date .9/15/2023 Will have elopement risk minimized through next 120 days or next review. Will remain in safe confines of center unless supervised by staff/representative . The completion date of the discharge summary revealed it was completed after her discharge and could not have been sent or faxed to [Named Facility #2] on the day of discharge 7/27/2024. During an interview on 7/29/2024 at 4:10 PM, Social Service Director (SSD) stated, .We were wanting to find safer placement for [Named Resident #4] .she was needing more of a secured unit .dementia unit .she was on the 2nd floor but she was exit seeking .flushing clothing and food down the toilet .daughter was aware of her transfer to [Named Facility #2] .a discharge summary would have been sent . During a telephone interview on 7/29/2024 at 7:38 PM, The Complainant stated, .I was told it would be more beneficial for [Named Resident #4] to transfer to another facility with memory care .they didn't give me a definite date at that point .On 7/27/2023 I was told I needed to go to the new facility [Facility #2] and sign papers .I explained to them I couldn't go until 7/28/2023 because I was out of town. The new facility [Named Facility #2] called me and said mom was already there .[Named Facility #1] had mom to wear an ankle monitor and had a secured door but the facility they sent her to does not have ankle monitors and no secured doors .[Named Facility #1] transferred mom to where she was a flight risk . During an interview on 8/1/2024 at 10:15 AM, Social Worker H stated, .[Named Resident #4] needed a specialized dementia unit .the daughter was aware of the discharge and I faxed out the referral to [Named Facility #2] .the Admission Coordinator at the facility is the one that accepted her transfer . During a telephone interview on 8/1/2024 at 10:25 AM, the Director of Nursing (DON for Named Facility #2) stated, .[Named Resident #4] is no longer at our facility .she is now at a memory care unit at [Named Facility #3] .our doors can be pushed on and after a few seconds they will open we are not a locked unit .when she got here she was confused, wandering, pushing on exit doors, cursing, threatening behaviors .we had to place her on 1 on 1 supervision .We sent her out for a psychiatric stay and she came back but she was still exit seeking .I sent out further referrals and found a locked facility for her .the daughter understood from the previous facility [Named Resident #4] wound be transferring to a secured unit .it was not a safe transfer .it was not in her referral that she was exit seeking and that is not what we understood when she was being transferred to our facility .we do not have a wanderguard system . The DON was asked to email this surveyor a copy of the referral the facility received from (Named Facility #1) on (Named Resident #4). Review of the referral received by Facility #2 revealed Resident #4's wandering and intrusive behavior and risk for elopement was not documented on the Nursing Summary referral. No discharge summary was provided to Facility #2. During an interview on 8/1/2024 at 12:08 PM, the NP stated, .[Named Resident #4] wandered and was exit seeking, very ambulatory .a secured unit would have been better for her . During an interview on 8/1/2024 at 1:00 PM the Administrator was asked if the facility kept a copy of the referral that was sent out on (Named Resident #4). The Administrator stated, .We don't keep a copy of the referrals we send out . During an interview on 8/1/2024 at 3:25 PM, SW H stated, .I saw [Named Resident #4] get on elevator behind some visitors .I was not aware the facility [Named Facility #2] did not have locked doors .I was not aware the facility did not have a wanderguard [ankle monitoring] system . SW H was asked if he had any email correspondence with the Admission Coordinator at [Named Facility #2] he stated, we only talked by phone about [Named Resident #4]. During an interview on 8/1/2024 at 4:07 PM, the Administrator stated, .She [Named Resident #4] was always on the 2nd floor .she never got on the elevator .It was my understanding that [Named Facility #2] had a secured unit . The Administrator was asked does she feel Resident #4 had a safe transfer considering the facility did not have a secured unit. The Administrator stated, .I still feel it would be better for her . During an interview on 8/2/2023 at 8:40 AM, the Medical Director (MD) stated, .[Named Resident #4] was transferred to another facility where I make visits also [Named Facility #3] . The MD was asked why Resident #4 had to be transferred to (Named Facility #3). MD stated, .she needed to be in a locked memory unit the previous settings were not appropriate for her needs .

Based on facility policy review, medical record review, facility documentation, and interview, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed discharge plans for 1 (Resident #4) of 3 sampled residents reviewed for discharge. The findings include: Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included Dementia, Obsessive-compulsive disorder, Unspecified Psychosis, Depression, Alcohol Dependence with alcohol-induced persisting Dementia, Anxiety Disorder, and Pseudobulbar affect. Resident #4 was discharged on [DATE]. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of Resident #4's Comprehensive Care Plan, with revision date 5/31/2023, revealed no discharge plan. Review of the Psychiatric Nurse Practitioner (NP) Progress Notes for Resident #4, revealed, .6/9/2023 .Chronic pacing .Due to severity of cognitive deficits, her behaviors will most likely progress/worsen as her overall condition declines. Redirection or patient education is not effective due to her cognition and inability to recall information .Prognosis is guarded and she may eventually need placement in a memory care unit or a geriatric behavioral nursing facility . Review of the Care Conference Report for Resident #4, dated 7/20/2023, revealed, .Care Plan meeting held today. Present were Social Work, Nurse Manager, Dietician, and participating by telephone was patient's daughter .Patient's behavior was discussed and nurse shared that there are memory care units that are designed for patients that wander and might be more helpful to her. Daughter agreed with referral being made . Review of the Progress Notes for Resident #4, dated 7/26/2023, revealed, .SW (Social Worker) made referral to several long term care facilities that have Dementia and Memory Care units per daughter .agreement during recent care plan meeting .[Named Facility #2] has accepted .[Named Resident #4] as a patient and daughter is in agreement with her mother being transferred and admitted there. [Named Facility #2] to contact daughter and set up a date and time for admission and will inform SW . Review of the Progress Notes for Resident #4, dated 7/27/2023, revealed, .[Named Facility #2] social worker called and stated they are able to admit [Named Resident #4] today .Care Ride Van Service has been arranged to transport patient around 3:30 PM today . During an interview on 8/1/2024 at 3:25 PM, Social Worker H was asked to review [Named Resident #4]'s care plan to see if a discharge plan was noted in her care plan. SW H stated, .I don't see one . During an interview on 8/1/2024 at 4:07 PM, the Administrator was asked to review [Named Resident #4]'s care plan for a discharge plan. The Administrator stated, .I don't see a discharge care plan on her .

Based on the facility policy review, medical record review, hospital record review, facility documentation, review of photographs, and interview, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 sampled residents (Resident #3) reviewed for accidents. The findings include: Review of the facility policy titled .Incident and Accident Process . dated 1/2024 revealed, .An incident or accident is defined as 'any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient' .Some examples .are Falls .Found on floor .Unexplained bruising .All patient incidents should be documented in the EHR [electronic health record] .Injury is defined, for reporting purposes, as Significant injury including: Fracture or dislocation of bones or joints .Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .is data complete and thorough and paints a picture of what happened .Was hospitalization necessary to treat the patient .Was the care plan updated to reflect the incident .Is additional investigation needed to determine the exact events of the incident .What can be done to avoid similar incidents recurring on this or any patient in the center .The data may be used for occurrence trending and improvement/prevention by the Safety Committee and QAPI [Quality Assurance Performance Improvement] Committee . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Local infection of the skin and subcutaneous tissue, Acute Respiratory Failure with Hypoxia, Metabolic Encephalopathy, Muscle Wasting and Atrophy, Unspecified Dementia, Contusion of right lower leg, and History of falling. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Continued review revealed Resident #3 required extensive assistance of two plus person physical assistance for bed mobility, transfer, toileting, personal hygiene, and limited assistance of one person for dressing. Continued review revealed Resident #3 had limitation in range of motion with both lower extremities. Further review revealed Resident #3 had a fall in the last 2-6 months. Review of the Safety Events (Incident Report) revealed Resident #3 had an unwitnessed fall in her room and sustained a bruise on right abdomen on 11/3/2022.?Resident #3 had two additional unwitnessed falls in her room on 11/7/2022, and 11/23/2022. Resident #3 had 3 falls during 11/2022. 1 of 3 falls resulted in injury. Review of the Safety Events revealed Resident #3 had unwitnessed fall in her room on 12/29/2022. Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room on 2/17/2023, after staff had placed her back in center of bed 3 times prior to the fall. Resident #3 had an unwitnessed fall on 2/21/2023 at 2:30 AM and sustained bruising on her right elbow and both knees. Resident #3 had a second unwitnessed fall in her room on 2/21/2023 at 6:15 AM which resulted in discoloration and tenderness to bilateral patella and bruising to her hand. Resident #3 had a third fall on 2/21/2023 at 8:10 PM and sustained small half dollar shaped red/bruised area to both kneecaps. Resident #3 had an unwitnessed fall in her room on 2/27/2023. Resident #3 had 5 falls during 2/2023. 3 of 5 falls resulted in injury. Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room on 3/6/2023 at 3:14 AM and sustained bruising on both knees. Resident #3 had an unwitnessed fall in her room on 3/11/2023, and sustained bruising to her left wrist. Resident #3 had 2 falls during 3/2023. 2 of 2 falls resulted in injury. Review of the Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 4, which indicated severe cognitive impairment. Continued review revealed Resident #3 required extensive assistance of two plus person physical assist for bed mobility, transfers, dressing, toileting, personal hygiene, and was totally dependent for locomotion on and off unit and bathing. Further review revealed Resident #3 had 2 falls with no injury and 2 falls with injury since prior assessment. Review of the Safety Events revealed Resident #3 rolled out of bed while Certified Nursing Assistant (CNA) was in the process of changing the resident on 4/3/2023 and sustained a skin tear to her right hand. Resident #3 had an unwitnessed fall off low bed to fall mat on 4/13/2023. Resident #3 had been restless, agitated, talking loudly, delusional, and seeing men in her room prior to the fall. Resident #3 had an unwitnessed fall on 4/29/2023, and sustained skin tear on left forearm. Resident #3 had 3 falls during 4/2023. 2 of 3 falls resulted in injury. Review of the Safety Events revealed Resident #3 was found lying on the ground in front of her geriatric chair (a large, padded chair that can be reclined for comfort) while sitting at nurses' station on 5/6/2023 at 11:25 PM and sustained a large hematoma to her right forehead, eye orbit, and temple. Resident #3 had an unwitnessed fall in her room on 5/9/2023. Resident #3 was found in the floor after an unwitnessed fall in her room on 5/16/2023. Resident #3 was found sitting with her back by the bed after an unwitnessed fall in her room on 5/25/2023. Resident #3 had 4 unwitnessed falls during 5/2023. 1 of 4 falls resulted in injury. Review of the Safety Events revealed Resident #3 was found on the floor next to her bed after an unwitnessed fall on 6/4/2023. Resident #3 was found sitting beside her bed after an unwitnessed fall on 6/11/2023. Resident #3 was found sitting in floor after an unwitnessed fall in her room on 6/16/2023. Resident #3 was found on the floor in her room after an unwitnessed fall on 6/18/2023. Resident #3 had bruising under her left eye the following day on 6/19/2023. Resident #3 had an unwitnessed fall in her room on 6/21/2023. Resident #3 had 5 unwitnessed falls in her room during 6/2023. Review of the Psychiatric Progress Notes dated 6/19/2023 revealed, .[Resident #3] tells writer that there are 'two men' in her room .they have been there all morning and is unsure why they are in her room or how they got there .Discussed VH [visual hallucinations] with her and she admits that sometimes her mind plays tricks on her .she [Resident #3-with severe cognitive impairment] agrees to believe staff if they tell her there is no one in her room . Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room and sustained 2 small bruises on each patella with bilateral knee pain, bruising to left hand on 2nd, 3rd, and 4th fingers at knuckle on 7/2/2023. An X-ray was obtained on 7/3/2023, results were positive for a fracture to right hip. Resident #3 had an unwitnessed fall in her room on 7/5/2023. A CNA heard Resident #3's clip on alarm and was unable to answer the alarm in time to prevent the fall. Resident was placed back in bed without further intervention. Resident #3 had unwitnessed fall in her room on 7/21/2023. Resident #3 had 3 falls during 7/2023. 1 of 3 falls resulted in major injury. Review of the Progress Notes for Resident #3 dated 8/6/2023 revealed, .Patient confused and climbing out of bed. Delusional, crying . Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room on 8/12/2023. Resident #3 had an unwitnessed fall in her room on 8/14/2023 and sustained bruising on her left knee with bilateral knee pain. Resident #3 had 2 falls during 8/2023. 2 of 2 falls resulted in injury. Review of the comprehensive care plan for Resident #3 dated 9/15/2023, revealed, .Transfer via [by way of] [named mechanical lift] and 2 person assist . Review of the Progress Notes for Resident #3 dated 9/21/2023 revealed, .pt having inc [increase] behaviors, crying and trying to get out of chair, explaining pt that there is no man, reassuring pt she is safe but unable to reorient her .PRN [as needed] diazepam [antianxiety medication given for anxiety] . Review of the Psychiatric Progress Note for Resident #3 dated 9/21/2023 revealed, .She tells writer that she did not sleep well last night but she cannot tell me why she had difficulty sleeping .She has periods of increased confusion, agitation, aggression and crying spells .Nursing report that she had increased behaviors last night with crying, trying to get out of her chair and talking about a 'man' . Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room on 9/1/2023, and was confused, agitated, and unable to be redirected. Resident #3 had a witnessed fall from her chair while sitting in front of the nursing station on 9/2/2023. Resident #3's clip alarm sounded upon nurse entering the room, resident was up unassisted. The nurse was unable to get to resident in time and resident sat upright on fall mat on 9/25/2023. Review of the Progress Notes for Resident #3 dated 9/28/2023 revealed, .4:49 PM Pt seen by NP [Nurse Practitioner], has shingles. Contact precautions initiated . Review of the Progress Notes for Resident #3 dated 9/29/2023 revealed, .1:50 PM .Pt requires private room isolation for shingles-pt has cognitive deficit and does not understand precautions. She is not able to understand to avoid picking at skin and then touching other surfaces, roommate, or other people. Staff attempt to keep areas covered but pt is able to self-remove and adjust coverings. All care and services provided in pt's private room . Resident #3, a severely cognitively impaired resident with a history of multiple unwitnessed falls with injury, was relocated for isolation purposes to a room that was approximately 38 feet from the nurse station which was located on a separate hall. Review of the Safety Events revealed Resident #3 was up unassisted in her room and a CNA (Certified Nursing Assistant) walked in and had to lower her to the floor on 9/30/2023 at 8:00 AM. Resident #3 was placed back in the bed. Resident #3 had an unwitnessed fall in her room [ROOM NUMBER] hours later and sustained a large hematoma noted on her right lower extremity (RLE) with pain rated 8 out of 10 (pain scale of 1-10 with 10 being the highest pain level) in her leg. Resident #3's injuries required transfer to the local emergency room for evaluation. Review of Hospital #1's History and Physical dated 9/30/2023 for Resident #3 revealed, .medical history of dementia .paroxysmal A-Fib [Atrial Fibrillation] on Eliquis [blood thinner], history of DVT/PE [Deep Vein Thrombosis/Pulmonary Embolism] present from nursing home to hospital after a fall .patient was in shingle isolation at nursing home, had unwitnessed fall this morning. Nursing facility states they are unsure what happened exactly .Patient is requiring high amount of pain medication for leg pain .Reviewed CT [Computed Tomography] scan including CTA [Computed Tomography Angiography] lower extremity right showed large hematoma .ongoing small arterial bleeding [most severe and urgent type of bleeding which can result from a penetrating injury or blunt trauma] .Hematoma of right lower leg .Primary diagnosis is an acute or chronic illness with a high risk disease process that poses a threat to life or bodily function in the near term without treatment .Dementia .Severe, oriented to person. Also has sundowning . Review of Hospital #1's Consult Notes dated 10/1/2023 for Resident #3 revealed, .She came in from a nursing home status post a fall .history, she sustained an unwitnessed fall because she was in insolation [isolation] secondary to a shingles diagnosis. She is on Eliquis for Afib .physical examination today .right lower extremity has a 15cm [centimeter] x [by] 10 cm hematoma along the medial calf with serous blisters .fall was unwitnessed .facility states they are unsure of when it exactly happened .CTA was ordered and showed a hematoma measuring 22cm x 11.4cm x 6.5cm with multiple areas of contrast with ongoing bleeding . Review of a pictures provided by Family Member (FM) G dated 10/3/2023 at 11:24 AM, (3 days after Resident #3's fall at facility) revealed a large hematoma with swelling noted covering the top of her right lower leg. A picture dated 10/8/2023 at 2:09 PM revealed, the hematoma was black in color with the appearance of necrotic tissue. Review of medical records revealed Resident #3 was readmitted to the facility on [DATE]. Review of the Safety Events revealed Resident #3 had an unwitnessed fall in her room on 10/9/2023. Review of the comprehensive care plan for Resident #3 dated 10/9/2023, revealed .Pt recently returned from hospital and is in new room closer to nurses station; reorient to new environment . (Resident #3 had severe cognitive impairment) Review of a picture provided by FM G dated 10/10/2023 at 1:08 PM, revealed a circular bruise to Resident #3's lower left leg. Review of the Safety Events revealed a nurse heard Resident #3's clip alarm going off and Resident #3 was found sitting on her buttocks after an unwitnessed fall in her room on 10/11/2023. Review of the comprehensive care plan for Resident #3 dated 10/11/2023, revealed, .Encourage pt to sit in common areas such as nurses station, tv [television] room while up in chair to increase staff supervision . Resident #3 with dementia and was totally dependent on a mechanical lift and 2-person assist could not be encouraged but rather needed staff assistance to stay in common areas for closer staff supervision. Resident #3 had 28 unwitnessed falls in her room before 10/11/2023. Review of the Progress Notes dated 10/15/2023 at 12:27 AM revealed, Resident #3 had moments of confusion and hallucinations. Resident #3 stated that a fire was nearby and able to each the building. Review of the Safety Events revealed on 10/15/2024 at 12:45 AM, Resident #3's bed alarm sounded. Resident #3 had increased anxiety and confusion and staff noted she wanted to get out of bed because a fire was approaching. Review of the Safety Events revealed on 10/17/2023, .CNA was getting ready to transfer pt to her chair and when she turned her back to but [put] the pad in the chair pt slide out of low bed onto the mat with her buttocks . Resident #3 was care planned for use of a mechanical lift with 2 persons for all transfers. The event note above does not indicate a second person available for transfers present in the room. Review of the comprehensive care plan for Resident #3 revealed, .10/17/2023 .When pt anxious and agitated use x2 staff assistance with ADL [Activities of Daily Living] care . Resident #3 had an unwitnessed fall in her room on 10/18/2023. Resident #3 was found lying face down and tilted to right side at foot of geri chair. Resident #3 had skin tear to left elbow and bruising to inner right forearm. On 10/20/2023, CNA walked into Resident #3's room and resident was found lying on mat beside bed. Review of a picture provided by FM G dated 10/23/2023 at 10:12 AM, revealed Resident #3's clip alarm was unattached from the resident, lying next to the TV. Review of the Quarterly MDS dated [DATE] revealed Resident #3 had a BIMS score of 4, which indicated severe cognitive impairment. Resident #3 had functional limitation in range of motion in upper and lower extremities on both sides. Resident #3 was dependent for toileting, upper and lower body dressing, personal hygiene, roll left and right, and chair/bed-to-chair transfer. Resident #3 had an acute diagnosis of Contusion of right lower leg. Resident #3 had 1 fall with no injury and 1 fall with injury since the prior assessment.?Resident #3 had a bed alarm used less than daily. Review of a picture provided by FM G dated 10/26/2023 at 1:53 PM, Resident #3's clip alarm was laying on top of sheets not clipped to anything. During an interview on 7/29/2023 at 4:00 PM, the Social Service Director (SSD) stated, .I do remember the daughter having concerns about the fall with injury, but I really don't remember the details . Observation on the 100 hall on 7/31/2024 at 3:00 PM, revealed room [ROOM NUMBER]B (the room Resident #3 was relocated to for isolation and had a fall with a major injury on 9/30/2023), was the last room on the hall approximately 38 feet from the nurse station which was located on a separate hall. During a telephone interview on 7/29/2024 at 7:30 PM, FM G stated, .[Resident #3] fell out of bed .it caused a big hematoma .she had to have several surgeries to debride it .the facility couldn't tell me how long she had been in the floor .it never healed up .she was in severe pain every time they changed the bandage .I never could get an explanation out of them [facility staff] .when I would come to visit her the alarm was either on the table or not hooked up to her gown .I never saw [Resident #3] remove it .I would go in and they wouldn't have it hooked up .after all this happened [fall with Arterial Bleed] the staff wouldn't get [Resident #3] up and she just got worse .I talked to the Director of Nursing and the Administrator .I never seen anything improve and then they put her in that back corner in the rehab part to isolate her because they thought she had shingles .[Resident #3] was supposed to have a low bed but it wasn't always in the low position .she just kept declining and then she passed away . Review of pictures provided by FM G revealed undated pictures of Resident #3 with bruising noted to her right temple area close to her hair line, above her right eye, down the right side of her face, and bruising to back of ear and down her neck. FM G stated, I lost some of my phone information, but that picture was taken around 9/2023. During an interview on 7/31/2023 at 4:25 PM, MDS Coordinator/Quality Assurance (QA) Nurse stated, . [Named Resident #3] had severe dementia, very restless .was dependent with transfers .the care plan on admission has assist with ADLs per patient needs and preferences .[Resident #3] was impulsive on her own and her range of motion was impaired . The MDS Coordinator/QA Nurse reviewed the therapy notes and confirmed Resident #3 was dependent for transfers with a mechanical lift using 2 persons. The MDS Coordinator/QA Nurse stated nursing staff could review care plans in the computer and she expected staff to follow interventions related to resident care. During an interview on 7/31/2024 at 5:15 PM, the Physical Therapist (PT) stated, .her [Resident #3] transfer during the evaluation was a [Named mechanical lift] with 2 assist .she had limitation in her range of motion in her lower extremities and could not hold a movement .when we saw her in 7/2023, we recommended use of a [Named mechanical lift] . During an interview on 7/31/2024 at 5:20 PM, CNA K confirmed Resident #3 was a fall risk and required use of a mechanical lift using 2 persons assist for transfer. During an interview on 7/31/2024 at 5:30 PM, Licensed Practical Nurse (LPN) L stated, .the CNAs and nurses can look in the computer at the care plan to see how much assistance a resident need with care .you always need 2 people if you are getting someone up with a lift . During an interview on 7/31/2024 at 5:35 PM, CNA M stated, .I cared for [Named Resident #3] .She would try to get up without help .very restless . During an interview on 7/31/2024 at 8:50 PM, CNA N stated, .I was charting when I heard [Named Resident #3]'s bed alarm sound, when I opened the door, she was in the floor .a bruise was on her right leg where she hit the table .I know she had to hit the overbed table because it was beside the bed .the table was scooted across the floor in front of her . During an interview on 8/1/2023 at 11:00 AM, LPN I stated, .I was here the day she [Resident #3] fell [9/30/2023] .the 8:00 AM fall, [Resident #3] said she was getting up to get something out of the dresser .the CNA found her up and had to lower her to the ground .the second fall happened in her room .she was found on the floor .when I assessed her, the right leg had started getting red and swelling . During a telephone interview on 8/1/2024 at 1:54 PM, FM O stated, .the facility called me when [Resident #3] had the fall 9/30/2023 .[Resident #3] got at the ER about the same time I did .she was shaking and hurting so bad .[Resident #3] said she laid in the floor and hollered for help .[Resident #3] was crying and said I didn't think they would come get me .she was begging for someone to come kill her she was hurting so bad .they had to sedate her in the ER .She was in that room all the way at the end of the hall away from the nurse's desk with the door closed .she had so many falls since she had been there .the Administrator called me the next day .she couldn't tell me how long she laid in the floor or what time for sure it happened . During a telephone interview on 8/1/2023 at 2:00 PM, CNA P stated, .I was told when I came in after [Named Resident #3] fell [9/30/2023], she had been trying to get up and they found her in the floor and the staff didn't know how long she had been in the floor .I found her clip alarm not clipped several times .I would tell them her alarm wasn't on .the staff was very aware of her fall risk . During a telephone interview on 8/1/2024 at 2:28 PM, the Activity Staff stated, .I done some in room stuff with [Named Resident #3] she didn't come to group activities much .I don't remember any meetings we had where they discussed a specific activity plan for her .I just encouraged her to come to group activities . During an interview on 8/2/2024 at 8:40 AM, Medical Director stated, .[Named Resident #3] had Afib that is why she was on Eliquis [blood thinner] .constantly trying to get up, [Resident #3] just couldn't remember she couldn't walk anymore and needed help .the hematoma was a complication from the Eliquis .I vaguely remember her being put on isolation .dementia was a contributing factor .she was placed in a room at the end of the hall to limit the people going by the room . The Medical Director was asked why he felt limiting people going by the room would be necessary to stop the spread of Shingles. The Medical Director stated, .it was a reasonable decision to make .it's more commonly spread by touch .less traffic better idea . The Medical Director was asked if a special focus, trending, or tracking was performed for Resident #3 since she had numerous falls with injuries. The Medical Director stated, .I can't recall .falls happen no way to prevent falls . During an interview on 8/2/2024 at 4:30 PM, the Administrator was asked if the facility considered placing the resident in isolation so far from the nurse's station could have contributed to her falls. The Administrator stated, .the family met with us after the fall, and they voiced concerns about her being moved at the end of the hall, we moved her back closer to the nurse's desk . The Administrator was asked if the Interdisciplinary Team had performed any tracking, trending, root cause analysis, or developed a specific activity plan related to Resident #3's multiple (over 30) unwitnessed falls in her room, with various injuries (including two major injuries). The Administrator stated, .just what we have given you and what is in the chart .I don't know of anything else .she was on a low bed, fall mat, everything was in place already .she was never transferred out to the psych unit . During an interview on 8/2/2024 at 4:45 PM, the Interim DON was asked to review Resident #3's care plan and her fall event for 10/17/2023. The Interim DON confirmed Resident #3 required use of a mechanical lift with 2 persons assist. The Interim DON stated the CNA was trying to prepare to transfer Resident #3 on 10/17/2023 when the resident slid off the bed and stated, .I think any fall could be prevented with another person but maybe she was just getting her ready .

Based on facility policy, medical record review, Facility Reported Investigation (FRI), observation, and interviews the facility failed to prevent abuse, for 1 of 3 residents (Resident #3) reviewed for abuse. The findings include Review of the facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation revised 12/11/2017 revealed .Abuse .will not be tolerated by anyone .patient has the right to be free from abuse .center administrator is responsible for assuring that patient safety .holds the highest priority .center will not employ individuals .found guilty of abusing .patients/residents by a court of law .currently listed on the State Nurse Aide Registry or any other State employee screening .have a disciplinary action in effect against his or her professional license .check references for all applicant to obtain information from previous employers and current employers .center will train all partners through orientation and ongoing in-services on the prevention, identification, investigation and reporting of abuse .any partner having either direct or indirect knowledge of any event that night constitute abuse .must report the event immediately .external reporting to the state .agency and all other state required agencies will follow .patient will be protected from harm during an investigation . Review of the FRI Incident ID # 316 investigation report dated 4/11/2022, revealed Resident #3 reported that CNA #4 (former employee of the facility) struck her on the arm during care on 4/11/2022. CNA #4 had already left the facility after her shift on 4/11/2022. Administrator and DON interviewed CNA #4 by phone. CNA #4 stated that she did strike the patient on the arm as a reaction to the patient striking her first. CNA #4 stated it was a reflex in the interview. CNA #4 was immediately informed she was terminated. Facility substantiated the abuse in the investigation. Review of the medical record revealed Resident #3 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual MDS assessment dated [DATE], revealed that Resident #3 had a BIMS score of 15 and required limited to total assist for all ADL care except eating.

Based on facility policy, medical record review, facility reported incident (FRI) investigation review, observation, and interviews the facility failed to prevent abuse and protect the resident from extreme humiliation during a shower while lying on the shower gurney in the shower room without clothing, completely nude, for 1 of 6 residents (Resident #2) reviewed for abuse which resulted in Immediate Jeopardy (IJ). IJ situation (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to promote, maintain, and enhance Resident #2's quality of life. The Administration was notified of the IJ on 9/27/2021 at 1:30 PM in the conference room. The facility was cited IJ at F-600 at the scope and severity of J which is Substandard Quality of Care. The IJ began on 8/31/2021 and was removed on 9/17/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/27/2021. The corrective actions were validated onsite by the surveyor on 9/27/2021. The findings include Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, misappropriation of Property, and Exploitation revised 12/11/2020 revealed .abuse will not be tolerated by anyone .the patient has the right to be free from abuse .the center administrator is responsible for assuring that patient safety including freedom from risk of abuse .hold the highest priority .abuse also includes .facilitated or enabled through the use of technology .the center will not employ individuals who have been found guilty of abusing .residents .the center will train all partners through orientation and ongoing in-services on the prevention, identification, investigation, and report of abuse .any patient event .reported .will be considered an allegation of .abuse .if it meets .any complaint of humiliation .including staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of the patient's cognitive status or consent .any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately . Review of FRI # 10 investigation report dated 9/2/2021 revealed the Administrator received a call from a former employee, Certified Nurse Assistant (CNA) #2. During the telephone call CNA #2 stated she had seen a video on Nurse Assistant (NA) #1's social media site of Resident #2 in the shower room on a shower gurney with no clothes on, nude, lying on her back. CNA #2 also stated another adult female dressed in scrubs holding a hand-held shower sprayer was NA #1. CNA #2 further stated NA #1 sprayed water over Resident #2's right side causing a startle and yelling by the resident. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored 1 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Inattention and disorganized thinking fluctuated. Total assistance of 2 or more staff members was required for bathing. Medical record review of the Comprehensive Care Plan for Resident #2 revised 7/1/2021 revealed assessment and monitoring occurred for activities of daily living (ADLs), self-care deficit, and distress during bathing. Observation of Resident #2 on 9/15/2021 at 9:50 AM revealed the resident was alert and pleasantly confused. She was disoriented to the date, time, and location. Observation of the video on 9/16/2021 at 3:15 PM revealed a female dressed in scrubs holding a hand-held shower sprayer was standing beside an elderly female resident lying on the shower gurney in the shower room without clothing, completely nude. The female dressed in scrubs sprayed water across the elderly female's right side and caused a startle effect by the elderly female with yelling. During a telephone interview attempted with NA #1 on 9/15/2021 at 10:31 AM and on 9/16/2021 at 10:26 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #2 on 9/15/2021 at 10:35 AM and on 9/16/2021 at 10:40 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #4 on 9/15/2021 at 10:37 AM and 9/16/2021 at 10:29 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During an interview with the Administrator, Regional Vice President, and Regional Corporate Nurse on 9/15/2021 at 3:00 PM and on 9/16/2021 at 11:00 AM confirmed the incident with Resident #2, NA #1, NA #3, and CNA #4 had been substantiated following the facility investigation. They also confirmed the video provided by CNA #2 was taken in the shower room on 2 east unit and included NA #1 and Resident #2. They further confirmed Resident #2 was lying without clothes, nude, on a shower gurney and was sprayed with water on her right side by NA #1. They confirmed confirmed NA #3 was assigned to Resident #2 on 8/31/2021. NA#1 and CNA #4 had been asked by NA #3 to assist with Resident #2's shower. They also confirmed NA #1, NA #3, and CNA #4 had been suspended pending the outcome of the facility investigation and terminated from employment at the conclusion of the facility investigation from the facility. They further confirmed according to facility policy for cellular phones, NA #1 should not have had her cellular phone in use while assisting with resident care. They confirmed the video showed an undignified and disrespectful existence for Resident #2. During a telephone interview with NA #3 on 9/16/2021 at 10:29 AM it was revealed she had worked at the facility and cared for Resident #2. She stated on 8/31/2021 in the 2 east shower room she observed NA #1 wearing ear buds, holding her cellular phone and talking to someone on the cell phone. She also stated she had no additional information about the incident. During a telephone interview with the Detective at the local police department on 9/16/2021 at 2:30 PM confirmed NA #1 had been interviewed, initially denied, and later confessed to the events occurring on 8/31/2021 in the 2 east shower room with Resident #2. He stated he was unable to reveal any other information related to the case at this time. He also stated no charges had been made at the current time. The IJ was removed onsite and was effective 8/31/2021 to 9/17/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy was completed and effective on 9/27/2021. The corrective actions were received and validated onsite by the surveyor 9/27/2021 at 1:30 PM. through review of facility documentation, observations, and interviews. 1. The surveyor verified a facility investigation was immediately initiated 9/2/2021 with notification of the local police, Adult Protective Services, Medical Director, and the Family members of Resident #2. 2. The surveyor verified Resident #2 was immediately interviewed and physically assessed on 9/2/2021. 3. The surveyor verified on 9/16/2021, Resident #2's Comprehensive Care Plan was updated on 9/2/2021. 4. The surveyor verified all other facility residents with a Brief Interview for Mental Status (BIMS) score of 8 or less were physically assessed and residents with a BIMS score of greater than 8 were interviewed on 9/2/2021. 5. The surveyor verified employee interviews for NA #1, NA #3, and CNA #4 were conducted by the facility from 9/2/2021 to 9/3/2021. 6. The surveyor verified staff education was initiated 9/2/2021 for employees facility-wide over the abuse policy, use of cellular phones and social media policy, Dementia care, and bathing. This was verified by review of sign-in sheets as well as employee list for comparison. Staff education was concluded 9/16/2021. 7. The surveyor verified beginning 9/6/2021 the Administrative team monitored compliance of the facility's abuse policy through the Quality Assurance Performance Improvement (QAPI) process. The Administrative team interviewed 75 employees and 40 residents with BIMS scores greater or equal to 8 monthly for 3 months. Additionally, 30 skin assessments per month of residents with a BIMS score less than 8 monitored for 3 months were scheduled to ensure no injuries of unknown origin. 8. The surveyor verified the Administrator and Director of Nursing (DON) reported findings of each monitor to the QAPI committee. The facility was compliant with the IJ removal plan 9/27/2021.

Based on facility policy, medical record review, facility reported incident (FRI) investigation review, observation, and interviews the Administration failed to maintain the highest well-being of life and failed to prevent abuse and protect the resident from extreme humiliation during a shower, lying on the shower gurney in the shower room without clothing, completely nude for 1 of 6 residents (Resident #2) reviewed for Administration which resulted in Immediate Jeopardy (IJ). IJ situation (a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to promote, maintain, and enhance Resident #2's quality of life. The Administrator was notified of the IJ on 9/27/2021 at 1:30 PM in the conference room. The facility was cited IJ at F-835 at the scope and severity of J. The IJ began on 8/31/2021 and was removed on 9/17/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 9/27/2021. The corrective actions were validated onsite by the surveyor on 9/27/2021. The findings include Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, misappropriation of Property, and Exploitation revised 12/11/2020 revealed .abuse will not be tolerated by anyone .the patient has the right to be free from abuse .the center administrator is responsible for assuring that patient safety including freedom from risk of abuse .hold the highest priority .abuse also includes .facilitated or enabled through the use of technology .the center will not employ individuals who have been found guilty of abusing .residents .the center will train all partners (facility staff/employees) through orientation and ongoing in-services on the prevention, identification, investigation, and report of abuse .any patient event .reported .will be considered an allegation of .abuse .if it meets .any complaint of humiliation .including staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of the patient's cognitive status or consent .any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately . Review of FRI # 10 investigation report dated 9/2/2021 revealed the Administrator received a call from a former employee, Certified Nurse Assistant (CNA) #2. During the telephone call CNA #2 stated she had seen a video on Nurse Assistant (NA) #1's social media site of Resident #2 in the shower room on a shower gurney with no clothes on, nude, lying on her back. CNA #2 also stated another adult female dressed in scrubs holding a hand-held shower sprayer was NA #1 . CNA #2 further stated NA #1 sprayed water over Resident #2's right side causing a startle and yelling by the resident. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored 1 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Inattention and disorganized thinking fluctuated. Total assistance of 2 or more staff members was required for bathing. Medical record review of the Comprehensive Care Plan for Resident #2 revised 7/1/2021 revealed assessment and monitoring occurred for activities of daily living (ADLs), self-care deficit, and distress during bathing. Observation of Resident #2 on 9/15/2021 at 9:50 AM revealed the resident was alert and pleasantly confused. She was disoriented to the date, time, and location. Observation of the video on 9/16/2021 at 3:15 PM revealed a female dressed in scrubs holding a hand-held shower sprayer was standing beside an elderly female resident lying on the shower gurney in the shower room without clothing, completely nude. The female dressed in scrubs sprayed water across the elderly female's right side and caused a startle effect by the elderly female with yelling. During a telephone interview attempted with NA #1 on 9/15/2021 at 10:31 AM and on 9/16/2021 at 10:26 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #2 on 9/15/2021 at 10:35 AM and on 9/16/2021 at 10:40 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #4 on 9/15/2021 at 10:37 AM and 9/16/2021 at 10:29 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During an interview with the Administrator, Regional Vice President, and Regional Corporate Nurse on 9/15/2021 at 3:00 PM and on 9/16/2021 at 11:00 AM confirmed the incident with Resident #2, NA #1, NA #3, and CNA #4 had been substantiated following the facility investigation. They also confirmed the video provided by CNA #2 was taken in the shower room on 2 east unit and included NA #1 and Resident #2. They further confirmed Resident #2 was lying without clothes, nude, on a shower gurney and was sprayed with water on her right side by NA #1. They confirmed confirmed NA #3 was assigned to Resident #2 on 8/31/2021. NA#1 and CNA #4 had been asked by NA #3 to assist with Resident #2's shower. They also confirmed NA #1, NA #3, and CNA #4 had been suspended pending the outcome of the facility investigation and terminated from employment at the conclusion of the facility investigation from the facility. They further confirmed according to facility policy for cellular phones, NA #1 should not have had her cellular phone in use while assisting with resident care. They confirmed the video showed an undignified and disrespectful existence for Resident #2. During a telephone interview with NA #3 on 9/16/2021 at 10:29 AM it was revealed she had worked at the facility and cared for Resident #2. She stated on 8/31/2021 in the 2 east shower room she observed NA #1 wearing ear buds, holding her cellular phone and talking to someone on the cell phone. She also stated she had no additional information about the incident. During a telephone interview with the Detective at the local police department on 9/16/2021 at 2:30 PM confirmed NA #1 had been interviewed, initially denied, and later confessed to the events occurring on 8/31/2021 in the 2 east shower room with Resident #2. He stated he was unable to reveal any other information related to the case at this time. He also stated no charges had been made at the current time. The IJ was removed onsite and was effective 8/31/2021 to 9/17/2021. An acceptable Removal Plan, which removed the immediacy of the jeopardy was completed and effective on 9/27/2021. The corrective actions were received and validated onsite by the surveyor 9/27/2021 at 1:30 PM. through review of facility documentation, observations, and interviews. 1. The surveyor verified a facility investigation was immediately initiated 9/2/2021 with notification of the local police, Adult Protective Services, Medical Director, and the Family members of Resident #2. 2. The surveyor verified Resident #2 was immediately interviewed and physically assessed on 9/2/2021. 3. The surveyor verified on 9/16/2021, Resident #2's Comprehensive Care Plan was updated on 9/2/2021. 4. The surveyor verified all other facility residents with a Brief Interview for Mental Status (BIMS) score of 8 or less were physically assessed and residents with a BIMS score of greater than 8 were interviewed on 9/2/2021. 5. The surveyor verified employee interviews for NA #1, NA #3, and CNA #4 were conducted by the facility from 9/2/2021 to 9/3/2021. 6. The surveyor verified staff education was initiated 9/2/2021 for employees facility-wide over the abuse policy, use of cellular phones and social media policy, Dementia care, and bathing. This was verified by review of sign-in sheets as well as employee list for comparison. Staff education was concluded 9/16/2021. 7. The surveyor verified beginning 9/6/2021 the Administrative team monitored compliance of the facility's abuse policy through the Quality Assurance Performance Improvement (QAPI) process. The Administrative team interviewed 75 employees and 40 residents with BIMS scores greater or equal to 8 monthly for 3 months. Additionally, 30 skin assessments per month of residents with a BIMS score less than 8 monitored for 3 months were scheduled to ensure no injuries of unknown origin. 8. The surveyor verified the Administrator and Director of Nursing (DON) reported findings of each monitor to the QAPI committee. The facility was compliant with the IJ removal plan 9/27/2021.

Based on facility policy, medical record review, facility reported incident (FRI) investigation review, observation, and interviews the facility failed to to provide a dignified existence, treat with respect and dignity, and promote maintenance and enhancement of quality of life for 1 of 6 residents (Resident #2) reviewed for resident rights. The findings include Review of undated facility policy Patient Rights revealed .patient rights are really nothing more than your individual rights as a United States citizen .the important point however is that you have not lost any rights during your stay here .you or your authorized agent will be asked to agree with your plan of care .individuals have the right to participate in planning and making decisions about their own care including the right to accept or refuse .we provide you with privacy so that you may maintain a dignified existence .you will be afforded at least visual privacy .people not directly involved in your medical care will not be present without your consent .privacy is also maintained during toileting, bathing, and other activities of personal hygiene . Review of facility policy Internet Social Networking and Blogging dated 1/1/2010 revealed .have been many instances .where people and health care providers have been hurt by things that have been posted on the Internet .[the facility] respects the right of partners (facility staff/employees) to view and utilize social networking sites .on your own personal time .partners are a representative of their employer even when not at work .partner conduct in public and on the Internet can impact the opinion of patients, patient's family members and our community in terms of the quality of patient care we provide .the following guidelines must be followed by all partners who utilize the Internet or any other medium or communication .partners must not disclose any confidential information they obtain as a result of holding their position at [the facility] .partners must not relate stories .as having happened at [the facility] regardless of intent .any partner found to be in violation of any portion of this policy will be subject to immediate disciplinary actions up to and including termination of employment . Review of facility policy Use of Personal Cellular Phones/Camera-Equipped Mobile Devices revised 5/1/2021 revealed .this policy serves to define and limit the acceptable use of cellular phones .by partners during working time including phones with digital photographic and recording capability .[the facility] wants to ensure that the use of personal electronic devices does not result in discourtesy to others or to prevent partners from being attentive to their job responsibilities .examples of personal electronic devices are .cellular phone/'smart' phone .any device with data services .earphones of any size/shape .use of personal cellular phones during working time is strictly prohibited .while .performing job duties .personal cellular phones .must be kept in their bag or locker, not on his/her person and must be turned off .partners may not take digital or 'still' photographs or record audio or video footage .for personal use while on company premises . Review of the Confidentially Statement provided, explained, signed and dated at general orientation training revealed .care of a patient is always personal in nature .any protected health information about his/her condition, treatment or personal data is absolutely confidential and must not be discussed with anyone other than those who are directly responsible for his/her care and treatment .such information must never be discussed outside the facility .considered a breach of patient confidentiality .extends to all forms and formats in which the information is maintained and stored including but not limited to verbal, written and/or electronic forms .the confidentiality of patient protected health information .MUST be maintain .employees found violating these rules will be subject to disciplinary action up to and including immediate termination of employment . Review of FRI # 10 investigation report dated 9/2/2021 revealed the Administrator received a call from a former employee, Certified Nurse Assistant (CNA) #2. During the telephone call CNA #2 stated she had seen a video on Nurse Assistant (NA) #1's social media site of Resident #2 lying on the shower gurney in the shower room without clothing, completely nude. CNA #2 also stated another adult female dressed in scrubs holding a hand-held shower sprayer was NA #1. CNA #2 further stated NA #1 sprayed water over Resident #2's right side causing a startle and yelling by the resident. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #2 scored 1 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Inattention and disorganized thinking fluctuated. Total assistance of 2 or more staff members was required for bathing. Medical record review of the Comprehensive Care Plan for Resident #2 revised 7/1/2021 revealed assessment and monitoring occurred for activities of daily living (ADLs), self-care deficit, and distress during bathing. Observation of Resident #2 on 9/15/2021 at 9:50 AM revealed the resident was alert and pleasantly confused. She was disoriented to the date, time, and location. Observation of the video on 9/16/2021 at 3:15 PM revealed a female dressed in scrubs holding a hand-held shower sprayer was standing beside an elderly female resident lying without clothes totally nude on a shower gurney in a shower room. The female dressed in scrubs sprayed water across the elderly female's right side and caused a startle effect by the elderly female and yelling. The video also showed a the icon screen of a cellular phone. During a telephone interview attempted with NA #1 on 9/15/2021 at 10:31 AM and on 9/16/2021 at 10:26 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #2 on 9/15/2021 at 10:35 AM and on 9/16/2021 at 10:40 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During a telephone interview attempted with CNA #4 on 9/15/2021 at 10:37 AM and 9/16/2021 at 10:29 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During an interview with the Administrator, Regional Vice President, and Regional Corporate Nurse on 9/15/2021 at 3:00 PM and on 9/16/2021 at 11:00 AM confirmed the incident with Resident #2, NA #1, NA #3, and CNA #4 had been substantiated following the facility investigation. They also confirmed the video provided by CNA #2 was taken in the shower room on 2 east unit and included NA #1 and Resident #2. They further confirmed Resident #2 was lying without clothes, nude, on a shower gurney and was sprayed with water on her right side by NA #1. They confirmed confirmed NA #3 was assigned to Resident #2 on 8/31/2021. NA#1 and CNA #4 had been asked by NA #3 to assist with Resident #2's shower. They also confirmed NA #1, NA #3, and CNA #4 had been suspended pending the outcome of the facility investigation and terminated from employment at the conclusion of the facility investigation from the facility. They further confirmed according to facility policy for cellular phones, NA #1 should not have had her cellular phone in use while assisting with resident care. They confirmed the video showed an undignified and disrespectful existence for Resident #2. During a telephone interview with NA #3 on 9/16/2021 at 10:29 AM it was revealed she had worked at the facility and cared for Resident #2. She stated on 8/31/2021 in the 2 east shower room she observed NA #1 wearing ear buds, holding her cellular phone and talking to someone on the cell phone. She also stated she had no additional information about the incident. During a telephone interview with the Detective at the local police department on 9/16/2021 at 2:30 PM confirmed NA #1 had been interviewed, initially denied, and later confessed to the events occurring on 8/31/2021 in the 2 east shower room with Resident #2. He stated he was unable to reveal any other information related to the case at this time. He also stated no charges had been made at the current time.

Based on facility policy, medical record review, facility reported incident (FRI) investigation review, observation, and interviews the facility failed to report incidents and/or allegations of abuse in a timely manner, according to facility policy for 3 or 6 residents (Resident #1, Resident #3 and Resident #4) reviewed for abuse. The findings include Review of facility policy Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, misappropriation of Property, and Exploitation revised 12/11/2027 revealed .abuse will not be tolerated by anyone .the patient has the right to be free from abuse .the center administrator is responsible for assuring that patient safety including freedom from risk of abuse .hold the highest priority .abuse also includes .facilitated or enabled through the use of technology .the center will not employ individuals who have been found guilty of abusing .residents .the center will train all partners through orientation and ongoing in-services on the prevention, identification, investigation, and report of abuse .any patient event .reported .will be considered an allegation of .abuse .if it meets .any complaint of humiliation .including staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of the patient's cognitive status or consent .any partner having either direct or indirect knowledge of any event that might constitute abuse must report the event immediately . Review of FRI # 9 investigation report dated 9/3/2021 revealed during an interview on 9/3/2021 with Certified Nurse Assistant (CNA) #6 an allegation of abuse involving Resident #1 occurred on either 8/10/2021 or 8/17/2021. CNA #6 stated Nurse Assistant (NA) #3 verbally demonstrated how to keep Resident #1 from being aggressive against his care by telling Resident #1 to shut the hell up. Review of FRI # 5 investigation report dated 9/3/2021 revealed during an interview on 9/3/2021 with CNA #5 an allegation of abuse involving Resident #3 occurred 2 or 3 weeks ago. The social media account of NA #1 was observed to have a selfie photograph of Resident #3 and NA #3 during a meal. Resident #3 was dressed with a napkin place on the upper center chest at the neck. Resident #3 had her eyes closed. The photograph was not able to be obtained due to the nature of the social media site, meaning the post (placement of the photograph) was only visible for 24 hours. Review of FRI # 39 investigation report dated 9/3/2021 revealed during an interview on 9/3/2021 with CNA #6 an allegation of abuse involving Resident #4 occurred on either 8/10/2021 or 8/17/2021 revealed NA #1 was overheard by CNA #6 to tell Resident #4 .I don't have to get you ready right now; just give me a damn minute. Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Inattention fluctuated. Extensive to total assistance of 1 staff member was required for dressing, toileting, personal hygiene, ad bathing. Medical record review of the Comprehensive Care Plan for Resident #1 revised 8/3/2021 revealed assessment and monitoring occurred for activities of daily living (ADLs) and self-care deficit. Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Annual MDS dated [DATE] revealed Resident #3 scored 6 on the BIMS indicating severe cognitive impairment. Behaviors of inattention fluctuated. Extensive assistance of 1 staff member was required for activities of daily living (ADLs). Medical record review of the Comprehensive Care Plan for Resident #3 revised 7/26/2021 revealed assessment and monitoring occurred for self-care deficit. Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #4 scored 13 on the BIMS indicating no cognitive impairment. Poor decision making and inattention were noted. Extensive assistance of 1 staff member was required for eating. Medical record review of the Comprehensive Care Plan for Resident #4 revised 7/26/2021 revealed assessment and monitoring occurred for self-care deficit. Observation of Resident #3 on 9/15/2021 at 9/50 AM revealed the resident was sitting in her WC in her room looking at the television. She was alert and made eye contact to her name being called. She was unable to provide appropriate answers to simple, direct questions. She appeared calm and not distressed. Observation of Resident #1 on 9/15/2021 at 10:00 AM revealed the resident was sitting in a wheel chair (WC) in the open area at the nurse's station. He was alert and pleasantly confused. He was disoriented to the date, time, and location. Observation of Resident #4 on 9/15/2021 at 10:10 AM revealed the resident was sitting in a WC in the open area at the nurse's station. She was alert but not receptive to answering questions. During a telephone interview attempted with NA #1 on 9/15/2021 at 10:31 AM and on 9/16/2021 at 10:26 AM revealed there was no answer to either attempt. Voice messages were left after each attempt requesting a call back. No call back was received during the investigation. During an interview with the Administrator, Regional Vice President, and Regional Corporate Nurse on 9/15/2021 at 3:00 PM and on 9/16/2021 at 11:00 AM confirmed the incidents involving Resident #1, Resident #3, and Resident #4 were unsubstantiated due to lack of evidence. They confirmed the allegations of abuse involving Resident #1, Resident #3, and Resident #4 reported by CNA #5 and CNA #6 were not reported to the facility in a timely manner according to facility policy. During a telephone interview with NA #3 on 9/16/2021 at 10:29 AM it was revealed she had worked at the facility and cared for Resident #2. She stated on 8/31/2021 in the 2 east shower room she observed NA #1 wearing ear buds, holding her cellular phone and talking to someone on the cell phone. She also stated she had no additional information about the incident.

Based on facility policy, record review, observation, and interview, the facility failed to provide adequate supervision 1 of 3 sampled residents (Resident #6), which had the potential to result in accident or injury. The Administrator and Assistant Director of Nursing was notified of the investigation. The following information was requested for review during the investigation: resident list with room numbers, list of key personnel, facility floor plan, resident right policy, transportation policy, toileting policy, accident, falls, and injury policy, grievance logs with resolution from 3/2/2021 - 9/20/2021, resident council minutes from 3/2021 - 9/2021 and access to electronic health records. Review of the facility's undated policy titled, Patient Rights, revealed .at NHC [National HealthCare Corporation] we support the patient/resident's rights to live in an environment which is individualized for them. We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient/resident's preferences, choices, values and beliefs. Your sense of well-being and your safety during your stay here are of the utmost importance to us. You, more than anyone else, know what your wishes and goals are .Federal regulations require that health care facilities provide each patient with a written outline of the rights and responsibilities of a patient receiving care. This center strongly favors this action, for we believe that your right and responsibility to participate in decisions about your own life and goals is vital to your sense of well-being .Your need for extended health care does not in any way affect your individual right to the kinds of choices you have as a citizen and as a human being. Patients, like all people, are entitled to exercise their rights and privileges to the fullest extent possible. The management and staff of this center will make every effort to assist you in exercising your Patient Rights .You are entitled to participate in planning for the kinds of treatment you will receive and for choosing between the various treatment options available. You, or your authorized agent, will be asked to agree with your plane of care .The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning possible within the limits set by your medical condition and your wishes regarding the plan .since it is your plan of care, you will be asked to participate in choosing from treatment options available to you .you may designate a family member/patient representative to represent you at regular meetings .you, or someone speaking on your behalf will be involved in many kinds of day-to-day decisions. In the event of differences of opinion regarding your best interest and your preferences, your own personal choices will be primary . Review of the undated facility's policy titled, Bowel and Bladder Guideline, revealed, .A resident who is incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore or maintain as much normal bowel and bladder function as possible .each resident who is incontinent of urine is identified, assessed and provided appropriate treatment and services to achieve or maintain as much normal urinary function as possible .by day 14, the patient is assessed using the Resident Assessment Instrument [RAI] assessment process .the patient will be placed on the appropriate toileting regimen, if indicated, based on the collected data . Review of the undated facility's policy titled, NHC Murfreesboro Falls Program, revealed, .to identify patients at risk for falling and to implement the appropriated interventions .to reduce the patient's risk of falling and related injuries .implement appropriate interventions . Review of the facility's policy titled, Incident and Accident Process, dated 8/13/2013, revealed, An incident or accident is defined as [any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient] .some examples of incidents/accidents are .falls .found on floor .caught between equipment .contact with heat . Review of the facility's policy titled, Resident Rights, dated 12/2016 revealed, .Employees shall treat residents with kindness, respect, and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .be free from abuse, neglect, misappropriation of property, and exploitation .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .voice grievance to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal .have the facility respond to his or her grievances .communicate with outside agencies [e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.] regarding any matter .Orientation and in-service training programs are conducted routinely to assist our employees in understanding our resident's rights. Resident #6 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses which included Primary Generalized [CONDITION(S)], Abrasion Left foot, Cognitive Communication Deficit, Anxiety Disorder, and History of Falling. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 10 which revealed decreased cognitive abilities. Continued review of the MDS revealed she had delusional behaviors and required supervision of 1 staff member to transfer, dress, and toilet. Further review of the MDS revealed Resident #6 used a wheelchair for locomotion. Continued review of the MDS section J revealed she had 2 falls since her prior quarterly assessment dated [DATE]. Review of the Care Plan dated 8/5/2020, revealed a plan of care developed to address cognition non-Dementia interventions included offer patient redirection to wait for assistance if attempting to get out of bed or chair unassisted, patient liked to travel around the environment and may follow others into rooms or other areas. Further review of the Care Plan revealed a plan of care developed to address mood state related to diagnosis of anxiety evidenced by wandering. Her mood Care Plan goal revealed patient safety and security will be maximized. Her Care Plan also revealed Resident #6 was at risk for falls with intervention which included encourage patient to lock wheelchair, wheelchair breaks covered in bright green tape. On 11/13/2021, Resident #6's social work note revealed poor safety awareness, wandering in hallway, seen by Psychiatric NP. Review of the grievance logs from 6/2021 to 9/2021 revealed on 7/6/2021 a grievance was reported that Resident #6 arrived at her appointment by wheelchair van did not know where to go and resident stated she was rushed to get to her appointment. During an interview on 9/22/2021 at 11:09 AM, the Administrator stated she had been with the facility for almost [AGE] years. The Administrator stated the residents would go with family or staff would set up transportation for them to go out to an appointment. She stated sometimes Medicaid would help set up wheelchair van, but it is not always reliable. The Administrator stated we do not send employees with the resident; the family would meet the resident at the doctor's appointment. When Administrator was asked about a resident going out that may wander or have periodic confusion, she stated we would depend on the family going with the resident. During an interview on 9/22/2021 at 11:30 PM, the Social Worker (SW) reported he does not set up transportation for the residents. He stated the nurse would fill out a form, give SW the form which would have the residents name, doctors name and time for the appointment. He stated then SW would get the insurance approved to pay for transportation. He stated normally Tennessee carrier would take over and get the van set up to take the resident. SW stated no one goes with the resident, the family is always notified to go with the resident. He does recall a concern with Resident #6, the family was out of the country when she had a doctor's appointment. He reported CNA #3 handled this transfer per wheelchair van and the resident did go by herself. SW stated Resident #6, was pretty alert and oriented sometimes her pain meds would cause her to be confused but typically could communicate her needs. During an interview on 9/22/2021 at 12:50 PM, CNA #3 stated she assists with setting up transportation for residents with outside appointments. She stated, Nurses will hand the forms to me, the form will say where the appointment is located, and therapy will let me know how they need to go either wheelchair or ambulance. CNA #3 reports she has set up appointments for Resident #6 before and usually the family would meet her at the doctor's office. CNA #3 does not recall if she talked to Family Member #1 about the appointment and that sometimes she just leaves the family messages on cell phone about the appointment. CNA #3 stated, I only keep the forms for 30 days and that is the only way I can prove the family was notified. She stated employees do not go out with the residents to any appointments. During an interview on 9/22/202 at 1:11 PM, Director of Nursing (DON) stated most of our residents do go by themselves to their doctor's appointment if they have a good BIMS score. DON reports to her knowledge the family knew about the appointment. DON does report CNA #3 does set up the transportation. DON reports Resident #6 didn't like to be in the bed she usually was in her recliner or wheelchair. DON reports she did have a skin problem to her left foot after her fall where she fractured her toe. When DON was asked if she felt it was a safety concern for Resident #6 to go to the doctor alone, she stated, When we send them to the doctor, the staff doesn't have any way of knowing that the family hasn't showed up at the appointment. Don stated normally the wheelchair van attendant would have gave the resident to the family at the door at the doctor's office. During a phone conversation on 9/22/2021 at 2:20 PM, Family Member #1 reported van dropped Resident #6 off at door of doctor's office and a stranger seen she had on an orthopedic boot to her left foot and felt she needed to take her into doctor's office. Family Member #1 stated Resident #6 was able to remember her phone number and office manager dialed the phone for her. Family Member #1 stated she did not know why she was awakened so early and why she was at the doctor's office. Family Member #1 stated she called the facility about resident being at doctor's office alone and filed a grievance. Family Member #1 stated, the facility staff knew I was going out of the country, if I had known about the appointment, I could have got it changed or had another family member meet her at the doctor's office. Family Member #1 stated, I am concerned that this could happen to another resident and it is not safe for the patients. This surveyor emailed Tennessee Orthopaedic Alliance Center (TOA) of Murfreesboro to contact the business manager in regard to Resident #6's appointment to speak with office manager that assisted resident with making phone call to her family. On 9/24/2021 at 9:04 AM business manager returned my call and stated, What the family has told you is exactly what happened, a stranger did bring her into our office, resident did remember her family's phone number. The resident was confused, voiced she was hungry, cold and did not know why she was at the office.She further stated she did not recall the resident crying, but she was confused and dropped off alone at the office. Business Manager also stated she called the facility concerned about the resident being alone and she was told by the facility if the resident is alert, they can go by themselves to the doctor.

Based on medical record review, observation and interview, the facility failed to treat 1 of 20 residents (Resident #25) reviewed for indwelling urinary catheters with dignity related to not covering the resident's indwelling urinary catheter drainage bag with a privacy cover. The findings include: Review of the medical record, showed Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#25, showed .Suprapubic Catheter change Q (every) month on the 8th and PRN (as needed) . Observation in the resident's room on 2/18/2020 at 3:49 PM and on 2/19/2020 at 8:32 AM, showed Resident #25's indwelling urinary catheter bag was placed on the right side of bed facing the door, without a privacy cover. During an interview conducted on 2/18/2020 at 4:28 PM, Licensed Practical Nurse #1 confirmed Resident #25's indwelling urinary catheter bag was not placed in a privacy cover. During an interview conducted on 2/18/2020 at 4:39 PM, the Director of Nursing stated that her expectations were for the indwelling urinary catheter bags to be placed in a privacy cover while residents were up and about and when the catheter bags were facing the door when the residents were in their rooms.

Based on facility policy review, medical record review, and interview, the facility failed to prevent abuse for 2 of 2 residents (Resident #47 and Resident #60) involved in a resident to resident altercation. The findings include: Review of the facility policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 12/11/2017, showed physical abuse included slapping, pinching, and kicking. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Mininmum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. Review of the medical record, showed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], showed Resident #60 had a BIMS score of 3 indicating severe cognitive impairment. Review of the facility investigation dated 11/4/2019, showed Resident #47 was found in Resident #60's room rearranging the sheets on Resident #60's bed. Continued review showed the actions of Resident #47 scared Resident #60 and she grabbed Resident #47's hands which caused a skin tear to her right hand. Resident #60 had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on 2/19/2020 at 8:35 AM, Family Member #2 stated, (named Resident #47) was aggressive and wandered into other resident's rooms and fought with other residents. During an interview conducted on 2/19/2020 at 3:48 PM, Certified Nurse Aid (CNA) #3 stated she was walking to the dining room around 8:00 PM or 9:00 PM and she heard (named Resident #60) yell help. When she entered (named Resident #60's) room (named Resident #60) was lying in bed and (Named Resident #47) was standing over (named Resident #60) and her wheel chair was right behind her. (named Resident #47) had (named Resident #60's) blankets in her hands. Resident #60 was grabbing the blankets and also grabbed (named Resident #47's) hands. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 stated (named Resident #47) got easily annoyed. During an interview conducted on 2/20/2020 at 5:22 PM, the Director Of Nursing confirmed there was a physical altercation between Resident #47 and Resident #60 which resulted in a skin tear for Resident #47 and pain to the right hand resulting in a need for an Xray for Resident #60.

Based on facility policy review, medical record review, and interview the facility failed to revise a care plan for 1 of 52 residents (Resident #47) reviewed for behaviors. The findings include: Review of the facility policy titled, Care Plan Development, revised 7/3/2008, showed care plans were updated as needed, and on quarterly basis within 7 days of completion of the Minimum Data Set (MDS) assessment. Review of the medical record, showed Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record, Quarterly Minimum Data Set ((MDS) dated [DATE] showed Resident #47 had a Brief Interview for Mental Status score 99 indicating severe cognitive impairment. Continued review showed Resident #47 had behaviors of wandering, hitting, kicking, pushing, scratching, and grabbing others. Review of the care plan dated 7/1/2019, 11/4/2019, and 11/7/2019 showed no new behavior interventions for Resident #47. Review of the facility investigation dated 11/4/2019 showed Resident #47 was found in Resident #60's room rearranging the sheets on Resident #60's bed. Continued review showed the actions of Resident #47 scared Resident #60 and she grabbed Resident #47's hands which caused a skin tear the right hand. Resident #60 had an X-ray of the right 5th digit because of pain due to physical contact with Resident #47. During an interview conducted on 2/20/2020 at 4:40 PM, Social Worker #2 confirmed the behavioral care plan for Resident #47 was not updated to reflect behaviors prior to the resident to resident incident on 11/3/2019.

Based on facility policy review, medical record review and interview the facility failed to administered the correct medications for 1 (#1) of 3 residents reviewed on 4/27/19 related to Licensed Practical Nurse #2 during the evening medication pass. The findings include: Review of the facility policy, Medication Administration--General Guidelines , effective 6/2016 revealed .medications are administered as prescribed in accordance with good nursing principles and practices .the five rights are applied for each medication being administered . Medical record review revealed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Admission Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 7 indicating severe cognitive impairment Medical record review of a comprehensive care plan revised 4/9/19 revealed Resident #1 was monitored and assessed for functional potential, mobility and generalized weakness. Medical record review of the Physician's orders revealed medications given in error to Resident #1 included: Keflex for infection; [MEDICATION NAME] to relax the muscles; Requip for [MEDICAL CONDITION] or Restless Leg Syndrome; [MEDICATION NAME] for Constipation, [MEDICATION NAME] for Benign [MEDICAL CONDITION] of the Prostate; and [MEDICATION NAME] for depression and [MEDICAL CONDITION]. Medical record review of the SBAR (Situation, Background, Appearance, Review/Notify) form dated 4/27/19 revealed a med error occurred. Medical record review of a transfer form from the facility to the hospital dated 4/27/19 revealed the key reason for transfer was a possible allergic reaction with the primary reason for transfer being diagnostic testing, not admission. Continued review revealed a medication error involving Resident #1 had occurred. Interview with the Director of Nursing on 5/6/19 at 9:00 AM in the conference room confirmed LPN #2 made a medication error by administering the wrong medications to Resident #1 on 4/27/19 during the evening medication pass. Interview with the Nurse Practioner on 5/6/19 at 11:40 AM in the conference room confirmed LPN #2 gave Resident #1 the wrong medication on 4/27/19 during the evening medication pass.

Based on medical record review and interview, the facility failed to follow the interventions on the Comprehensive Care Plan for 1 (Resident #81) of 39 residents reviewed. This failure resulted in actual Harm to the resident. Findings include: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status of 9 indicating she was moderately cognitively impaired. Continued review revealed the resident required assistance of 2 or more people for transfers and toileting. Medical record review of a Comprehensive Care Plan updated 8/23/17 and 11/13/17 revealed a problem of required assistance with activities of daily living. Continued review revealed an intervention to Assist patient with transfers using two person assist. Medical record review and interview with Certified Nurse Aide (CNA) #6 on 2/28/18 at 3:50 PM by the East shower room door confirmed she was transferring Resident #81 alone when she fell into the bathtub on 12/15/17. Continued interview revealed the CNA was asked if the resident was ever a 2 person assist with transfers stated, She used to be, but she's gotten stronger and I try to let her do as much as she wants to. She gets anxious when you touch her and likes to do things herself. Interview with the Director of Nursing on 2/28/18 at 11:41 AM in the Administrator's office confirmed the resident was to be transferred with assistance of 2 or more people at the time of the fall on 12/15/17. Continued interview confirmed the facility failed to transfer Resident #81 with assistance of 2 people resulting in a sacral fracture (HARM)

Based on medical record review, hospital records, facility post fall investigation and interview, the facility failed to prevent falls for 2 residents (#81 and #285) of 23 residents reviewed for falls. This failure resulted in actual Harm for Resident #81 and Resident #285. Findings include: Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #81 had a Brief Interview for Mental Status (BIMS) score of 9 indicating she was moderately cognitively impaired. Continued review revealed the resident required assistance of 2 or more people for transfers and toileting. Medical record review of a Comprehensive Care Plan dated 8/23/17 and 11/13/17 revealed the resident required assistance with activities of daily living (ADL). Continued review revealed an intervention to Assist patient with transfers using two person assist. Medical record review of Post Falls Nursing assessment dated [DATE] revealed Resident #81 had a fall on 12/15/17 at 9:40 PM. Further review revealed, .PT (patient) was being transferred from toilet to wheelchair by CNA (Certified Nurse Assistant) CNA .CNA said while transferring the PT she pulled the wheelchair closer and PT got startled and let go of CNA and fell backwards into the bathtub on the left side and hit her shoulder . Continued review revealed the resident's position after the fall was .Sitting in bathtub, leaning to left, head against wall. Pain following the fall? Y (yes) .Pain Intensity: 07 .Immediate intervention was sending PT to hospital. Care plan intervention is transfer with gait belt . Medical record review of Nurse's Notes dated 12/16/17 at 1:55 AM revealed, .(At 9:40 PM) Pt. was being transferred by CNA .from toilet to wheelchair. During transfer Pt. fell into bathtub hit head and (left) shoulder .Family requested Pt. be sent to (hospital) .Pt left (at 11:00 PM). Pt had bump on back of head (and) bruise on (left) shoulder, arm (and) hand . Medical record review of the Emergency Department (ED) record dated 12/16/17 revealed, .The pt family reports that she was in using the restroom when she told her caregiver that she was about to fall and they did not catch her as she fell backwards into the bathtub. She hit the back of her head, her L (left) shoulder and buttock on the bathtub. She complains of lower back pain .shoulder/hand pain and tailbone pain .Physical Examination .Head: On exam: Moderate, occipital, swelling, occipital hematoma no bleeding .Back: lower back tenderness .Musculoskeletal: No swelling, L shoulder tenderness .Radiology results .probable sacral fx (fracture) .Reexamination/Reevaluation .remaining sacral pain .Impression and Plan head injury, shoulder strain, sacral fx . Medical record review of the hospital report of the sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and the coccyx (a small triangular bone at the base of the spinal column) dated 12/16/17 revealed, .Focal lucency (absorbing less radioactive energy) in the inferior third of the sacrum which is nonspecific, but does raise possibility of underlying nondisplaced sacral fracture .Osteopenia and [MEDICAL CONDITION] spinal changes . Interview with CNA #6 on 2/28/18 at 3:50 PM by the East Shower Room door confirmed she was transferring Resident #81 without assistance when the resident fell into the bathtub on 12/15/17. Continued interview revealed the CNA#6 was asked if the resident was ever a 2 person assist with transfers and CNA #6 stated, She used to be, but she's gotten stronger and I try to let her do as much as she wants to. She gets anxious when you touch her and likes to do things herself. Further interview revealed the CNA #6 was asked if she used the gait belt to transfer the resident after the fall and CNA #6 stated, No. I guess I should because we have enough of them. Interview with the Director of Nursing (DON) on 2/28/18 at 11:41 AM in the Administrator's office confirmed the resident was to be transferred with assistance from 2 or more people at the time of the fall on 12/15/17. Continued interview confirmed the facility failed to transfer Resident #81 with assistance of 2 people resulting in and a sacral fracture (HARM). Medical record review revealed Resident #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical Record review of the 14 day MDS dated [DATE] revealed a BIMS score of 9 (indicating the resident was moderately impaired). Further review revealed the resident was extensive assist with 2 person for bed mobility, transfer, toilet use and personal hygiene. Continued review revealed Resident #285 was not steady, only able to stabilize with staff assistance for moving from seated to standing position, walking, turning around and facing opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair). Medical record review of the Care Plan dated 12/4/17 revealed: Resident 285 at risk for falls with interventions including: call light in reach and bed in lowest position while in bed, educate on call light use; resident able to return demonstration due to Dementia may need additional reminders; and non-skid footwear on while up, keep area free of clutter. Intervention dated 12/6/17; low bed. Intervention dated 12/7/17: fall mat to both side of bed. Medical record Review of the POS [REDACTED]. Further review revealed PT (Patient) was found sitting in front of bathroom sink. Continued review revealed .Pt has a small laceration on the back of the head with small amount of bleeding .A bandage was put on it and then the head was wrapped .upon assessment Pt has a sluggish pupil response and her SBP (Systolic Blood Pressure) was 99 which was lower than normal. The doctor was called and gave the order to send to the ER (emergency room ) for eval (evaluation). Pt was sent to ER for eval. Further review revealed: Describe task: patient attempting at time of fall: Ambulating in room unattended. Location of incident: Patients room. Safety device in use: Patient was wearing footwear. Pain following the fall? Y (YES). Pain intensity: 06. Immediate intervention: Send to ER. Medical record review of Emergency Department (ER) records dated 12/17/17 revealed, The patient presents following a fall. Staff states the patient fell backwards and struck her head on the ground at the nursing home. There was no report of loss of consciousness. Location: Left scalp lower extremity. The character of symptoms is bleeding. The degree at present is minimal. The exacerbating factor is movement. Risk factor consist of age and frequent falls. Additional history: She was just released from the hospital recently, with a history of frequent falls and dementia. Continued review revealed. Impression and Plan: Diagnosis: [REDACTED].Plan: Condition: Stable. Disposition: discharged to nursing home. Medical record review of ER records dated 12/17/17 of the computerized tomography (CT) of the cervical spine revealed, No clear evidence of acute trauma to the cervical spine. CT of the head revealed, No acute intracranial abnormality is evident . right posterior parietal/occipital scalp hematoma with overlying skin staples present. Interview with CNA #7 on 2/28/18 at 5:10 PM confirmed the resident was found sitting up on her buttocks in front of the sink with a laceration to the back of her head and a small amount of bleeding. Review of the Facility Post Fall Investigation for revealed a telephone interview with Family Member #1 on 2/17/17 at 8:30 AM confirmed a family friend notified her. The facility failed to supervise Resident #285 which had a hisory of being a high risk for falls resulting in a fall with injury with staples to the back of her head. (HARM). Medical record review of ER records dated 12/17/17 of the computerized tomography (CT) of the cervical spine revealed, No clear evidence of acute trauma to the cervical spine. CT of head revealed, No acute intracranial abnormality is evident .right posterior parietal/occipital scalp hematoma with overlying skin staples present. Interview with CNA #7 on 2/28/18 at 5:10 PM confirmed the resident was found sitting up on her buttocks in front of the sink with a laceration to the back of her head and small amount of bleeding. Telephone interview with Family Member #1 on 2/17/17 at 8:30 AM confirmed a family friend notified her Resident #285 had staples to the back of her head after a fall. (HARM).

Based on review of facility policy, review of the Grievance Log and interview, the facility failed to address reported greivances and failed to confirm or take corrective action regarding the facility findings and conclusions. Findings include: Review of facility policy, Grievance Procedure, dated 11/2016 revealed . the person with the grievance could contact various entities to report an allegation. Further review revealed no information addressing what the facility process was to address and document the grievance, including a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued. Review of the facility grievance log dated12/2017 through 1/2018 revealed the facility failed to include the specific concern/grievance, the investigation steps taken, a summary of the conclusion, a statement if the concern was confirmed or not or a dated written decision. Interview with the Social Services Director on 2/27/18 at 2:25 PM in the conference room confirmed the facility had no documentation to show the summary of the pertinent findings or conclusions regarding the resident's concerns; whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility or a date written decision was issued. Further interview revealed .After I'm done with the investigation and put information on the log, I dispose of all the paperwork . Interview with the Administrator and the Administrator-in-Training on 2/27/18 at 4:30 PM in the conference room, confirmed the facility failed to provide a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or a written decision. Interview with the Regional Social Worker on 2/27/18 at 5:20 PM in the and conference room, when asked about the Resident's concerns on 12/8/17 and 12/17/17 from the grievance log, the Regional Social Worker stated .I don't know . Further interview when asked how the facility would track Resident concerns yielded no response from the Administrator or the Regional Social Worker.

Based on medical record review and interview, the facility failed to ensure the (Mininmum Data Set) accurately reflected the residents state of the assessment reference date for 5 hospice resident (#24, #52, #60, #81, #106) of 11 hospice residents reviewed. Findings include: Medical record review revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #24 was admitted to hospice services on 9/13/17. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #24 revealed hospice services was not captured on the assessment. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #52 was admitted to hospice services on 10/1/17. Medical record review of the Quarterly MDS dated [DATE] for Resident #52 revealed hospice services was not captured on the assessment. Medical record review revealed Resident #106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Hospice Certification of Terminal Illness form revealed Resident #106 was admitted to hospice services on 5/24/17. Medical record review of the Quarterly MDS dated [DATE] for Resident #106 revealed hospice was not captured on the assessment. Interview with Registered Nurse (RN) #5/MDS Coordinator on 2/28/18 at 3:42 PM in her office confirmed Residents #24, #52, and #106 were receiving hospice services. Continued interview confirmed the facility failed to accurately assess each resident as having hospice services on their individual MDS. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #81 was assessed as receiving hospice services. Medical record review of a Quarterly MDS dated [DATE] revealed Resident #81 was not receiving hospice services. Medical record review of a Hospice Contact Information form revealed Resident #81 .has elected his or her Hospice benefit starting 4/7/17 . Interview with Licensed Practical Nurse (LPN) #3 on 2/27/18 at 8:30 AM in the East Nurse Station confirmed Resident #81 had been receiving hospice services for several months. Interview with RN #5/MDS Coordinator on 2/27/18 at 9:40 AM in the East Nurse's station confirmed the facility failed to capture hospice services for Resident #81 on the Quarterly MDS dated [DATE]. Medical record review revealed Resident #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed hospice services were ordered for Resident #60 on 10/10/17. Further review revealed no order for the discontinuation of the hospice service. Medical record review of the Hospice Certification of Terminal Illness revealed Resident #60's was admitted to hospice services on 10/9/17. Medical record review of the Significant Change MDS dated [DATE] revealed hospice services were provided while the resident was in the facility. Medical record review of the Quarterly MDS dated [DATE] revealed hospice services was not captured on the assessment for Resident # 60. Interview with RN #5/MDS Coordinator on 2/28/18 at 11:58 AM in the conference room confirmed the facility failed to accurately assess the hospice status on the Quarterly MDS dated [DATE] for Resident #60.

Based on review of the therapeutic diet spread sheet, observation and interview, the facility dietary department staff failed to serve food at the portion specified on the therapeutic diet spreadsheet for 16 residents of 141 residents receiving a meal tray. Findings include: Review of the therapeutic diet spreadsheet for Week 1 Day Monday dated 2/26/18 revealed Regular and Mechanical Soft textured diets were to receive 1 cup (8 ounces) pasta and 4 ounces (oz) of meat sauce. Further review revealed the pureed textured diets were to receive 6 oz of pureed pasta and 4 oz of pureed meat sauce. Observation on 2/26/18 beginning at 11:23 AM of the dietary department resident mid-day meal trayline service with Registered Dietitian (RD) #1 present revealed the dietary staff member serving 4 ounces (oz) of pasta and 4 oz of meat sauce. Further observation revealed the dietary staff member serving 6 oz of the combined pureed pasta and pureed meat sauce for the first meal cart served and 3 pureed textured diets served in the main dining room. Interview with RD #1 on 2/26/18 beginning at 11:23 AM at the dietary department resident mid-day meal trayline confirmed the facility failed to serve the food portion per the therapeutic spreadsheet for 16 residents of 141 residents reviewed.

Based on review of facility policy, observation, and interview, the facility failed to maintain a safe and orderly environment in 1 resident room of 50 resident rooms on the first floor. Findings include: Review of facility policy,Housekeeping Cleaning Schedule, Daily undated revealed .Patient Rooms .Damp dust all horizontal and vertical surfaces of patient furniture .Remove clutter and arrange furniture neatly .Damp dust all light fixtures, window sills, blinds, etc. with disinfectant solution .Spot clean walls . Observation of room [ROOM NUMBER] on 2/27/18 at 12:09 PM revealed an unsampled resident in bed near the door with a BIMS( Brief Interview of Mental Status) of 99 and none interviewable. Continued observation revealed the resident's family member was sitting in a chair. Further observation revealed there was narrow access around the resident's bed. Continued observation revealed multiple items were present in the room in cardboard boxes and plastic totes lining all of the walls around the perimeter of the room extending into the normal walkway and the entire area was extremely cluttered. Observation revealed a bed was in the corner of the room with cardboard and plastic containers, creating only a narrow access around the bed to bathroom, sink and commode. Boxes were lining all the walls around the perimeter extending into the walkway; the shower also had boxes stacked from the floor to the ceiling. Observations of room [ROOM NUMBER] on 2/27/18 at 3:00 PM and 2/28/18 11:00 AM revealed the same continued cluttered and unsafe environment. Interview with Registered Nurse (RN) #3 at the West Nurse station on 2/28 12:00 PM revealed several staff members had asked the resident's family to remove the clutter, boxes, etc. and she would not comply with the request. Continued interview with RN #3 states it was s safety issue for the resident with all the clutter in the room and having to walk around the multiple objects presents a unsafe environment. Interview with Certified Nurse Assistant (CNA) #5 on 2/27/18 at 1:00 PM at the West Nurse's Station revealed it was difficult to care for the resident with all the clutter and get around the narrow pathways in the room. Interview with RN #4/Unit Manager on 2/27/18 at 1:07 PM at the West Nurse's station revealed the staff was unable to keep a safe physical environment due to the refusal by the resident's family member. Interview with Environmental Services Technician #1 on 2/27/18 at 1:21 PM in the hall near room [ROOM NUMBER] revealed the resident's family member refused to allow staff to organize or clean the resident's room with cleaning supplies. Interview with the Administrator on 2/28/18 at 2:38 PM in her office confirmed the resident's room was not kept in a sanitary, orderly, and safe manner.

Based on medical record review, facility policy review, facility investigation review, observation, and interview the facility neglected to provide the necessary care to prevent an avoidable pressure sore for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle accompanied by tunneling) to the sacrum. The Senior Vice President and Administrator were notified of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. F-224 represents Substandard Quality of Care. The findings included: Review of the facility policy entitled Skin Integrity Prevention and Management: Assessment and Treatment Guidelines: Pressure Ulcer Assessment and Treatment Guidelines for all Patients with Pressure Ulcers revealed the "...turn schedule and positioning will be individualized to the patient. Patient/family involvement in the development of plan of care. Education to ensure support and compliance with treatment plan..." Review of the facility policy entitled Skin Integrity Prevention and Management: Interventions/Positioning revealed "...Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated..." Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13-15 equals cognitively intact); had no behavior issues; required extensive assistance with bathing, grooming and dressing; had a [MEDICAL CONDITION] and indwelling urinary catheter to prevent irritation of skin; had no pressure ulcers; and used a sliding board for transfer from the bed to the chair. Medical record review revealed the resident was being treated weekly at a wound care clinic at the hospital for [MEDICAL CONDITION] to the lower legs. On August 7, 2012 the resident had an appointment at the wound care clinic (was seen at clinic at approximatley 1:30 p.m.). Medical record review revealed, prior to the transfer to the wound care clinic, Certified Nursing Assistant (CNA) #1 assisted the resident from the bed to the wheelchair using the transfer board. When the resident returned from the wound clinic on August 7, 2012 the sliding board was missing. Medical record review revealed on August 15, 2012 (9 days later) the sliding board was found on the resident's bed between the bottom sheet and the mattress. Interview with CNA #3 on December 11, 2012 at 7:55 a.m. in the 2 East Nursing Station revealed CNA #3 went into the resident's room (on August 15, 2012) to get...up for an appointment. Continued interview revealed the CNA turned the resident to change...and something hard was under the resident which turned out to be the sliding board. Further interview revealed "...I looked at...back end and I was horrified. I called the nurse who then called the Wound Care Nurse. The wound was grapefruit size, open, very red, and looked as if it had been there awhile. It covered most of one cheek and part of the other..." Continued interview revealed the CNA was unaware the resident's sliding board had been missing. Interview with the Wound Care Nurse (WCN) on December 10, 1012 at 1:50 p.m. in the conference room revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview revealed when the resident was turned over completely, the WCN's "knuckles hit something hard." Interview revealed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Medical record review of the Weekly Wound Assessment Record dated August 15, 2012 (not timed) revealed an unstageaable pressure ulcer on the sacrum measuring 8.5 centimeters (cm) by 17.5 cm. Continued review of the Wound Assessment revealed exudate (oozing fluid) was present and the wound bed was moist. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed "...Noted pressure site unstageable sacrum. Mod (Moderate) amt (amount) clear serous exudates (oozing fluids). Rt.(right) buttock area purplish in color with peeling skin. Lt.(left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn (foam dressing used for partial to full thickness wounds) daily until healed..." Review of the Physician Progress/Procedure Note from the Wound Care Center, dated August 22, 2012 revealed "...(patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar... " Medical record review of a nurse's note dated August 22, 2012 at 4:30 p.m. revealed "...Pt. (Patient) pale, warm diaphoretic (sweating) with rapid shallow resp (respirations) BP (blood pressure) 160/88, pulse 140. Pt. Voiced c/o (complaints of) SOB (shortness of breath). Pt. Assisted back to room and nurse updated on pt. condition... " Medical record review of a nurse's note dated August 22, 2012 at 5:30 p.m. revealed "...Pt. assessed D/T (due to) diaphoresis, increased BP, pulse, and respirations. Pt. SOB with talking/minimal exertion. Attempt to contact WCC (Wound Care Center) for report upon pt return from visit today. NP (Nurse Practitioner) notified with order to transfer pt to ER (emergency room ) for evaluation..." Medical record review of the Emergency Department visit dated August 22, 2012 at 6:18 p.m. revealed resident "...had wound debridement today and felt weak, flushed, SOB, and has been [MEDICAL CONDITION] (rapid pulse)..." Continued review of the Emergency Department notes revealed the resident was admitted to the hospital on August 22, 2012. Medical record review of the Hospital History and Physical dated August 22, 2012 revealed "...pt recently had trouble with increasing odor from the wound on the sacrum. It is a stage IV decubitus. The patient is noted to have a very bad odor from the wound. Patient has minimal sensation from about the couple of inches below the rib cage down..." Medical record review of a Hospital Consultation by the Infectious Diseases physician dated August 26, 2012 revealed "...patient was started on triple antibiotic coverage [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococcus Aureus) and Pseudomonas in right lower leg as well as multi drug resistant Pseudomonas UTI (urinary tract infection). Patient will likely need debridement of the sacral wound but will refer back to Wound Care Clinic..." Medical record review of the Hospital Discharge Summary dated August 29, 2012 revealed the patient requested and was transferred from the hospital to a different long-term care facility. Observation of and interview with resident #3 at the new facility on December 7, 2012 at 12:00 p.m. revealed the resident had a white plastic sliding board which was used to transfer from the bed to the chair. The resident reported the transfer board was missing for nine days. Continued interview with the resident revealed the resident experienced a "big sore" to his buttock. The resident reported having a sore to the buttocks before which had healed, but the sore had reopened after laying on the transfer board for nine days. The resident reported if the facility had changed the bed, the transfer board would have been found under the bottom sheet. The resident further reported not being bathed or showered from August 7 through 15, 2012 and was only turned on the night shift and that was for placement of a wedge behind the back. Review of an undated facility investigation revealed resident #3 reported the transfer sliding board missing. Staff were questioned and a search began. The resident had stated the last time the board was used was the day the resident went to the wound clinic on August 7, 2012. The resident also stated the last person to assist to and from the bed using the sliding board was Certified Nursing Assistant (CNA) #1. Review revealed on Wednesday, August 15, 2012 the unit manager nurse who completed the investigation was called to the resident's room by a CNA to report "a bad place on...bottom". The unit manager nurse and another Licensed Practical Nurse (LPN) and a CNA entered the room and when they assisted the resident to turn over they noticed a large possible stage IV area to the sacrum. Due to the loss of sensation the resident was unaware of the area. The nurse immediately contacted the facility wound care coordinator who came and evaluated and dressed the wound. During turning and repositioning the patient, the wound care coordinator felt something hard in the bed and discovered the patient's sliding board between the sheet and the bed mattress. The unit manager nurse and the Director of Nursing (DON) began an investigation as to how and when this transfer sliding board could have been left between the sheet and the mattress. Interview with Licensed Practical Nurse (LPN) #1 on December 11, 2012 at 7:40 a.m. in the 2 East Nursing Station confirmed bed linens were changed at the time a bath was given. Further interview with LPN #1 confirmed the CNAs completed a skin assessment daily on all residents. Further interview confirmed the CNA was to report any changes including bruises and was expected to turn the resident over to view the coccyx and back. Continued interview with the LPN revealed resident #3 did not go to the shower but would usually ask for a bath when an appointment was scheduled the next day. Interview on December 11, 2012 at 8:25 a.m. in the conference room with the nurse completing the facility investigation, revealed the nurse was the unit Manager on the floor where the resident resided at the time of the incident. Continued interview revealed, as part of the investigation, staff were questioned; the resident was interviewed; and staff were inserviced on turning and positioning as well as skin assessment. Further interview confirmed no one on the staff was aware the board was under the resident for nine days or how it got under the fitted sheet. Continued interview with the nurse revealed the CNAs completed an inspection of the resident's skin from head to toe when vital signs were taken. Further interview revealed vital signs were taken once a day and were divided up so each shift did some vital signs so the skin inspections were divided up so some were completed on each shift. Continued interview revealed linens were changed at the time of the bath as the resident permited. Further interview with this nurse confirmed no one knew how the sliding board got there or who left it on the bed. Telephone interview with the resident's physician on December 11, 2012 at 8:55 a.m. revealed the physician also became the facility's Medical Director on December 1, 2012. Continued interview with the physician revealed the Wound Care Nurse called on August 15, 2012 to report the area on the sacrum which could break open and finding the board under the resident, both of which were concerning. Continued interview revealed since the area had been open in the past the resident was at increased risk of the area breaking down again. Further interview confirmed with daily skin assessments, turning and positioning, and linen changes, the staff should have found the sliding board much earlier. Continued interview confirmed staff "...careless in not doing what they are supposed to be doing. It is concerning. The skin could discolor in a couple of days but would take longer to break open..." Further interview revealed the physician did not recall if the resident was examined by the physician after the pressure ulcer was identified. Interview with LPN #2 on December 12, 2012 at 7:20 a.m. in the 2 East Nursing station revealed LPN #2 performed some skin assessments on resident #3 and would look over the resident while giving medications. Continued interview revealed the LPN would ask the resident if there were any problems or pain. Further interview revealed it was hard to get the resident to roll but the resident would hold onto the half rail and pull self over. Continued interview revealed the LPN could observe the resident's back from the waist upward but was unable to see the resident's buttocks on any skin assessment. Further interview with LPN #2 revealed "...did not know about the sliding board being under the resident until everything broke..." Continued interview revealed if the sheets were dirty the resident would ask for them to be changed, but the resident did own [MEDICAL CONDITION] care. Interview with LPN #2 confirmed the resident needed help turning to get all the way over but preferred to remain on the back to eat and watch TV. Continued interview revealed the LPN was not sure if the risks of not turning and staying on the back for long periods of time were discussed with the resident. Further interview revealed the resident "...wouldn't allow us to do certain things for...and wanted to self turn but probably was not capable of repositioning self..." Further interview with LPN #2 confirmed the Weekly Skin Assessment was completed on August 9, 2012 without observing the resident's buttocks. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room confirmed an area was noticed on the resident's bottom; several people were called to assess the area; and the Wound Care Nurse found the sliding board under the resident. Further interview with the DON revealed staff were asked how the board got there but no one knew how. The DON stated staff were in-serviced on turning and providing skin care. Continued interview revealed the DON was unable to remember knowing the board was missing but the resident reported the board missing to the Administrator. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repositioning in the bed and chair. Staff were to encourage the resident to turn and reposition. The care plan noted the resident had a history of [REDACTED]. Continued review revealed the care plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken other than encourage the resident to turn and reposition. Further interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem. The DON confirmed no documentation from the physician and/or Nurse Practitioner following the discovery of the stage IV pressure ulcer on the sacrum of resident #3 to indicate the resident was seen and examined by medical personnel. In Summary: The facility failed to follow facility policies for Skin Integrity Prevention and Management and Pressure Ulcer Assessment and Treatment which resulted in resident #3 developing an avoidable pressure ulcer which was not discovered until it was a stage IV open wound. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction.

Based on medical record review and interview, the facility failed to revise and update the Plan of Care to address refusal of care and failed to develop interventions for a Stage IV pressure ulcer for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure sore to the sacrum. The Senior Vice President and Administrator were informed of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. A partial extended survey was conducted on December 14, 2012. The findings included: Medical record review revealed resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13 -15 equals cognitively intact); had no behavioral issues; required extensive assistance with bed mobility; required extensive assistance with bathing, grooming, and dressing; required limited assistance with eating; had a [MEDICAL CONDITION] and indwelling foley catheter to prevent irritation of skin; did not have one or more unhealed pressure ulcers at Stage I or higher; had no mood issues; and used a sliding board to transfer from the bed to the chair. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed "...Noted pressure site unstageable sacrum. Mod (moderate) amt (amount) clear serous exudate (oozing fluids). Rt (right) buttock area purplish in color with peeling skin. Lt (left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn daily until healed...". Medical record review of the Wound Care Assessment Progress Notes dated August 22, 2012 at 12:20 p.m. revealed "...pressure area to sacrum remains unstageable with moderate amt serous exudate noted with slough in wound bed ..." Review of the Physician Progress/Procedure Note dated August 22, 2012 revealed " ...pt (patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar..." Interview with the Wound Care Nurse (WCN) on December 10, 2012 at 1:50 p.m. in the conference room, revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview with the WCN revealed when the resident was turned over completely, the WCN's knuckles hit something hard. Continued interview with the WCN confirmed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room revealed if a resident refused care it would be reflected in the care plan as well as documented in the monthly summary completed by the nurse. Continued interview with the DON revealed documentation should be entered in the care plan that refusal of care was the resident's usual behavior. Continued interview revealed Social Services and nursing document in the nursing care plan regarding care given to the resident or refusal of care. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repostioning in the bed and chair. Staff were to encourage the resident to turn and repostion. The care plan noted the resident had a history of [REDACTED]. Continued review of the nursing care plan revealed no entry for behavior issues to include refusal to turn. Continued review revealed the plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room, confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken. Continued interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem with planned interventions. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, facility policy review, facility investigation review, observation, and interview the facility failed to provide the necessary care to prevent an avoidable pressure sore for one (#3) of twenty-two residents reviewed. The facility's failure resulted in an Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death) for resident #3 who developed a stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle accompanied by tunneling) to the sacrum. The Senior Vice President and Administrator were notified of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the conference room. F-314 represents Substandard Qualtiy of Care. The findings included: Review of the facility policy entitled Skin Integrity Prevention and Management: Assessment and Treatment Guidelines: Pressure Ulcer Assessment and Treatment Guidelines for all Patients with Pressure Ulcers revealed the "...turn schedule and positioning will be individualized to the patient. Patient/family involvement in the development of plan of care. Education to ensure support and compliance with treatment plan..." Review of the facility policy entitled Skin Integrity Prevention and Management: Interventions/Positioning revealed "...Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. If the resident refuses care, an evaluation of the basis for refusal, and the identification and evaluation of potential alternatives is indicated..." Medical record review revealed resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].) Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 14 (13-15 equals cognitively intact); had no behavior issues; required extensive assistance with bathing, grooming and dressing; had a [MEDICAL CONDITION] and indwelling urinary catheter to prevent irritation of skin; had no pressure ulcers; and used a sliding board for transfer from the bed to the chair. Medical record review revealed the resident was being treated weekly at a wound care clinic at the hospital for [MEDICAL CONDITION] to the lower legs. On August 7, 2012 the resident had an appointment at the wound care clinic (was seen at clinic at approximatley 1:30 p.m.). Medical record review revealed, prior to the transfer to the wound care clinic, Certified Nursing Assistant (CNA) #1 assisted the resident from the bed to the wheelchair using the transfer board. When the resident returned from the wound clinic on August 7, 2012 the sliding board was missing. Medical record review revealed on August 15, 2012 (9 days later) the sliding board was found on the resident's bed between the bottom sheet and the mattress. Interview with CNA #3 on December 11, 2012 at 7:55 a.m. in the 2 East Nursing Station revealed CNA #3 went into the resident's room (on August 15, 2012) to get...up for an appointment. Continued interview revealed the CNA turned the resident to change...and something hard was under the resident which turned out to be the sliding board. Further interview revealed "...I looked at...back end and I was horrified. I called the nurse who then called the Wound Care Nurse. The wound was grapefruit size, open, very red, and looked as if it had been there awhile. It covered most of one cheek and part of the other..." Continued interview revealed the CNA was unaware the resident's sliding board had been missing. Interview with the Wound Care Nurse (WCN) on December 10, 1012 at 1:50 p.m. in the conference room revealed the nurse called to say a wound was found and the nurse needed the WCN to assist. Continued interview revealed when the resident was turned over completely, the WCN's "knuckles hit something hard." Interview revealed the resident's sliding board was found between the fitted sheet and the mattress. Continued interview with the WCN revealed a purple area with fluid under it on the resident's sacrum with one side peeling. Continued interview with the WCN confirmed a Stage IV pressure ulcer to the sacrum. Medical record review of the Weekly Wound Assessment Record dated August 15, 2012 (not timed) revealed an unstageaable pressure ulcer on the sacrum measuring 8.5 centimeters (cm) by 17.5 cm. Continued review of the Wound Assessment revealed exudate (oozing fluid) was present and the wound bed was moist. Medical record review of the Weekly Wound Care Assessment Progress Notes dated August 15, 2012 at 1:00 p.m. revealed "...Noted pressure site unstageable sacrum. Mod (Moderate) amt (amount) clear serous exudates (oozing fluids). Rt.(right) buttock area purplish in color with peeling skin. Lt.(left) buttocks green skin peeling blister like. Physician notified with new orders for Allevyn (foam dressing used for partial to full thickness wounds) daily until healed..." Review of the Physician Progress/Procedure Note from the Wound Care Center, dated August 22, 2012 revealed "...(patient) has developed sacral decubitus ulcer after lying on sliding board for 9 days. Patient will likely need several debridements of sacral wound. Clinitron bed. Sacral wound has dark necrotic eschar... " Medical record review of a nurse's note dated August 22, 2012 at 4:30 p.m. revealed "...Pt. (Patient) pale, warm diaphoretic (sweating) with rapid shallow resp (respirations) BP (blood pressure) 160/88, pulse 140. Pt. Voiced c/o (complaints of) SOB (shortness of breath). Pt. Assisted back to room and nurse updated on pt. condition... " Medical record review of a nurse's note dated August 22, 2012 at 5:30 p.m. revealed "...Pt. assessed D/T (due to) diaphoresis, increased BP, pulse, and respirations. Pt. SOB with talking/minimal exertion. Attempt to contact WCC (Wound Care Center) for report upon pt return from visit today. NP (Nurse Practitioner) notified with order to transfer pt to ER (emergency room ) for evaluation..." Medical record review of the Emergency Department visit dated August 22, 2012 at 6:18 p.m. revealed resident "...had wound debridement today and felt weak, flushed, SOB, and has been [MEDICAL CONDITION] (rapid pulse)..." Continued review of the Emergency Department notes revealed the resident was admitted to the hospital on August 22, 2012. Medical record review of the Hospital History and Physical dated August 22, 2012 revealed "...pt recently had trouble with increasing odor from the wound on the sacrum. It is a stage IV decubitus. The patient is noted to have a very bad odor from the wound. Patient has minimal sensation from about the couple of inches below the rib cage down..." Medical record review of a Hospital Consultation by the Infectious Diseases physician dated August 26, 2012 revealed "...patient was started on triple antibiotic coverage [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococcus Aureus) and Pseudomonas in right lower leg as well as multi drug resistant Pseudomonas UTI (urinary tract infection). Patient will likely need debridement of the sacral wound but will refer back to Wound Care Clinic..." Medical record review of the Hospital Discharge Summary dated August 29, 2012 revealed the patient requested and was transferred from the hospital to a different long-term care facility. Observation of and interview with resident #3 at the new facility on December 7, 2012 at 12:00 p.m. revealed the resident had a white plastic sliding board which was used to transfer from the bed to the chair. The resident reported the transfer board was missing for nine days. Continued interview with the resident revealed the resident experienced a "big sore" to his buttock. The resident reported having a sore to the buttocks before which had healed, but the sore had reopened after laying on the transfer board for nine days. The resident reported if the facility had changed the bed, the transfer board would have been found under the bottom sheet. The resident further reported not being bathed or showered from August 7 through 15, 2012 and was only turned on the night shift and that was for placement of a wedge behind the back. Review of an undated facility investigation revealed resident #3 reported the transfer sliding board missing. Staff were questioned and a search began. The resident had stated the last time the board was used was the day the resident went to the wound clinic on August 7, 2012. The resident also stated the last person to assist to and from the bed using the sliding board was Certified Nursing Assistant (CNA) #1. Review revealed on Wednesday, August 15, 2012 the unit manager nurse who completed the investigation was called to the resident's room by a CNA to report "a bad place on...bottom". The unit manager nurse and another Licensed Practical Nurse (LPN) and a CNA entered the room and when they assisted the resident to turn over they noticed a large possible stage IV area to the sacrum. Due to the loss of sensation the resident was unaware of the area. The nurse immediately contacted the facility wound care coordinator who came and evaluated and dressed the wound. During turning and repositioning the patient, the wound care coordinator felt something hard in the bed and discovered the patient's sliding board between the sheet and the bed mattress. The unit manager nurse and the Director of Nursing (DON) began an investigation as to how and when this transfer sliding board could have been left between the sheet and the mattress. Interview with Licensed Practical Nurse (LPN) #1 on December 11, 2012 at 7:40 a.m. in the 2 East Nursing Station confirmed bed linens were changed at the time a bath was given. Further interview with LPN #1 confirmed the CNAs completed a skin assessment daily on all residents. Further interview confirmed the CNA was to report any changes including bruises and was expected to turn the resident over to view the coccyx and back. Continued interview with the LPN revealed resident #3 did not go to the shower but would usually ask for a bath when an appointment was scheduled the next day. Interview on December 11, 2012 at 8:25 a.m. in the conference room with the nurse completing the facility investigation, revealed the nurse was the unit Manager on the floor where the resident resided at the time of the incident. Continued interview revealed, as part of the investigation, staff were questioned; the resident was interviewed; and staff were inserviced on turning and positioning as well as skin assessment. Further interview confirmed no one on the staff was aware the board was under the resident for nine days or how it got under the fitted sheet. Continued interview with the nurse revealed the CNAs completed an inspection of the resident's skin from head to toe when vital signs were taken. Further interview revealed vital signs were taken once a day and were divided up so each shift did some vital signs so the skin inspections were divided up so some were completed on each shift. Continued interview revealed linens were changed at the time of the bath as the resident permited. Further interview with this nurse confirmed no one knew how the sliding board got there or who left it on the bed. Telephone interview with the resident's physician on December 11, 2012 at 8:55 a.m. revealed the physician also became the facility's Medical Director on December 1, 2012. Continued interview with the physician revealed the Wound Care Nurse called on August 15, 2012 to report the area on the sacrum which could break open and finding the board under the resident, both of which were concerning. Continued interview revealed since the area had been open in the past the resident was at increased risk of the area breaking down again. Further interview confirmed with daily skin assessments, turning and positioning, and linen changes, the staff should have found the sliding board much earlier. Continued interview confirmed staff "...careless in not doing what they are supposed to be doing. It is concerning. The skin could discolor in a couple of days but would take longer to break open..." Further interview revealed the physician did not recall if the resident was examined by the physician after the pressure ulcer was identified. Interview with LPN #2 on December 12, 2012 at 7:20 a.m. in the 2 East Nursing station revealed LPN #2 performed some skin assessments on resident #3 and would look over the resident while giving medications. Continued interview revealed the LPN would ask the resident if there were any problems or pain. Further interview revealed it was hard to get the resident to roll but the resident would hold onto the half rail and pull self over. Continued interview revealed the LPN could observe the resident's back from the waist upward but was unable to see the resident's buttocks on any skin assessment. Further interview with LPN #2 revealed "...did not know about the sliding board being under the resident until everything broke..." Continued interview revealed if the sheets were dirty the resident would ask for them to be changed, but the resident did own [MEDICAL CONDITION] care. Interview with LPN #2 confirmed the resident needed help turning to get all the way over but preferred to remain on the back to eat and watch TV. Continued interview revealed the LPN was not sure if the risks of not turning and staying on the back for long periods of time were discussed with the resident. Further interview revealed the resident "...wouldn't allow us to do certain things for...and wanted to self turn but probably was not capable of repositioning self..." Further interview with LPN #2 confirmed the Weekly Skin Assessment was completed on August 9, 2012 without observing the resident's buttocks. Interview with the Interim Director of Nursing (DON) on December 12, 2012 at 12:20 p.m. in the conference room confirmed an area was noticed on the resident's bottom; several people were called to assess the area; and the Wound Care Nurse found the sliding board under the resident. Further interview with the DON revealed staff were asked how the board got there but no one knew how. The DON stated staff were in-serviced on turning and providing skin care. Continued interview revealed the DON was unable to remember knowing the board was missing but the resident reported the board missing to the Administrator. Review of the nursing care plan dated May 24, 2012 revealed the resident was at times non-compliant with turning and repositioning in the bed and chair. Staff were to encourage the resident to turn and reposition. The care plan noted the resident had a history of [REDACTED]. Continued review revealed the care plan was not updated to address the stage IV pressure sore to the sacrum, the treatment of [REDACTED]. Interview with the Interim DON on December 13, 2012 at 3:00 p.m. in the conference room confirmed the nursing care plan did not address the resident's refusal of baths and turning as problems or interventions to be taken other than encourage the resident to turn and reposition. Further interview with the DON confirmed the stage IV pressure sore and the sliding board had not been care planned as a problem. The DON confirmed no documentation from the physician and/or Nurse Practitioner following the discovery of the stage IV pressure ulcer on the sacrum of resident #3 to indicate the resident was seen and examined by medical personnel. In Summary: The facility failed to develop a care plan with interventions and failed to provide care for resident #3 who was at risk for pressure sores and who developed an avoidable stage IV pressure sore. The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review; review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction.

Based on medical record review, facility documentation review, facility policy review, interview, and observation, the facility failed to be administered in a manner to monitor and ensure turning and positioning of residents; to update careplans and develop interventions regarding a resident's refusal of care; to investigate the disappearance of a sliding board; and to provide the necessary care to prevent the development of a Stage IV (4) pressure ulcer. The facility's failure placed resident #3 in Immediate Jeopardy (a situation in which a provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death) for development of a stage IV decubitus ulcer. The Senior Vice President and the Administrator were informed of the Immediate Jeopardy on December 12, 2012 at 1:40 p.m. in the Conference Room. The findings included: Interview with the Administrator on December 6, 2012 at 4:00 p.m. and December 11, 2012 at 7: 40 a.m., in the Conference Room confirmed the facility did not have an effective system in place to ensure the completion and monitoring of skin inspections; turning/positioning; or bathing of residents. Refer to F224 for neglecting to provide the necessary care to prevent a Stage IV pressure ulcer. Refer to F279 for failure to update and develop the Care Plan Refer to F314 for failure to provide the necessary care to prevent a stage IV pressure sore The Immediate Jeopardy was effective from August 7, 2012 through December 13, 2012. An acceptable Allegation of Compliance, which removed the Immediate Jeopardy, was received and corrective actions were validated by the survey team through medical record review, review of inservice education records; review of assessments; and interview. The survey team verified the Allegation of Compliance through: 1. Review of inservice records from education on revised process for CNAs to complete and document daily skin assessments of residents. 2. Review of Weekly Skin Assessment records for all residents in the facility which were completed on December 12, 2012. 3. Review of revised CNA skin inspection form and documentation for 55 residents completed on December 12 and 13, 2012. 4. Review of twenty-five records to ensure the nursing care plan had been updated appropriately to reflect changes in the resident's status. 5. Review of inservice records from education on completion and update of nursing care plan to reflect changes in resident status. 6. Review of inservice records from education on Incidents of Abuse & Neglect. 7. Interview with CNAs and nurses regarding their understanding of completion of CNA Inspection Report, Weekly Skin Assessment, completion/updating care plan and recognition and reporting residents who may be the victim of abuse and/or neglect. 8. Interview with the Senior Vice President to ensure those staff who were not present for the inservices would receive the information before being allowed to care for residents. Noncompliance continues at a "D" level for monitoring corrective actions. The facility is required to submit a plan of correction.