Every finding on record at Paradigm at First Colony

Based on observation, record review and interview the facility failed to ensure 7 of 7 residents reviewed for admission to the secured unit were free from involuntary seclusion. The facility failed to ensure Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9 and Resident #10, whose assessments indicated they were low risk for elopement, had no evidence of history of elopement, had no physician's order for admission to the secure unit, had no IDT decision, were admitted to the secure unit with evidence of clinical criteria. The failures placed all residents on the secured unit at risk of not being assessed properly, not meeting the criteria to be placed on the unit., diminished quality of life and involuntary seclusion. 1. Record review of Resident #4's admission face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included arthritis (condition that cause joint pain, stiffness and swelling), Non-Alzheimer disease (brain disorder that causes a decline in thinking skills), seizure disorder (involuntary movement), and malnutrition (a serious health condition caused by a lack of excess of or imbalance in nutrient and energy intake. Record review of Resident #4's admission MDS dated [DATE] revealed a BIMS score of 10 indicating she was moderately impaired for decision making. Record review of Resident #4's physician's order dated revealed Resident #4 was to be placed on the secured unit. Further record review of Resident #4's clinical record revealed no documentation that the resident was assessed, the resident had a prior risk of elopement, or that the IDT had discussed the resident's placement in the secured unit. Record review of Resident #4's elopement risk assessment dated [DATE] revealed she was coded as low risk for elopement. Observation on 7/24/2026 at 9:18am, Resident #4 was observed in the secured unit. She was clean and groomed with no offensive odor. She was alert with some confusion. Interview with Resident #4 revealed she wanted to go home. She said her home was in north side, and she could take care of herself. She said she had seizures and sometimes she forgot to take her medication. Resident #4 said she did not care about moving to another part of the facility, said she wanted to leave and go home. She said she had a cell phone but it was not working. 2. Record review of Resident #5's admission face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included non-Alzheimer (disease brain disorder that causes a decline in thinking skills), hypertension (high blood sugar), and unspecified dementia (decline in memory and thinking). Record review of Resident #5's admission MDS dated [DATE] revealed a BIMS score of 10 indicating she was moderately impaired for decision making and had no behaviors. Record review of Resident #5's physician's order dated revealed no physician's order for Resident #5 to be placed in the locked unit. Further record review of Resident #5's clinical record revealed no documentation that the resident was assessed, the resident had no prior risk of elopement, or that the IDT discussed the resident's placement in the locked unit. Further record review revealed no documentation of Resident #5 wandering and trying to exit. Observation of Resident #5 at 2:45pm revealed she was sitting in a chair, asleep in the lobby area. She was clean and groomed with no offensive odor. 3. Record review of Resident #6's admission face sheet revealed she was a 62-year - old female who was admitted to the facility on [DATE]. Her diagnoses included arthritis (swelling and tenderness in one or more joints), non-Alzheimer (disease brain disorder that causes a decline in thinking skills), and malnutrition (a serious health condition caused by a lack of excess of or imbalance in nutrient and energy intake). Record review of Resident #6's admission MDS dated [DATE] revealed a BIMS score of 10 indicating she was moderately impaired for decision making. Record review of Resident #6's physician's order dated July 2026 revealed no order for Resident #6 to be placed on the locked unit. Further record review of Resident #6's clinical record revealed no documentation that the resident was assessed, the resident had no history of elopement, or that the IDT discussed the resident's placement in the locked unit. Record review revealed the incident happened overnight and decides on 7/6/2026 based on the charge nurse documentation. Where Resident #6 pull the door alarm around 12 mid night when Resident #6 pull the alarm at the exit door and walk out. The CNA got the Resident #6 and brought him back. Resident #6 was placed on 1 to 1 and the following day he was placed in the secured unit. Record review of the Resident #6's elopement risk assessment dated [DATE] revealed he was coded as low risk for elopement. Further record review revealed no documentation that the resident was monitored or any other intervention was put in place before the resident was placed on the unit. Observation on 7/23/2026 at 2:40pm revealed Resident #6 was not alert or oriented. He was in his wheelchair. He was clean and groomed with no odor. 4. Record review of Resident #7's admission face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included hypertension (high blood pressure), metabolic encephalopathy (brain failure caused by body illness or chemical imbalance), diabetes (high blood sugar), Parkinson's (brain disorder characterized by tremors, muscle stiffness and slow movement), and unspecified dementia (decline in memory and thinking), unsteady gait and, muscle weakness. Record review of Resident #7's admission MDS dated [DATE] revealed a BIMS score of 00 indicating she was severely impaired for cognitively for decision making and had no behaviors. Record review Resident #7's physician's order dated July 2026 revealed no physician's order for Resident #7 to be placed in the locked unit. Further record review of Resident #7's clinical record revealed no documentation that the resident was assessed, the resident had no prior risk of elopement, and that the IDT team did not discussed the resident's placement in the locked unit. Record review of the Resident #7's elopement risk assessment dated [DATE] revealed the resident was coded as low risk for elopement. Observation 7/24/2026 at 9:36 am of Resident #7 revealed she was in bed, and she was unable to transfer herself from the bed to wheelchair. Resident #7 was non interview able, and she did not respond to any questions. Record review of the care plan dated 3/27/2026 for Resident #7 requires a secure unit related to dementia. Revision on 3/27/2026Resident #7 safety will be maintained through appropriate supervision and a structured/supportive environment through the review. Administer medications as ordered. Behavior Control: utilize techniques such as redirection, distraction, and calming.ELOPEMENT RISK: Resident #7 at risk for wandering and elopement related to Dementia. Resident #7 safety will be maintainedthrough a structured environment through the review date revised on 4/11/2026. Resident #7 will not wander outside the facility or elope through the review date. Conduct frequent checks on the resident, especially during high-risk times, Maintain resident safety during increased episodes of wandering. Missing Resident: initiate elopement protocols, Monitor resident's location frequently throughout shift. Offer engaging activities that interest the residents and reduce restlessness. Offer fluids and snacks during increased episodes of wandering - encourage frequent rest breaks. Provide comfort measures such as familiar objects, music, or sensory activities that calm the resident. 5. Record review of Resident #8's admission face sheet revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), anxiety (reaction to stress), Paranoid schizophrenia (heavy distrust, false belief and sensory disturbance) depression (mood disorder catheterized by persistent sadness and loss of interest in activities), cognitive communication (way of thinking, reasoning and understanding), and unspecified dementia (decline in memory and thinking). Record review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS score of 00 indicating he was severely impaired for cognitive decision making and had no behaviors. Record review Resident #8's physician's order dated July 2026 revealed no physician's order for Resident #8 to be placed in the locked unit. Further record review of Resident #8's clinical record revealed no documentation that the resident was assessed, the resident had a prior risk of elopement, or that the IDT team discussed the resident placement in the locked unit Record review of Resident #8's elopement risk assessment dated [DATE] revealed she was coded as low risk for elopement. Observation of Resident #8 on 7/23/2026 at 2:40 pm in her wheelchair asleep in the lobby area. She was clean groomed with no odor. 6. Record review of Resident #9's admission face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included hypertension (high blood pressure), diabetes (high blood sugar), Alzheimer (progressive brain disorder) and unspecified dementia (decline in memory and thinking). Record review of Resident#9's quarterly MDS dated [DATE] revealed for cognitive decision making she was coded as moderately impaired and had no behaviors. Record review Resident #9's physician's order dated July 2026 revealed no physician's order for Resident #9 to be placed in the secure unit. Further record review of Resident #9's clinical record revealed no documentation that the resident was assessed, the resident had a prior risk of elopement, and that the IDT team discussed the resident's placement in the locked unit. Record review of Resident #9's elopement risk assessment dated [DATE] revealed was coded as low risk for elopement. Observation of Resident #9 on 7/23/2026 at 4:45pm revealed she was sitting in a chair asleep in the lobby area. 6. Record review of Resident #10's admission face sheet dated 7/24/2026 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and was readmitted on [DATE]. Her diagnoses included hypertension high blood pressure), bipolar disorder (a mental health condition that causes extreme shift in mood and energy level), metabolic encephalopathy (brain failure caused by body illness or chemical imbalance), diabetes (high blood sugar), Parkinson (brain disorder characterized by tremors, muscle stiffness and slow movement), and unspecified dementia(decline in memory and thinking). Record review of Resident #10's admission MDS dated [DATE] revealed a BIMS score of 00 indicating she was severely impaired for decision making and had no behaviors. Record review Resident #10's physician's order dated July 2026 revealed no physician's order for Resident #10 to be placed in the locked unit. Further record review of Resident #10's clinical record revealed no documentation that the resident was assessed, the resident had a prior risk of elopement or that the IDT discussed the resident's placement in the locked unit. Record review of Resident #10's care plan dated 7/15/2026 has a diagnosis of dementia and is at risk for increased confusion and decline in ADL's as the diseases progress. Resident #10 needs will be anticipated and met by staff over the next 90 days. Administer medication(s) as ordered by MDRecord review of the Resident #10's elopement risk assessment dated [DATE] revealed the was coded as low risk for elopement. Observation on 7/24/2026 at 11:00 am revealed Resident #10 in activity. The resident was clean with no offensive odor. The resident was alert but confused, and the resident did not respond when her name was called. Interview on 7/23/26 12:25pm the memory care Unit Manager said he had been working at the facility since September 2025.He said residents who were admitted to the secured unit usually have diagnosis of dementia or history of elopement and needed to be in memory care. He said the elopement risk was done at admission and follow ups and evaluations were usually done. He said the residents would be considered if they were not cognitive aware. He said they some residents were assessed by other facility or hospital and make they will make recommendation as to which unit in a facility a resident should be admitted . He said admission would be determined based on medical history and evaluation. He said the Unit Manager did not play a role in determining which resident was admitted . He said the elopement assessment was done 30 days from the time of admission. He said the IDT group determined who was admitted to the unit. He said the main reasons for admission to the memory care unit was elopement (the main reason), being severely confused and dementia. Interview on 07/24/26 at 10:08AM with the Social Worker revealed she had been working at the facility for 4 years. She said she was not a part of the admission process regarding admission to the MCU but provided input as needed when the facility has their morning meetings if she felt the resident was not properly placed on the MCU. The SW said it was the nurses who did the elopement assessment/risk. The SW said she thought the criteria to place a resident on the MCU would be memory issues with a diagnosis of dementia, low BIMS under 12, and elopement risk. She said if a resident's elopement risk was not high in her opinion, the resident should not be on the MCU but a resident's BIMS could also change. The SW said sometimes she disagrees with the placement of residents on the MCU when discussed in the morning meetings. The SW said regarding Resident #4 the speech therapist assessed Resident#4 and her BIMS score was 6 and that she went later and Resident #1's BIMS score was 10. The SW said was admitted to the NF on 07/02/26. The SW said a care plan meeting was done with Resident #4's family members because the resident was very confused and that family member was very involved with the resident care. The SW said when a resident was admitted to the facility, she noticed the resident did not have a RP and they added the family member to the face sheet as the RP who signed the admission paperwork. The SW said the family had shared that Resident #4 was independent and until recently. The SW said the family or Resident #4 never shared that there were any problems with their relationship. The SW said the facility had not done an IDT meeting regarding Resident #4 but had done the Comprehensive Care Plan. The SW said Resident #4 was on skilled care at the present time because she was not safe to go home and the family members could not drive. The SW said a POA had not been signed for Resident #4 due to resident's decreased cognition, and the resident's plan of care was still being discussed. The SW said no guardianship had been initiated for Resident #4 but she would start today on initiating the process. The SW said ongoing assessments needed to be done for resident's residing on the MCU. The SW said if a resident was improperly placed on the MCU, it would place the resident at risk of their freedom, depression, and decline in health. In an interview on 7/24/26 at 10:50am with the Regional Nurse revealed that residents on the memory care unit are reassessed when there was a change in condition or quarterly. She said they receive clinical risk assessment and risk of elopement. She said residents are placed in secure unit when they have a history of elopement but still will evaluate them. She said resident history was important and past behaviors can be triggered. She said they did not confine residents to the unit and they can go outside. She said she did not feel residents' rights were not violated, she said their safety was important. She was asked about Resident #6 being placed on the unit because he pulled the exit door alarm and went through the door. She said they had him on 1:1 monitoring and lab work was done to see if he had a UTI before he was placed on the unit. She said he needed constant redirecting and attempted to leave one night, and he was placed on the unit. The Regional Nurse reported the nurses did not document Resident #6's exact behaviors, but she knew he tried to get out the exit door. She said they were aware that staff had issues with documentation. She said the nursing team reassessed residents on the secure unit on the night of 7/23/2026 and Resident #7 and Resident #10 would be moved off the secure unit to the general population and Resident #6 would be discharged home. In an interview on 7/24/2026 at 11:00am with the DON, she said before admission of a resident they reviewed their clinical records to ensure the proper criteria for the secured was met. She said moving forward they will also gather information from family and previous facility and monitor residents to ensure they are properly placed. In an interview with the DON on 7/24/2026 at 1:23 PM she said they had QAPI meeting monthly, but it did not specifically address the secured unit. She said QAPA usually addresses changes in condition and behaviors of residents. She said the IDT also discussed who should be on the secured unit. She said they usually involved the MDS nurse, the SW, and in the care plan meetings. She said moving forward they will ensure that residents were properly assessed ensuring the criterias for the secured unit were met. Record review of the facility's policy and procedures for the Secured Unit dated 1/2026 read in part.PolicyThe facility may provide a secure unit environment for residents requiring additional supervision related to cognitive impairment, wandering risk, behaviors, or safety concerns. The facility will provide care and supervision in a safe manner while maintaining resident rights and dignity.Procedureadmission to Secure UnitResidents may be admitted or transferred to the secure unit based on:Physician recommendation, Cognitive impairment, Wandering or exit-seeking behaviors and Interdisciplinary Team recommendation Resident CareResidents will: Receive supervision based on assessed needsHave individualized care plans and interventionsBe monitored for changes in condition or behaviorsReceive activities and services appropriate to their needs Safety The facility will:Use the least restrictive interventions possible

Based on observation, interview and record review the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 2 of (Resident #2, Resident #3) of 3 residents reviewed for incontinent care. -CNA A failed to provide incontinent care in a timely manner for Resident #3. During incontinent care on 07/22/26, Resident #3's brief and draw sheet was heavily soiled with urine. -CNA C failed to clean Resident #2's perineal area one wipe at a time during incontinent care. These failures could place residents at risk for unwanted skin breakdown and infections. Resident #3 Record review of Resident #3's face sheet dated 07/22/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 07/12/26. Resident #3's diagnoses included: altered mental status, depression, and anxiety. Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 9 indicating the resident's cognition was moderately impaired. Section H-Bladder and Bowel revealed that Resident #3 was always incontinent of bladder and bowel. Record review of Resident #3's Comprehensive Care Plan dated 06/15/26 reflected the resident was care planned for urinary incontinence that include the following intervention: perform routine rounding to include incontinence care and brief changes. Observation on 07/22/26 at 9:48AM of incontinent care for Resident #3 by CNA A and CNA B revealed Resident #3's brief was heavily soiled in urine. When Resident #3 was positioned to her left side, it was observed the resident had a towel on top of the draw sheet, and both linens were heavily soiled in urine. Resident #3 had a wound to her sacral region (the bone that is situated at the base of the spine, above the tailbone, and between the hip bones). The dressing to the sacral wound was no longer intact. When done providing care for Resident #3, the CNAs informed the Wound Care Nurse to redress the resident's wound to the sacral region. Interview on 07/22/26 at 10:34 AM Resident #3 said the last time her brief had been changed was on the night shift around 3:00AM. Resident #3 said the morning CNA had not changed her brief until the surveyor observed incontinent care on 07/22/26 at 9:48AM. Interview on 07/22/26 via phone at 4:30PM CNA A said she worked at the facility full time on the morning shift from 6AM-2PM. CNA A said she was Resident #3's CNA. CNA A said she provided incontinent care for the residents every 2 hours. CNA A said the reason she did not provide incontinent care for Resident #3 when she came on shift was because she could not find any disposable wipes or towels. CNA A said she attempted to provide incontinent care for Resident #3 around 7:00AM after she took wipes from the hospice storage room to provide care for Resident #3. She said she did not provide care to Resident #3 because she had to start passing breakfast tray. CNA A said it was important to provide the residents with timely incontinent care to avoid skin breakdown and infections. Interview on 07/22/26 at 5:06PM the Laundry Supervisor said the facility did not have any issues with linen and that the laundry aide made rounds on each nursing unit every 2 hours and as needed stocking the units with linen. The laundry supervisor said the staff in the laundry department went home at 7:00PM. The laundry supervisor said every unit charge nurse had a key to the laundry room if they needed more linen. Observation on 07/22/26 at 5:15PM revealed the laundry room having linen with the staff organizing clean linen to be delivered to the units. Further observation of the laundry department having a storage room with overflow of linen that consisted of towels, sheets, blankets, and bedspreads. Observation on 07/23/26 at 6:10AM of the units stocked with resident care supplies on carts on the halls that consisted of clean linen, disposable wipes, and briefs. Interview on 07/23/26 at 7:00AM the DON said she took the role of the DON about 2 weeks ago and her prior role was the facility ADON. The DON said the facility was not having problems with resident care supplies. The DON said the facility was having an issue with the CNAs hoarding supplies in the resident rooms because they did not want to take the extra steps to get resident care supplies. The DON said initially only the managers had the code to the laundry room but that had changed to where the nurses had the code. The DON said the facility had a storage room just for resident care supplies that was easily accessible to the CNAs. The DON said the facility ordered a huge supply of resident care supplies on a weekly basis. The DON said the CNAs should be making rounds on the residents for incontinent care at least every 2 hours. The DON said if the CNAs were not doing that for the residents, it could place the residents at risk for skin breakdown. Interview on 07/23/26 at 7:50AM the Unit Manger said she had been working at the facility since January 2026. The Unit Manger said the facility did not have any problems with resident care supplies to care for the residents. The Unit Manger said in the past the CNAs had been storing a lot of resident care supplies in resident rooms which they were not supposed to do. The Unit Manager said the CNAs had been in-serviced on that and the issue had improved. The Unit Manger said she had created a room for storage that consisted of resident care supplies that was easily accessible to the CNAs. The Unit Manager said she left work at 6:00PM and made rounds to ensure that the storage rooms were stocked with resident care supplies. Resident #2 Record review of Resident #2's face sheet dated 07/22/26 revealed an [AGE] year-old female admitted to the facility on [DATE] and again 10/27/25. Resident #2's diagnoses included the following: chronic (a long time) multifocal (different areas) osteomyelitis (infection within the bone) of the left ankle and foot, age related osteoporosis (when the bones become weak and easy to break), muscle weakness, contracture (permanent tightening of the joints that restricts movement) hip, elbow, right knee, left knee, abnormal posture, dementia (severe decline in memory, thinking, and reasoning that interferes with a person's ability to perform daily activities), and Alzheimer's late onset(brain disorder appearing at or after the age of 65 that slowly destroys the memory, thinking skills, and the ability to carry out daily tasks). Record review of Resident #2's annual MDS dated [DATE] Section C-cognitive Patterns reflected that resident cognitive skills were severely impaired. Section H-Bladder and Bowel revealed that Resident #2 was always incontinent of urine and bowel. Record review of Resident #2's Comprehensive Care Plan dated 07/21/26 initiated and revised reflected that resident was being care planned for incontinent care r/t impaired mobility an intervention included to monitor/document for s/sx of UTI. Observation of incontinent care for Resident #2 on 07/22/26 at 11:15AM by CNA B and CNA C revealed Resident #2's contained of urine and feces. CNA C began to clean the resident's perineal (body area located between the genitals {sex organs of the body used for reproduction and urination} and the anus {opening on the outside of the body where waste leaves}) area with the same wipe instead of cleaning the resident one wipe at a time. During incontinent care CNA B asked CNA C to allow her to proceed in providing incontinent care for Resident #2. CNA B began to provide incontinent care for Resident #2 by cleaning the resident from front to back, one wipe at a time. Interview on 07/22/26 at 2:36PM CNA C said when providing incontinent care, she was supposed to clean Resident #2's vaginal area from front to back, one wipe at a time to prevent infections. CNA C said she forgot to follow those steps because she was nervous. Interview on 07/22/26 at 3:05PM CNA B said the reason she asked CNA C to allow her to finish providing incontinent care for Resident #2 was because CNA C was not cleaning Resident #2 one wipe at a time. CNA B said when providing incontinent care, she was trained to clean the perineal area from front to back one wipe at a time to prevent infections. CNA B said CNA C repeatedly used the same wipe to clean Resident #2. Interview on 07/23/26 at 7:00AM the DON said when providing incontinent care, the resident's perineal area should be cleaned from front to back one wipe at a time to avoid fecal matter getting into the vaginal area that could lead to infections. Record review of facility policy on Perineal Care revised December 2023 reflected in part: .The facility will provide perineal care in a manner that maintains privacy, reduces the risk of infection, and promotes integrity.For female residents, separate labia (folds of skin that form the outer parts of the female genitals) and clean from front to back using a clean wipe for each stroke.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident#1 Resident #2, Resident #3) of 3 residents reviewed for infection control. The wound care nurse failed to change gloves, sanitize her hands and place on a new set of gloves before applying a clean dressing to Resident #3's sacral wound. CNA A and CNA B failed to wash hands prior to providing incontinent care for Resident #3 on 07/22/26. CNA A and CNA B failed to don (put on) full PPE on 07/22/26 when providing incontinent care for Resident #3 who was on enhanced barrier precautions. CNA C failed to wash/sanitize hands prior to, during, and after providing incontinent care for Resident #2 on 07/22/26. The facility failed to ensure Resident #1's Foley bag was not on the floor on 7/22/2026 and 7/24/2026 These failures place residents at risk for cross contamination and unwanted infections. Record review of Resident #3's face sheet dated 07/22/26 revealed a [AGE] year-old female admitted to the facility on [DATE] and again on 07/12/26. Resident #3's diagnoses included: altered mental status, depression, and anxiety. Record review of Resident #3's admission MDS dated [DATE] revealed a BIMS score of 9 indicating the resident's cognition was moderately impaired. Section M-Skin Condition revealed the stage 4 is a deep opening where the bone, muscle and tendon are visible through the opening)at resident had a pressure ulcer/injury over bony prominence and being at risk of developing pressure ulcer with 1 stage 4 (pressure ulcer that was present upon admission. Record review of Resident #3's Physician's Order Summary Report for the month of July 2026 reflected the following order: -Dated 06/28/26 Enhanced Barrier Precautions-PPE: gloves and gowns during high contact resident care activities Record review of Resident #3's Comprehensive Care Plan revealed that resident was being care planned for Enhanced Barrier Precautions dated 06/28/26. An intervention included PPE: gown and gloves during high-contact resident care activities (dressing, bath/showering, transferring, providing hygiene, changing, changing briefs, assisting with toileting, device care, and wound care). Observation of incontinent care on 07/22/26 at 9:48AM by CNA A and CNA B for Resident #3 revealed there was EBP signage outside of the room entrance door. CNA A entered the room with gloves in hand. CNA B, who was already in the room, left the room to go and gather supplies for incontinent care. CNA B returned to the room at 9:50AM with a plastic bag. Inside of the plastic bag was resident care supplies that consisted of gloves and disposable wipes. CNA A put on gloves without washing or sanitizing hands. CNA A did not don (put on) a disposable gown. CNA B began to place on gloves but not a disposable gown and began to assist with incontinent care for Resident #3. Further observation was made of Resident #3 having an EBP signage over the head of bed. Resident #3's brief was heavily soiled with urine. Resident #3 had a towel on top of the draw sheet, and both the towel and drawsheet were heavily soiled with urine. Resident #3's dressing to the sacral region (a flat triangle shaped bone at the base of the spine) was not intact and the wound was exposed. The wound was approximately the size of coin (quarter). The wound bed was a pale pink color with small amount of redness with no drainage or odor detected. When done providing care for Resident #3, CNA A left the room without washing or sanitizing her hands, and had passed by a hand sanitizer dispenser that was mounted on the right side of the wall, continuing to take soiled materials to the soiled utility room. After CNA A placed the soiled bag of linen inside of the soiled utility room. CNA A proceeded to remove clean linen off clean linen cart and went inside of another resident's room. Observation of wound care on 07/22/26 at 10:20AM for Resident #3 by the Wound Care Nurse revealed the Wound Care Nurse was observed in the resident's room standing at the foot of resident bed with PPE donned (putting on an item of clothing) that consisted of a gown and gloves and holding wound care supplies to do Resident #3's dressing change. Resident #3's dressing to the sacral region had come off during incontinent care. The wound bed was pale pink in color with no drainage or odor detected. The Wound Care Nurse began to clean the resident's wound to the sacral region with normal saline. After cleaning the resident's wound bed, the Wound Care Nurse did not remove her gloves or sanitize her hands and instead proceeded to provide care to the other wound with the same gloves on. After patting dry the wound bed with dry gauze, the wound care nurse applied collagen (wound treatment to increase tissue growth, manage drainage) to the wound bed and covered the wound with a gauze border dressing. When the Wound Care Nurse was done providing dressing change, she then removed her gloves along with remaining PPE and placed the soiled materials inside of a red biohazard bag and washed her hands. The Wound Care Nurse disposed of the soiled materials inside of the soiled utility room.Interview on 07/22/26 at 3:31PM the Wound Care Nurse said she should have changed her gloves after cleaning Resident #3's wound to prevent cross contamination of the wound bed. The Wound Care Nurse said she became nervous.Record review of the facility on Dressing Changes: Wound revised June 2019 reflected in part: It is the policy of this facility that dressing changes will follow specific manufacture's guideline and general infection control principles.Wash hands before and after donning gloves.Put on gloves, remove old dressing and packing (if present), remove gloves and wash hands, put on clean gloves, cleanse the wound bed of drainage, debris, or dressing/filler residue, remove gloves and wash hands, put on clean gloves. Record review of Resident #2's face sheet dated 07/22/26 revealed an [AGE] year-old female admitted to the facility on [DATE] and again 10/27/25. Resident #2's diagnoses included the following: chronic (a long time) multifocal (different areas) osteomyelitis (infection within the bone) of the left ankle and foot, age related osteoporosis (when the bones become weak and easy to break), and gastrostomy (surgical opening from the outside of the belly directly into the stomach used to place a feeding tube so a person can receive food, liquids, and medicine when they cannot swallow). Record review of Resident #2's annual MDS dated [DATE] Section C-cognitive Patterns reflected that resident cognitive skills were severely impaired. Section H-Bladder and Bowel revealed that Resident #2 was always incontinent with urine and bowel. Record review of Resident #2's Physician's Order Summary Report for the month of July 2026 included the following order: -Dated 05/22/26 Enhanced barrier precautions. Record review of Resident #2's Comprehensive Care Plan dated 07/21/26 reflected that resident was care planned for incontinent care r/t impaired mobility with an intervention that included to monitor/document for s/sx of UTI. Further review revealed that resident was being care planned for Enhanced Barrier Precautions dated 05/22/26 with an intervention to monitor for s/s of infection. Observation on 07/22/26 at 11:15AM of incontinent care for Resident #2 by CNA B and CNA C revealed on the outside of resident room door was an EBP signage. CNA C began to place a disposable gown on outside Resident #2's room in the hallway. CNA C while in the hallway, placed on gloves without washing or sanitizing her hands. CNA B went into Resident #2's room, washed her hands, put on a pair of gloves, and a disposable gown. CNA C began to provide incontinent care for Resident #2. At 11:35AM CNA C removed her PPE and said she needed to get more supplies to finish incontinent care because she had discovered the resident was also incontinent of bowel as well. CNA C left the room without washing her hands. CNA C returned to room at 11:38AM with extra linen. CNA C placed on a disposable gown and a new set of clean gloves without washing her hands first and resumed care for Resident #2. When CNA B and CNA C had finished providing incontinent care for Resident #2, CNA B removed her PPE and washed her hands. CNA C removed her PPE and left the room without washing her hands, carrying the soiled bagged linen to the soiled utility room. After CNA C placed the soiled linen in the soiled utility room she then proceeded to enter another resident's room without washing or sanitizing her hands. Record review of Resident # 1's admission face sheet dated 07/22/2026 revealed he was a [AGE] year old male who was admitted to the facility on [DATE]. His diagnoses included hypertension (high blood pressure), neurogenic bladder (when nerves of the urinary system work together to work and release urine at the right time), obstructive uropathy (blockage in the urinary tract that stops urine from flowing normally leading to urine backup). Record review of Resident # 1's quarterly MDS dated [DATE], stated: Resident #1 has a BIMS score of 05 which indicated severely impaired cognition. Resident #1 was incontinent of bowel and had an indwelling catheter. Record review of Resident #1's care plan dated 4/15/2026 revealed Resident #1 has Foley catheter and is at risk for increased UTIs and skin breakdown and has diagnoses of Neurogenic bladder. The F/C will remain patent and will not develop increased incidence of UTIs or have any noted skin breakdown due to F/C over the next 90 days. Interventions included: Change Foley catheter, tubing and bag per order Encourage po/fluid intake within dietary limitsRCS: Foley catheter care as ordered Monitor for s/sx of infection or skin break down - report any noted to MD Monitor urine for odor, color, sediments, and amount of urine, etc. - reportabnormalities to MD Resident # 1 has potential for skin breakdown. Is incontinent of bladder and bowel. Care plan approach dated 12/14/2024 reflected: Follow standard precaution to prevent cross contamination and spread of infection. Resident #1 has a Foley catheter and is at risk for increased UTIs and skin break down AEB--Dx/condition for F/C: Neurogenic bladder, (Specify type: Urethral indwelling urinary, catheter: (16) Fr with (10) cc normal saline balloon. Observation of Resident #1 on 7/22/2026 at 9:30am and on 9/24/2026 at 9:18 am revealed he was lying in a low bed and the Foley bag with urine was directly on the floor. There was a privacy bag hanging before the Foley bag. Interview on 07/22/26 at 2:36PM CNA C said she had been working at the facility for 3 years. CNA C said it was important to practice hand hygiene before placing on gloves and removing gloves for infection control. CNA C said she forgot to wash her hands before and after administering care for Resident #2 because she was nervous. Interview on 07/22/26 at 3:05PM CNA B said EBP was for residents that had an indwelling Foley catheter, wounds, and on isolation. CNA B said when taking care of a resident on EBP, she had to wear gowns and gloves for infection control and for universal precautions. CNA B said she was assisting CNA A with incontinent care and therefore was not aware that Resident #3 had any wounds. Interview on 07/22/26 at 4:30PM CNA A said hand hygiene/handwashing was done before providing care for a resident and afterwards, and before leaving the resident room for infection control. CNA A said EBP was for residents that had gastrostomy tube (surgical opening from the outside of the belly directly into the stomach used to place a feeding tube so a person can receive food, liquids, and medicine when they cannot swallow), tracheostomy (tube surgically placed into the windpipe to help a person breathe), wounds, and Foley catheters. CNA A said gowns and gloves needed to be worn when providing direct care for the residents on EBP and if not, it placed the residents at risk for infections. CNA A said she forgot to wear a gown when providing incontinent care for Resident #3. Interview with the DON on 07/23/26 at 7:00AM revealed when a resident was on EBP, the staff needed to wear PPE that consisted of gown and gloves when providing direct care for a resident. The DON said it was important to protect the resident from infections due to the resident having openings on the body such as wounds, gastrostomy tubes, Foley catheters, and intravenous lines (when a plastic tube or device is placed inside of a person vein to deliver fluids, medications, nutrition, or blood directly into the bloodstream). The DON said hand hygiene should be practiced before entering a resident room, during care for the resident, and after administering care for a resident for infection control. In an interview on 7/23/2026 at 10:30am CNA B said she was not Resident #1's aide. She said she was in-serviced on infection control, peri care, abuse neglect, Foley care and mechanical lift transfers. She said with regards to Resident #1's Foley bag, it should not be on the floor. She said it should be attached to the bed rail and should be off the floor. She said the Foley bag directly on the floor placed residents at risk of infection. Interview on 7/24/2026 at 10:20 am with the DON regarding the Foley bag directly on the floor, she said the Foly bag should not be on the floor and she was going to fix it. She said all staff needed to do was just lift the bed a little higher so the bag could be off the floor. She said she was going to in-service the staff and do an audit to ensure no Foley bags were directly on the floor. The facility policy on Infection Control Program revised December 2024 reflected in part: .The facility will establish a comprehensive infection control program encompassing essential elements to safeguard the health and safety of residents, staff, and visitors. The facility is dedicated to maintaining a safe and healthy environment by implementing and effective infection control program that adheres to state and federal regulations and follows evidence-based practices recommended by the CDC. Record review of the facility policy on Enhanced Barrier Precautions revised March 2024 reflected in part: .EBP's is an infection control intervention designed to reduce the transmission of multidrug-resistant organisms and employs target gown and gloves use during high-contact resident care activities for targeted residents.EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices.EBP should be employed for the following high resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing briefs, assisting with toileting, device care, and wound care. Record review of the facility policy on Hand Hygiene revised December 2024 reflected in part: .It is the policy of the facility to prioritize hand hygiene as a fundamental practice in preventing the spread of infections. All staff must perform hand hygiene.When to utilize hand hygiene: before/after resident contact, after removing gloves or PPE.

Based on interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (CR #1) residents reviewed for respiratory care.The facility administered oxygen to CR #1 without an order from the physician from [DATE] through [DATE].This failure could have placed residents who received respiratory care at an increased risk of developing respiratory complications and receiving a decreased quality of care.Findings includedRecord review of CR #1's face sheet dated [DATE] revealed she was admitted to the facility on [DATE] from the hospital and expired on [DATE]. CR #1 had diagnoses which included presence of aortocoronary bypass graft (surgery that created a new path for blood to flow around a blocked or narrowed artery in the heart), atherosclerotic heart disease (plaque buildup inside the arteries that supplied blood to the heart), atrial fibrillation (irregular and chaotic heartbeat), and heart failure (heart could not pump enough blood to meet the body's needs).Record review of CR's MDS assessment revealed CR #1 did not have any completed MDS assessments because she was a new admission.Record review of CR #1's BIMS dated [DATE] revealed CR #1 had a BIMS score of 13, indicating intact cognition.Record review of CR #1's baseline care plan, initiated on [DATE], revealed CR #1 had oxygen via nasal cannula to maintain adequate oxygen saturation and respiratory comfort; Intervention: follow physician orders for oxygen therapy delivery.Record review of CR #1's orders dated [DATE] did not reveal that the resident had an order for oxygen administration.Record review of CR #1's MOT(Memorandum of Transfer) with EXP [DATE] revealed, in part, .oxygen flow rate 1.5 -4L[PM] NC.During a telephone interview on [DATE] at 9:32 a.m., LVN A said CR #1 received oxygen through a nasal cannula when she made her initial round, and that it was her first day working with CR #1. LVN A said she did not check if CR #1 had an order for oxygen because CR #1 already had oxygen on, and she assumed CR #1 had an order, but she could not recall how many liters of oxygen CR #1 was receiving. She said oxygen was considered a medication and CR #1 should have had an order before oxygen was administered to her.During an interview on [DATE] at 3:37 p.m., LVN B said she verified CR #1's orders with the NP, and the NP said to continue with all orders from the hospital discharge list. She said she was not the person who transcribed CR #1's orders into the computer and that it was the DON who transcribed the orders. She said the paper (MOT) that was given to her by the admission staff, had an oxygen order, and that was why she administered oxygen to CR #1. She was not aware the DON did not transcribe the oxygen order. LVN B said the nurse should have had an order for oxygen before oxygen was administered to CR #1 because it was considered a medication. LVN B said she documented that she administered 3 liters (per minute) of oxygen to CR #1 for anxiety because of the oxygen order on the MOT, and the NP said to continue all medications. She assumed the oxygen was part of the order even though there was no oxygen order on the hospital discharge summary. During a telephone interview on [DATE] at 1:36 p.m., the NP said she reviewed CR #1 medication orders with LVN B and she did not mention that CR #1 needed oxygen or had oxygen on her discharge orders from the hospital. The NP said if a resident had an emergency respiratory condition that required oxygen, then the nurse could use the facility's protocol, start oxygen administration, and then call the physician or NP to obtain an oxygen order. During an interview on [DATE] at 1:00 p.m., the DON said oxygen was considered an intervention during respiratory distress, which meant the nurse could put oxygen on a resident, and after the resident had stabilized, the nurse would call the Physician to obtain an order for oxygen. The DON said the facility did not have a policy to administer oxygen for anxiety and did not know where LVN B got the order to administer oxygen; maybe she came up with the intervention. The DON said he reviewed the hospital discharge orders and there was no oxygen order. He said the ADON was supposed to verify the orders for a new admit within 24 hours and ensure CR #1's orders were transcribed correctly. He did not respond when he was asked if he checked whether CR #1 had an order for oxygen because he transcribed CR #1's orders on admission. He said he did not know if there were any negative side effects for CR #1 when oxygen was administered without an order.During an interview on [DATE] at 4:41 p.m., the ADON said LVN B documented that CR #1 was on continuous oxygen at 1.5-4 L(PM). She said she reviewed the orders from the night of admission, and they revealed the DON transcribed the orders and did not transcribe any order for oxygen. She said CR #1 came from the hospital with a discharge order summary, and there was no order for oxygen. The ADON said the facility did not have any policy regarding oxygen when a resident was demonstrating anxiety. She said if the resident was having a respiratory emergency, the nurse could apply oxygen to the resident and, after the resident was stabilized, the nurse would notify the doctor, and the doctor would provide an order for oxygen administration. She said if there was no emergency, the resident would have had an order for oxygen before the nurse applied oxygen to the resident. She said the ADON would follow up and review the new admit' s medications and make sure they were verified and transcribed correctly. The ADON said she did not check the MOT to determine whether it had an order for oxygen for CR #1. The ADON did not respond when she was asked if she checked CR #1's orders since she was aware LVN B documented administering oxygen to CR #1. The ADON said if a resident did not need oxygen and it was given, then it would do the exact opposite of what the administration of oxygen was intended to do.Record review of the undated facility Policy on Oxygen Therapy revealed, in part, .it is the policy of this facility that the facility will provide oxygen therapy. procedures. 1. Review physician's order on the chart for completeness. a. modality (method used to administer oxygen), liters, frequency.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #1) reviewed for rights. -The facility failed to ensure CR #1 was not left in a soiled bed after his colostomy bag leaked on the evening of 1/8/26.-The facility failed to ensure CR #1 was not left in a soaked bed of urine and tube-feeding formula after his g-tube leaked on 1/28/26. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity.Findings included:Record review of CR #1's face sheet dated 3/17/26, revealed a [AGE] year-old male with an original admission date of 12/6/23 and readmitted to the facility on [DATE]. CR #1's diagnoses included: atherosclerotic heart disease of native coronary artery, dementia (loss of memory, language, problem-solving and other thinking abilities), dysphagia (difficulty swallowing), esophageal obstruction (a blockage or severe narrowing of the food pipe that prevents food or liquid from entering the stomach) colostomy status, unspecified ileus (a condition in which the bowel does not work correctly), and unspecified intestinal obstruction.Record review of CR #1's most recent Quarterly MDS dated [DATE], revealed a BIMS score of 6 indicating severe cognition. CR #1 was dependent (helper does all of the effort) on toileting hygiene. CR #1 had an indwelling catheter and ostomy; urinary and bowel continence was not rated. Further review of the Quarterly MDS indicated CR #1 did not have a swallowing disorder. CR #1 while a resident had parenteral/IV feeding and a feeding tube.Record review of CR #1's care plan dated 1/4/26 indicated CR #1 had the following care areas:*required the use of an ostomy and was at risk for complications AEB ostomy type-colostomy. 5/8/24-Staff report he plays with his colostomy. Interventions included: document colostomy care in the clinical record, monitor site for swelling, pain, redness-report to MD, teach/educate resident to leave colostomy in place, staff will empty bag as needed, make sure bag is properly placed.*feeding tube- at risk for aspiration, unplanned weight loss, dehydration, and nutritional complications d/t dysphagia. Feeding- Jevity 1.2. Interventions included: assess abdomen prior to initiating feeding/water flush- assess bowel sounds, check for residual, report abnormalities to MD. Check placement of tube prior to initiating feeding/water flush, report abnormalities to MD. Give all feedings/water flushes via feeding tube as ordered, check for tolerance. Continue feedings as ordered. Monitor for s/sx of aspiration such as coughing, runny nose, increased secretions, report any noted to MD/RP. Staff will serve Grafition diet-regular pureed diet. He will continue with current tube feeding as ordered.*an ADL self-care deficit and was at risk for further decline in ADL functioning and injury. Intervention was to provide (extensive) assistance x1 for toileting/incontinent care.*at risk for alteration in skin integrity and pressure ulcer formation AEB dependence on assistance with mobility and w/c status. Interventions included assist resident with incontinent care as indicated, assist with turning/repositioning during rounds and PRN. Record review of CR #1's orders indicated the following:*colostomy observation- SN to assess stoma site daily for any s/s of infection to site. Every shift for colostomy observation monitor resident's colostomy. Ensure colostomy is intact, free from s/s of infection and functioning properly. Notify MD for any changes. Order date 3/10/25.*Colostomy- Empty every shift for e empty colostomy bag each shift, Licensed nurse will monitor colostomy and ensure it emptied every shift and as needed. Order date 1/5/24.*enteral order-monitor resident for signs/symptoms of misplacement of enteral tube: difficulty with medication/feeding/water administration, abnormal findings with residual checks, severe abdominal distention, or changes in the length of the tube. Notify MD PRN. Order date 3/10/25.Review of photo submitted by CR #1's family member dated 1/8/26 at 8:00 p.m. revealed CR #1 was lying in a light brown liquid substance that was on his colostomy bag, stomach, adult brief, bedsheets, and clothing.Review of photo submitted by CR #1's family member dated 1/28/26 at 6:49 p.m. revealed CR #1 had an adult brief underneath him, opened, with light tan stains inside the adult brief. The bed sheets were soaked behind the resident with a light tan substance on the sheets.During an interview with CR #1's family member on 3/18/26 at 12:08 p.m., she said on 1/8/26 she visited CR #1. She said she cleaned CR #1, changed his bed sheets and cleaned his floor. The Family Member said she left at approximately 6:40 p.m. The Family Member said when she returned to the facility an hour later, CR #1 was covered in feces. The Family Member said she got the Unit Manager and RN A to come to the room and requested for CR #1 to be showered. The Family Member said on 1/28/26 she visited CR #1 and when she removed the sheet off him, his adult brief was left opened and his bed was soaked with urine and milk. The Family Member said she called LVN B into CR #1's and showed him the mess.On 3/18/26 at 2:14 p.m., surveyor attempted to contact CNA C via phone and left a message with request to call surveyor, but no call back received prior to exit.During an interview with the Unit Manager on 3/18/26 at 2:16 pm., She said she remembered CR #1's Family Member was upset back in January and grabbed her and RN A to put CR #1 in the shower. The Unit Manager said it looked like CR #1's colostomy bag was leaking. The Unit Manager said the Family Member did not say how long he was like that. The Unit Manager said CNA C came and assisted with the shower. She said residents were checked frequently, every 2 to 4 hours. The Unit Manager said the risk to the residents when they are lying in a mess could lead to skin breakdown.During an interview with RN A on 3/18 at 2:28 p.m., she said she remembered when the Family Member was upset back in January because she found CR #1 with feces on him. RN A said CR #1's stoma was leaking. She said the CNAs do their rounds every 2 hours. RN A said she and the Unit Manager took CR #1 to the shower, cleaned up him, and put clean clothes on him. RN A said she did not know how long CR #1 was there in that state. She said the Family Member told her she had just left the facility and when she came back, she found CR #1 in a mess. RN A said the risk to the residents when they are left soiled could result in skin breakdown.During an interview with the DON on 3/18 at 3:19 p.m., he said residents should be checked every 2 hours. The DON said both photos showed the substance glistening and looked wet and fresh. He said brown rings would have formed on the sheets if it had been sitting on the sheets for a long time. The DON said if a resident was left soiled for a short amount of time there was no risk, for a longer period there could be a risk for infection. The DON said it was very common for colotomy bags to fail or bust, or a resident could have a new colostomy, and the skin can reject that. The DON said the colostomy bag can leak through the seal or pop if the resident rolled over hard to one side. He said residents are changed as needed.During an interview with the Administrator on 3/18 at 3:39 p.m., she said CR #1 always had his colostomy bag leaking. The Administrator said CR #1 had come to the facility with this issue. The Administrator said the Family Member did not talk to them. She said the Family Member would send pictures to her, the social worker, the state and the Ombudsman by email. She said nursing staff were supposed to provide care when they need it. She said anytime a resident had an episode, we want it cleaned up, people have diarrhea all the time. The Administrator said in the picture of CR #1, the substance looked fresh and wet. The Administrator said the risk to the resident could cause infection and wounds. The Administrator said she did not think the Family Member complained to her about that issue in January. She said the last complaint she got from the Family Members was CR #1's towels were missing.During an interview with LVN B on 3/18 at 3:56 p.m., he said he recalled CR #1's colostomy bag and his peg tube would leak. LVN B said the colostomy bag would not stick to his skin and had to put extra tape on the bag and skin. LVN B said the colostomy would constantly leak and CR #1 would have to get checked more frequently. LVN B said the risk to the resident when left in a mess could be an infection control issue and a dignity issue.Record review of the facility's policy titled Activities of Daily Living (ADLs)-Highest Level of Functioning dated 01/2026 read in part . the facility promotes resident independence to the greatest extent possible while providing necessary assistance, supervision, and interventions when residents are unable to safely perform ADLs independently . Activities of daily living (ADLs) include personal care task such as bathing, dressing, grooming, oral hygiene, eating, transferring, bed mobility, toileting, and communication .

Based on interview and record review the facility failed to ensure resident representatives had the right to exercise resident's rights to the extent provided by state law for 1 of 1 (Resident #1) residents reviewed for resident rights.The facility failed to ensure clinical records were provided to Resident #1's Power of Attorney (POA) as requested.This failure could place residents at risk of their needs not being met or disrupted continuity of care. Findings Included:Record review of Resident #1's clinical record revealed a [AGE] year-old female admitted on [DATE] with the following diagnosis Altered Mental Status, Unsteadiness on feet, Muscle Weakness, Lack of Coordination, Unspecified Macular Degeneration, Psychotic Disturbance Mood Disturbance and Anxiety. Record review of Residents #1's History and Physical dated 3/15/2025 revealed resident was Alert x3 and AMS was resolved. Record review of Residents #1's admission MDS dated revealed upon admission resident had a BIMS score of 11out of 15, indicating moderately impaired cognition. impaired cognition. Record review of Residents #1's admission Agreement revealed Resident #1's signed all necessary documentation for admission and consent to treatment dated 3/15/2025. Record review of Residents #1's Psychosocial Evaluation by Psychological Services Supportive dated 3/17/2025 Mental Status Exam section Orientation: Fully Oriented, Memory: Intact, Cognitive: Cognition Functionally Intact, Judgement: Adequate, and Thought Process: Adequately Integrated. Record review of Resident #1's Social Services progress note dated 3/31/2025 revealed SW spoke with APS worker and APS worker stated POA was allowed to visit and assist Resident # 1, APS case was still open but no allegations currently against POA. Record review of Residents #1 Texas Durable Power of Attorney dated April 15, 2025, revealed Resident #1's signature as Principal's signature and appointed agent as POA. Texas Durable Power of Attorney revealed the signature of the Notary Public of the State of Texas and official stamped by the Notary Public of the State of Texas along with ID number and expiration date of the Notary Public of State of Texas. Interview with Resident #1's Power of Attorney (POA) on 10/08/2025 at 11:30AM. , POA stated she was told the POA she provided to the facility on Resident #1's behalf was not valid by the facility Administrator and as far as the Administrator was concerned, this was a trash piece of paper and that POA could not move nor did POA have the rights to Resident #1 because POA did not have the right too. The Administrator also told POA that Resident #1 had dementia and could not know what she was signing. POA tried to explain to the Administrator POA was not trying to take Resident #1 home POA just wanted to move Resident #1 closer to her so that POA could visit more and get Resident #1 the things she needed due to POA not driving very far. POA was told there was an open APS case on her and Resident #1 was put into the facility by the APS caseworker and POA was not to have any contact with Resident #1. POA stated she contacted APS and was told Resident #1's case was closed and POA was not accused of anything and POA had all rights to visit and assist Resident #1. Interview with APS worker on 10/08/2025 at 1:30PM. , APS worker stated she was somewhat familiar with the case and the case was closed, no allegations towards POA were established. Interview with facility Social Worker on 10/08/2025 at 1:40PM she stated that she had some concerns with the POA documentation due to the APS case against the POA. The Social Worker stated that she was told by the facility Administrator not to send clinical records because of the POA not being valid. Social Worker stated that Residents #1 was alert x 3 at times but may need some redirection. Social Worker said Resident #1was currently being seen by psychological services for anxiety and psychoactive behaviors. Interview with facility Administrator on 10/08/2025 at 2:00PM she stated that the POA was not valid due to Resident #1 having cognitive impairment and dementia. Administrator stated that Resident #1 could not have known what she was signing because of memory issues and the POA coerced Resident #1 into signing the invalid document. Administrator stated the POA signed Resident #1 out and did not disclose where she was taking her and returned to the facility with Durable Power of Attorney paper stating she was now the POA and would like Resident #1's clinicals to be faxed to another skilled nursing facility. The Administrator stated, I did not have my Social Worker faxed clinicals due to the POA did not appear to be valid. The Administrator stated the Durable Power of Attorney was not valid because it was notarized by someone that did not know Resident #1 and she looked up the notary and she only sold food. The Administrator stated she did not have to send notary to a corporate attorney due to her feeling the notary was not valid even though it had the seal of the State of Texas along with Notary ID # and expiration date. The Administrator stated when she asked Resident #1 if she wanted to go to another facility, Resident #1 told her No. Interview with Resident #1 on 10/09/2025 at 10:10AM Resident #1 stated she was ok with moving to another facility because she can never live by herself anymore. Resident # 1 stated she knew her POA and they lived in the same apartment complex and she was her friend. Resident #1 stated she recalls signing a lot of paperwork since she has been in this place and she knows her friend will take care of her. Resident#1 stated she was not forced into sign POA she wanted her friend and neighbor to help her make good decisions. Resident #1 stated that the president was Trump and she was in a nursing home, it was 2025 and Fall time of the year. Record review of the facility's discharge and transfer policy states as follows:The Facility is committed to ensuring safe discharge dispositions and will make every effort to facilitate a smooth transition of care. In cases of difficult or immediate discharges, the Facility will follow CMS and State guidelines to maintain regulatory compliance and protect resident's rights and well-being.

Based on observations, interviews, and record review the facility failed to ensure residents had the right to reside and received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and or safety of the resident or other residents for 2 of 12 residents (Resident #1 and #2) reviewed for resident rights. The facility failed to ensure Resident's #1's and Resident #2's call lights were within reach on 11/12/2025. This failure could place residents at risk of their needs not being met. Findings include: 1. Record review of Resident #1's quarterly MDS assessment, dated 08/25/25, reflected a [AGE] year-old female with an original admission date of 02/07/24. Her diagnoses included non-Alzheimer's dementia (confusion, memory impairments, difficulty with attention), cerebrovascular accident, transient ischemic attack, or stroke (interrupted blood flow to the brain or temporary blockage to the brain), spinal stenosis (narrowing of one or more spaces within your spinal canal), and muscle weakness. Resident #1 was independent for eating, required substantial/maximal assistance for toileting, required substantial/maximal assistance for bathing, and required partial/moderate assistance for personal hygiene. Resident #1 had a BIMS score of 13, which indicated she had intact cognition.Record review of Resident #1's care plan, dated 11/11/25, reflected: Falls: [Resident #1] is at risk for falls and injuries AEB Goal: Resident #1 would be free from falls and injuries over the next 90 days.Interventions included: 2/9/25 Ensure call light is within reach and answer promptly-make sure bed controls are in reach at all times.In an interview and observation on 11/12/25 at 2:00 PM, Resident #1 stated sometimes the staff did not return her call light to her reach after they helped her with things. She stated if she needed help, and could not find or reach her call light, she would wave at someone when they walked past her room to get their attention. Observed Resident #1's call light was hanging down behind the right side of the bed below where the resident's right elbow was positioned, and not within the reach of her left arm. Her bed control was hanging on the left side of her bed near her left arm, and she was observed to use her left hand to press the controls to control her bed. 2. Record review of Resident #2's quarterly MDS assessment, dated 09/16/25, reflected an [AGE] year-old male with an original admission date of 02/20/25. His diagnoses included debility, cardiorespiratory conditions (range of medical conditions that affect the heart and lungs), heart failure (heart cannot pump enough blood to meet the body's needs), neurogenic bladder (nerve damage that affects bladder control), respiratory failure (when the body does not get enough oxygen or has too much carbon dioxide in the blood), lack of coordination, and muscle weakness. Resident #2 was independent for eating and required supervision or touching assistance from staff for toileting, bathing, and personal hygiene. Resident #2 had a BIMS score of 02, which indicated he had severely impaired cognition.Record review of Resident #2's care plan, dated 11/06/25, reflected: Falls: [Resident #1] is at risk for falls and injuriesGoal: Resident #2 would be free from falls and injuries over the next 90 daysInterventions included: 11/2/25-Ensure call light is within reachIn an interview and observation on 11/12/25 with Resident #2, his call light was observed to be behind his bed and behind a nightstand, twisted up amongst other cords that were plugged into the wall. He stated he used his voice to yell for help, because oftentimes his call light was not on his bed. He stated he did not get out of bed often, but he used the restroom and looked around when he could. In an interview on 11/12/25 at 2:50 PM with RN A, she stated Resident #2 often called for help with his voice. She stated it would be easier on the resident if he were to use his call light. She stated she was unsure why the call light was behind the bed and it was the nurses' responsibility to ensure call lights were within reach. She stated it was important for a resident's call light to be within reach because sometimes it was hard to understand residents and ultimately the call light was to alert someone to go provide assistance to the resident(s).In an interview on 11/14/25 at 8:50 AM, the DON stated her expectation for call lights was that they were to always be within the residents' reach. She stated staff were trained on call light placement. She stated Resident #2 had a lot of behaviors, but she had not heard any about call lights. She stated Resident #1 did her own thing and would sometimes throw her call light down. In an interview on 11/14/25 at 9:45 AM, the ADM stated it was her expectation that all residents' call lights were within reach, and it was all staff's responsibility for ensuring call light placement and any staff could answer call lights to see what residents needed and to ensure safety. She stated if a resident was non-compliant or lacked the mental capacity for use of a call light, staff should still ensure the call light was in place. She stated they should care plan systemic issues they saw so staff would be aware.Record review of the facility's policy titled Call Lights, dated 12/23, reflected The facility will provide a call light system that is accessible, functional, and responsive to meet the needs of the residents. Call lights will be placed within reach of the resident's bed or sitting area in the resident's room.

Based on interview, and record review, the facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated, and that the results of the investigations were reported to the State Survey Agency within five working days of the incident for 6 of 8 residents (CR #1, CR#2, CR#3, CR#6, Resident #4, Resident#5 ) reviewed for Abuse, Neglect, and Exploitation.The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the allegations made on 12/26/2024, by CR #1 and CR#2, stating that CNA A provided rough care during activities of daily living (ADL) assistance. The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the family complaint made on 12/26/2024, regarding rough care provided by MA L during medication pass to CR#3.The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the family complaint made on 02/25/2025, regarding CNA R's failure to provide essential care to CR#3. The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the allegations made on 02/10/2025, of Resident #4 hitting Resident #5 across the head.The facility failed to submit via State Survey Agency database, TULIP the five-day thoroughly investigated evidence that the allegations made on 09/16/2024, reported by insurance provider regarding CR#6, including a new-onset rectal bleeding noted on 9/17/24 (reported to be absent on 9/16/24) with concern of possible sexual assault, absence of a dressing on the dialysis catheter, and unsanitary conditions in the room with mold and mildew.These failures could place residents at risk for abuse and/or neglect by not having their concerns and allegations of abuse thoroughly investigated and reported. 1.Record review of facility reported intake created on 01/18/2025 via TULIP, with allegations of Resident Abuse, indicated CR# 1 and CR #2 alleged that CNA was rough when providing ADL care. Further review revealed no five-day investigation submission was found. No additional information related to the incident was submitted via the TULIP intake database. Record review of CR#1's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] due to end Stage 4 chronic kidney disease (kidneys are moderately or severely damaged and are not properly filtering waste from your blood) and discharged from the facility on 02/04/2025. Record review of CR#1's care plan last reviewed on 02/10/2025 revealed CR#1's had a self-care deficit related to below knee amputation, with interventions including provide prompt assistance, aid of for toileting/incontinent care, provide total assistance for bed mobility, bathing, and showering. Record review of CR#1's Comprehensive MDS (resident assessment tool) dated 04/29/2024 revealed a BIMS score of 15, indicating intact cognition. Further review revealed that CR#1 was totally dependent on helper(s) for toileting hygiene. Record review of CR#2's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] due to Type 2 diabetes mellitus with other specified complication (a lifelong disease that keeps your body from using insulin the way it should) and discharged from the facility on 04/18/2025. Record review of CR#2's care plan last reviewed on 04/23/2025 revealed CR#2's had a self-care deficit, with interventions including provide prompt assistance, provide encouragement and cueing as needed to performed ADL cares, aid of for toileting care, aid with bathing, and showering. Record review of CR#2's Comprehensive MDS (resident assessment tool) dated 02/07/2025 revealed a BIMS score of 15, indicating intact cognition. Further review revealed that CR#2' was dependent on helper(s) for toileting hygiene. Record review of CR#1's and CR#2's progress notes revealed: On 01/16/2025 at 5:00pm, reflected Nurse V wrote that she was notified by CR#1 and CR#2 that CNA was rough when ADL care was provided. The progress note did not identify the CNA and included additional details. Grievance dated 01/15/2025, reflected CR#2 reported that she would like CNAs to take more time and care when doing patient care. Documentation did not identify a particular CNA. The surveyor was unable to interview CR#1's and CR#2 as residents no longer resided at the facility. The interview on 09/08/2025 @ 11:00am with the Regional Nurse, she stated CNA A was identity during the facility investigation as the CNA assigned to CR#1's and CR#2 on 01/16/2025. Regional Nurse stated CNA A was suspended to ensure CR#1's and CR#2 safety during the facility investigation. Regional Nurse stated that the allegations of abuse and neglect related to CNA A providing rough care during med pass were unfound due to lack of information provided evidence, CNA A's denial of allegations. She stated the facility is required to report allegations of abuse and conduct a thorough internal investigation within 5 days timeframe. If an incident (such as an injury, abuse, or neglect) is not reported in a timely manner, it could delay any necessary investigations or interventions to protect the safety and well-being of residents and could place residents at risk of harm. She stated the facility reported the incident, but the five-day report evidence findings were not submitted to the state agency and retained by the facility's former administrator. She stated that it was uncertain why the investigation findings were not reported and retained. She stated she was recently, on 09/05/2025, made aware of this failure upon the state surveyor's request for documentation. She started an audit was completed and no additional intake reporting failure has been identified since the termination of the former administrator. She stated the facility has implemented an additional step to prevent similar problems in the future. She stated that the facility has crated an internal secure share drives are all reportable investigation and finding are retained by the facility. She stated that the DON and current Administrator have been trained on the process as of 09/06/2025. Attempted interview with the CNA A on 09/07/2025 at 11:53am, left a voicemail requesting a return call. 2. Record review of facility reported intake created on 12/31/2025 via TULIP, with allegations of Resident Abuse, indicated CR #3' family member alleged MA was rough during medication pass. Further review revealed no five-day investigation submission was found. No additional information related to the incident was submitted via the TULIP intake database. Record review of CR#3's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] due to acute respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body) and discharged from the facility on 04/11/2025. Record review of CR#3's care plan last reviewed on 03/17/2025 revealed CR#3's had a self-care deficit, with interventions including aid with personal hygiene/grooming, aid of for toileting/incontinent care, provide total assistance for transfers, bathing, assistance for upper/lower body dressing, and assistance with meals. Record review of CR#3's Comprehensive MDS (resident assessment tool) dated 02/13/2025 revealed a BIMS score of 00, severe cognitive impairment. Further review revealed that CR#3 was dependent on two or more helper(s) to complete daily living activity. Record revie of grievance document, titled Concern Report dated, 12/29/2024 indicated RP reported concern related med pass to CR#3 on Friday, 12/26/2025. Documented resolution indicated staff was re - educated on medication administration. No additional documentation related to allegation details provided. The interview on 09/08/2025 @ 11:00am with the Regional Nurse, she stated MA L was identity during the facility investigation and the MA assigned to CR # 3 on 12/26/2024 @ 9:00am. Regional Nurse stated MA L was suspended to ensure CR #3's safety during the facility investigation. Regional Nurse stated that the allegations of abuse and neglect related to MA L providing rough care during med pass were unfound due to lack of information provided by the RP and MA L denial of rough incident. The surveyor was unable to interview CR #3; no longer resided at the facility. Attempted interview with the RP on 09/05/2025 at 11:53am, left a voicemail requesting a return call. Record review of MA L file revealed MA L was suspended on 12/26/2024 no documentation of date of return. Attempted interview with the MA L on 09/05/2025 at 1:58pm, left a voicemail. Record review of documentation provided revealed Medication Administration in- service was provided on 02/01/2025, no evidence of training provided on the date or surround dates of the incident. 3. Record review of facility reported intake created on 03/01/2025 via TULIP, with allegations of Resident Neglect, indicated CR #3' RP alleged CNA R was not providing the essential level of care on 02/25/2025. Further review revealed no five-day investigation submission was found. No additional information related to the incident was submitted via the TULIP intake database. Record review of training documentation revealed Abuse and neglect training was provided on 02/28/2025. Record review of CR # 3 clinical documentation, Skin Observation dated 02/27/2025, indicated not finding. Attempted interview with the former Administrator on 09/06/2025 at 10:16am; surveyor left a voicemail requested a return call. During interview on 09/07/2025 @ 4:48pm with CAN R, CAN R stated she could recall the alleged incident, she stated that CR # 3 often presented with aggressive behaviors towards staff. CAN R denial neglecting the CR # 3 when she previously provided patient care. She stated she was not sure of the details related to the incident. She stated she was suspended after the report was made and was later informed that the allegations were unfound. She stated abuse and neglect training was provided following the incident. She stated additional training regarding patient care and abuse was provided by the facility monthly. She stated that when care is provided to current residents who may present with behaviors, she used the support of the unit nurse or staff to aid in redirecting the resident. 4.Record review of facility reported intake created on 02/12/2025 via TULIP, indicated Resident #4 hitting Resident #5 across. Further review revealed no five-day investigation submission was found. No additional information related to the incident was submitted via the TULIP intake database. Record review of Resident #4's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] due to skin infection. Record review of Resident #4's care plan last reviewed on 07/07/2025 revealed Resident #4's focus areas: Behaviors related to physical aggression, documented occurrence of 02/11/2025 with interventions including, monitor and chart behaviors as they occur and report progress/declines to provider, provide psych consult, re-evaluated, and admission to behavioral hospital as ordered.Psychotropic medications related to behavior management with interventions including, administer psychotropic medications as ordered by physician; monitor for side effects and effectiveness every shift; discuss with medical provider/family regarding ongoing need for use of medication; monitor/document/report as needed for any adverse reactions of psychotropic medications. Record review of Resident #4's Comprehensive MDS (resident assessment tool) dated 07/02/2025 revealed a BIMS score of 13, indicating intact cognition. Further review revealed that Resident #4 was able to function with a helper provided verbal cues and/or touching. Record review of Resident #5's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] with schizophrenia. Record review of Resident #5's care plan last reviewed on 08/08/2025 revealed Resident #5's focus areas: Behaviors: occurrence date 02/11/2025- roommate hitting him, at risk for further increased episodes and injury with interventions Resident #5's was moved to another location for safety, occurrence was reported to abuse coordinator; skin and pain assessment completed and reported to medical providers, DON and Administrator. Psychotropic medications, with interventions including, administer antipsychotic medications as ordered by physician; monitor for side effects and effectiveness; Monitor for episodes of psychotic/psychosis driven behaviors such as Visual/Auditory hallucinations, delusions, thought insertion/withdrawal, increased physical/verbal aggression; and provide psych consult as ordered. Record review of Resident #5's Comprehensive MDS (resident assessment tool) dated 07/02/2025 revealed a BIMS score of 14, indicating intact cognition. Further review revealed that Resident #5 was able to function with helper provided setup or clean up assistance. Record review of nursing clinical documentation dated 02/11/2025 at 11:30am, revealed a head-to-toe assessment was completed on Resident #4 following the incident, no injury identified. Record review of nursing clinical documentation dated 02/11/2025 at 11:31am, revealed a head-to-toe assessment was completed on Resident #4 following the incident, no injury identified. Record of progress notes revealed: Resident #4 was transferred to a behavioral hospital on [DATE], following the incident. Resident #5 was immediately moved to a different room on 02/11/2025. Nursing assessment completed without finding of injury, and social worker consult. During interviews on 09/08/2025 @ 5:18pm with Resident #4, he stated he feels safe at the facility. Residents denied he had experienced or witnessed abuse at the facility. Resident #5 could not recall the incident. During interviews on 09/08/2025 @ 5:42pm with Resident #5, he stated he feels safe at the facility. Residents denied he had experienced or witnessed abuse at the facility. Resident #5 could not recall the incident. 5.Record review of facility reported intake created on 01/15/2025 via TULIP, indicated facility reported allegation of abuse and neglect reported by insurance provider regarding CR#6, including a new-onset rectal bleeding noted on 9/17/24 (reported to be absent on 9/16/24) with concern of possible sexual assault, absence of a dressing on the dialysis catheter, and unsanitary conditions in the room with mold and mildew. Further review revealed no five-day investigation submission was found. No additional information related to the incident was submitted via the TULIP intake database.Record review of CR#6's Face Sheet dated 09/07/2025 revealed a [AGE] year-old who was originally admitted on [DATE] with primary diagnosis of sepsis (a serious condition in which the body responds improperly to an infection) and chronic kidney disease (occurs when a disease or condition impairs kidney function) and discharged from the facility on 09/23/2024. Record review of CR#6's care plan last reviewed on 09/14/2024 revealed CR#6's bowel incontinence, with interventions including apply a house moisture barrier cream after each episode of incontinence; encourage the resident to maintain mobility and participate in activities that promote regular bowel movements; monitor for signs of discomfort or agitation that may indicate the need for toileting; perform routine rounding to include incontinence care and brief changes; and remind and assist the resident to use the toilet regularly as indicated/able. No additional information related to self-care deficit was identified in care plan. Record review of CR#6 Comprehensive MDS (resident assessment tool) dated 04/29/2024 revealed a BIMS score of 06, indicating severe cognitive impairment. Further review revealed that CR#6's was totally dependent on helper(s) for toileting hygiene. The surveyor unable to interview CR#6 as resident no longer reside at the facility. During an interview on 09/05/2025 at 2:18pm, the SW stated she's worked in his role as the SW at the facility for many years. The SW explained her role as part of a comprehensive abuse investigation was to assess the safety and psychosocial well-being of the resident identified in the investigation and other residents. She stated when an abuse allegation is made, involving a staff member, it's critical to determine whether the abuse was isolated or systemic. She stated other residents may have been affected or were at similar risk. She stated when notified of an abuse incident it was her responsibility to identify at-risk residents. She stated she would start by reviewing other residents under the care of the alleged abuser (same hall/unit). Thereafter, she would conduct safety care rounds by meeting with each identified resident privately to assess. She explained in the individual meetings, he would assess for the resident safety, signs of fear or distress, or unreported incidents. When asked if she recalled the identified incidents involving CR #1, CR#2, CR#3, CR#6, and Residents #4, #5, she stated she recalled the incident. She stated she completed safety care rounds related to the incidents. When asked where the information was documented, she stated that safety care round documentation was submitted to the Former Administrator, FS M. When asked if her encounter with the resident was documented in the clinical record, he stated all encounters were documented in social worker's progress notes which is part of the resident clinical record. Attempted interview with the former Administrator on 09/05/2025 at 3:58pm, left a voicemail. Attempted interview with resident family member on 09/07/2025 at 1:05pm, left a voicemail requesting a return call. During an interview on 09/05/2025 at various times, with staff (LVN, K, LVN D, RN C, CMA M, CNA L, CAN J, and CAN R) stated they had been trained in abuses and neglect, repositioning techniques. Staff denied witnessing abuse and/or neglect at the facility. All staff identified the Administrator as the abuse coordinator. Staff stated they feel that there was enough staff support with resident's needs. They stated that sometimes they were short, but staff work together to meet the needs of the resident. During an interview with Administrator and DON on 09/07/2025 at 10:00am, the Administrator she was the facility's abuse coordinator. She stated as the abuse coordinator she must report to HHSC immediately and then start the investigation and complete it within five days of the incident. The Administrator stated that if a staff member were identified in the incident, she would suspend the staff member while continuing the investigation. The Administrator stated, she realized that there was a failure by the previous administration, FS M with the 5-day submission of investigation findings involving CR #1, CR#2, CR#3, CR#6, and Residents #4, and #5. The Administrator stated she gathered all the documentation to review that incidents were initiated but was unable to locate documentation evidence that a thorough investigation was completed, and findings reported to the state. The Administrator stated each intake was reviewed upon surveyor's request for evidence. The Administrator stated supporting documentation was gathered to confirm that each incident was addressed with acknowledgement that it was noted and addressed with education or clinically assessed. The Administrator stated five-day reports for the identified incidents were not submitted to by the pervious Administrator, FS M. The Administrator stated the facility was now required to store all investigations on a shared drive with regional staff to prevent the reoccurrence of the facility not retaining the documentation and evidence for all incident investigations. Record review of TULIP (portal where facilities report incidents to the state) on 09/05/2025 revealed no facility five-day investigation findings were reported for CR #1, CR#2, CR#3, #4, #5 CR#6. Record review of CNA A, CNA R, and MA L's file revealed abuse and neglect training to staff and a follow up incident follow ups were made regarding involving CR #1, CR#2, and CR#3. Record review of training and in-services revealed that the facility had provided the following trainings: 08/04/2025 - Abuse Reporting06/27/2025 - Abuse, Neglect, and Exploitation05/10/2025 - Abuse, Neglect, and Exploitation04/17/2025 - Abuse, Neglect, and Exploitation04/17/2025 - Turing and Reportioning04/07/2025 - Abuse, Neglect, and Exploitation 04/14/2025 - Abuse, Neglect, and Exploitation02/01/2025 - Abuse, Neglect, and Exploitation01/24/2025- Abuse, Neglect, and Exploitation 12/22/2024 - Reporting Abuse and Neglect Timely Record review of the facility's Abuse, Neglect and Exploitation Policy, revised 10/2024 revealed: The Facility will conduct a timely investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property. The investigation should include gathering evidence, interviewing witnesses, conducting surveys as indicated, reviewing medical records, and examining any relevant documentation.The Facility will submit a summary of its investigation as required by applicable state and federal regulations.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident, for 1 of 1 Resident (Resident #1) reviewed for medication administration. MA-A did not pull down on the lower eye lid prior to instilling medicated eye drops to Resident #1. MA-A placed the medication cap for the eye drops on an unclean surface, with the inside facing down then replaced the cap onto the bottle after administering the medication to Resident #1. These failures could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction, infection, or a decline in health. Findings included: Record review of Resident #1's face sheet dated 06/01/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and initially admitted on [DATE]. Her diagnoses included heart failure, fainting and collapse; glaucoma (condition that damages the optic nerves) and elevated blood pressure. Record review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. She had impairment to one side of the lower extremity. She was dependent on staff assistance for some ADLs and others she required only substantial assistance. Record review of Resident #1's undated care plan revealed Focus - Resident #1 had impaired visual functioning and was at risk for decreased in ADLs due to Glaucoma. Interventions did not include to administer medications as MD ordered. Record review of Resident #1's physician order dated 1/19/25 indicated an order for Latanoprost 0.005%, instill one (1) drop in both eyes in the evening for treatment. Record review of Resident #1's MAR dated 6/1/25 at 3:51 PM, indicated an order for Latanoprost 0.005%, instill one (1) drop in both eyes in the evening for treatment and scheduled for 7:00 PM. During an observation on 06/01/25 at 6:20 PM, MA-A performed hand sanitization, put on clean gloves, positioned Resident #1 to receive eye drops then removed the medication cap of the Latanoprost eye drops and placed the cap inside facing down on top the nightstand. The nightstand was not disinfected prior to the procedure. MA- A instructed Resident #1 to open her eyes wide. Resident #1 slightly opened her eyes. MA- A held the bottle over Resident #1's right eye and instilled one drop. MA-A instructed Resident #1 to close her eyes. Resident #1 had her eyes closed for three seconds. MA-A instructed Resident #1 to open her eyes and attempted to instill a drop into the left eye, resident blinked, and the solution did not enter into the eye. MA-A attempted again, and 2 drops entered the eye. Resident #1 closed both eyes, MA-A wiped excess solution using a clean tissue. MA-A replaced the medication cap onto the bottle, removed gloves and sanitized hands. In an interview on 06/01/25 at 6:53 PM, MA-A stated Resident #1's eye drop order was one drop per eye. MA-A stated Resident #1 was receiving Latanoprost eye drops because she does not see clearly. MA-A stated she was taught to drop medication into the inside of the eye by the medication aides who had been working at the facility for a long time. MA-A stated she received training during orientation in February 2025. MA-A stated normally she would put the medication cap in a way it would stay clean, but she was nervous. In an interview on 6/01/25 at 7:12 PM, LVN-B stated when administering eye drops she would wash hands, put on clean gloves, pull lower eye lid down, administer eye drop into the lower portion of the eye then have the resident close their eye and massage the lower lid or ask the resident to close eyes and move eye ball around in order to better absorb and spread the medication. LVN-B stated Resident #1 needs the Lantanoprost eye medication for glaucoma and if not instilled correctly her vision could worsen. LVN-B stated she would ensure the tip of the dropper stays clean by putting the medication cap on a clean surface upside down on a clean surface so the inside of the cap remains clean otherwise if the cap is placed facing down it could contaminate the tip of the dropper when the cap is replaced, and this could possibly cause an eye infection. LVN-B stated she will follow up and re-educate MA-A and notify the DON so a new bottle can get ordered and the old bottle should not be used again. In an interview on 6/1/25 at 8:20 PM the DON stated she expected nurses and medication aides to put on clean gloves, pull down on the lower eye lid and instill the ordered number of eye drops into the lower lid area. Then have the resident close their eyes. The DON stated if the facility policy and procedure was not followed the resident may not receive the full dose. The DON stated Resident #1 receives Latanoprost for glaucoma or cataracts. The DON stated it was important to ensure the tip of eye dropper stays clean to reduce chance of infection. The DON states she would hold the medication cap in the palm of her hand and would not put the cap down on a surface as it could potentially cross-contaminate the tip of the dropper and cause eye infection. The DON stated she would conduct in-service with MA-A on proper administration of eye drops. Record review of MA-A's Medication Aide-Medication pass competency check list dated 2/30/25, indicated the performance criteria was met for eye drop administration including to gently pull down the lower eyelid to form a pouch while instructing the resident to look up. Further review indicated MA-A signed the checklist and was evaluated by the Lead MA. Record review of the facility policy and procedure for Medication Administration and Management revised on June 2019, read in part: It is the policy of this facility that the facility will implement an Medication management Program that incorporates systems with established goals to meet each resident's needs as well as regulatory requirements .9. The authorized licensed or certified/permitted medication aide or by state regulatory guidelines staff member administers eye medications as follows: A. Administer according to pharmacy/manufacturer specifications .G. Use the index finger to pull down the lower lid. H. Instruct the resident to look up. I. Steady your hand holding the dispenser against the resident's forehead, and instill the drop inside the lower lid L. Release the eyelid, instruct resident to close eyes slowly, and gently wipe off excess medication with a clean tissue from the inside to the outside .O. If indicated, it may be necessary to apply pressure to the tear duct (inner canthus) following the instillation of a specific eye drop for one (1) minute or per manufacturer's specifications .

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accident for 1 (CR #1) of 18 residents reviewed for accidents in that: - The facility failed to provide CR#1, who was on an anticoagulant medication, adequate supervision and interventions to prevent falls on 11/13/24, 11/14/24, 11/17/24, and 11/21/24 causing head injury and hospitalization . -The falls were unwitnessed, CR #1 had dementia and did not remember to use their call light when they needed assistance. Cr #1 was admitted to the hospital with diagnosis of Acute Subdural Hematoma with mass effect left craniotomy evacuation. An IJ was identified on 11/25/2024. While the IJ was removed on 11/27/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This failure could place residents at risk for unwanted hospitalization s and death. Findings included: Record review of CR #1's face sheet dated 11/22/24 revealed a [AGE] year-old female admitted to the NF originally on 05/11/2024 and again on 11/02/2024. CR #1 diagnoses included the following: muscle weakness, unsteadiness on feet, vascular dementia (memory loss), end stage renal disease (kidney disease), and osteoporosis (bones become weak and brittle). Record review of CR#1's MDS dated [DATE] revealed a BIMS score of 7 indicating that resident cognition was severely impaired. Further review section GG-Functional Abilities and Goals reflected that CR #1 required supervision with transfer. Record review of CR #1's Comprehensive Care Plan dated 11/04/2024 reflected that resident was being care planned for risk for falls and injuries due to a hx of falls prior to admission. Further review reflected that CR #1 experienced falls on the following days for the month of November 2024 (11/13/24 unwitnessed fall in room no apparent injuries, 11/14/24 unwitnessed fall in room, 11/17/24 unwitnessed fall in room no injury, and 11/21/24 unwitnessed fall in room). The interventions included the following: -Anticipate needs- provide prompt assistance -Assure lighting is adequate and areas are free of clutter -Encourage resident to ask for assistance of staff -(Revised on 11/21/24) CR #1 will be reeducated to call for assistance from staff for all transfers, she continued to try to be independent, staff would make frequent rounds for closer monitoring, bed in lowest position, and call light in reach. Record review of CR #1's Physician Orders for the month of November 2024 reflected the following order: -Dated 05/16/24 Eliquis 5mg give one capsule by mouth q 12 hrs related to atherosclerosis (build-up of fats, cholesterol, and other substances in and around the artery {a vessel that carry blood away from the heart to the entire body}) walls. Record review of CR #1's MAR for the month of November 2024 reflected that the NF was administering the medication Eliquis as ordered by the physician. Record review of CR #1's fall incidents: -11/13/24 4:26 pm on the facility's incident report list -11/14/24 4:55 pm on the facility's incident report list -11/17/24 5:50 am on CR #1's change in condition assessment -11/21/24 5:50 am on CR #1's change in condition assessment Record review of CR #1's fall risk assessments, CR #1 had the following fall assessments with scores: -11/14/24 - high risk 25.0 -11/17/24 - high risk 19.0 -11/21/24 - high risk 19.0 Record review of CR #1's fall incident reports: -11/13/24: resident found sitting on bottom beside bed in bedroom. No witness. Resident unable to give description. -11/14/24 incident report- patient found on floor in bedroom, unbothered, patient confused no question answered. No witness. Resident unable to give description. Record review of CR #1's fall incident reports: -11/13/24: resident found sitting on bottom beside bed in bedroom. No witness. Resident unable to give description. -11/14/24 incident report- patient found on floor in bedroom, unbothered, patient confused no question answered. No witness. Resident unable to give description. Record review of CR #1's Nursing Progress Notes: -11/15/2024 17:02: S/P: Day 1 of 3. Fall occurrence on 1/14/2024. No complaint of pain or distress at this time. resident is moving around in her wheelchair in the common area interacting with other residents. Vitals are WNL. will continue with plan of care. Record review of CR #1's Nursing Progress Notes dated 11/21/24 at 5:50 AM CR #1 was found in room sitting on floor by RN A. RN A assessed resident and documented that resident had swelling to her right cheek. Further record review revealed that resident was transferred to the hospital on 11/21/24 at 7:40AM. Further record review CR #1's Nursing Progress Notes documented by RN A dated 11/21/24 reflected the following: . CR #1 was assessed, V/S were evaluated to be stable and WNL. Swelling / hematoma was noted to the Right cheeks. No distress is noted at this time. CR #1 denies any pain or discomfort at this time. Fall precaution is in place. Neuro assessment is initiated and ongoing. CR #1 educated to call for assistance whenever she needed help, CR #1 verbalized understanding. Bed is put in the lowest position with call bell and personal belonging within her reach. MD was notified. DON and RP were also notified. This nurse called report to hospital. CR #1 is awaiting transfer to the hospital . Further Record review of SBAR documented by RN A reflected the following: -Form Summary: SBAR (Change of Condition) - Fall Event Date/Time of Fall: 11/21/2024 5:50 AM Location of the Fall: Resident's room Classification of the Fall: Unwitnessed What was the resident doing prior to the fall: Resident states I was trying to turn and I rolled over. Initial Vital Signs Post Fall Event: Blood Pressure-124/71 Pulse-78 Temperature-97.6 Respirations-17 02 Saturation-99% Medication Reviewed with the Physician: Yes Notifications Physician/Physician Extender: PCP; 11/21/2024 5:54 AM Resident/Responsible Party: 11/21/2024 5:55 AM Interview on 11/22/24 at 10:12AM with the NF Administrator and the DON present, the Administrator said CR #1 was residing on the Memory Care Unit and on 11/21/24 around 5:30AM the staff (RN A and CN B) had gotten CR #1 up for dialysis. The Administrator said from her understanding the staff placed CR #1 near the nurse station in wheelchair. The Administrator said the staff began to round on other residents in the MCU at 5:40AM. The Administrator said CNA B said shortly after she saw CR #1 laying on her bed. The Administrator said at 5:50AM the Charge Nurse heard a noise coming from CR #1's room and went to see what was going on. The Administrator said when RN A arrived to CR #1' room, she found CR #1 sitting on the floor in between the 2 beds. The Administrator said CR #1 could walk. The DON interjected and said that CR #1 could walk but had an unsteady gait. Interview on 11/22/24 at 1:58PM with family member of CR #1 said CR #1 was still at the hospital in a coma and her condition was not looking good because CR #1 had a lot of bleeding on the brain. The family member said the NF called her on 11/21/24 around 6:40AM telling her that CR #1 had a fall, and they were preparing to send CR #1 to the hospital for further evaluation. The family member said she spoke with CR #1 prior to leaving the NF and CR #1's speech was slurred. Interview on 11/22/24 at 2:34PM RN A said she worked the 6:00 PM - 6:00 AM shift and worked on 11/20/24. RN A said herself and CNA B had gotten CR #1 out of bed at 5:30AM to dress CR #1 and placed in wheelchair for dialysis. RN A said CR #1 was taken to the common area across from the nurse station. RN A said the CNA that was assigned to CR #1 CNA C, but CNA B assisted with getting CR #1 out of bed for dialysis. RN A said CNA B was in the common area as well but later began to make rounds with the other CNA C getting the other residents out of bed and taking some to the common area as well but still checking on CR #1. RN A said she began to pass medications on the other residents while keeping an eye on CR #1. RN A said she could see CR #1 because of the way her cart was positioned on the hallway. RN A said when she came out of a resident room, she did not see CR #1. RN A said she rushed to CR #1's room where she found CR #1 sitting on the floor. RN A said she never heard a noise coming from CR #1's room. RN A said she called CNA C to come and assist her with CR #1. RN A said after she finished assessing CR #1, herself and CNA C placed CR #1 back in bed. RN A said CR #1 had some swelling to the right side of face but was not complaining of pain. RN A said CR #1 vital signs were stable and she initiated neurological checks on CR #1 which were within normal limits. RN A said she called the doctor, resident family member as well as the Administrator. Interview on 11/22/24 via phone at 3:05PM CNA B said she worked the night shift from 10PM-6AM. CNA B said she was not the CNA assigned to CR #1. CNA B said she never provided any type of care for CR #1 including assisting with placing resident in wheelchair on 11/21/2024 at 5:30AM. Observation on 11/23/24 at 11:30AM CR #1 in the ICU resting in hospital bed connected to ventilator unresponsive wearing a neck collar. Further observation on the top and left side of CR #1's head was bald with dressing on the top of head. There was a small plastic bulb what appeared to be connected to CR #1's head with red fluids draining inside of bulb. CR #1 was receiving the medication Cardene (used to treat high blood pressure and control chest pain) IV 40mg in 200ml of fluid at 75ml/hr. Resident was receiving gastrostomy feedings Nova Source that read on pump 20ml/hr. Record review of CR #1's Admitting diagnoses revealed that CR #1 was admitted to the hospital for Acute Subdural Hematoma with mass effect left craniotomy evacuation. Interview on 11/23/24 at 11:35AM the hospital nurse said CR #1 would be taken off the ventilator 11/23/24 and the family wanted comfort measures (treatments that focus on relieving pain and distress for a dying person) after taking CR #1 off the ventilator. Interview on 11/24/24/ at 7:26PM via phone CNA C said she worked the 10PM-6AM shift. CNA C said on 11/20/24 she was CR #1's CNA on the Memory Care Unit. CNA C said the nurse helped her in getting resident ready for dialysis. CNA C said after her and the nurse got CR #1 ready for dialysis at 5:30AM CR #1 was taken to the common area in her wheelchair across from the nurse station. CNA C said she went to check on the other residents. CNA C said the nurse was on another hallway passing medications. CNA C said CNA B was making rounds on the residents. CNA C said the last time she saw CR #1 prior to the fall was at 5:40AM in her room laying on her bed. CNA C said shortly after, she heard RN A calling her to come to CR #1's room. CNA C said when she arrived too CR #1's room, she saw CR #1 sitting on the floor. CNA C said RN A assessed CR #1 and afterwards, she assisted RN A in placing CR #1 back in bed. CNA C said CR #1 denied any pain. CNA C said RN A was preparing to send CR #1 to the hospital. Interview on 11/25/24 at 1:00 PM, the MDS Coordinator said the ways the facility tried to prevent CR #1 from falling was by keeping CR #1 in the common area across from the nurse station as much as possible, but CR #1 moved freely in her wheelchair in the MCU. The MDS Coordinator said the NF also tried to keep CR #1 engaged in activities. The MDS Coordinator said the interventions that were in place for CR #1 were sufficient in preventing continuous falls for CR #1. The MDS Coordinator said due to CR #1 being mobile in her wheelchair, the only other intervention was to place resident maybe on 1 on 1 supervision. Interview on 11/25/24 at 1:25 PM, the DON said, regarding falls. she started working at the NF on 10/21/2024. The DON said she was aware of how often CR #1was falling because it was discussed in the morning meetings. The DON said the NF tried to put interventions in place to prevent CR #1 from falling. The DON said because of CR #1's resident disease process, regarding her dementia it made it difficult to prevent CR #1 from falling. The DON said the NF did not have the staff to place resident on 1 on 1 supervision. The DON said the interventions that the NF put in place for CR #1 was the best the facility could do to prevent resident from falling. The DON said she could not say if the NF could have done anything different to keep resident from falling. Interview on 11/25/24 at 2:08 PM, the Administrator said CR #1's falls were discussed in the morning meetings. The Administrator said she was aware of CR #1's continuous falls in the month of November, but would have to review her notes to see what was discussed about resident falls. The Administrator never provided any notes about CR #1's falls during the morning meeting. Interview on 11/26/24 at 8:54AM the Rehab Director said she participated in the morning meetings. The Director said she was familiar with CR #1. The Director said CR #1 was pretty much independent prior to hip fracture which took place at the facility about a month and a half ago. The Director said prior to CR #1 hip fracture she was transferring independently but after, she required assistance with transfers. The Director said CR #1's falls on 13, 14, 17, and 21st of November 2024 were discussed in morning meetings and the interventions included all that were in CR #1's care plan. The Director said the problem was due to CR #1's dementia, she would not remember about safety. The Director said she did not meet with the family regarding CR #1's repeated falls. The Director said CR #1 was receiving therapy but cognitively, CR #1 thought she could do what she was doing before. The Director said the NF were trying to keep CR #1 in the common area as much as possible. The Director said she remember coming to pick up another resident and remembered seeing CR #1 trying to walk back to her room. The Director said she had to redirect CR #1 back to the common area. The Director said CR #1 would go to her room and self-transfer. The Director said in some cases during morning meetings they discussed medications and fall. The Director said she could not say if CR #1's medications were discussed, but they should have discussed it. The Director said she was not working at the NF on the 15th and 18th of November. The Director said an intervention would be to ask the psychiatrist to review medications, do labs for UTI maybe, but that was done on an individual basis. The Director said she did not recall if the NF talked about medications and labs regarding CR #1. The Director said the interventions that the facility had in place regarding falls for CR #1 were sufficient. The Director said the NF could not do 1-on-1 supervision. The Director said after reviewing the interventions, the NF implemented their suggestions one being getting CR #1 up earlier so she would not get up on her own. Interview on 11/26/2024 at 9:31am via phone with CR #1's family member/RP said she never attended a meeting regarding CR #1's falls with the NF. The RP said the NF would sometimes call regarding a fall, and other times would wait until CR #1's family member visited the facility, to tell them CR #1 had a fall. The RP said that on 11/21/2024 the facility called the RP to say that CR #1 fell but that she was okay and that she only had a small hematoma on her cheek. CR #1 speech was slurred on the phone. When the RP went to see CR #1, see saw the entire left side of CR #1's face was swollen and that her nose appeared broken and bent to the side and there was a lot of swelling and discoloration. The RP said that CR #1 had successfully completed emergency brain surgery to stop the bleed, but that CR #1 did not wake up afterward. The hospital informed the RP that another CT scan showed there was still internal bleeding in the brain but that a second surgery would have been too risky, and the chance of survival was low. CR #1 was currently on hospice at that time. Interview on 11/26/2024 at 12:57 PM, the Regional Nurse she said that after a resident fell , the unit manager should conduct a fall risk assessment and that would trigger an incident report. The Regional Nurse said based on that information a skin, pain, or change in condition assessment would be triggered. Those forms could be completed by either the unit manager or charge nurse. The Regional Nurse said from what she was told, a lot of CR #1's falls would be a staff member finding her on the floor, but she was comfortable and unbothered. The Regional Nurse said she was aware of the fall on 11/21/2024 and that the Administrator told her the family called the facility to inform that CR #1 was transferred to another hospital. The Regional Nurse said she was aware that an intervention the NF came up with was placing CR #1 in a common area, but CR #1 would wheel herself around the unit. The Regional Nurse said CR #1 had the right to go into her room or the dining room. The Regional Nurse said the NF notified the family of all CR #1's falls and updated them on lab work, etc. The Regional Nurse said there were no specific meetings regarding the falls. Record review of the NF's policy on Fall Management revised 07/2024 reflected in part: .The facility will provide a safe environment for all residents by implementing a fall management program. This program includes fall risk assessment, individualized care plans, staff education, and post fall evaluations .The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medications review, and receive orders as indicated .If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the physician/Physician Extender . The Administrator and Regional Nurse was notified on 11/25/2024 at 3:58 PM an Immediate Jeopardy situation (IJ) was identified due to the above failure. The Administrator was provided the IJ template on 11/25/2024 at 3:58 PM and a Plan or Removal (POR) was requested. The facility POR was accepted on 11/26/2024 4:45PM. PLAN OF REMOVAL F689 Name of facility: 11/25/2024 Immediate Action According to the IJ template: The facility failed to provide CR#1, who is on an anticoagulant medication, adequate supervision and interventions to prevent falls after multiple falls which lead to an unwitnessed fall on 11/21/24 resulting in a hematoma to the right cheek requiring hospitalization due brain bleed and placed on ventilator. CR #1 was transferred to the hospital on 11/21/24. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/25/24 to review the IJ template and Plan of Removal. CR #1 had a fall on 11/13/24. On 11/13/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: Neuro vital signs in place- lab work ordered to rule out infection. Neuros were initiated and completed with no adverse findings. CR #1 had a fall on 11/14/24. On 11/14/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: Staff will redirect/offer her to attend activities of choice in the common area. CR #1 had a fall on 11/17/24. On 11/17/24 the resident's careplan was reviewed and fall interventions updated by MDS Coordinator to include: staff will offer to get her up early in the morning is she chooses and she can sit in common area and watch tv/or visit with staff On 11/21/24 the MDS coordinator reviewed residents who had a fall for the last 60 days to ensure adequate interventions are in place, with no adverse findings. The Regional Nurse did 1:1 in-service with MDS on 11/21/24. Topics included: Fall management: to include developing an individualized fall prevention plan for each resident identified at risk and updating the care plan with each fall event to ensure new interventions are implemented according to the resident's risk. Residents who experience a fall event are reviewed during the daily clinical morning meeting, which includes members of the Interdisciplinary Team (IDT). During this meeting, the IDT evaluates the fall event, reviewing documentation in the medical record (progress notes) and the incident report. The MDS Coordinator/Designee updates the resident's care plan to reflect the agreed-upon fall prevention interventions that are individualized and aimed at preventing further falls. The facility will identify residents who are on anticoagulants by Physician Orders, Anticoagulant Care Plans, and side effect monitoring on the EMAR. Residents are assessed for risk for falls by the charge nurse on admission, quarterly, with significant change and fall events. Residents noted at risk for falls careplans are updated to identify the fall risk and appropriate interventions. The ADON conducted an audit on 11/26/24 with no adverse findings. The Director of Nursing initiated an in-service on 11/21/24 with licensed nurses. Topics included: Fall management, change of condition, Kardex; Education was completed on 11/23/24. Licensed nurses will receive education before their next shift, with new hires receiving training during orientation. The Director of Nursing provided education with staff members that provide direct care to residents on 11/21/24. Education included: Reviewing the Kardex for resident-specific fall prevention measures. Staff will receive education before their next shift, with new hires receiving training during orientation. Completion date 11/23/24. The Regional Nurse Consultant provided 1:1 education with the DON on 11/21/24. Education included Fall management to include Developing an individualized fall prevention plan for each resident identified at risk and updating the care plan with each fall event to ensure that any new risks or necessary interventions are addressed. On 11/25/24, the Regional Nurse discussed with CR#1's Nurse Practitioner (NP) the interventions implemented by the facility in response to the falls on 11/13, 11/14, and 11/17. It was determined that the interventions were appropriate for the resident's plan of care and aligned with clinical guidelines. There was no indication or order for 1:1 observation at the time. However, while the interventions were appropriate, the resident remains at high risk for falls. The Administrator and DON reviewed the policy on Fall Management on 11/21/24 with no changes required. Fall trends are brought to QAPI and reviewed monthly with the Medical Director. The Administrator reviewed the facility assessment, staffing on the memory care unit (supervision), and residents who are at risk for falls on 11/21/24 with no adverse findings identified. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 11/26/2024 at 10:07 am via phone, RN A said she received in-services from the DON on 11/22/2024 around 4:00 pm by phone after checking her phone log. RN A said the in-services were on falls regarding residents with physical or head injuries to be sent out by calling 911, notifying the doctor/ NP, RP and DON by phone calls and not through text messaging. RN A also said that she received an in-service on residents taking blood thinners. Interview on 11/26/24 at 10:50 PM via phone, LVN K 6PM-6AM said she had been in-serviced on falls with head injury, anticoagulants, fall prevention (making rounds on the resident anticipating their needs, making sure call light in reach and responding to the resident light in a timely manner, keeping bed locked and in low position, reviewing the resident Kardex on how to care for the resident looking at interventions for resident, make sure resident wearing non-slip socks or shoes) when to call 911 to transport resident to a higher level of care, notifying the doctor, family, DON when there was a change in a resident condition, and documentation. Interview on 11/26/24 at 11:15 PM, CNA B said she worked the 10PM-6AM shift. CNA B said she had received the following in-services: if a resident experienced a fall prevention and falls to report to the nurse immediately so that the nurse could assess the resident, reviewing resident Kardex that was found in POC on how to care for each resident, abuse and neglect, and resident rights. Interview on 11/26/24 at 11:27 PM, CNA O said she worked the 10PM-6AM shift. CNA O said she received in-service on falls and the prevention of falls, how to access the Kardex in POC to review resident plan of care that included if the resident was a fall risk. CNA O said when a resident experienced a fall, she was in-serviced to send for the nurse immediately, notifying the nurse if notice a change in a resident condition. Interview on 11/26/24 at 11:37 PM, CNA BB on the 10PM-6AM shift said she was in-serviced on resident rights, fall preventions (making sure bed was in the low, locked position, fall mats on the floor, checking the resident frequently every 2 hours or sooner, call light in reach, room free of clutter with call light in reach, answering the call lights in a timely manner, and making sure residents had a on non-slip socks or shoes), reviewing resident Kardex that instructed her on how to care for the resident, notifying the nurse if the resident had a change in condition. Interview on 11/26/24 at 11:39 PM, CNA C 10PM-6AM said she had received in-service on looking at the Kardex to see how to better care for the resident, fall preventions, and abuse/neglect. Interview on 11/26/24 at 11:43 PM, CNA P 10PM-6AM said she received in-service on fall preventions, how to access the Kardex in POC to show how her to care for the resident, and to notify the nurse of any changes in the resident condition. Interview on 11/26/24 at 12:00 AM, CNA Q said she worked the 2PM-10PM and 10PM-6AM shifts. said she had been in-serviced on how to access the resident Kardex in POC to review the resident care, fall preventions, resident rights, and abuse and neglect. Interview on 11/26/24 at 7:35 AM, LVN J said she worked the 6PM-6AM shift and had been in-serviced on fall prevention and supervision of the residents, responding to resident call lights in a timely manner, leaving the resident bed locked and in low position, fall mats in position on the floor for residents on fall risk, keeping the call light in reach along with their personal belongings, keeping the resident room free of clutter and providing adequate lighting, rounding on the residents at least every 2 hours or sooner pending on what was going on with resident, utilizing the Kardex because it provided guidance on how to care for the resident, documenting changes in a resident condition, along with notifying the doctor, family, and DON, falls witnessed and unwitnessed, assessments, blood thinners, and when to send a resident out via 911 services. Interview on 11/27/24 at 7:45AM, LVN R said she worked the 6PM-6AM shift and was in-serviced on fall preventions, falls witnessed and unwitnessed with head injury, blood thinners, sending the resident out 911, calling the doctor, family, and Administration, know what residents that were on blood thinners, utilizing the Kardex to care for the resident, and documentation. Interview on 11/27/24 at 8:00 AM, RN L said she worked the 6PM-6AM shift and was in-serviced on the following: when to send a resident to the hospital via 911 services, falls witnessed and unwitnessed with injuries, blood thinners, the use of the Kardex, abuse and neglect, and resident rights. Interview on 11/27/24 at 10:30 AM, CNA S said she worked the 6AM-2PM shift and the 2PM-10PM shift. CNA S said she had been in-serviced on where to find the Kardex in POC to review the care for a resident, fall prevention and falls witnessed and unwitnessed not moving the resident but alerting the nurse immediately, making sure residents who were fall risk, had their fall mats on the floor at the bedside, keeping call light in reach, answering the call lights, keeping the resident room organized, making sure the resident was wearing non-slip socks or shoes to prevent any falls, and constantly monitoring the residents because she worked on the Memory Care Unit. Interview on 11/27/24 at 10:35 AM, CNA T 6AM-2PM shift been in-serviced on falls, fall prevention, abuse and neglect, keeping resident room free of clutter, importance of using the Kardex to care for the resident, keeping resident bed in low position and locked, fall mats, and the use of grip socks to prevent residents from slipping and falling. Interview on 11/27/24 at 10:40 AM, LVN G 6AM-6PM in-serviced on falls and fall prevention falls with head injury, sending a resident to the hospital via 911, notifying the doctor, family member, and DON, blood thinners, Kardex, assessments, documentation, and PICC line care. Interview on 11/27/24 at 10:44 AM, CNA U 6AM-2PM on the Memory Care said she had received in-services on abuse and neglect, resident rights, usage of the Kardex regarding resident care, fall prevention, and rounding on the residents frequently. Interview on 11/27/24 at 10:48 AM, the MDS Coordinator said she had been in-serviced on fall prevention, head injuries, how to transport a resident to a higher level of care via 911 services, anticoagulants, being more resident specific to meet each resident needs when discussed in the morning meetings, and the IDT meetings. Interview on 11/27/24 at 10:50AM, the Certified Occupational Therapist Assistant said she had received in-service on fall preventions, making sure a resident on fall precautions mats were on the floor at the bedside, leaving calling light in reach, and making sure the resident wore grip socks to prevent falls. Interview on 11/27/24 at 10:54 AM, the Activity Director said she had received in-services on fall prevention and 1 on 1 supervision when needed, keeping residents engaged, and grip socks. Interview on 11/27/24 at 10:58 AM, the Unit Manager for the weekend said she had received in-services on abuse and neglect, anticoagulants, fall prevention (bed in low position, making sure fall matts on floor at the bedside, resident wearing non-slip shoes or socks, answering call lights in a timely manner, call light in reach, where to find resident Kardex in the computer. The Unit Manager said the Kardex would alert the staff if the resident was a fall risk, etc, and basically how to provide care for the resident). The Unit Manager said she had also been in-service on head injuries and to send the resident to the hospital via 911 and informing the physician, responsible party, and administration. Interview on 11/27/24 at 11:06 AM, CNA V 6AM-2PM shift said she worked at the NF PRN and had received in-services about the Kardex, fall preventions, keeping residents' bed locked and in low position, call light in reach, answering the call lights as quickly as possible, if a resident fell not to move the resident, and to notify the nurse immediately. Interview on 11/27/24 at 11:10 AM, RN H, on the 6AM-6PM shift, said she had received in-service regarding resident Kardex, fall preventions, falls with head injury, anticoagulants, and PICC Lines. Interview on 11/27/24 at 11:11 AM, CNA W 6AM-6PM shift said she received in-services on answering call lights, keeping call light within resident reach, Kardex, rounding on the residents every 2 hours and as needed, keeping the resident room clutter free, bed locked and in low position, fall mats to prevent falls. CNA W said if the resident had a fall, she would not move the resident but call for the nurse to assess the resident. Interview on 11/27/24 at [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices based on the comprehensive assessment of resident for 1 (CR#1) of 18 residents reviewed for anticoagulants. -The facility delayed sending CR #1 to a higher level of care on 11/21/2024 when CR #1 experienced an unwitnessed fall with a head injury (swelling to right cheek). CR #1 was receiving the medication Eliquis (blood thinner). -CR #1 was diagnosed with an Acute Subdural Hematoma with mass effect An Immediate Jeopardy (IJ) was identified on 11/23/2024 at 4:24PM. While the IJ was removed on 11/25/2024, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This failure has the potential to place residents at risk for hospitalization and death. Findings: Record review of CR #1's face sheet dated 11/22/24 revealed a [AGE] year-old female admitted to the NF originally on 05/11/2024 and readmitted on [DATE]. CR #1's diagnoses included the following: muscle weakness, unsteadiness on feet, vascular dementia (memory loss), end stage renal disease (kidney disease), and osteoporosis (bones become weak and brittle). Record review of CR#1's MDS assessment dated [DATE] revealed a BIMS score of 7 indicating the resident's cognition was severely impaired. Record review of CR #1's Comprehensive Care Plan dated 11/04/2024 reflected that the resident was being care planned for anticoagulants that reflected the following: -Give meds per order -Monitor for increase bruising, bleeding, etc. -Notify MD if bleeding is not stopped with pressure Record review of CR #1's Physician Orders for the month of November 2024 reflected the following orders: -Dated 05/16/24 Eliquis 5mg give one capsule by mouth q 12 hours related to atherosclerosis (build-up of fats, cholesterol, and other substances in and around the artery {a vessel that carry blood away from the heart to the entire body}) walls. -Dated 05/14/24 Acetaminophen Tablet 325mg give 2 tablets by mouth every 6 hours for general discomfort. Record review of CR #1's MAR for the month of November 2024 reflected that RN A medication administered on 11/21/24 to CR #1 included: -Tylenol (325 mg 2 tablets administered by mouth) with a pain level documented as 0. Further review of CR #1's MAR dated November 2024 reflected that Medication Aide RR administered the medication Eliquis 5mg po prior to resident being transported to the hospital on 11/21/24. Further review revealed that CR #1 was receiving the medication Eliquis twice a day as ordered by the physician. Record review of CR #1's Nursing Progress Notes dated 11/21/24 at 5:50 AM revealed CR #1 was found in her room sitting on the floor by RN A. RN A assessed resident and documented that resident had swelling to her right cheek. Further record review revealed that CR #1 was transferred to the hospital on 11/21/24 at 7:40 AM. Record review of CR #1's Progress Notes documented by RN A dated 11/21/24 reflected the following: .CR #1 was assessed, V/S were evaluated to be stable and WNL. Swelling / hematoma was noted to the Right cheek. No distress is noted at this time. CR #1 denies any pain or discomfort at this time. Fall precaution is in place. Neuro assessment is initiated and ongoing. CR #1 educated to call for assistance whenever she needed help, CR #1 verbalized understanding. Bed is put in the lowest position with call bell and personal belonging within her reach. MD was notified. DON and RP were also notified. This nurse called report to hospital. CR #1 is awaiting transfer to the hospital . Record review of CR#1's SBAR dated 11/21/2024 documented by RN A reflected the following: -Form Summary: SBAR (Change of Condition) - Fall Event Date/Time of Fall: 11/21/2024 5:50 AM Location of the Fall: Resident's room Classification of the Fall: Unwitnessed What was the resident doing prior to the fall: Resident states I was trying to turn and I rolled over. Initial Vital Signs Post Fall Event: Blood Pressure-124/71 Pulse-78 Temperature-97.6 Respirations-17 02 Saturation-99% Medication Reviewed with the Physician: Yes Notifications Physician/Physician Extender: PCP; 11/21/2024 5:54 AM Resident/Responsible Party: 11/21/2024 5:55 AM Observation on 11/23/2024 at 11:30AM revealed CR# 1in the ICU unresponive, resting in the hospital bed connected to a ventilator, and a neck collar. The top and left side of CR #1's head was bald with dressing on top of her head. There was a small plastic bulb that appeared to be connected to CR #1's head with red fluids draining inside of bulb. CR #1 was receiving the medication Cardene (used to treat high blood pressure and control chest pain) IV 40 mg in 200 ml of fluid at 75 ml/hr. Resident was receiving gastrostomy feedings Nova Source that read on pump 20 ml/hr. Record review of CR #1's hospital records revealed that CR #1 admitting diagnoses was Acute Subdural Hematoma (a pool of blood between the brainand its outermost coverin) with mass and a left craniotomy ( surgical procedure that involves removing a section of the skull to access the brain) evacuation. In an interview on 11/22/24 at 10:12 AM with the NF Administrator, and the DON present, the Administrator said CR #1 was residing on the Memory Care Unit and on 11/21/24 around 5:30 AM, the staff (RN A and CN B) had gotten CR #1 up for dialysis. The Administrator said from her understanding, the staff placed CR #1 near the nurse station in her wheelchair. The Administrator said the staff began to round on other residents in the MCU at 5:40 AM. The Administrator said CNA B said shortly after, she saw CR #1 laying on her bed. The Administrator said, at 5:50 AM, the Charge Nurse heard a noise coming from CR #1's room and went to see what was going on. The Administrator said when RN A arrived to CR #1's room, she found CR #1 sitting on the floor in between the 2 beds. The Administrator said CR #1 could walk. The DON interjected and said that CR #1 could walk, but had an unsteady gait. The surveyor requested copies from the Administrator of everything that the NF had done (investigation/in-services, etc.) regarding CR #1's fall on 11/21/2024. The Administrator said she had not completed her investigation, but would email so far what the facility had completed. Interview on 11/22/24 at 1:58 PM with a family member of CR #1 said CR #1 was still at the hospital in a coma and her condition was not looking good because CR #1 had a lot of bleeding on the brain. The family member said the NF called her on 11/21/24 around 6:40 AM telling her that CR #1 had a fall, and they were preparing to send CR #1 to the hospital for further evaluation. The family member said she spoke with CR #1 prior to leaving the NF and CR #1's speech was slurred. The family member said the nurse, who name she did not recall, told her it was probably CR #1's medications causing the slurring of speech. The family member said when the nurse called her to report that CR #1 had a fall, the nurse told her that she had called transportation instead of 911. Interview on 11/22/24 at 2:34 PM, RN A said she worked the 6:00 PM- 6:00 AM shift, and worked on 11/20/24. RN A said herself and CNA B had gotten CR #1 out of bed at 5:30 AM to dress CR #1 and placed in her wheelchair for dialysis. RN A said CR #1 was taken to the common area across from the nurse station. RN A said the CNA that was assigned to CR #1 was CNA C, but CNA B assisted with getting CR #1 out of bed for dialysis. RN A said CNA B was in the common area as well but later began to make rounds with CNA C getting the other residents out of bed and taking some to the common area as well, but still checking on CR #1. RN A said she began to pass medications on the other residents while keeping an eye on CR #1. RN A said she could see CR #1 because of the way her cart was positioned on the hallway. RN A said when she came out of a resident room, she did not see CR #1. RN A said she rushed to CR #1's room where she found CR #1 sitting on the floor. RN A said she never heard a noise coming from CR #1's room. RN A said she called CNA C to come and assist her with CR #1. RN A said after she finished assessing CR #1, herself and CNA C placed CR #1 back in bed. RN A said CR #1 had some swelling to the right side of face but was not complaining of pain. RN A said CR #1 vital signs were stable and she initiated neurological checks on CR #1 which were within normal limits. RN A said she called the doctor, resident family member as well as the Administrator. RN A said CR #1's family member wanted to speak to CR #1. Therefore, she took the phone to CR #1's room so she could speak to the family member. RN A said when she initially called the doctor, he did not answer. RN A said CR #1's PCP came to the facility later. RN A said because CR #1 appeared stable, she used her own judgment to send CR #1 to the hospital via regular EMS and not 911. RN A said she was aware that CR #1 was receiving the medication Eliquis and reiterated that she used her own judgement. RN A said the facility policy on unwitnessed falls with head injuries receiving anticoagulants was to send to hospital via 911. RN A said if a resident experienced an unwitnessed fall with a head injury and on blood thinners, they should be sent to the hospital via 911. RN A said if this was not done, the resident could die. Interview via phone on 11/22/24 at 3:05 PM, CNA B said she worked the night shift from 10 PM - 6 AM and worked on 11/20/24 on the MCU. CNA B said she was not the CNA assigned to CR #1. CNA B said she never provided any type of care for CR #1 including assisting with placing CR #1 in the wheelchair on 11/21/2024 at 5:30AM. Interview on 11/22/24 at 3:13 PM, the Administrator said RN A initially called regular transportation to transport CR #1 to the hospital. The Administrator said she asked RN A why she called regular transportation instead of 911. The Administrator said RN A said because CR #1 appeared to be stable. The Administrator said according to CR #1's Nursing Progress Notes, RN A sent CR #1 to the hospital via regular EMS at 7:40AM. Interview on 11/22/24 at 3:26 PM, the DON, with the Administrator present, said the NF did not have a policy on unwitnessed falls with head injury receiving anticoagulants. The DON said prior to reviewing CR #1's chart on 11/21/24, she was not aware that CR #1 was on the medication Eliquis. The DON said she was not aware what time CR #1 left the NF to go to the hospital until she reviewed the Nursing Progress Notes. The DON said if the nurse felt that it was okay to send CR #1 to the hospital via regular EMS, she would have to trust RN A's judgement because she was not present at the time of the incident. The DON said if she was present when CR #1 experienced the unwitnessed fall with head injury, she could not say what she would have done. The DON said she in-serviced the staff on falls on 11/21/24. Interview on 11/22/24 at 3:40 PM with the Administrator and the DON being present, the Administrator said she informed the Medical Director about CR #1's fall on 11/21/24. The Administrator said the Medical Director told her she would have to review CR #1's medical records to see if there were concerns about resident's fall with a head injury. The Administrator said she spoke with the Medical Director on 11/22/24 asking the MD about how the resident was transferred to the hospital via regular EMS instead of 911 after an unwitnessed fall with head injury and receiving the medication Eliquis. The Administrator said the MD told her after reviewing CR #1's medical records that the situation regarding CR #1's unwitnessed fall with head injury was tricky. The Administrator did not elaborate further what the MD meant by tricky. The Administrator said after herself and the DON discussed CR #1's incident further, they decided moving forward that any resident that experienced a fall with a head injury witnessed or unwitnessed needed to be transported to the hospital via 911 transport even if the resident was not on blood thinners. The Administrator said this should be done because of the gray areas and one could not see what may be happening to the resident internally. The Administrator said the NF could not perform CT scans (type of x-ray). Therefore, the resident should be sent to the hospital for further evaluation. Interview on 11/22/24 at 4:13 PM the Administrator provided a copy of more in-service, she said, had been conducted by the DON that entailed falls, anticoagulant, and visible head injury. The Aministrator said this in-service was in a book with other in-services the DON had done. Attempted an interview via phone on 11/22/24 at 3:52 PM with the Medical Director. There was no answer, and the mailbox was full. Interview on 11/22/24 at 4:45 PM via phone with the NP revealed the NF notified her of CR #1's fall on 11/21/24 and resident went to the hospital. The NP said the PCP made rounds at the facility on 11/21/24. The surveyor asked the NP if a resident experienced an unwitnessed fall with head injury receiving an anticoagulant medication, should the resident be sent out via regular EMS or 911. The NP said she could not really answer the question and that the surveyor would need to speak with CR #1's PCP. Attempted an interview via phone on 11/22/24 at 4:55 PM with CR #1's PCP. There was no answer; left voicemail. Interview on 11/23/24 at 11:35 AM, the hospital nurse said CR #1 would be taken off the ventilator on 11/23/24, and the family wanted comfort measures (treatments that focus on relieving the pain and distress for a dying person) after taking CR #1 off the ventilator. Interview on 11/24/24/ at 7:26 PM via phone, CNA C said she worked the 10 PM-6 AM shift. CNA C said on 11/20/24, she was CR #1's CNA on the Memory Care Unit. CNA C said the nurse helped her in getting the resident ready for dialysis. CNA C said after her and the nurse got CR #1 ready for dialysis at 5:30 AM, CR #1 was taken to the common area in her wheelchair across from the nurse station. CNA C said she went to check on the other residents. CNA C said the nurse was on another hallway passing medications. CNA C said CNA B was making rounds on the residents. CNA C said the last time she saw CR #1, prior to the fall, was at 5:40 AM in her room laying on her bed. CNA C said shortly after, she heard RN A calling her to come to CR #1's room. CNA C said when she arrived to CR #1's room, she saw CR #1 sitting on the floor. CNA C said RN A assessed CR #1, and afterwards, she assisted RN A in placing CR #1 back in bed. CNA C said CR #1 denied any pain. CNA C said RN A was preparing to send CR #1 to the hospital. CNA C said after assisting RN A, she went to check on the other residents. CNA C said she left the facility at 6 AM. Interview on 11/25/24 at 12:38 PM, the Administrator said the reason she provided the surveyor more in-services via email on 11/22/24 at 4:13 PM, regarding falls and anticoagulants, was due to the surveyor asking about polices. The Administrator said it prompted her to tell the DON to get the rest of the training the NF had done with the staff. Interview on 11/25/24 via phone at 12:50PM with CR #1's PCP said if CR #1's speech was slurred, CR #1 should have been sent to the hospital via 911. The PCP said a good rule of thumb, was if a resident with dementia experienced an unwitnessed fall with head injury, the resident should be sent to the hospital via 911 because the resident might be experiencing bleeding on the brain. The doctor said that he never received a call from the NF because it was not in his call log. Interview on 11/25/24 at 3:25PM via phone, at 3:25PM RN A said on the morning of CR #1's fall, 11/21/24, she administered CR #1 Tylenol because the family asked her to. A follow up interview via phone on 11/26/24 at 9:31am with CR #1's family member revealed CR #1 was on hospice. The family member said, on 11/21/24, the NF called to tell her that CR #1 fell , but she was okay. The family member said she wanted to talk to CR #1, but when CR #1 was talking back, she was slurring her words. The family member said the only thing the NF told her was that CR #1 had a small hematoma in her cheek. The family member said when she went to see CR #1 , CR #1's left side of the face and nose looked broken and bent to the side. CR #1's face had a lot of swelling and discoloration. The family member said the hospital had to do an emergency surgery on her brain to stop the bleeding. The family member said CR #1 wasn't waking up and she got another CT scan and it showed there was still internal bleeding in the brain and that the second surgery would have been too risky, and the chances of survival were low. Interview on 11/27/24 at 2:15 PM, Medication Aide RR said she worked on the MCU on 11/21/24. The medication aide said when she arrived at the facility on the MCU, the time was between 6:30 AM. Medication Aide RR said CR #1 was sitting up in a wheelchair at the nurse station. Medication Aide RR said CR #1 did not appear to be in any pain. Medication Aide RR said she was told that CR #1 had fallen. Medication Aide RR said CR #1 had some swelling to her face. Medication Aide RR said she asked RN D if it was okay to administer CR #1 her medications before CR #1 went to the hospital, and RN D said that it was okay. RN D said that she administered CR #1's morning medications including the medication Eliquis. Interview on 11/27/24 at 4:02 PM via phone, the Medical Director said she was aware of CR #1's fall on 11/21/24. The Medical Director said if a resident was clinically stable, without doctor's orders, the nurse could not hold a medication. The Medical Director said giving it or not giving Eliquis, it wouldn't have changed any outcome in CR #1's case. The Medical Director said it would not have mattered even with CR #1's face being swollen. The Medical Director said CR #1's vitals were stable before and after the fall. The Medical Director said Medication Aide RR did their job. The Medical Director said she did not have any concerns about the facility administering the medicine Eliquis after the resident had an unwitnessed fall with head injury. Record review of the NF's policy on Change in Condition Communication revised January 2024 reflected in part: . To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition .If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified. The Medical Director will provide medical orders as necessary to treat the patient's/resident's condition . Record review of the NF's policy on Fall Management revised 07/2024 reflected in part: .The facility will provide a safe environment for all residents by implementing a fall management program. This program includes fall risk assessment, individualized care plans, staff education, and post fall evaluations .The charge nurse will notify the Physician/Physician extender of the fall, provide assessment findings and medications review, and receive orders as indicated .If the resident's condition warrants, the charge nurse will arrange for appropriate emergency services or hospital transfer in collaboration with the physician/Physician Extender . The Administrator and DON were notified on 11/23/2024 at 4:24 PM that an Immediate Jeopardy situation (IJ) was identified due to the above failures. The Administrator was provided the IJ template on 11/23/2024 at 4:30 PM and a Plan or Removal (POR) was requested. The facility's POR was accepted on 11/24/2024 at 12:40 PM and indicated: PLAN OF REMOVAL F684 Name of facility: [facility]: 11/24/2024 Immediate Action POR F684 CR #1 was transferred to hospital on 11/21/24. The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting on 11/23/24 to review the IJ template and Plan of Removal. RN A was suspended pending investigation on 11/21/24. On 11/22/24 and 11/23/24 the Director of Nursing and Assistant Director of Nursing assessed residents who had unwitnessed fall in the last 10 days for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings. The Director of Nursing initiated an in-service on 11/21/24 with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents who has a fall with a visible head injury. 911 should be activated upon identification and notification to Physician and the DON would be secondary. Licensed nurses will be educated before starting their next shift. Education will be included in orientation. Education will be completed on 11/23/24. The Director of Nursing provided 1:1 education with RN A on 11/22/24. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury. 911 should be activated upon identification of the abnormal findings and notification to Physician and DON would be secondary; and completing through assessments post-fall with consideration for residents on anticoagulants. The Regional Nurse Consultant provided 1:1 education with the DON on 11/22/24. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury ' 911 should be activated upon identification and notification to Physician and DON secondary; and completing through assessments post-fall with considerations for resident on anticoagulants. Fall documentation will be reviewed each weekday in morning meeting on weekends, holidays, and after hours by DON/designee to ensure completed and appropriate actions are taken and documented. The Administrator and DON reviewed the policy on Fall Management and Changes of Condition no changes noted. The surveyor confirmed the plan of removal had been implemented sufficiently to remove the IJ by the following: Interview on 11/24/24 at 12:50 PM, RN D, on the Memory Care Unit (6AM-6PM), said she had been in-serviced on abuse and neglect as well as falls. RN D said if a resident experienced a fall with head injury witnessed or unwitnessed to prepare to send the resident to the hospital 911, notify the Physician, DON, and the resident's RP. RN D said she was in-serviced to assess the resident for pain, skin assessment, check their vital signs, and began neurological checks per facility protocol. RN D said if the resident was in pain to medicate the resident. RN D said even if the resident was not complaining of pain to give something for pain due to residents in the MCU decrease in cognition, the resident may not be able to express that they were in pain. RN D said she was also in-serviced to document all actions taken in the facility's electronic medical records system. Interview on 11/24/24 at 1:03 PM, RN E said she was the weekend supervisor and worked from 6AM-6PM. RN E said she had been in-serviced on falls witnessed and un-witnessed with head injury and anticoagulants. RN E said a resident that had fallen and developed a head injury, she would have to send to the hospital right away via 911 services. RN E said an assessment had to be done on the resident that included neurological assessment, vital signs, checking for bleeding. RN E said she would also notify the physician, family, DON and document all necessary actions taken in PCC. Interview on 11/24/24 at 1:10 PM, RN F said she was a new grad in orientation. RN F said she had received in-services on fall precautions witnessed or unwitnessed with head injuries receiving blood thinners. RN F said the resident should be sent to the hospital via 911. RN F said, at the time of the fall, neurological checks should be done on the resident and the resident should assessed for pain. RN F said the vital signs were taken and the doctor should be notified as well as the RP and the DON. RN F said documentation had to be done as well. Interview on 11/24/24 at 1:30 PM, LVN G said she worked from 6AM-6PM shift PRN. LVN G said she had been in-serviced on the following: abuse and neglect, resident falls, being sure to round on the residents regularly to see if they needed anything, making sure that personal belongings were in reach to prevent falls, answering their call lights in a timely manner. LVN G said she had been in-serviced on falls with injuries, particularly falls, with head injuries along with resident receiving blood thinners. LVN G said a resident with a head injury had to be sent to the hospital right away via 911 services. LVN G said when a resident had a fall, the resident had to be assessed by the nurse along with initiating neurological checks, vital signs, notifying the physician, DON, and responsible party. LVN G said she was in-serviced to also document all actions taken. Interview on 11/24/2/4 at 1:40 PM, RN H said she worked the 6AM-6PM shift. RN H said she had been in-serviced on falls witnessed and unwitnessed with head injuries to send to the hospital 911 services. RN H said she had been in-serviced on residents receiving blood thinners, notifying the physician of falls with injuries and the resident receiving blood thinners, how to assess a resident that had a fall being sure to initiate neurological checks per facility protocol, assessing the resident for pain, taking the residents vital signs, documentation and to notify the family and the DON of the incident. Interview on 11/24/24 at 7:11 PM, LVN I said she worked at the NF PRN on the 6PM-6AM. LVN I said she received in-services on falls, witnessed and unwitnessed with head injuries, to send the resident to the hospital via 911 because the resident's life depended on it. LVN I said the physician needed to be notified right away along with the RP and the DON. LVN I said she was in-serviced on blood thinners and documentation. Interview on 11/24/24 7:40 PM via phone at LVN J said she worked 6PM-6AM shift. LVN J said she was in-serviced on falls with head injuries, blood thinners, notifying the doctor of any changes in a resident condition as well as the DON and RP, documentation, and sending resident out to the hospital 911 if they had fallen and hit their head. Interview on 11/25/24 at 11:58 AM with LVN M 6AM-6PM said she use to work at the facility full time but worked on a PRN basis at that time. LVN M said she had received in-services on the following: witnesses and unwitnessed falls with head injuries to send the resident to hospital 911, call the doctor, family, and the DON. LVN M said she was in-serviced on documentation, assessments, and blood thinners. Interview on 11/25/24 at 12:05 PM, the DON said if a resident experienced a fall with a head injury and speech was slurred, there could be something going on neurologically such as a stroke or bleeding on the brain. The DON said it could only be determined by a test. The DON said she had been in-serviced on falls witnessed and unwitnessed with head injury to notify the physician, sending resident to hospital via 9ll. Interview on 11/25/24 at 12:19 PM, LVN N said she worked full time 6AM-6PM and had been in-serviced on falls witnessed and unwitnessed. LVN N said a fall with a head injury, 911 services and the doctor should be called right away. LVN N said if they were unable to reach the doctor or NP, they were supposed to call the Medical Director, DON, and document. LVN N said if a resident was on blood thinners need to monitor the resident for bleeding. Interview on 11/25/24 at 3:25 PM via phone, RN A said she had been in-serviced on falls witnessed and unwitnessed with head injuries, blood thinners, sending the resident out via 911, notifying the physician, DON, and family. On 11/25/2024 at 4:56 p.m., the Administrator was informed that the IJ was removed, however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. Medication Eliquis Reference www.fda.gov/dragsatfda reference ID: 3237516: .Call your doctor or get medical help right away if expereince unexpected pain .swelling .

Based on observations, interviews and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. -The facility failed to post the daily nursing staffing information 11/14/24 - 11/19/24. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Included: Observation on 11/19/24 at 9:09 a.m., during entrance revealed the nursing staffing information was posted at the receptionist desk dated 11/13/24. Interview on 11/19/24 at 9:24 a.m., with the Staffing Coordinator, she said she was responsible for posting the daily nursing staff information at the front desk. She said she forgot to update it for the past few days. She said the information was posted to let the public and others know the staffing on each shift and the census. Interview on 11/19/24 at 5:34 p.m., the Administrator said the staffing coordinator was responsible for posting the daily staffing information. The Administrator said the daily nursing staffing was supposed to be posted at the front of the facility each day. Interview on 9/10/2024 at 1:15 p.m., the Administrator said the facility did not have a staffing posting policy.

Based on observation, interview and record review, the facility failed to ensure the residents' rights to privacy for 7 (#1, #2, #3, #4, #5, #6, #7) of 10 residents reviewed for personal privacy. The facility failed to ensure CMA A locked the computer screen, displaying the names of 7 residents, while CMA A was in a resident's room administering medication. This failure could allow residents' protected HIPAA information to be shared with individuals who did not have a need or right to know. The findings included: An observation 11/19/24 at 10:10 a.m. revealed an open laptop on the nurse's cart on Unit C. The screen displayed the full name and room number of 7 residents on the C unit. CMA A was in a resident's room providing administering medication. The cart was outside the door of the room CMA A was in. A housekeeping staff was next to the cart and in direct sight access of the laptop and screen. During an interview 11/19/24 at 10:12 a.m., CMA A stated she was supposed to lock the screen when away from the computer. She stated it was a HIPAA violation to leave the screen open, unattended, with resident information displayed. She said she had been trained to lock the laptop screen, but she forgot before she administered medication to a resident. She said resident information could be viewed by others who did not have authorization. During an interview with the RN A 11/19/24 at 1:12 p.m., said CMA A should lock the computer when not using it, because resident information could be seen, and it was a HIPAA violation. She said this was a privacy issue for residents. She said during orientation all staff are trained on resident rights and how to keep medical information confidential. Record review of the facility policy, revised April 2024, titled Resident Rights revealed the following in part: .The facility staff will safeguard the privacy of the resident's protected health information from improper use and disclosure . Record review of the facility policy, revised 6/1/2019, titled Minimum Necessary Standard - HIPAA Manual revealed the following in part: .The facility staff should be mindful not to divulge clinical information such as diagnoses or other personal information in .halls .facility staff will keep medical records secure and confidential .

48923 Based on observation, interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 (Resident #37) residents reviewed for intravenous fluids. - The facility failed to ensure Resident #37 had physician orders and care plan in place for monitoring and dressing change of Resident #37's PICC line (Peripherally Inserted Central Catheter, a tube inserted through a vein in the arm which passes to the larger veins near the heart and used to deliver medications, liquid nutrition or other treatments) from when Resident #37 was readmitted from the hospital with a PICC line on 9/09/2024 to 10/2/2024 when the NP put in an order for the PICC line to be discontinued. -The facility failed to ensure Resident #37 's PICC line was removed after completion of IV antibiotics which ended on 09/19/24. -The facility failed to ensure Resident #37 's dry dressing was changed every 5 to 7 days per facility policies and procedures, including orders for monitoring the site. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system. This deficient practice could place residents at risk of serious harm, injury or death by leaving the PICC line in longer than necessary and exposing residents to infections in the blood stream and serious illness. Findings included: Record review of Resident #37's face sheet dated 10/03/2024 revealed he was a [AGE] year-old male that was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of acute cystitis with hematuria (a bladder infection that may cause blood in the urine), anemia(low red blood cell count), hypotension (abnormally low blood pressure), colostomy (a surgical opening for the colon in the abdomen which provides an alternative channel for feces to leave the body), intestinal obstruction, and schizophrenia (a serious mental health condition which may include hallucinations, delusions and disorganized thinking and behavior) . Record review of Resident #37's hospital discharge records dated 9/9/24 revealed Resident #37's midline placement (a catheter placed in a vein used to deliver medications and other treatments quickly to the body) date was 09/05/24. Further review revealed Resident #37 was ordered meropenem (MERREM) 500 mg intravenously every 8 hours for 9 days with a start date of 9/10/2024 and a stop date of 9/19/2024. He had a transfer diagnosis of hematuria (blood in urine). Record review of Resident #37's September MAR revealed he received the medication every shift as ordered starting 09/10/2024 at 11:00pm to 09/19/2024 at 3:00pm. Record review of Resident #37's physician's orders last updated 10/03/2024 and care plan last revised 09/11/2024 revealed no documented orders or instructions for maintenance of midline and dry bandage. Record review of Resident #37's physician's progress notes dated 9/11/24 revealed, Patient is being seen today to follow up on hospitalization . Patient is on IV abx (antibiotics) for 9 days for sepsis . Observation on 10/1/24 at 5:10 p.m., revealed Resident #37 lying in bed and , had a PICC line in his left arm, double lumen (a catheter which splits into two tubes, with each tube being used to take or give blood products and the other used for medication or IV fluids) with two tape dressings cover it one on the other. The first dressing was dated 9/5/24 which was when Resident #37 was in the hospital and the second dressing on top was used to secure the first dressing and was not dated. Both dressings and tape were brownish in color. Resident #37 was not interview-able and had a representative at bedside. Interview with the DON on 10/2/2024 at 2:54pm, nurses should ensure residents with PICC line have physician orders for it. PICC line dressings should be changed every 5 to 7 days and that nurses should observe the PICC line site every shift to ensure no redness, drainiage, not be hot to the touch. Interview with the MDS Coordinator A on 10/3/24 at12:28p.m., she was not aware of Resident #37's PICC line. She always assessed a resident with PICC on admission, documenting how the PICC line site is and checking for infection. She said currently the facility had 2 residents with a PICC. Interview with LVN B on 10/03/2024 at 11:52am, she stated that nurses were to follow physician's orders for residents with PICC llines. LVN B stated that dressing changes should be done every 5 to 7 days and as needed and that nurses should inform the doctor when a resident's antibiotic therapy was completed. LVN B said sometimes a PICC Line was not removed immediately after antibiotic therapy completion because the resident's physician ordered more labs before discontinuing the PICC Line, but that she would continue to monitor and flush the PICC line every shift until it is discontinued. She said she never worked with Resident #37. Interview with LVN C on 10/03/2024 at 12:00pm, he stated that when a resident is admitted to the facility with a PICC Line, they should already have physician's orders for it, including dressing changes. LVN C stated that after a resident completes antibiotic therapy, the physician should be notified. Interview with LVN A on 10/03/2024 at 3:00 pm, LVN A stated when a resident was admitted the nurse was supposed to call the physician do all the paperwork such as verifying and entering medications and treatments into the MAR. Interview with NP A on 10/3/2024 at 4:32pm, she stated that when a resident is admitted from the hospital the NP will review medications that day and review the resident's clinical notes the next on-site visit. NP A stated she did not put any orders for the resident's PICC line to be discontinued nor for dressing changes it, but that it was her fault that the orders were not put in Resident #37's MAR and it was her responsibility to do that when her residents were admitted with a PICC line. She stated that nurses are to update her if there is changes in condition and to questions her orders, but that they did not do so. NP A stated that PICC lines would be discontinued after the treatment is completed and after all labs are done to confirm it can be removed. She stated the facility called her on 10/2/24 to get the PICC line discontinued. NP A said that risks for a resident not having their dressing changed per physician's orders or standard practice is that it could cause infection and sepsis. Interview on 10/3/24 at 5:04pm with the ADON and Administrator, the ADON said that the PICC line and dressing change should be administered according to physician's orders and that nurses were expected to let the doctor know when the antibiotics were completed. The ADON said that when a resident completed their antibiotics, the nurse should call the physician to see if the order should be discontinued, if labs needed to be drawn or if the antibiotics need to be continued. The Administrator said that staff should have followed physician's orders. The ADON said that having the dressing on since 9/5/24 would be an infection control concern and it could pose a risk of bacteria with a dressing on that long without being changed and cleaned. The Administrator said the risk due to leaving the bandage on for that amount of time is related to infection control . An IJ was identified on 10/04/2024. The facility was notified of the IJ on 10/04/2024 at 12:47pm with the Interim Administrator, RNC and DON present. The IJ template was provided to the facility on [DATE] 12:47pm and a POR was requested by email to the Interim Administrator, RNC and DON. The following Plan of Removal was submitted by the facility and accepted on 10/04/2024 at 5:45pm. Allegation F694: [Facility Name] - IJ Plan of Removal F694 10/4/2024 The facility failed to ensure a peripherally inserted central catheter (PICC) (a thin, flexible tube that is inserted into a vein in the upper arm and ends in a large vein near the heart) used to administer parenteral fluids and antibiotics had an order how to cleaned and discontinued consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. On October 2, 2024, Resident #37's PICC line was assessed by the Director of Nursing (DON), with no adverse effects or signs or symptoms of infection noted. A physician's order was obtained for the removal of the PICC line, and PICC line was discontinued without adverse effects. The Physician ordered lab work on 10/3/24 and results were noted with no adverse findings. On October 2, 2024, all other residents with central lines were assessed by the Director of Nursing to ensure an up-to-date dressing, active order sets to include monitoring, flushes, dressing changes, orders to obtain central lines after IV therapy is completed, and central line specific care plans. No adverse findings were noted. The Administrator and DON informed the Medical Director of the Immediate Jeopardy situation on October 4, 2024, through an AD Hoc QAPI meeting. The Regional Nurse Consultant provided 1:1 education with the DON on 10/2/24 on providing oversight with residents with central lines and ensuring compliance with central line policies and procedures to include active orders for monitoring central line site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. The Director of Nursing initiated in-services with licensed nurses on 10/2/24 on and ensuring compliance with central line policies and procedures to include active orders for monitoring central line site, flushing the central line, central line dressing changes, and obtaining orders to remove central lines after IV therapy is completed. Education will be completed on 10/4/24. Licensed Nurses will be educated prior to their next shift: including PRN employees or new hires. After the IJ was called out on 10/4/24, the Director of Nursing conducted 100% rounds on residents with central lines and compliance was noted with policies and procedures. The Administrator reviewed the Central Line Policies and Procedures on 10/4/24 and no changes were required. The charge nurse will input and complete orders for residents who obtain or admit with a central line and will be validated in clinical morning meeting by nurse leadership. The clinical morning meeting will include reviewing high risk residents to include residents with central lines and ensuring compliance with central line policies and procedures (orders and care plans). DON Inservice nurse leadership on 10/4 on the above process; The charge nurse will input and complete orders for residents who obtain or admit with a central line. Completion date 10/4. Record review of Physician Order policy last reviewed January 2024 revealed that all physician orders must be verified by the receiving nurse for accuracy and upon receipt the nurse will enter the order into the electronic health record. Nursing staff will review physician orders and follow up on any discrepancies or unclear orders with the prescribing physician. Record review of the facility's Nurses' Infusion Manual for Long Term Care Facilities last updated 05/16/2022 revealed a dressing changing must be done every 7 days or sooner if compromised adn be monitored for signs and symptoms of compllications from infection like swelling, redness or pain. Record review of the facility's Central Line policy last revised January 2024 revealed that nursing staff are not obtain physician orders to remove the central line once IV therapy is completed. [Signed by Interim Administrator, 10/4/2024] Monitoring the Plan of Removal for Effectiveness as follows: Observation on 10/05/2024 at 12:45pm of Resident #10 revealed the resident had a left peripheral IVF hep-lock single lumen (a single catheter line placed in a vein on a resident's left side of the body that contains a medication called heparin used to prevent blood clotting), the site was cleaned with no redness, dressing infiltration, odors, or warmth. The dressing on the site was dated 10/03/24. Observations and record review of other residents with a PICC line revealed: Record review of Resident #7's orders revealed nurses were to monitor the PICC line site every shift, midline dressing change every 5 days and as needed, a midline flush 10 millilters of Normal Saline every shift. Observation of the resident on 10/05/2024 revealed Resident #7 was sitting in the dining area eating lunch with their PICC line to their left upper arm intact. Resident #7 had a left upper arm IVF hep-lock double lumen, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. Record review of Resident #155's orders revealed nurses were to monitor the midline every shift, midline dressing changes every 5 days and as needed, a midline flush of 10 milliliters of Normal Saline every shift. Observation of Resident #155 on 10/05/2024 revealed the resident was sitting in the dining area eating lunch with the PICC line to their upper arm intact. Resident #115 had left upper arm IVF hep-lock double lumen line, the site was clean with no redness, dressing infiltration, odors, or warmth. Dressing on the PICC line site was dated 10/02/24. Interview with LVN I on 10/04/2024 at 4:30pm, she said she only took care of Resident #37 when he was admitted . LVN I said she was supposed to document in the TAR that Resident #37 is to have his PICC line inititaed but that she forgot. LVN I said that any nurse, including the nurse on the next shift could have obtained orders and entered them in Resident #37's chart. LVN I said she had not worked at the facility since that day when she admitted Resident #37. Interview with RN G on 10/05/2024 at 1:15pm, she said that she received in-services a few days ago for PICC line. RN G said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining the dressing, which should be changed every 5-7 days depending on the physician orders , and to notify the physician when the residents get to the facility and when antibiotics were completed so that the nurse could place an order to discontinue the PICC line. Interview with RN A on 10/05/2024 at 1:30 pm, she said that she received in-services a few days ago for PICC line. RN A said she was educated on making sure residents with a PICC line had orders from their physician for monitoring, maintaining dressing which should be changed every 5-7 days depending on the physician orders, and that she should notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with the DON on 10/05/2024 at 2:00pm, the DON said the nurses were not doing what they should have, which included the documenting residents with PICC line and to check the line every shift and flush the line, ensure the site is clean, and getting Physician Orders for removal of PICC line after antibiotics are completed. The DON said she immediately started in-services on PICC line for the nurses. Interview with RN E on 10/05/2024 at 8:30pm, she stated she worked every other weekend as a weekend supervisor. RN E said she had in-services and also conducted in-services for other nurses, which included making sure staff get physician orders for residents with PICC lines including monitoring the line site and maintenance of the line, notifying the physician when antibiotics are completed, contacting the physician with labs and when to discontinue the PICC line. RN E stated that staff are to notify the resident's physician if they do not see PICC line orders. RN E also said that all care provided to a resident for their PICC line should be documented in their MAR. Interview with LVN B on 10/05/2024 at 8:42pm, she said that she received in-services a few days ago for PICC line. LVN E said she was educated on making sure residents with a PICC line have orders from their physician for monitoring and changing the resident's dressing every 5 to 7 days depending on the physician orders, and to notify the physician when the residents get to the facility and when antibiotics are completed so that the nurse can place an order to discontinue the PICC line. Interview with LVN D on 10/05/2024 at 9:47pm, she stated that she had been at the facility for a year and works night shifts. She stated she received educations on PICC and IV lines, making sure residents have orders after having a PICC line placed, calling the physician and verifying that residents have orders for the PICC line, monitoring for signs and symptoms of infection, and dressing changes which are every 5 days. LVN D said she also received education on informing the physician when the antibiotics are completed and make sure that orders are put in for PICC line to be discontinued. LVN D said that after treatment is completed and before being discontinued, nurses should still observe for any changes in the PICC line site and to flush the line every shift and to document anything done for the PICC line in the resident's chart. Interview with RN D on 10/05/20234 at 9:54pm, she stated that she had been with the facility for more than a year and works night shifts. She stated that she received in-services on PICC line on 10/04/2024, which included making sure residents with a PICC line have orders for dressing changes every 5-7 days depending on the physician orders, flushing before and after medication and every shift, monitoring the PICC site for signs of infection and reporting any changes to the physician, and to inform the physician when the resident's antibiotics are completed and to get an order to discontinue the PICC line per physician orders. RN D stated that after a resident is admitted , nurses are to verify PICC line orders with the resident's physician, the nurse then assess the PICC line site to see where and when the line was placed, make sure there are orders for signs of infection, dressing changes, how often to flush the line, checking fluids through the lines, and documenting PICC line care in the resident's MAR. An IJ was identified on 10/04/2024. The IJ template was provided to the facility on [DATE] 12:47pm. While the IJ was removed on 10/06/2024 at 11:47am, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility need to evaluate the effectiveness of the corrected system.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement. 1. The facility failed to ensure foods were dated as opened or prepared and discarded after 72-hours (3 days) per facility policy. 2. The facility failed to store food off the floor in the storage room. 3. The facility failed to self-report to the local Department of Health for drain water backup in the kitchen, with less than a one-inch air gap. These failures could place residents at risk of food borne illness and disease. Findings Include: Observation of the facility kitchen in the walk in refrigerator on [DATE] at 8:15 AM revealed the following: 1. A plastic bag of boiled eggs not labeled. 2. A plastic bag of fresh salad not labeled. 3. A plastic bag of shredded cheese not labeled. 4. A plastic bag of sliced American cheese dated open ,d+[DATE]. 5. A plastic container of green beans dated open ,d+[DATE] 6. A plastic container of cooked pasta dated open ,d+[DATE]. 7. A plastic container of Mexican rice dated open ,d+[DATE]. 8. A plastic container of breaded fish dated open ,d+[DATE]. 9. Two cases of canned food were on the storage room floor. Observation of the facility kitchen on [DATE] at 8:15 AM revealed the following. 1. Kitchen floor was wet with water near dish machine and 3-sink compartment. 2. Ice machine and dish machine did not have proper air gap of one inch to prevent back flow drain water backup. 3. There were holes in the ceiling by the dishwashing machine and in the walls near the Dietary Food Service Manager (DFSM)'s office. Observation of the facility kitchen on [DATE] at 8:30 AM, revealed drain water backup on the floor was flowing. In an interview with the DFSM on [DATE] at 8:30 AM, she stated the leftover food stored in the refrigerator should have been used or discarded prior to use by date. She stated the cases of food should be off the floor due to cross contamination. She stated she or the designee were responsible for checking the refrigerator daily for food items that were expiring and should be discarded prior to expiration date. In an interview with the DFSM on [DATE] at 8:30 AM revealed that on [DATE], the kitchen had a drain water backup, and that the Contractor Plumber (CP) fixed the problem. DFSM stated that she did not report the drain water back up to the local health department. She stated that she needed to get maintenance to fix the holes in the ceilings and walls to prevent pest rodents to enter the facility. Observation on Tuesday [DATE] at 8:30 AM revealed the kitchen had another drain water back up. DFSM stated that she would contact the local health department. A local Health Department Inspector (HDI) came within that day and ordered the facility to cease operations, stop preparing, and serving food. All food not sealed at that point in time were to be disposed of immediately. In an interview with HDI revealed that the facility did not self-report the drain water backup the past weekend. She stated that according to Sec. ,d+[DATE] City Ordinance section where it stated that the establishment must cease operations in the case of a sewage backup. In an interview with ADM A on [DATE] at 08:42 AM, she stated that on [DATE] she entered the kitchen and observed a large board covering the drain in the dish room area. She stated she lifted the board and observed floor and tiles were removed and the pipes and dirt were exposed. She stated she learned from the Maintenance Director that the plumbing contractor had come out overnight and began repairing and unclogging the drainpipes that were damaged beneath ground. She stated that the facility's kitchen operations were approved for reopening on [DATE] by the HDI. She stated dietary service staff received an in-service on immediately reporting backflow water to maintenance on [DATE] and would receive another [DATE] and ADM A. In an interview with DFSM on [DATE] at 9:20 AM, she stated on [DATE] she first became aware of an issue with the airgap when it backed up in the dish room. She stated the staff immediately stopped washing dishes and notified the maintenance director who called a plumbing contractor. She stated that the dishwasher machine's water had come up from the drain and covered the dish room floor. She stated a plumbing service came in repaired the grease trap on the outside of the building. She stated on [DATE] the facility used paper products the whole day and into the next day until the CP fixed the backflow issue to ensure the backflow had not contaminated any of their eateries. She stated on [DATE] she learned from the state survey team that the airgap was not the required 1.5 inches from the floor. She stated the airgap positioning was low and allowed the potential for easy backflow into the airgap pipe if water levels rose. She stated that she called the Health Department on [DATE] to self-report the airgap and backflow issue. She stated on the morning of [DATE] she seen a large board had been laid over the drain. She learned from the Maintenance Director that the CP's team worked on the pipes overnight and the work was not completed. She stated the board was laid to allow for the area to dry while also allowing her staff to continue to work in that area. She stated that same morning, the HDI came to the facility and during the walkthrough noticed that the airgap was too low. She stated that the drain cap was off centered and the cylinder block under the cap had fallen over which caused the drain cap to be low and off centered. She stated that the HDI immediately discontinued food service operations in the kitchen, by closing the kitchen. She stated it was her understanding the kitchen was closed for precautionary measures from possible contamination from the airgap backup. She stated she provided an in-service to her dietary staff on [DATE] on the airgap, backflow system, and reporting backflow issues to the Maintenance Director and ADM A immediately. She stated they purchased food and/or prepared food from a sister facility. She stated during that timeframe they purchased disposable eateries, utensils and paper products as well as obtained disposable products from their sister facility. She stated the repairs to the kitchen were completed on [DATE], at which point a team came out and sanitized everything in the kitchen top to bottom, which included deep cleaning scrubbing floors, and throwing out food items that had been opened. She stated once the kitchen was opened on [DATE], they rewashed their dishes and began normal operations which allowed time to serve lunch. She stated her team and her received a reeducation in-service on [DATE] by ADM A on the airgap, backflow system, and reporting backflow issues to the maintenance director and ADM A immediately. In an interview on [DATE] at 9:20 AM, Maintenance Director stated on [DATE], he received notice from the DFSM that that the dish room had experienced water overflow. He stated he reported the overflow to ADM B and CP had been contacted. He stated the CP ran a snake system through the drain line and it was discovered that the grease trap was clogged and needed clearing. He stated the plumbing services did not interrupt any kitchen operations as the grease trap clearing took place on the exterior area of the facility. He stated on the morning of [DATE], he was made aware by the state survey team that the airgap was not measuring at its required height and the airgap had begun backed up in kitchen's dish room. He stated a drainage airgap was required at a minimum vertical distance, to be measured from the lowest point of the indirect water pipe or the fixture outlet to the flood-level rim. He stated the receptor shall not be less than 1-inch (25.4 mm). He stated on the evening of [DATE] the CP returned, reran the snake, found that the water drainpipe was broken, and tree roots had grown into the pipe causing the interruption of water flow. He stated the backflow consisted of water from the kitchen sinks and dish machine. He stated it was considered a part of the grey water sewage line or system. He stated grey water runs from the kitchen sinks, through the dishwasher machine, down the airgap, into the drain system on the dish room floor, under the kitchen floor, and under the concrete in the parking lot about 25-ft to where it reaches the cities mainline. He stated that the toilets do not run into that line. He stated that the toilets run on what was known as a black water sewer line. He stated that the kitchen water runs on the grey water sewer line and the two lines do not meet, cross, or run into the same lines. He stated that on [DATE], the kitchen repairs were still under construction, and kitchen services were discontinued by the HDI from what he understood, due to the airgap repairs. He stated the repairs took over 3-days and required cutting away the dish room flooring and tiles and the concrete in the facility's parking lot. He stated the facility brought food in from a sister facility and catered from local restaurants. He stated he had not spoken to the HDI. He stated there have been no issue with the back flow since the completion of the repairs on [DATE]. He stated he was in-serviced on [DATE] on the airgap and paying attention to the inches from the airgap and the floor by ADM A. Interview on [DATE] at 12:18 PM, CP stated that he was hired by the Master Plumber (MP) on [DATE] to unclog the facility's grease trap that had backed up on the outside of the building. He stated the grease trap filtered out food particles and had backed up and was cleaned. He stated he provided the facility with an invoiced dated [DATE] for that service. He stated on [DATE], the Maintenance Director rehired him to return to the facility and address a backflow issue, totally separate and unrelated service and repairs from his [DATE] visit. He stated that they ran the snake down the drainpipe and found that there were two old snake heads that had broken off in the line and had clocked and damaged the line. He stated when the kitchen staff ran the garbage disposal it would not allow for the food and the water to flow though causing a backup. He stated it did not even happen each time they ran the garbage disposal, but enough where when particles settled the backflow was created. He stated he reported the findings to the facility who gave them the go ahead to make whatever repairs were needed to correct the problem. He stated that began work on the late evening of [DATE] and was completed on [DATE]. He stated the MP prepared a report that was submitted to the Health Department. He stated the backflow was only grey water which accumulated from the kitchen sinks and dishwasher. He stated that the black water sewage was not and could not connect or backup in the kitchen when the airgap, line or drain clogged. Record review of Retail Food Establishment Inspection Report dated [DATE] from Health Department Inspector revealed, Violation Follow-up: Received a call from DFSM in regard to a sewage backup in kitchen. Arrived at the establishment at 11:15 AM. DFSM mentioned that issue had been resolved but noticed sewage backup during inspection . Ice machine in dish room have pipes without 1 inch air gap. These are signs of water backup in dish room, kitchen. By 3-compartment sink and ice machine drains. Licensed plumber must be contacted to inspect plumbing and water quality must be tested . May not operate until repairs are completed, and water quality has been cleared. May only use clean portable water. Must voluntary discard any food prepared onsite today. Will follow-up for final inspection once ready Signed acknowledgment by DFSM. Record review of in-service training dated [DATE] and [DATE] titled: Backflow revealed ADM A provided 1:1 in-service training to DFSM on all things hazardous conditions in the kitchen, reporting all environmental changes immediately, notifying managers of overflow, and ceasing meals until cleared by appropriate parties. Record review of in-service training dated [DATE] and [DATE] titled: Backflow revealed DFSM provided in-service training to dietary staff on reporting environmental changes including broken equipment, and notifying managers of overflow, and ceasing meals until cleared by appropriate parties. Record review of in-service training dated [DATE] titled: Emergency Maintenance Repairs and Concerns revealed ADM A provided 1:1 in-service training to Maintenance Director on reporting all emergency maintenance repairs immediately to the ADM A. Failure to do so can subject you to progressive disciplinary action. Record review of in-service training dated [DATE] titled: Air Gap revealed ADM A provided 1:1 in-service training to Maintenance Director. Record review of Health Inspector Report dated [DATE] revealed: Main initial violations: 1. S228.247 (A). A person may not operate a food establishment without a valid permit or license to operate issued by the regulatory authority. (Health Permit expired [DATE] and must be renewed as soon as possible) 2. S228.248 (5) Immediately discontinue operations and notify the regulatory authority if an imminent health hazard may exist as specified under S228.252(a) of this title; 3. S228.252 (a) Ceasing operations and reporting. (1) Except as specified in paragraph (2) of this subsection, a food establishment shall immediately discontinue operations and notify the regulatory authority if an imminent health hazard may exist because of an emergency such as a fire, flood, extended interruption of electrical or water service, sewage backup, misuse of poisonous or toxic materials, onset of an apparent foodborne illness outbreak, gross insanitary occurrence or condition, or other circumstance that may endanger public health. P [12] Corrections needed: 1. S228.66 Food protected from cross-contamination (Food products in walk-in cooler that were exposed to cross contamination from sewer backup and food not sealed must be discarded) 2. S228.146 (c) Backflow prevention, air gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). P [19] (Dish machine and ice machine must have a proper air gap/ these pipes must be replaced) 3. S228.174 (e) (1) (A) Except as specified in paragraphs (2) - (5) of this subsection, outer openings of a food establishment shall be protected against the entry of insects and rodents by: (A) filling or closing holes and other gaps along floors, walls, and ceilings; (Holes in ceiling must be repaired and sealed) 4. S228.114 (c) & S228.173 Nonfood-contact surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. [42] (Kitchen floors must be cleaned and sanitized) 5. S228.173 (a) Cleanability. Except as specified under subsection (d) of this section, and except for anti-slip floor coverings or applications that may be used for safety reasons, the floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable, (Air vents must be tested for possible mold contamination and must be cleaned properly) Below is the City Ordinance Section where it states that the establishment must cease operations in the case of a sewage backup: Sec. ,d+[DATE]. - Correction of violations 1. If an imminent health hazard exists, such as complete lack of refrigeration or sewage backup into the establishment, the establishment shall immediately cease food service operations. Operations shall not be resumed until authorized by the city. Record review of Retail Food Establishment Inspection Report dated [DATE] from Health Department Inspector revealed, Complaint Follow-up. A follow-up inspection was performed at 12:30 PM to ensure there were no sewage backup violations. The DFSM stated there had not been any issues Health Department Inspector's last visit. Upon inspection, noticed that there were no violations to report. No Issues with the following: - Air Vent Buildup - Air Gap in Drains - Water Backup Record review of facility's policies and procedures for Food Safety dated [DATE] reflected in part .d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers. e. Use all leftovers within 72-hrs. (3-days). Discard items that are over 72 hrs. old h. Store all items at least 6 inches above the floor to protect from contamination. Record review of facility's policies and procedures for Food Safety Requirements dated 2004 reflected in part b. foods/beverages be stored in a clean, dry area off the floor to prevent cross contamination. 44669

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment describing services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 3 residents (Residents #88 and #43) reviewed for comprehensive care plans. 1. The facility failed to care plan Resident #88's behavior of removing her oxygen cannula off her face and not properly storing the cannula when not in use. 2. The facility failed to care plan Resident #43 for potential skin issues due to being always incontinent with bladder and frequently incontinent with bowel . This failure could lead to residents not having their individual, medical, functional, and psychosocial needs identified and cause a physical or psychosocial decline in health. Findings included: 1. Record review of Resident #88's face sheet dated 09/30/2024 revealed a [AGE] year-old who was admitted to the facility on [DATE] with medical diagnoses including: chronic obstructive pulmonary disease (lung condition that limits airflow in and out of the lungs due to swelling and irritation), dysphagia (difficulty swallowing), Major Depressive Disorder, Post-Traumatic Stress Disorder, hypothyroidism (underactive thyroid gland), and hypertension (high blood pressure). Record review of Resident #88's Quarterly MDS assessment dated [DATE] revealed she had a BIMS (short assessment of mental status) score of 15, indicating high cognitive intactness. Further review revealed Resident #88 used a wheelchair and that she was fully independent in all self-care activities except for showering or bathing, where she required set-up or clean-up assistance . Resident #88's MDS did not reflect that she was on oxygen therapy. Record review of Resident #88's MAR (medication administration administration) for September 2024 revealed she had physician orders started on 10/16/2023 for oxygen at 2-6 liters to keep o2 sats above 92% as needed. Record review of Resident #88's physician notes dated 07/02/2024, the MD wrote under her COPD diagnosis: patient has a history of significant COPD, currently symptoms/COPD well-controlled, patient is sometimes noncompliant with keeping the oxygen on, patient has been advised to keep the supplemental oxygen on, understands risks. Record review of Resident #88's care plan last reviewed 09/10/2024 revealed she had a focus area of shortness of breath and at risk for respiratory distress/failure and increased episodes of SOB (shortness of breath) as evidenced by COPD diagnosis. Resident #88 refused to be sent to the ER for evaluation after complaining of SOB on 04/29/2024. Interventions included: applying O2 per order, check pulse oximetry as ordered, and observe for s/sx of respiratory infection and report any noted to the MD. Resident #88's care plan did not address her behavior of removing oxygen cannula against physician orders. Observation of Resident #88's room on 09/30/2024 at 9:30am, revealed the oxygen cannula was on the bed underneath two sheets and one blanket near the left edge of the bed. Observation and interview with RN G on 09/30/2024 at 9:30am, revealed RN G came into Resident #88's room and took the cannula out and put it in a clean bag. RN G stated a risk of keeping the cannula on the mattress would be it could catch fire and infection control . Interview with Resident #88 on 09/30/2024 at 12:55pm, she stated that her oxygen was working well and she had no issues and that she measured her own oxygen using her personal pulse oximeter because she was a smoker. She had been educated on oxygen use by staff. Interview with the Administrator and RNC on 09/30/024 at 2:16pm, the RNC said Resident #88 tended to lay her cannula on the sheet. The RNC said that the nurses should have cleaned the cannula when Resident #88 laid it on her bed but that it was not an infection control issue because it was unknown if Resident #88 placed the cannula back on for use without it being cleaned first. The RNC said Resident #88 had been at the facility for a few years and was independent and that nurses did not track or monitor the oxygen while she smokes. Interview with the MDS Coordinator A on 10/05/2024 at 1:01pm, she said that Resident #88 has PRN oxygen orders and that there is was documentation Resident #88 was educated on keeping her oxygen equipment clean and taking care of it. MDS Coordinator A said Resident #88 was care-planned for oxygen, but that MDS Coordinator A recently put in the care plan that Resident #88 tended to take off her cannula and leave the room without cleaning it and storing it. MDS Coordinator A said that Resident #88 leaving the cannula out in the open was an infection control risk because it could end up on the floor which is dirty and where people step on it. MDS Coordinator A said that Resident #88 is documented for respiratory issues and that she should know how to turn off her oxygen concentrator, but that staff are responsible for turning it off if they saw her going down the hall away from her room. Another interview with the Administrator on 10/07/2024 at 2:00pm, she said that each patient had individualized care plans which allowed staff to know how to better take care of the patient as an individual. 2. Record review or Resident #43's admission record dated October 3, 2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #43's diagnoses included cerebrovascular disease (conditions that affect blood flow to your brain) and hemiplegia and hemiparesis following cerebral infarction (both conditions that can occur after a cerebral infarction, or stroke, and are characterized by weakness or paralysis on one side of the body). Record review of Resident #43's admissions MDS dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 revealing he was cognitively intact. The MDS assessment revealed that Resident #43 was impaired on one side with upper extremities and limited on both sides with lower extremities with functional range of motions. Resident #43 was coded to be always incontinent of bladder and bladder. Record review of Resident #43's baseline care plan dated of 5/29/2024 revealed that he was always incontinent with bladder and frequently incontinent with bowel. 1. Urinary continence required assistance to total dependence with his ADL's Record review of Resident #43's comprehensive care plan revealed there was no skin/wound care planned though the area was triggered on the Admission CAA (Care Area Assessment summary) dated 6/2/2024. During an interview on 10/3/24 at 1:32pm the DON said that Resident #43 should have a comprehensive care plan to address the potential for skin issues, that Resident #43 was incontinent of bladder and also used the urinal. She added that a potential negative outcome of not having a care plan to address skin issues would be a potential unawareness of required care to provide. She said that the MDS Coordinators would be responsible for creating the care plans and that they facility had one MDS Coordinator on site along with a Regional MDS Nurse. During an interview on 10/4/2024 at 1:00 pm MDS Coordinator A said that Resident #43 should have a comprehensive care plans to address the resident for skin issues and she missed it. She said Resident #43 was in bed quite a bit, he was care planned for using the urinal, but she should have care planned him for skin issues. She said she used the RAI manual for assessments and care plans. She said that a negative outcome for a resident not care planned for skin could be skin irritation, rashes and possible skin break down. She added that there was another staff that also held responsibility for care plans that works off-site, MDS Coordinator B and she believed that Resident #43 admitted under skilled care so MDS Coordinator B would have completed Resident #43's initial care plan. During a telephone interview on 10/4/2024 at 1:15 pm with MDS Coordinator B, she said that Resident #43 should have had a care plan to address skin issues and the potential negative outcome could be skin breakdown, if not care planned. She confirmed using the RAI Manual for care plans. Record review of the facility's Care Planning Nursing Policies and Procedures last revised June 2019, revealed the comprehensive care plan is developed within seven days of the comprehensive assessment for each resident by the interdisciplinary team.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 5 residents (Resident #83 and Resident #205) reviewed for pharmacy services with 5 errors out of 33 opportunities from 2 of 2 staff (MA A and RN A) and a medication error rate of 15%. 1. The facility failed to ensure MA A administered Pantoprazole granules (medicine used to reduce amount of acid in teh stomach) mixed with 10 cc apple juice or applesauce per physician orders and Ferrous Gluconate (medicine used to treat or prevent low blood levels of iron) per physician orders for Resident #83 2. RN A failed to administer the following medications correctly for Resident #205: - Megastrol 40mg/ml oral suspension (medicines used to treat loss of appetite, malnutrition, and severe weight loss in patients with acquired immunodeficiency syndrome (AIDS) by not following pharmacy orders to Shake well -Ferrous Sulfate 325 mg (medicine used to treat or prevent low blood levels of iron) by administering Ferrous Gluconate 240 mg T tablet by mouth instead - Latanoprost 0.005% eyes suspension (medicine used to treat increased intraocular pressure) in the day time instead of at bedtime These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: 1. Record review of Resident #83's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #83 had diagnoses of sepsis,( a serious condition in which the body responds improperly to an infection) and ,schizophrenia ( a serious mental health condition that affects how people think, feel and behave),and Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause); and Cellulitis (a bacterial infection that affects the skin). , Record review of Resident# 83's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09 which indicated moderately impaired cognition. It also revealed the resident needed total care assist with ADL with two staffs assistance. Record review of Resident #83's physician's order summary report revealed the following order: order dated 07/8/2023, Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for anemia (9:00am). order dated 07/8/23 Pantoprazole 40 mg packet mix of 10cc apple juice or apple sauce po 2. Record review of Resident #205's face sheet dated 09/27/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. Resident #205 had diagnoses of heart failure, respiratory distress, malignant neoplasm, bronchus or lung and peripheral vascular disease (dysfunction of the veins by the lungs), and presence of cardiac pacemaker. Record review of Resident# 205's admission MDS dated [DATE] revealed a BIMS score of 12 which indicated moderate impairment of cognition. It also revealed the resident needed total care assist with ADL with two staffs assistance. Record review of Resident #205's physician's order summary report revealed the following orders: order dated 09/23/2023, Ferrous Sulfate Tablet 325 (65 Fe) MG Give 1 tablet by mouth one time a day for anemia (9:00am). . order dated 09/26/23, Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime. . ordered 9/27/2024 Megestrol Acetate Suspension 400 MG/10MLMegestrol Acetate Suspension 400 MG/10MLGive 10 ml by mouth two times a day for appetite for 30 Day. The bottle indicated for the user to Shake Well. Observation on 09/30/2024 at 8:48am revealed medication administration with MA A for Resident # 83. MA A was observed preparing and administering Resident # 83 medications by giving Resident #83 Ferrous Gluconate 240 mg 1 tablet po instead of Ferrous Sulfate Tablet 325 (65 Fe) MG. MA A also administered and Pantoprazole 40 mg packet mixed with yogurt instead of apple juice or applesauce as instructed by the pharmacist. Mixing Pantoprazole with yogurt can reduce the rate at which the drug dissolves, especially in the first 10 minutes due to yogurts high viscocity (https://www.fda.gov/media/149137/download#:~:text=This%20was%20due%20to%20the,10%20minutes%20in%20PBS%20stage.&text=Oral%20delivery%20is%20a%20widely%20used%20route%20of%20drug%20administration.) Later observation on 09/30/2024 at 9:06am, RN A was observed administering Megestrol 40 mg/ml/oral suspension 10 mls. RN A opened the top cap of the medication bottle, open the seal on top of the medication container in the plastic bag from the pharmacy, RN A did not shake the bottle before administering the medication to Resident #205. The bottle was labelled Shake Well. RN A also administered Latanoprost Solution 0.005 % at that time, with the solution's label instructing to instill 2 drops in both eyes at bedtime. Interview with MA A on 10/04/24 at 3:22 pm, the surveyor showed MA A the medication blister packet of Pantoprazole 40 mg packet which was labeled to adminster with apple juice or apple sauce. The surveyor also showed MA A the Ferrous Sulfate Tablet 325 (65 Fe) medication label. MA A said for Pantoprazole 40 mg packet, she had told the DON she needed applesauce for the medication and that the DON told her the facility did not have apple sauce or juice and it was fine to use yogurt. MA A said she was sorry for giving Ferrous Gluconate instead of Ferrous Sulfate and that she would be more careful . MA A stated that medications should be administered as ordered by the doctor and tofollow recommendations due to the potential side effects if she did not follow the instructions. MA A said she started working with the facility on 6/25/24 and had not had any medication training. Interview on 10/04/24 at 3:34 PM RN A regarding her administering to Resident #205 Ferrous Gluconate 240mg tablet po instead of Ferrous Sulfate Tablet 325 (65 Fe), and not shaking Megestrol 40 mg/ml/oral suspension 10mls before pouring into the medication cup, and instilling Latanoprost Solution 0.005 % Instill 2 drops in both eyes in teh daytime, she said she was very sorry and was nervous and that she would have to double check the medication. RN A said she knew giving medications not as ordered by the physician could result in residents not getting the benefit of the medication. RN A said she did not receive in-services on medication. In an interview on 10/04/2024 at 5:05 pm, Tthe DON stated that she recently started working at the facility a couple of months ago, but she would be the individual responsible for overseeing and having the pharmacist monitor the staffs during medication administration. The DON stated that all nurses and MA staff had been trained and were knowledgeable of the medication administration policy. The DON stated that additional training would be provided. Record review of RN A's personnel file reflected date of hired was 8/27/24 and there were no medication trainings in her personnel file. Record review of the facility's policy titled Medication and Treatment orders dated November 2014, read Medications shall be administered only upon the written order . The policy did not address administering meds timely and administering all the meds correctly.

Based on interview and record view the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 1 of 6 residents (Residents #91) reviewed for abuse and neglect. The facility failed to report an incident where Resident #91 reported to Family #1 she was slapped by CNA/someone at the facility on 07/13/2024 and 07/22/2024. These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #91's Facesheet dated 10/01/2024 revealed Resident #91 was an [AGE] year-old female who admitted to the facility on [DATE]. Her medical diagnoses included but not limited to chronic obstructive pulmonary disease (lung disease making it difficult to breath), dementia (cognitive loss), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, atherosclerotic heart disease of native coronary artery (plaque builds up in the coronary arteries) without angina pectoris (heart muscle not receiving enough oxygen), schizophrenia, anxiety disorder, depression, difficulty in walking, adult failure to thrive, and Alzheimer's disease. Record review of Resident #91's Quarterly MDS dated [DATE] revealed a BIMS, (a measure of cognitive function, with 15 being the highest cognitive function) score of 07 which indicated severe cognitive impairment. Record review of Resident #91's Care Plan revised 09/12/2024 revealed resident was care-planned for the following: Focus: increased pain, limited ambulation, Focus: Resident resides in the memory care unit, impaired cognition secondary to dx: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, schizophrenia, unspecified and need for reduced stimuli. date initiated: 04/24/2024 revision on: 04/24/2024 due to memory loss, she forgets and needs frequent reminders date initiated: 03/22/2024 revision on: 06/03/2024. Record review of Resident #91's Progress Notes dated 07/13/2024 at 02:12 PM entered by LVN M revealed Family #1 reported that Resident #91 told her that CNA (unknown) slapped her maybe 3 or 4-days ago and she had not remembered the person and she had not told nobody. LVN reported to the manager on duty the complaint. The manager on duty spoke with Family #1. Resident #91 stable, awake alert to her baseline. No distress or any discomfort noted at this time. Denied any spitting of blood or pain at this time. Plan of care continue on this shift. Record review of Resident #91's Progress Notes dated 07/22/2024 at 11:54 AM entered by LVN M revealed resident awake and alert to her baseline. Resident reported CNA/someone slapped her and when LVN M went with the CNA (unknown), resident stated nobody slapped her or had done anything to hurt her. Resident stated that it happens in her dream not in this place. Assessment done no bruise or redness noted on resident face, head, or any part of her body at this time. Plan of care will continue. During an observation and interview on 10/01/2024 at 02:57 PM Resident #91 stated that she could not remember reporting someone slapped her, but it was possible. She stated that staff rough me up. She stated that Family #1 would know about her being roughed up. She stated she had problems with staff all the time but could not neither provide any specifics on being roughed up, nor any staff names, descriptions, or dates of incidents. When asked had she felt safe at the facility resident responded, I guess. and shrugged her shoulders. During an interview on 10/02/2024 at 01:12 PM, Family #1 stated that Resident #91 reported to her that she was being assaulted by CNAs. She stated that Resident #91 was incontinence, frequently used the bathroom, and had issues with her holding down food. She stated that the resident reported to her that CNAs were not coming and change her briefs timely and the resident would become irritated with the soiled briefs and remove them. She stated that the resident told her that when removing the briefs, she would make a mess and staff would become frustrated with the resident because of the mess and roughed her up. She stated that the resident could not provide the name of the CNA but descripted her as a young Indian lady. She stated there were no bruise marks or evidence of resident being roughed up. She stated she never spoke with the CNA. She stated that the resident was moved to another room and that CNA no longer provided the resident care and she had not seen her since. She stated she reported the allegations to management and the nurses. She stated that they listened to her concerns, but they informed her without any names or descriptions there was nothing they could do. She could not recall the names of the management staff only than one of them was filling for the DON. She stated Resident #91 has not spoken about being roughed up in a while and hoped that incidents had stopped. During an interview on 10/02/2024 at 02:57 PM, the DON stated that she had been with the facility since May of 2024. She stated she had not been made aware that Resident #91 made allegations of abuse on 07/13/2024 and 07/22/2024. She stated that ADM B was the abuse coordinator and responsible for reporting abuse allegations to the State Survey Agency and initiated and complete the abuse investigations. The DON stated the potential negative outcome of not following the facility's abuse policy was that someone could be abused, harmed, or not be taken care of at the facility. She said she was familiar with the facility's abuse policy and had been trained on the policy. She stated had she been made aware of an allegation of abuse, she would immediately notify the ADM, ensure that the resident was safe from any further harm, complete a head-to-toe assessment of the resident to ensure no signs of pain or injury were present. She stated the ADM B's last day with the facility was 08/30/2024. During an interview on 10/03/2024 at 10:30 AM, the ADM A stated her first day with the facility was on 09/30/2024. She stated that she could not find that the Resident #91's abuse allegations were reported to HHSC. She stated she reported the allegations to the HHSC on 10/03/2024 and treating it as a brand-new allegation since it cannot be located. She stated that the SW would perform resident safety questionnaires. During an interview on 10/04/2024 at 01:05 PM, LVN M stated that she was PRN with the facility. She stated her last full-time shift with the facility was in July 2024. She stated she was familiar with Resident #91 and the abuse allegations. She stated Family #1 had visiting on the weekend and reported that someone had slapped Resident #91. She stated she checked on the resident walked the resident around and told her to point at the staff member who slapped her. She stated that the resident was unable to identify a staff member and told her that maybe it happened another day. She stated she performed a physical assessment on resident. The resident said she was slapped in the face, then the back, and then said, No, on the leg. The resident then told her that maybe it had been a dream and happened on another day, and maybe not in that facility. She stated that her physical assessment found no bruising or redness noted to resident's face, head or any part of her body at that time. She stated once the assessment was completed, Family #1 asked was the allegation going to report to ADM B. She told Family #1, yes, but Family member said not to report since there were no marks also stating that maybe the incident does not even happen, as the resident said things that have not happened all the time due to her dementia diagnosis. She stated that she told Family #1 since a slap had been reported, she had to report. She stated called the manager on duty, or maybe the therapy manager who spoke to Family #1. During an interview on 10/14/2024 at 03:11 PM, ADM B stated she was the interim administrator of the facility from approximately 05/23/2024 through 08/28/2024 and was the facility's abuse coordinator. She stated that she submitted several self-reports during her time at the facility, never received any communication from LVN M regarding Resident #91 being slapped by a staff of [NAME] nationality. During an interview on 10/18/2024 at 06:34 PM, ADM A stated on 07/13.2024, the manager on duty was the DOR. She stated on 07/22/2024 ADM B and the DON were on duty. Record review of the facility policy, Abuse, Neglect, and Exploitation, revised April 2024 revealed that the Administrator or designee shall report allegations of abuse to the State Health Department within 24 hours. Record review of HHSC reporting intake website does not reveal any reports/intakes of abuse involving Resident #91. In July 2024 10/03/2024. 48923

Based on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 resident (Resident #91) reviewed for abuse. LVN M failed to immediately report her suspicions of abuse when notified Resident #91 was slapped. The deficient practices could affect any resident and contribute to further abuse or neglect. Findings included: These failures could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm. Findings included: Record review of Resident #91's Facesheet dated 10/01/2024 revealed Resident #91 was an [AGE] year-old female who admitted to the facility on [DATE]. Her medical diagnoses included but not limited to chronic obstructive pulmonary disease (lung disease making it difficult to breath), dementia (cognitive loss), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, atherosclerotic heart disease of native coronary artery (plaque builds up in the coronary arteries) without angina pectoris (heart muscle not receiving enough oxygen), schizophrenia, anxiety disorder, depression, difficulty in walking, adult failure to thrive, and Alzheimer's disease. Record review of Resident #91's Quarterly MDS dated [DATE] revealed a BIMS, (a measure of cognitive function, with 15 being the highest cognitive function) score of 07 which indicated severe cognitive impairment. Record review of Resident #91's Care Plan revised 09/12/2024 revealed resident was care-planned for the following: Focus: increased pain, limited ambulation, Focus: Resident resides in the memory care unit, impaired cognition secondary to dx: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, schizophrenia, unspecified and need for reduced stimuli. date initiated: 04/24/2024 revision on: 04/24/2024 due to memory loss, she forgets and needs frequent reminders date initiated: 03/22/2024 revision on: 06/03/2024. Record review of Resident #91's Progress Notes dated 07/13/2024 at 02:12 PM entered by LVN M revealed Family #1 reported that Resident #91 told her that an unknown CNA had slapped her 3 or 4-days ago. Resident #91 could not remember the person and she had not told any staff. LVN M reported to the manager on duty the complaint. The manager on duty spoke with Family #1. Resident #91 stable, awake alert to her baseline. No distress or any discomfort noted at this time. Denied any spitting of blood or pain at this time. Plan of care continue on this shift. Record review of Resident #91's Progress Notes dated 07/22/2024 at 11:54 AM entered by LVN M revealed resident awake and alert to her baseline. Resident reported CNA/someone slapped her and when LVN M went with the CNA (unknown), resident stated nobody slapped her or had done anything to hurt her. During an observation and interview on 10/01/2024 at 02:57 PM Resident #91 stated that she could not remember reporting someone slapped her, but it was possible. She stated that staff rough her, and that Family #1 would know about happened. She was unable to provide any staff names, descriptions, or dates of incidents. During an interview on 10/02/2024 at 01:12 PM, Family #1 stated that Resident #91 reported to her that she was being assaulted by CNAs. She stated that Resident #91 was incontinence, frequently used the bathroom, and had issues with her holding down food and often removed her brief when staff would not timely. She stated that this frustrated staff who would then as reported by Resident #91 would rough her up, particularly a young Indian lady. She stated she reported the allegations to a manager on duty and the DON. During an interview on 10/02/2024 at 02:57 PM, the DON stated that she had not been informed of any abuse allegations reported regarding resident #91. She stated that ADM B was the abuse coordinator and responsible for reporting abuse allegations to the State Survey Agency and initiated and complete the abuse investigations. During an interview on 10/03/2024 at 10:30 AM, the ADM A stated that she could not find that the Resident #91's abuse allegations were reported to HHSC. She stated she reported the allegations to the HHSC on 10/03/2024 and treating it as a brand-new reportable allegation. During an interview on 10/04/2024 at 01:05 PM, LVN M stated that Family #1 had visiting on the weekends and reported that someone had slapped Resident #91. She stated called the manager on duty, or maybe the therapy manager but could not recall who either of those individuals were. During an interview on 10/14/2024 at 03:11 PM, ADM B stated she never received any communication from LVN M or any other staff or individual that Resident #91 was slapped by a staff. Record review of the facility policy, Abuse, Neglect, and Exploitation, revised April 2024 revealed that the Administrator or designee shall report allegations of abuse to the State Health Department within 24 hours. Record review of HHSC reporting intake website does not reveal any reports/intakes of abuse involving Resident #91. In July 2024 10/03/2024.

Based on observation, interview, and record review, the facility failed to ensure the resident's right to respect and dignity for 3 (Resident #78, Resident #70, and Resident #73) of 8 residents reviewed for respect and dignity, in that: 1. CNA M and MA J laughed while redirecting Resident #73 away from Resident #78 and #70. 2. CNA M and MA J called Resident #73 crazy while redirecting him away from Resident #78 and #70. This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment. The findings were: Record review revealed of Resident #78's Facesheet dated 10/14/2024 revealed she was an [AGE] year-old female who admitted to the facility on [DATE]. Her medical diagnoses included but not limited to cognitive communication deficit, diabetes mellitus (body's inability to regulate blood sugar) due to underlying condition with diabetic neuropathy (blood flow damage), muscle weakness, encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, pain, other lack of coordination, and difficulty in walking. Record review of Resident #78 Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS, with 15 being the highest cognitive function) score of 15 which reflected intact cognition. Record review of Resident #78's undated Care Plan revealed: MOOD/BEHAVIOR: Resident had a history of alteration in mood or exhibition of behavioral symptoms of crying withdrawal r/t depression. Record review of Resident #70's Facesheet dated 10/14/2024 revealed Resident #70 was a [AGE] year-old female who admitted to the facility on readmitted on [DATE] and initially admitted on [DATE]. Resident's medical diagnoses included but were not limited to metabolic encephalopathy (brain disorder causing imbalanced functions), benign neoplasm (brain cancer) of cerebral meninges (benign tumor), repeated falls, Alzheimer's disease with early onset, and major depressive disorder, recurrent. Record review of Resident #70's Comprehensive MDS dated [DATE] revealed a BIMS, (with 15 being the highest cognitive function) score of 13 which reflected intact cognition. Record review of Resident #70's Care Plan revised 09/09/2024 revealed resident MOOD/BEHAVIOR: Resident had a behavior or exhibition of behavioral symptoms, crying and increased confusion r/t: Depression. 07/15/2024 Crying in her room, offered r/t, stated she was fine. Date Initiated: 04/05/2023 Revision on: 07/16/2024. COGNITIVE IMPAIRMENT: Resident had impaired cognition and was at risk for further decline and injury as evidence by (AEB), diagnosis (Dx) ALZ/Dementia Date Initiated: 09/18/2023 Revision on: 09/18/2023. Record review of Resident #73's Facesheet dated 10/05/2024 revealed Resident #73 was a [AGE] year-old male who admitted to the facility on [DATE] and initially admitted on [DATE]. Resident's medical diagnoses included but were not limited to altered mental status, bipolar disorder, dementia, unspecified severity, with other behavioral disturbance, and insomnia. Record review of Resident 73's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS (with 15 being the highest cognitive function) score of 09 which reflected moderate impairment. Record review of Resident #73's Care Plan revised 09/12/2024 revealed Care Plan revised 09/09/2024 revealed resident had difficulty being engaged throughout the day. INSOMNIA: Resident had a potential for fluctuations in sleep patterns and injuries AEB, Dx insomnia Date Initiated: 09/09/2024. Resident had a Dx of Dementia and was at risk for increased confusion and decline in Activities of Daily Living (ADL)'s as the diseases progresses Date Initiated: 09/09/2024 Revision on: 09/09/2024. During an observation/interview on 10/05/2024 at 01:28 PM, Resident #78 stated that on 10/03/2024 Resident #73 came into her room in his wheelchair. She stated that she was lying down in her bed and jumped up into her wheelchair. She stated Resident #73 came towards her and began pulling her hair and t-shirt. She stated she began screaming and was able to wheel into the hallway screaming for help until staff whose names and descriptions she could not provide came to remove Resident #73 from her room. She stated the staff who came to remove resident #78 kept laughing, saying, What can we do he is crazy. She stated that was their only answer and response to Resident #73's actions and she does not feel they understood the emotional impact of fear and lack of peace and security it had brought to her. She could not understand why the staff thought it was funny to laugh when she was so upset. She stated that she does not feel like staff had taken the situation serious and it made her feel bad. She stated that this was the second time that Resident #73 had come into her room where staff had to remove him. She stated that she had only one leg and it hinders her ability to get around. She asked why she should not have to cope with Resident #73 coming into her room making her feel unsafe and fearful when her mobility was already affected. She stated that she wanted to live in peace not to be hurt and not to be hit by Resident #73. She stated the incident had affected her nerves negatively. She stated that the facility was a madhouse and not a decent place to live peacefully. She stated that the resident belonged in another area of the facility where he does not bother resident who need and receive normal care. She stated she wanted to get out of this facility so she could live a quiet life. She does not want to be afraid. Resident #78 provided her interview while visibly upset and tearful. During an observation and interview on 10/05/2024 at 01:37 PM, Resident #70 stated that on 10/03/2025 she was in her bed when Resident #73 entered into her and her roommate #78's room. She stated Resident #70 wheeled himself over to Resident #78's side of the room, but because of the privacy curtain she could not see. She stated then she began hearing Resident #78 screaming and crying and Resident #78 wheeled past her out of the room into the hall screaming and crying. She stated then Resident #73 then wheeling behind the curtain in front of Resident #78's bed, but his wheels had gotten stuck near the foot of Resident #78's bed and he could not move. She stated from her bed she continued to see and hear Resident #78 continued screams and yells. She stated that 2 or 3 staff came to assist Resident #73 out of their room. She stated that the staff were laughing saying Resident #73 was crazy and what could they do. She stated that she felt so bad for Resident #78 who was crying and very upset. She stated the staff's laughter had made her feel bad and she felt bad for Resident #78 when she heard the staff laughing about what had happened. She stated she had not seen Resident #73 pull Resident #78's hair or t-shirt maybe because that had happened when the privacy curtain blocked her line of sight. Resident #70 stated that she feels safe at the facility, but she does not appreciate how the staff laugh and called Resident #73 crazy. During the interview Resident #70 was observed confidently recalling the events of the incident. When the resident was specifically asked what she witnessed of the staff, Resident #70 shrunk down in her bed and began to speak softly. Resident #70 stated it had made her feel bad when the staff had laughed and called Resident #78 crazy for what he had done to Resident #78. She stated that she does not believe that was the professional response to the incident. During an observation and interview on 10/05/2024 at 01:41 PM, revealed Resident #73 lying in his bed under a blanket, alert. Resident #73 repeated everything asked of him. He was only able to respond that he was Resident #73. During an interview on 10/05/2024 at 01:42 PM, CNA O stated she worked PRN and had begun working with facility on 10/03/2024. CNA O was observed sitting in a chair at the foot of Resident #73's bed. She stated she had been assigned to provide one-on-one (1:1) care for the resident. She stated that she had been sitting with the resident since 6:00 AM and had fed him breakfast, lunch and changed his briefs throughout her shift with Resident #73. She stated she was not aware why but was told the resident was required 1:1 care 24-hours a day. She stated that she would sit with the resident until 2:00 PM when her shift ends and then another staff member would sit with the resident. She stated she was unaware when the 1:1 began but was told that someone had sat with the resident overnight. She stated that he had not gotten up out of the bed today but had spoken with her throughout the day making jokes and laughing. She stated 10/05/2024 was her first 1st time working with Resident #73. During an interview on 10/07/2024 at 12:41 PM, CNA M stated that on 10/03/2024 she was in another resident's room when she heard Resident #78 screaming. She came out to find Resident #78 screaming into her phone's interpreter app which translated that Resident #73 came into her room and hurt her. She stated that CM J told her that she had not seen Resident #73 in Resident #78's room, only at the resident's room door. She stated that MA J redirected Resident #73 back to his room. She stated that Resident #73 was hungry and may have entered Resident #78's room because she has food on her table. She stated that Resident #73 wanders and staff redirected him to his room by giving him snacks. She stated Resident #73 had usually went to the dining room to get snacks from the kitchen, but since remodeling he has not been able. She stated she had in-services on abuse and residents with behaviors. She stated that she cannot be everywhere and stated she was sorry the incident happened. She stated that MA J reported the incident to the RN F. She stated that Resident #78 does not have behaviors such as yelling or screaming, and never asked staff for assistance. She stated staff only attend to Resident #78's roommate Resident #70. She stated she had not laughed nor was aware if MA J laughed when redirecting the residents. During an interview on 10/07/2024 at 01:36 PM, RN F stated that MA J reported to her that Resident #78 was upset that Resident #73 entered her room. She stated she was unaware if MA J witnessed Resident #73 enter Resident #78's room. She stated she witnessed Resident #78 speaking in her language and speaking to MA J. She stated that she had not witnessed any staff laughing when redirecting the residents. She stated if she had witnessed inappropriate laughing or resident abuse or neglect, would report the incidents to the ADM who was the abuse coordinator. During an interview on 10/07/2024 at 01:39 PM, MA J stated she was on break when she heard a commotion. She stated she came into the hall but had not seen Resident #73 go into Resident #78's room. She stated she had not heard any laughter nor heard anyone call the residents crazy. She stated she does not know who removed Resident #73 from Resident #78's room. During an interview on 10/07/2024 at 01:41 PM, ADM A stated that she interviewed staff, and all denied laughing when redirecting residents. She stated Resident #73 was receiving 1:1 supervision until psych services and the DON could determine if he would be appropriate placed in the secure unit. She stated that Resident #73 has a BIMS of 09 which reflected he was moderate impairment, but had ended up rummagin through resident's items. She stated that they had begun educating staff on resident rights. She stated the SW met with Resident #78 on 10/03/2024 and reported that she does not want Resident #73 in her room. She stated that Resident #70 had not mentioned any staff laughing when Resident #73 was in their room. During an interview on 10/07/2024, 01:41 PM, the DON stated that Resident #73 was evaluated by psych service to determine if he should be appropriately placed in the secure unit after incidents of rummaging. She stated they were waiting on the outcome of the assessment. Record review of Resident #78's Progress Note dated 10/04/2024 at 06:32 PM reveled Social Services Note Note Text: PSYCHO SOCIAL ASSESSMENT: SW met with resident in her room, resident appeared calm and relaxed. Resident was on her phone watching a video. SW spoke with resident regarding incident that occurred yesterday with the aid of an interpreter. When asked if she was ok, resident replied that she is fine. When asked if she felt safe, she said yes. When asked if she would like to see the psychologist or psychiatrist, resident declined. Resident does not appear to have any adverse effects from said incident. SW will continue to follow up with resident. Author, SW. Record review of Resident #78's Progress Note dated 10/04/2024 at 06:32 PM reveled Social Services Note Note Text: PSYCHO SOCIAL ASSESSMENT: SW met with resident in her room, resident appeared calm and relaxed. Resident was on her phone watching a video. SW spoke with resident regarding incident that occurred yesterday with the aid of an interpreter. When asked if she was ok, resident replied that she is fine. When asked if she felt safe, she said yes. When asked if she would like to see the psychologist or psychiatrist, resident declined. Resident does not appear to have any adverse effects from said incident. SW will continue to follow up with resident. Author, SW. Record review of Resident #78's Progress Note dated 10/04/2024 at 06:39 PM revealed Social Services Note Note Text: SW informed psychologist of incident that occurred yesterday. Author, SW. Record review of Resident #73's Progress Note dated 10/03/2024 at 06:01 PM revealed Summary Narrative: resident alert to self with needs anticipated by staff. Resident to be on 1:1 until further notice due to potential for wandering into other resident's room. Author, DON. Record review of Resident #73's Progress Note dated 10/03/2024 at 06:42 PM revealed Social Services Note Late Entry: Note Text: SW informed psych service's NP, SW r/t resident's aggressive behavior towards another resident. Social Services. Record review of Resident #73's Progress Note dated 10/03/2024 at 08:47 PM revealed, Nursing Note: Resident has been receiving one on one care until further notice, no behavior issue noted on shift. Will continue with the plan of care. Author, LVN OO Record review of Resident #73's Progress Note dated 10/03/2024 at 11:30 PM revealed, No Type Specified. Note Text: NP and responsible party (RP) notified about incident involving a second resident. No concerns presented at this time. Author, ADM A. Record review of the facility policy Resident Rights last revised June 2019, revealed the facility provides the resident with an environment that preserves dignity, privacy and contributes to a positive self-image . 13. The facility must provide a safe, functional . and comfortable environment for residents, staff and the public.

Based on interview and record review the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment plan of care for 2 of 9 residents (CR#1 and CR#8) reviewed for comprehensive care plans in that The facility failed to implement CR #1's comprehensive person-centered Care Plan for pain to provide pressure reducing and positioning devices (air mattress) and CR#1 did develop 3 pressure sores on [DATE]. The facility failed to implement CR#1's comprehensive person-centered Care Plan for ADL self-care deficits as she required extensive assistance of 2 support persons for bed mobility, toileting/incontinent care and transfers. The facility failed to care plan for CR#8's behaviors such as playing with his bed remote and rearranging his furniture. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on developing and implementing a person centered comprehensive care plans. These failures placed residents at risk of not having their care needs met, which could cause a decline in physical and psychosocial health or even death. Findings include: CR #1 Record review of CR #1's face sheet dated [DATE] revealed a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and is at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and is at risk for skin breakdown as evidenced by cognitive impairment, ADL self care deficits and is at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on [DATE], risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe cognitive impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene were extensive assistance with 2 person assisting, transfer was activity occurred once or twice with 2 person assisting and bathing, and she was totally dependent for bathing with 2 person assist. Record review of CR #1's Physician Orders dated [DATE] revealed: Fentanyl Patch 72 hour 75 mcg/HR apply 1 patch trans dermally dated [DATE] Lidocaine-Menthol (Spray) External Liquid 4- 1% Lidocaine-Menthol apply to wound topically dated [DATE] Right Buttocks Stage 4: Cleanse with Vashe, pat dry and packed with Vashe moist gauze sponge cover with ABD (used to absorb discharges) pad + island dressing PRN every 1 hour as needed dated [DATE] Morphine Sulfate (Concentrate) Solution 20 mg/ml give 0.5 ml sublingually every 4 hours as needed for pain dated [DATE] Lorazepam Tablet 0.5 mg give 1 tablet by mouth dated [DATE] Gemtesa Oral Tablet 75 mg (Vibegron) give 1 tablet by mouth one time a day for overactive bladder dated [DATE] Nystatin Powder (Nystatin Bulk) Apply to breast topically dated [DATE] Lidocaine External Patch 4% (Lidocaine) Apply to right shoulder dated [DATE] Hydrocodone-Acetaminophen 7XXX,d+[DATE] mg give 1 tablet by mouth every 8 hours as needed for pain level ,d+[DATE] dated [DATE] Turn and reposition every 2 hrs. Every shift [DATE] Wound consult No directions dated [DATE] Lidocaine External patch 4% (Lidocaine) Apply to both thigh topically dated [DATE] Hydrocodone Acetaminophen Tablet 7XXX,d+[DATE] mg give 1 tablet by mouth dated [DATE] Phenergan Injection Solution (Promethazine HCl) Inject 12.5 mg intramuscularly every 8 hours as needed for nausea dated [DATE] Palliative Care only, no labs, no diagnostic exams. May Administer pain and nausea medication only, hold PO medications if unable to swallow x 7 days then discontinue dated [DATE] O2 Sat. via nasal cannula, ,d+[DATE] liters/92% continuously Every shift for difficulty breathing dated [DATE] Record review of CR#1's progress notes dated [DATE] at 4:45 p.m. by The Wound Care Nurse revealed, Patients assigned nurse notified me of skin injury to patient. Skin &Wound assessment done with indications of pressure injuries to right & left buttocks and deep tissue injury to the right ischium. [Wound Care Doctor] notified and new orders given for wound treatment as indicated . In an interview on [DATE] at 12:14 p.m. with the Wound Care Nurse she stated the wound care doctor started taking care of CR #1 for pressure sores on [DATE] when he saw CR #1 for the first time. The Wound Care Nurse stated she started working at the facility in [DATE]. She stated the assigned nurse of whoever was taking care of CR #1 on ,d+[DATE] or ,d+[DATE] identified that CR #1 had 3 pressure sore areas and they were debrided and they all kept getting worse at unstageable to right buttock 7.5 by 3.5, unstageable left buttock and it was 5.5 x 2.5 and the 3rd site was an unstageable DTI on the right buttocks 9 x 0.8. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on [DATE] after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already placed on the bed. The Wound Care Nurse stated she finished CR#1's wound care on [DATE] and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks or the back of legs even if it is non pressure wounds and that is when they determine the resident can have an air mattress. In an interview on [DATE] at 3:31 p.m. with CR#1's Family member she stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1's family stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. In an interview on [DATE] at 4:05 p.m. with the Maintenance Assistant he stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that is all he does. In an interview on [DATE] at 5:06 p.m. with the DON she stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. In an interview on [DATE] at 12:15 p.m. with the Wound Care Nurse she stated CR#1 was being put on the air mattress on [DATE]. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed and she positioned CR#1 on her side on [DATE] to do the wound. In an interview on [DATE] at 10:25 a.m. with LVN C she stated she had worked with CR#1. She stated she was total care and unable to move by herself. In an interview on [DATE] at 11:27 a.m. with CNA A she stated she took care of CR#1. CNA A stated she was here at the facility when CR#1 had her fall on [DATE]. She stated the wound care nurse did not come to tell her that CR#1 was on her side or that she (CR#1) needed changing. CNA A stated she heard the Wound Care Nurse was looking for her but it was too late then. CNA A stated CR#1 did not have any rails and she did not recall any pillows around CR#1. CNA A stated she was surprised CR#1 was on the floor because she was not able to move herself around the bed. She stated for CR#1 to be on the floor that means she was in a position she should not have been in because CR#1 could not move. CNA A stated she did not remember CR#1 getting an air mattress. CNA A stated it takes 2 staff to put a resident on Hoyer lift and CR#1 needed 2 people to help her with ADL's and bed mobility because she could not move. CNA A stated CR#1 just laid there in the bed like she did not want to be bothered. She stated sometimes CR#1 would moan when she (CNA A) moved her around in the bed and she did not want to be touched on. In an interview on [DATE] at 10:16 a.m. with LVN A she stated when CNA A called her on [DATE], she was in another room taking care of another resident and when she got there CR#1 was trying to grab with both hands holding the edge of the bed. She stated CR#1 should not have been left on her side. In an interview on [DATE] at 11:12 a.m. with Charge Nurse A she stated the Hoyer Lift was a 2 person lift used for transfers and to do weights and it is not ok to transfer someone without assistance. She stated when installing an air mattress they can put the air mattress to the side of the bed and have maintenance to air it up on the side of the bed while the patient is still in the bed. She stated once the air mattress is aired up they get the patient up and put the resident in the bed. In an interview on [DATE] at 12:50 p.m. with the Wound Care Nurse she stated she should have had a 2nd person with her when she was going to do CR#1's wound care from the beginning. She stated she should have had 2 people because CR#1 was a 2 person assist. The Wound Care Nurse stated CR#1 was positioned comfortably on her side, she did not think anything was wrong with her positioning. In an interview on [DATE] at 1:29 p.m. with CNA A she stated she was in-serviced on Hoyer lift and she stated it took 2 people to transfer with the Hoyer lift. She stated there was never a time it is acceptable to only have 1 person with a Hoyer lift. She stated she never transferred CR#1 on Hoyer lift. CNA A stated she never saw the wound care nurse on [DATE], and nobody told her CR#1 needed to be changed. In an interview on [DATE] at 12:46 p.m. with the DON she stated she did not know why the wound care nurse did not have 2 staff present with her. The DON stated the Therapy department completed the in-service on Hoyer Lifts. They did in-service on 2 person assist and always have 2 people on Hoyer's. She stated the care plans should be updated and make sure they are patient specific. In an interview on [DATE] at 2:47 p.m. with CR#1's family member she stated she came to the facility everyday. She stated on [DATE] that was the first time she saw the wound nurse. She stated she asked the wound nurse for an air mattress and maybe 2 or 3 days later they still had not done the air mattress. She stated CR#1 fell off the bed on [DATE] because the wound nurse left CR#1 all the way to the side of the bed on the edge on her side. CR#1's family member stated she spoke with the Wound nurse and she said she guessed she left CR#1 on her side and left her too close to the edge, but she said she went to tell the aide CR#1 needed to be changed. She stated CR#1 did not get the air mattress the day the Wound Care Nurse found the wound. CR#1's family member stated the next day on [DATE], they brought the air mattress to CR#1's room and it sat on the floor for 2 days not aired up. CR #8 Record review of CR#8's face sheet dated [DATE] revealed CR #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with dementia, unspecified severity, with other behavioral disturbance, osteoarthritis, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, insomnia, cachexia, overactive bladder, major depressive disorder, recurrent, severe with psychotic symptoms and hallucinations. Record review of CR#8's Care Plan dated [DATE] revealed, CR#8 had delusions and was at risk for injury with interventions to report delusions in the clinical record, notify MD of changes in behavior, psychiatric consult as needed. CR#8 resident in Memory Care Unit for impaired cognition secondary to diagnosis of dementia, elopement risk, wandering with interventions to call resident by name when giving care, explain procedures, keep environment free of possible hazards .He also took psychotropic medication and was at risk for adverse reactions and episodes of driven behavior as evidenced by taking anti-psychotic with interventions to give medication as ordered, monitor each behavioral episode for frequency, intensity, duration and document in the clinical record .He was at risk for falls and injuries as evidenced by unsteady gait, confusion with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is in reach and answer promptly, keep frequently used items at resident bedside, monitor for incontinent episodes-provide peri care as indicated and therapy to screen resident. Evaluate/treat per order. Self care deficits was identified with interventions to anticipate needs-provide prompt assistance, ensure light is within reach and answer in a timely manner, provide (extensive) assistance of (,d+[DATE] support persons for bed mobility, provide extensive assistance of (,d+[DATE] support persons) for transfers and provide (Supervision/Set up) assistance of (,d+[DATE] support persons for eating and staff to monitor for tolerance of intake, provide total assistance of (1 support person) for toileting/incontinent care and provide privacy and maintain dignity. CR#8 was identified for being at risk for wandering as evidenced by dementia/Alzheimer's and he was full code. Record review of CR#8's Care Plan did not reveal he was care planned for behaviors such as playing with his bed remote or rearranging furniture. Record review of CR#8's MDS assessment dated [DATE] revealed a BIMS Summary score of 3 indicating severe cognitive impairment, no behaviors exhibited, verbal behavior occurred 4 to 6 times, the functional status revealed bed mobility, transfer, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with one person physical assist and limited assistance for walking in room and corridor, and locomotion on unit. Record review of CR#8's physician orders revealed: Observation: Behaviors, target behaviors (Hallucinations, Aggression, Wandering, Depressive Feature) every shift Monitor resident for presence of behaviors. Document yes or no to whether behaviors were observed? Notify MD as needed for behaviors. Started on [DATE] Observation: Pain-observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PN's. every shift. Started on [DATE]. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 5 mg by mouth one time a day related to essential (primary) hypertension (110) Hold for systolic blood pressure <110, diastolic blood pressure <60, pulse <60. Started on [DATE] Aricept Oral tablet 10 mg (Donepezil Hydrocholoride) Give 0.5 tablet by mouth one time a day for dementia started on [DATE] Gemtesa Oral tablet 75 mg (vibegron) give 1 tablet by mouth one time a day related to overactive bladder started on [DATE] Megestrol Acetate oral suspension 400 mg/10ml (Megestrol Acetate) give 10 ml by mouth two times a day for loss of appetite started on [DATE] Memantine HCl oral tablet 10 mg (Memantine HCl) give 10 mg by mouth two times a day for dementia started on [DATE]. ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 1 inhalation inhale orally every 6 hours as needed for COPD started on [DATE] ProMod Oral Liquid (Nutritional Supplements) give 30 ml by mouth three times a day related to unspecified protein-calorie malnutrition started on [DATE]. Tylenol Oral tablet 325 mg (Acetaminophen) give 2 tablets by mouth every 6 hours as needed for OA related to unspecified osteoarthritis started on [DATE]. Record review of CR#8's Facility Provider Investigation Report dated [DATE] and reported to the State on [DATE] at 1:50 p.m. revealed Incident Category Death on [DATE] at 6 a.m. in resident's room. CR#8 functional assistance was total assistance in Memory Care. CR#8 was independently ambulatory, not interviewable, no capacity to make informed decisions and not wearing a wander guard at time of incident. Description of the allegations: Allegedly while the CNA was making her rounds she observed the resident lying on the floor in his room unresponsive. LVN E immediately assessed the resident (CR#8) noting bleeding from the right side of the forehead, resident unresponsive. Staff in-service initiated on fall prevention. Investigation Summary: Based on the information provided this investigation, while making AM rounds the CNA observed the resident lying on the floor in his room unresponsive. Per the CNA, she started her rounds at 10:00 p.m. the resident was in bed resting. Rounds were made again at 12:00 a.m. and then at 2 am, resident was resting in bed. When the CNA made rounds at 4 AM she noted the resident lying on the floor. She went into the room, called his name but did not get a response. The CNA immediately notified the Charge Nurse of her findings. The Charge Nurse immediately assessed the resident noting blood on the right side of his forehead and resident unresponsive. Resident continued to be unresponsive and was pronounced by the EMS. Record review of County EMS date of Service [DATE] with primary role: Medic Transport, Paramedic, Ambulance Response Info: Nature of Call: Cardiac Arrest/Death, Patient found: On floor, Initial Patient Acuity: Dead without Resuscitation Efforts (Black) . Disposition: Type of Service 911 Response (Scene) Outcome: Dead at Scene- No Resuscitation Attempted- No Transport Record review of police body camera dated [DATE] at 4:58 a.m. revealed Paramedic stated the facility staff said they last saw CR#8 at 2 a.m. and he was okay and at 4:34 a.m. they were rounding and found CR#8. Observation of CR#8's room did not reveal a crash cart, nothing on the floor, no [NAME] bag observed. The police stated you can still see the blood right there. The Paramedic stated some facilities have a bed alarm. Police asked did the resident pee and pointed to something on the floor and EMS said they have no idea what that was on the floor. The paramedic stated he did not know what the facility policy was. Police officer was heard asking the facility for CR#8's paperwork and observation revealed LVN E was still trying to get the face sheet. LVN E stated at 2 a.m. CR#8 was still in bed and at around 4 am. LVN E stated they decided to start their morning job. The Police officer was observed asking LVN E did they have something for when residents fell out the bed, and LVN E stated the facility did not have anything. Observation revealed the Nurses station and there were no other nurses assisting LVN E at this time printing paperwork. LVN E was observed trying to Observation did not reveal a crash cart out or an [NAME] bag at the nurses station. LVN E was observed printing all CR#8's paperwork for the paramedic and the police. LVN E stated all the facility had was the call light that the resident may use when they need help. LVN E stated the CNA found CR#8 and CR#8 was diagnosed with dementia. LVN E was observed printing out the face sheet for the police officer. LVN E stated there was no DNR on record for CR#8 and he was full code. LVN E stated the full code was the first thing he checked. LVN E told the police officer that nursing homes did not allow bedrails. LVN E stated bedrails were considered a restraint. The police was heard asking for the paperwork and saying the facility smelled like urine. Observation revealed the police was saying something and they muted the body camera. LVN E stated CR#8 raised the bed and CR#8 fell out of the bed. The police stated CR#8 bled for a minute and the police said they probably could have saved him [CR#8]. Police was heard asking LVN E if anybody walked down that aisle and LVN E said no body walked down that aisle. The police asked if LVN E called his boss. LVN E said he would call his boss at 5:07 a.m. to tell his boss. The police officer stated he did not know what the cause of death would be because CR#8 fell . LVN E could be heard stating that 911 was at the facility and they were working with CR#8 and police was heard asking what did LVN E's boss say. LVN E stated the paramedics called the death at 4:46 a.m. LVN E was heard calling the family at 5:12 a.m. The police asked was CR#8's family member's coming to the facility and if they stayed far. The police officer asked where the family member's were coming from and she said she was not too far. Police asked how long it would take to get here and if they had a funeral home in mind. She said they need to get all the paperwork and call the funeral home. Police said the funeral home could not get the body yet because he needed to call the Medical Examiner. The family member said they would come after they get the paperwork for the funeral home. LVN E was heard telling the family member to wait until she got to the facility to call the funeral home. LVN E told the police he just spoke with the Director but said it was the DON. LVN E stated CR#8's doctor does not sign the death certificate in a situation like this. The police asked for the doctor information. The police said CR#8's room smells. The police asked LVN E to call for CNA C. LVN E was heard calling for CNA C to come. The police asked CNA C what happened and she stated the first time she rounded to see the residents was around 10 p.m. CNA C stated they check the resident's every 2 hours and her next round was around 2 a.m. and he was laying in bed face up. CNA C stated at 2 a.m. CR#8 had been in the room fumbling around and picking stuff of the floor. CNA C stated after 4 a.m. she saw CR#8 on the floor and ran back out the room. CNA C stated she kind of touched CR#8 and said LVN E went into the room and she saw CR#8's blood. She stated when she saw CR#8, he was facing on the side downward. She said the bed was not high when she went into the room. She grabbed LVN E and LVN E touched CR#8. On [DATE] at 5:26 a.m. CR#8's family member spoke with the police and he told her they could not call the funeral home now because he had to call the medical examiner. He said the funeral home will have to get the body from the medical examiner. She said she had the mortuary for the funeral home. The Police asked what time they were coming to the facility. Police said they could start heading towards the facility. He said he was sorry for their loss. The police continued with CNA C and she stated CR#8 was cold to the touch and that CR#8 got hit on the left side of the temple and that was where the blood was coming from. LVN E heard that the iron tire on the bed was where CR#8 hit. Before he hit the ground he hit a metal piece that was attached to the bed. Police called the medical examiner at 5:36 a.m. LVN E stated he just spoke with CR#8's family member. LVN E told the police CR#8 was a full code. Police stated the facility staff did not hear CR#8 fall. Police was observed asking LVN E to print CR#8's physician orders. Observation did not reveal any other nurses printing any paperwork or assisting LVN E with anything. Observation revealed the police had the SILK test and the police said he would give it to the medical examiner. Case number ,d+[DATE]. Record review of Police body camera on [DATE] at 6:02 a.m. Resident observed laying on his back with both arms across his chest. Observation revealed blood at the head of roommates bed. Police observed walking down the hallway towards the Nurse Station. LVN E stated the roommate was walking in the hallway right now. The police stated the room and CR#8's body needed to be cleaned and he said the room smelled. They have to clean that room and they are going to come get the body. Police stated CR#8 peed in the bed. Police asked LVN E to call the family member at 6:05 a.m. CNA C was heard saying that CR#8 continued to raise the bed up and mess with the bed remote. The police said the family member could not come look at the body like that. The police spoke with the family member and said the body will be transported and they will not be able to see the body right now and the family member was already in the car right now. He said he could not let them see the body like this. ,d+[DATE]F for Medical Examiner and the number is [DATE]. Police instructed them to say case in regards to her father and the medical examiner is [NAME], [NAME]. The police said he could not let them see the body like this. They will pick the body up in the next 30 minutes. Record review of police body camera video dated [DATE] at 6:26 a.m. revealed 911 Police instructing LVN E tell to write specifics on the report stating CR#8 had a hole in the right temple of the head at 6:26 a.m. Police officer was heard asking how was CR#8's body was so close to the other bed (roommates bed) in the room. LVN E stated the foot of CR#8's bed was always up. LVN E was heard saying the bed was all the way up when he found CR#8. LVN E stated when he went into the room LVN E put the bed down low. CR#8 was found on his side. The black thing on the edge of the bed is metal and this is where CR #8's head was found. LVN E stated CR#8 liked to move his bed and his bed was moved all the way by the roommates bed. Observation revealed Police said he had the staff to remove roommate out of the room. CR #8 body's was observed on the floor with both of his arms across his chest. Observation of CR#8's room on the video did not reveal a crash cart, [NAME] bag and no other staff assisting LVN E. Observation of the body camera video revealed Police was heard asking how he can lift the bed up and he was heard asking for CR#8's bed remote. Observation revealed blood on the floor by roommates bed. Record review of 29 photographs taken on [DATE] of CR#8 and CR#8's room by First Responders revealed a large amount of blood on the floor and bed wheel of the (resident's) roommate. The blood was both smeared and puddled. CR#8 was observed laying at the end of his own bed with his feet towards the door. His arms were resting on his chest. HE was wearing socks and a gown. A puddle of blood was on the floor by his head. CR#8's eyes were open, mouth was closed. CR#8 was observed with a wound (appeared to be a hole) to right side of his head above his eye. The bed was observed to have 3 stacked pillows at the head of the bed. The pictures revealed the head of CR#8's bed was lower than the foot of the bed. One photograph revealed the bed was in a low lying position, head of bed lower than the foot of bed. A separate photo of the bed revealed the bed was in a raised position, the head of bed was lower than the foot of bed. Call light was attached to CR#8's) and roommates bed. Observation revealed there was a small amount of blood on the roommates call light cord. There was no blood visible on CR#8's bed. In a telephone interview on [DATE] at 1:25 p.m. with CNA C she stated she worked the night shift in the Memory Care Unit from 10pm-6am and had been working on the unit for a year. CNA C said when she arrived to work on [DATE] at 10:00pm she made rounds on the residents and that CR#8 was sleeping in bed with the bed in low position with no concerns identified. She said she made rounds on the residents every 2 hours going in the resident's room making sure they were breathing and doing okay. CNA C said she made rounds again at 12:00am and 2:00am with CR#8 continuing to rest quietly in bed with bed in low position and bed had not been moved. She said when she went to check on CR#8 again at 4:00a.m., she found CR#8 on the floor in his room with his head somewhat under his roommate's bed and thought resident was resting on his left side but was not certain but resident (CR#8) was not responding when she started calling his name. CNA C said resident bed was still in the low position and the bed had not been moved. She said CR#8 could walk and dress himself always rearranging stuff in his room such as his table. CNA C said CR#8 did have the behavior of liking to play with the bed remote a lot raising the bed in the highest position or raising the head or foot of bed putting in different positions. In an interview on [DATE] at 12:19 p.m. with LVN E he stated on [DATE] at first CR#8 was in bed the last time they saw him was 2 a.m. and around 4:15 a.m. LVN E stated he was giving meds and CNA C started changing the residents. He stated CNA C went to CR#8's room to change him and when she entered the room CNA C came out running and calling his name. LVN E stated he asked what was going on and CNA C said come, come, it looks like [CR#8] fell out of his bed and they found CR#8 between his bed and his roommate's bed because CR#8 pushed his bed close to his roommate's bed. LVN E stated CR#8's bed was able to move. CR#8 was lying on his right side and CR#8's forehead was against the head of his roommate's bed on the tire. LVN E stated CR#8's head came s [TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident's right to be free from neglect for 8 of residents (CR#1, CR#2, Residents #3, #4, #5, #6, #7 and CR#8) of 9 reviewed for neglect. The facility failed to oversee the implementation of resident care policies and failed to ensure residents received appropriate wound care and CPR and were free of accidents and injuries. The facility Administration failed to thoroughly and accurately investigate the incident of CR#8 being found unresponsive with a laceration, requiring emergency services, and passing away at the facility, therefore, not identifying and correcting the CPR failures. The facility failed to ensure the administration and nursing staff were educated on CPR. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. The facility failed to follow physician orders and treat pressure wounds for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. The facility failed to practice safe positioning for CR #1 when she was placed on her side, left alone and CR #1 had an unwitnessed fall. An Immediate Jeopardy (IJ) was identified on [DATE] at 4:46 p.m. The IJ template was provided to the facility on [DATE] at 4:46 p.m. While the IJ was removed on [DATE] at 3:50 p.m., the facility remained out of compliance at the severity level of actual harm that is not immediate jeopardy, and a scope of pattern while the facility continued to monitor the implementation of effectiveness of their plan of removal. A second Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that was Immediate Jeopardy due to the facility's needs to evaluate the effectiveness of the corrective systems. These failures placed residents at risk of neglect and not having their care needs met, receiving treatments, which could cause a decline in physical and psychosocial health or even death. Findings included: CR #1 CR #1 was a [AGE] year old female who was admitted to the facility on [DATE] and re admitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated [DATE] revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and is at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and is at risk for skin breakdown as evidenced by cognitive impairment, ADL self care deficits and is at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on [DATE], risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Review of care plan with closed date [DATE] revealed CR #1 had pressure wound. stage 4 buttock and DTI (Deep Tissue Injury) to the right ischium. Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene were extensive assistance with 2 person assisting, transfer was activity occurred once or twice with 2 person assisting and bathing, and she was totally dependent for bathing with 2 person assist. Review of MDS dated [DATE] section revealed CR #1 was identified as at risk for pressure ulcers/injuries. Review of MDS dated [DATE] section M0300 revealed CR #1 had pressure ulcers. Review of Treatment Administration Record for the month of April and [DATE] revealed there were no documentation of wound care provided to CR#1 on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. Review of physician order dated [DATE] revealed the following: Left Buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Right buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Right Ischium Unstageable DTI: Cleanse with normal saline, pat dry, apply house barrier cream daily. Review of skin assessment during admission on [DATE] reveal CR #1 only had redness under her bilateral breast. Record review of facility weekly skin assessment for the month of February and [DATE] revealed there were no skin assessments done for CR #1 in the months of February and [DATE]. Further review revealed there were no weekly skin assessment for CR#1 in the month of [DATE], until [DATE]th when three wounds were first identified. The skin assessment on [DATE] revealed the following: Wound #1 was acquired in the facility, first observation, size was (length x width x height) 7.5cm x 5.3cm x 0.0cm. Wound #1 was identified as pressure wound at the right buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage, no odor, peri wound tissue was described to have redness and wound edges well defined. Stage of the wound was not documented, Wound #2 acquired in the facility, first observation, size was (length x width x height) 5.5cm x 2.5cm x 0.0cm. wound #2 was identified as pressure wound at the left buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage and no odor, peri wound tissue was described having redness and wound edges well defined. Stage of the wound was not documented, Wound #3 acquired in the facility, first observation, size was (length x width x height) 9.0cm x 0.8cm x 0.0cm. wound #3 was identified as pressure wound at the right ischium, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, no drainage and odor, peri wound tissue was described as normal and wound edges well defined. Stage of the wound was not documented, Record review of CR#1's progress notes dated [DATE] at 4:45 p.m. by The Wound Care Nurse revealed, Patients assigned nurse notified me of skin injury to patient. Skin &Wound assessment done with indications of pressure injuries to right & left buttocks and deep tissue injury to the right ischium. [Wound Care Doctor] notified and new orders given for wound treatment as indicated . Record review of CR#1's family members text message dated [DATE], at 5:16 p.m. revealed, Painful [CR#1] was suspended by a lift to keep her off the bed while they put blow up mattress on her bed to help with bed sores. I was trying to hold her head up the whole time by bracing my leg up on the metal part of the bed and stacking pillows on to my knee to it touched [CR#1's] head. Awful but not torture. Her legs were dangling and that was hurting so once the Nurse left, I stacked pillows until they reached under her leg. The Nurse came back and argued with me that the bed wouldn't fill with air with the pillows, and I said the man said the bed would inflate regardless and she said he didn't say that and said, well if you want it to never inflate and her stay dangling forever and walked out. The mattress filled with air just fine and I'm so thankful I was here. They would have left her neck/head with no support just dangling like her legs if I hadn't had been here. I do thank God for that. I can't even begin to understand what she would have gone through. I talked to the Dr. today and he did up one of her pain patch meds. I told him she's still not on Hospice because she is Medicaid pending but with Palliative Care, we're trying to keep her comfortable and she isn't comfortable. So at least a little more pain meds but it still isn't enough. Record review of CR#1 family member text message dated [DATE] at 7:06 p.m. revealed, I forgot to tell you they forgot [CR#1] and left her dangling .I was told the mattress would take 20 min to fill so after 30 min the mattress felt full and read normal. I waited another 15 minutes then headed to the Nurse Station. Finally, the Nurse came and lowered the sling on to the bed. She could have been there for hours. Record review of CR#1's progress notes dated [DATE] revealed no notes regarding CR#1 being left dangling on a Hoyer lift without staff present. Record review of LVN A's text message to NP dated [DATE] at 1:33 p.m. revealed, Good morning Just letting you know that [CR#1] fell from her bed, no injuries vital signs ok, she stated that she was trying to sit on the wheelchair and NP response revealed Ok thanks. Record review of CR#1 progress notes dated [DATE] at 1:34 p.m. by LVN A revealed, Resident fell from the bed, no injuries, vital sign ok, RP, NP all notified, Neuro check in progress. Record review of CR#1's Neurological Evaluation Flow Sheet dated [DATE] revealed: Eyes Open to: Spontaneously, to Speech, To Pain, None was not documented on [DATE] at 1:30 p.m., 1:45 p.m., 2 p.m., 2:15 p.m., 2:30 p.m., 2:45 p.m., 3 p.m. 4 p.m., 5 p.m., 6 p.m. [DATE] documented once during the shift 6 p.m. to 6 a.m. 2 to pain, [DATE] was not documented for pain at all. [DATE] at 2 p.m. and 8 p.m. documented 4 for spontaneously [DATE] at 6 (unknown a.m. or p.m.) documented 4 for spontaneously Record review of CR #1's SBAR (Change of Condition) dated [DATE] at 4:17 p.m. revealed, Resident fell out of bed, No injuries, position lying left arm .Resident fell out of bed with no injuries noted, vitals sign completed and correct, neuro check in progress .Recommendation monitor vital signs, x ray/ultrasound/ekg, other . Record review of CR#1's family member text message dated [DATE] at 9:48 p.m. revealed, Poor [CR#1] fell off her bed today between 12 and 1 PM, right before I got there .The Nurse said they checked her out and she seemed to be ok. After taking to the Nurse, a while to try to see how it could have happened, I found out that the Wound Nurse had just changed her bandage and I'm sure left her on her stomach because she needed the aide to change the diaper, but they all know if can take up to hours for an Aide to show up. Also, she left the bed as high as it goes up and she claims the aide was coming. Anyway, I told the Nurse that it hurts [CR#1] to lay on her stomach and being close to the edge of the bed managed to try to turn over and went off the bed. I told the Nurse to tell the Wound Nurse not to leave [CR#1] close to the edge or on her stomach. [CR#1] seemed to be really scared of anyone coming up to her except me .She (CR#1) said my head hurts then my body hurts, etc. I told her I know she fell on the floor because the stupid Nurse and it won't happen again. She kept saying help me help me off and on for the whole time I was there .I felt so bad for her. After I got there, she said don't leave .I checked her head while I was lightly rubbing her face and head and didn't feel any lumps. Praying she didn't break anything. The Nurse said they would check her out every day for 3 days. Record review of CR#1's Physician note dated [DATE] revealed, Uncontrolled pain, Patient currently on palliative care services, responsible party does not want any aggressive care, patient has a history of probable metastatic cancer, is on multiple pain medications, patient reported to be in uncontrolled pain at times as per her responsible party. Patient is currently not able to swallow medications. Hospice services not available due to insurance issues. Review of systems general: unreliable due to patients lethargy .bedbound, ulcers on bilateral buttocks .Uncontrolled, patient is currently on palliative services, patient appropriate for hospice services, hospice services not available due to insurance issues., patient currently on scheduled fentanyl 50 mcg patch per hour, methadone 10 mg p.o. daily, also Norco scheduled, pain reported to be uncontrolled, patient not able to take medications by mouth, have ordered sublingual morphine, 10 mg every 4 hours as needed for pain .Lethargy Patient has not been eating for several days, patient's responsible party does not want aggressive measures, continue with palliative care, goals of care palliative. Decline in condition expected due to patient's severe comorbidities. Continue with palliative care and symptoms control as much as possible. Pharmacy Orders: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution Take ,d+[DATE] ml under tongue every four hours as needed for pain . In an interview on [DATE] at 11:30 a.m. LVN A stated the CNA came and called her on [DATE] at around 12 p.m. and she found CR #1 on the floor. LVN A stated she assessed CR #1, and she was fine, and they checked on her for 3 days. She stated she notified the NP and CR #1's family member. LVN A explained CNA A was going to take care of CR #1's roommate and she found CR #1 on the floor. Record review and interview with LVN A did not reveal CR #1 had any x rays or labs completed. In an interview on [DATE] at 12:14 p.m. the Wound Care Nurse stated the wound care doctor started taking care of CR #1 for pressure sores on [DATE] when he saw CR #1 for the first time. The Wound Care Nurse stated she stated working at the facility in [DATE]. She stated the assigned nurse of whoever was taking care of CR #1 on ,d+[DATE] or ,d+[DATE] identified that CR #1 had 3 pressure sore areas and they were debrided, and they all kept getting worse at unstageable to right buttock 7.5 by 3.5, unstageable left buttock and it was 5.5 x 2.5 and the 3rd site was an unstageable DTI on the right buttocks 9 x 0.8. The Wound Care Nurse stated all the wounds became 1 before (all the wounds blended together and become 1 big wound) she passed away. The Wound Care Nurse stated CR #1 passed away while at the facility on [DATE]. The Wound Care Nurse stated on [DATE], CR #1's family member said she would not allow them to treat CR #1 without the lidocaine spray. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on [DATE] after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already on. The Wound Care Nurse stated CNA A had CR #1 most of the time and the nurse over her was LVN A. The Wound Care Nurse stated she went back the next day and CR #1 was already on it. Wound Care Nurse stated she did not recall the details of the day CR #1 got the air mattress because they had to use the Hoyer lift and put CR #1 up and put the mattress on and the CNA stayed with her. The Wound Care Nurse stated it took about 10 minutes and she told the CNA once it pumps up a little, although it was not finished just put CR #1 on and it would be enough cushion. The Wound Care Nurse stated she left the CNA that had her for that day stayed with the resident and they used pillows to help to hold her feet up and put a pillow at her back. The Wound Care Nurse stated she told the CNA (unknown) that she did not need to wait that long, and she thinks CR #1's family member came into the room. The Wound Care Nurse stated she left CR #1's room and the CNA was there. The Wound Care Nurse stated she could not recall what day, she did not even document about it. The Wound Care Nurse stated she finished CR#1's wound care and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. The Wound Care Nurse stated she did not document CR#1's fall. The Wound Care Nurse did check CR#1's clinical record and she stated that she does not see any notes about CR#1's fall on [DATE]. The Wound Care Nurse stated CR#1 did not have any injuries. The Wound Care Nurse stated she was told CR#1 had fallen but by the time she got into the room they had already picked her up. She stated CR#1 was found on her right side on the floor with her back on the bed. The Wound Care Nurse stated there was no blood, no wound, and the wound dressing was intact. The Wound Care Nurse stated CR #1's bed did not go all the way down but was the lowest that it could go. She stated she did not know if the facility reported the fall, she did not have injury and she thought they reported when there was injury. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks, or the back of legs even if it there were no pressure wounds and that was when they determine the resident can have an air mattress. In an interview on [DATE] at 3:31 p.m. CR#1's Family member stated everyday she showed up at the facility CR#1 was left wet all night long and they would change the resident once a shift. CR#1's Family member stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came, and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1 stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. CR#1's family member stated the Wound Care Nurse and maintenance left her in the room and CR#1 was on the Hoyer Lift in pain and she tried to put pillows to help her. She stated it was the time right before the night shift and everybody was already gone. CR#1's Family member stated she asked LVN A to come look and LVN A said Oh, I can put that back down and she said she cannot believe they left her (CR#1) like that. CR#1's Family member stated she even made the comment I can't believe they left her like this. She stated the maintenance person put the mattress up and it was the Wound Care Nurse and maintenance who were in the room. CR#1's family member stated she made it to the facility while they were lifting her up out of the bed with the Hoyer Lift. She stated CR#1's head was not lifted up. CR#1's Family member stated LVN A was also the one that told her that CR#1 had fallen out the bed about an hour after she arrived at the facility. She stated LVN A told her the Wound Care Nurse left her (CR#1) on her side and the bed was all the way up which made it a harder fall. CR#1's Family member stated CR#1 was really hurting, especially the next day. She stated CR#1 could have easily broken something on the inside. She stated if the facility had not left CR#1 in urine and poop she would not have had a wound. She stated during the day she did change CR#1 because she always found CR#1 dirty. She stated she would go and ask for help and it take them hours to come to change CR#1. She stated, pee and poop burns, so she changed CR#1 herself, but that did not have anything to do with why the facility did not change her at night. She stated she pushed the call button, and no one came, and CR#1 would say get her out of here. In an interview on [DATE] at 4:05 p.m. the Maintenance Assistant stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that was all he does. The Maintenance Assistant stated its takes about 30 minutes to an hour to air up the air mattress. He stated they should not put a resident down on an air mattress after 10 min because it is not fully inflated. He stated he does not stay in the room to wait for the air mattress to inflate. In an interview and Record review on [DATE] beginning at 4:20 p.m. LVN A stated CR#1's family member came and asked her to come look for a little bit, but she did not know it was so urgent. LVN A stated when she went to CR#1's room, she was in the Hoyer lift. She stated Maintenance was already gone. LVN A stated she was sorry she did not know it was something she could do because she thought it was a maintenance issue. She stated CR#1 was in the Hoyer lift and she was in the air, so she put CR#1 down into the bed and took the Hoyer lift. She stated she did not know who did that and put CR#1 in that position that day ([DATE]). She stated no one else was in the room. LVN A stated it was CR#1, her family member and her in the room. LVN A stated at the time CR#1's family member came to her and reported, it took about 10 to 15 minutes that CR#1's family member waited for her to come to the room. She stated before that she did not know how long CR#1 had been up in the Hoyer lift. LVN A stated the air mattress was fully inflated. LVN A stated she worked the 6 a.m. to 6 p.m. shift on [DATE]. LVN A stated when CR#1 had her fall there were multiple pillows in her bed and she was dirty because the CNA was going to her room to change her. LVN A stated the bed was in normal position and they assessed CR#1 for 3 days with no injuries. LVN A reviewed CR#1's clinical record and she stated the Doctor did not order labs or x rays. In an interview on [DATE] at 5:06 p.m. the DON stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. She stated she does not believe that someone left the resident with a family member hooked to a Hoyer lift. She said she would hate to believe that would happen. In an interview on [DATE] at 12:15 p.m. the Wound Care Nurse stated CR#1 was being put on air mattress and CR#1 was positioned over the bed on Hoyer Lift a few inches above the bed. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief, so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come, and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed, and she positioned CR#1 on her side to do the wound. In an interview on [DATE] at 12:03 p.m. the NP stated CR#1 had cancer, she was very sick, CR#1 was by CR#1's bed side, and CR#1 was unable to go to hospice. The NP stated she did not recall CR#1 having a fall and would have to look at the chart. The NP stated CR#1 had wounds that were being taken care of by wound care team. The NP stated she thought they did weekly skin assessments, and she gives wound care orders if she is notified. In an interview and Record review on [DATE] beginning at 12:21 p.m. the DON stated she was not working at the facility when CR#1 was at the facility. The DON stated she started working at the facility on [DATE], and CR#1 has a fall on [DATE]. The DON stated CR#1 had a fall out of bed no injuries, vital signs, neuro checks and the RP/NP were informed. The DON stated she did not see an assessment for CR#1. She stated the facility did a change of condition so that was considered an assessment and it said CR#1 fell out the bed. The DON stated the change in condition revealed the NP was informed and stated to start neuro checks and it did say x ray. The DON completed a record review of CR#1's clinical records and she did not see the x rays for [DATE]. The DON stated the only circumstance a resident should be left alone on a Hoyer lift was in an extreme emergency when you go to the door and scream for a nurse. She stated CR#1 should not have been left alone when hooked up to a Hoyer lift unless it was a 911 emergency situation. The DON stated CR#1 should not have been left for 45 minutes. In an interview on [DATE] at 2:50 p.m. the Administrator stated she did not recall who CR#1 was. She stated they discuss all of their incidents in the morning meeting. She stated she did not make a report to the State because there was no injury. She stated the nurse should do an incident report. She stated if the unwitnessed fall required a transfer out of the facility, then she would begin her investigation. In a telephone interview on [DATE] at 1:18 p.m. the NP stated on [DATE] the nurse said there was no visible trauma and CR#1 was able to move her extremities, and there was no hematoma. She stated she did not remember what the nurse (LVN A) told her. The NP stated she only went by what was documented, and she saw a lot of patients. The NP stated if the nurse says the fall was unwitnessed then it was unwitnessed, then she would assess the patient and tell her that if the patient did not have injuries, then start neuro assessments. She stated if there was a change in condition within 72 hours, they would do something else. The NP stated the Doctor saw CR#1 on [DATE]. She stated there was no definite time that they send patients out after a fall. The NP stated CR#1 could not tell her about her pain, but the nurses were taking care of CR#1. She stated the CNAs would pay attention and say CR#1 was grimacing more after a fall, then they would report. She stated if it was not documented then it did not occur when asked if the nurse informed her if there was a bruise on CR#1's head or body. The NP stated if it was not documented, there was an error of omission. The NP stated from her assessment and interview with the nurse (LVN A) she did not see an indication for diagnostics. She stated there was no change in condition and CR#1 had a terminal disease that CR#1's family member did not want treated. The NP stated Cr#1 was already on morphine; multiple pain meds, and a fentanyl patch and CR#1 was consistently being covered with pain meds. The NP stated death was imminent given her terminal disease and there was no increased pain. She stated the pain meds were efficient. The NP asked, Would an x ray have made more of a difference than a neurological assessment that was being carried out. In an interview on [DATE] at 10:25 a.m. LVN C stated she had worked with CR#1. She stated she was not here when CR#1 fell , but she was total care and unable to move by herself. She stated when they have a resident that has an unwitnessed fall, she lets the resident stay in the position and she would let the nurse know. LVN C stated she would take CR#1's vital signs, carry out her neuro checks to do their assessments and observations, take vitals and assess for pain, try to carry out range of motion to rule out fracture. She would notify her supervisor, Unit manager, call the doctor and the family member. She stated they put the resident back in bed after and they continue to monitor. She stated she would have completed the SBAR for change in condition and the questions on the SBAR are what happened, her opinion, should the patient be sent out. Whatever action she would take is based on the Doctor's order and that they use to fill out the SBAR. She stated most of the time they send the patient for an x ray order. LVN C stated the doctor's do not say no about an x ray because they are their eyes of the doctor. She stated most of the time they get an x ray stat order. LVN C stated the doctor sends them out sometimes, but the doctor's do not say no. LVN C stated CR#1 was alert and oriented x2 and was able to tell them she was in pain, up to a point and she was taking pain meds. She stated she was not lucid very much and was not able to communicate a lot, but she still made sense. LVN C stated before she does the SBAR, she would have spoken with the doctor already and that was the priority. She stated CR#1 was in a lot of pain because she had a big tumor on her neck. She stated as long as they left CR#1 alone in a state of rest she had no pain, but when they touched her, she had pain. If a resident is on anticoagulant, she would have sent the resident out of the building if they had an unwitnessed fall. LVN C stated CR#1 started morphine on [DATE] according to the Medication Administration Record. In an interview and record review on [DATE] at 10:56 a.m. Unit Manager A stated when there is an unwitnessed fall, she does an assessment to make sure the resident was ok and she does a quick assessment to make sure there are no injuries and no pain. Unit Manager A stated she does range of motion and a complete body assessment of all, checks for injuries, does neuro checks, SBAR, a risk assessment, nurse note, notify the doctor, family/RP, DON, and Administrator. She stated she documents the neuro checks on a neuro check list, does vitals on the neuro checks every 15 minutes for the first hour, every half an hour for the 2nd hour, every hour after the 2nd hour, every 4 hours after that, and then its every 8 hours and every day for 4 days. She stated if the patient does not have any injuries, they monitor them (the resident) and chart on them (the neuro checks) daily. Unit Manager A stated the Doctor, and the RP was notified. She stated she does the SBAR at the same time when she speaks with the Doctor/NP, and she likes to get the exact times. She stated the SBAR asks them some of the same questions, it asks the time you talk to the Doctor and the orders, and it asks the same question about when they speak with the RP and what their reaction was. Unit Manager A stated they document the SBAR with what they get from the Doctor and the nurse note will have the same information from the SBAR. She stated if the fall was unwitnessed, they are supposed to write it there because it asks them the question. She stated if the Doctor did not order an x ray, you don't check that. She stated on the SBAR they put what the Doctor said to do, and they always follow what the Doctor says to do. She stated if x ray was ordered then they call the x ray company. She stated it was up to the Doctor to make the decision to send the resident out or not. Unit Manager A stated they offered CR#1 nourishment, and pain meds and sometimes she took it and sometimes she did not. She stated around [DATE] CR#1 started having more pain and that was when she started getting morphine. Unit Manager A stated she was not here when CR#1 had the fall. In an interview on [DATE] at 11:27 a.m. CNA A stated she took care of

Based on interview and record review, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 9 residents (CR #8) reviewed for Administration, in that: The administration failed to ensure CR#8 received CPR in accordance with professional standards of practice on [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. These failures could affect all residents placing them at risk of the facility not being administered in a way to assist with physical, mental, and psychosocial needs. Findings include: Record review of CR #8's face sheet dated [DATE] revealed CR #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with dementia, unspecified severity, with other behavioral disturbance, osteoarthritis (degeneration of joint cartilage and the underlying bone), hypertension (high blood pressure), benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlarged), insomnia, cachexia (weakness and wasting of the body due to severe chronic illness), overactive bladder, major depressive disorder, recurrent, severe with psychotic symptoms and hallucinations. Record review of CR#8's Care Plan dated [DATE] revealed, CR#8 had delusions and was at risk for injury with interventions to report delusions in the clinical record, notify MD of changes in behavior, psych consults as needed. CR#8 resident in Memory Care Unit for impaired cognition secondary to diagnosis of dementia, elopement risk, wandering with interventions to call resident by name when giving care, explain procedures, keep environment free of possible hazards .He also took psychotropic medication and was at risk for adverse reactions and episodes of driven behavior as evidenced by taking anti-psychotic with interventions to give medication as ordered, monitor each behavioral episode for frequency, intensity, duration and document in the clinical record .He was at risk for falls and injuries as evidenced by unsteady gait, confusion with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is in reach and answer promptly, keep frequently used items at resident bedside, monitor for incontinent episodes-provide peri care as indicated and therapy to screen resident. Evaluate/treat per order. Self-care deficits was identified with interventions to anticipate needs-provide prompt assistance, ensure light is within reach and answer in a timely manner, provide (extensive) assistance of (,d+[DATE] support persons for bed mobility, provide extensive assistance of (,d+[DATE] support persons) for transfers and provide (Supervision/Set up) assistance of (,d+[DATE] support persons for eating and staff to monitor for tolerance of intake, provide total assistance of (1 support person's) for toileting/incontinent care and provide privacy and maintain dignity. CR#8 was identified for being at risk for wandering as evidenced by dementia/Alzheimer's and he was full code. Record review of CR#8's Care Plan dated [DATE] did not reveal he was care planned for behaviors such as playing with his bed remote or rearranging furniture. Record review of CR#8's MDS dated [DATE] revealed a BIMS Summary score of 3 indicating severe cognitive impairment, no behaviors exhibited, verbal behavior occurred 4 to 6 times, the functional status revealed bed mobility, transfer, locomotion off the unit, dressing, toilet use, and personal hygiene were extensive assistance with one-person physical assist and limited assistance for walking in room and corridor, and locomotion on unit. Record review of CR#8's physician orders dated? revealed the following: -Observation: Behaviors, target behaviors (Hallucinations, Aggression, Wandering, Depressive Feature) every shift Monitor resident for presence of behaviors. Document yes or no to whether behaviors were observed? Notify MD as needed for behaviors. Started on [DATE] Record review of CR#8's Facility Provider Investigation Report dated [DATE] and reported to the State on [DATE] at 1:50 p.m. revealed Incident Category Death on [DATE] at 6 a.m. in resident's room. CR#8 functional assistance was total assistance in Memory Care. CR#8 was independently ambulatory, not interviewable, no capacity to make informed decisions and not wearing a wander guard at time of incident. Description of the allegations: Allegedly while the CNA was making her rounds she observed the resident lying on the floor in his room unresponsive. The assessment was on [DATE] at 6 a.m. Name and title of person who completed assessment was LVN E, with the description of assessment: Description of assessment including extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in resident's behavior that is different from the normal baseline. LVN E immediately assessed the resident (CR#8) noting bleeding from the right side of the forehead, resident unresponsive CPR initiated and 911 was called. The incident was reported to the police and CPR initiated, notification to DON, Administrator, staff in-service initiated on rounds, supervision, fall prevention. Investigation Summary: Based on the information provided this investigation, while making AM rounds the CNA observed the resident lying on the floor in his room unresponsive. Per the CNA, she started her rounds at 10:00 p.m. the resident was in bed resting. Rounds were made again at 12:00 a.m. and then at 2 am, resident was resting in bed. When the CNA made rounds at 4 AM she noted the resident lying on the floor. She went into the room, called his name but did not get a response. The CNA immediately notified the Charge Nurse of her findings. The Charge Nurse immediately assessed the resident noting blood on the right side of his forehead and resident unresponsive. CPR was initiated and 911 was called. Resident continued to be unresponsive and was pronounced by the EMS. As a result of the incident, the facility could not rule out a cardiac or neurological event prior to falling. The family and physician were notified. The investigation findings were inconclusive. Record review of Fall assessment dated [DATE] at 5:53 a.m. with incident description: The CNA made her regular round at 10:25pm, 2 am. Then started her morning job at 4 am. When she went in there and found the resident on the floor unresponsive. Immediate Action Taken: She run and called me. I came in and observed resident on the floor by the bed side. Resident was bleeding from the head and was unresponsive. CPR initiated. 911 called. Injury type: laceration, Injury location: top of scalp, mobility: wheelchair bound. Record review of police body camera dated [DATE] at 4:58 a.m. revealed Paramedic stated the facility staff said they last saw CR#8 at 2 a.m. and he was okay and at 4:34 a.m. they were rounding and found CR#8. Observation of CR#8's room did not reveal a crash cart, nothing on the floor, no [NAME] bag observed. The police stated you can still see the blood right there. The Paramedic stated some facilities have a bed alarm. Police asked did the resident pee and pointed to something on the floor and EMS said they have no idea what that was on the floor. The paramedic stated he did not know what the facility policy was. Police officer was heard asking the facility for CR#8's paperwork and observation revealed LVN E was still trying to get the face sheet. LVN E stated at 2 a.m. CR#8 was still in bed and at around 4 am. LVN E stated they decided to start their morning job. The Police officer was observed asking LVN E did they have something for when residents fell out the bed, and LVN E stated the facility did not have anything. Observation revealed the Nurses station and there were no other nurses assisting LVN E at this time printing paperwork. LVN E was observed trying to Observation did not reveal a crash cart out or an [NAME] bag at the nurses station. LVN E was observed printing all CR#8's paperwork for the paramedic and the police. LVN E stated all the facility had was the call light that the resident may use when they need help. LVN E stated the CNA found CR#8 and CR#8 was diagnosed with dementia. LVN E was observed printing out the face sheet for the police officer. LVN E stated there was no DNR on record for CR#8 and he was full code. LVN E stated the full code was the first thing he checked. LVN E told the police officer that nursing homes did not allow bedrails. LVN E stated bedrails were considered a restraint. The police was heard asking for the paperwork and saying the facility smelled like urine. Observation revealed the police was saying something and they muted the body camera. LVN E stated CR#8 raised the bed and CR#8 fell out of the bed. The police stated CR#8 bled for a minute and the police said they probably could have saved him [CR#8]. Police was heard asking LVN E if anybody walked down that aisle and LVN E said no body walked down that aisle. The police asked if LVN E called his boss. LVN E said he would call his boss at 5:07 a.m. to tell his boss. The police officer stated he did not know what the cause of death would be because CR#8 fell . LVN E could be heard stating that 911 was at the facility and they were working with CR#8 and police was heard asking what did LVN E's boss say. LVN E stated the paramedics called the death at 4:46 a.m. LVN E was heard calling the family at 5:12 a.m. The police asked was CR#8's family member's coming to the facility and if they stayed far. The police officer asked where the family member's were coming from and she said she was not too far. Police asked how long it would take to get here and if they had a funeral home in mind. She said they need to get all the paperwork and call the funeral home. Police said the funeral home could not get the body yet because he needed to call the Medical Examiner. The family member said they would come after they get the paperwork for the funeral home. LVN E was heard telling the family member to wait until she got to the facility to call the funeral home. LVN E told the police he just spoke with the Director but said it was the DON. LVN E stated CR#8's doctor does not sign the death certificate in a situation like this. The police asked for the doctor information. The police said CR#8's room smells. The police asked LVN E to call for CNA C. LVN E was heard calling for CNA C to come. The police asked CNA C what happened and she stated the first time she rounded to see the residents was around 10 p.m. CNA C stated they check the resident's every 2 hours and her next round was around 2 a.m. and he was laying in bed face up. CNA C stated at 2 a.m. CR#8 had been in the room fumbling around and picking stuff of the floor. CNA C stated after 4 a.m. she saw CR#8 on the floor and ran back out the room. CNA C stated she kind of touched CR#8 and said LVN E went into the room and she saw CR#8's blood. She stated when she saw CR#8, he was facing on the side downward. She said the bed was not high when she went into the room. She grabbed LVN E and LVN E touched CR#8. On [DATE] at 5:26 a.m. CR#8's family member spoke with the police and he told her they could not call the funeral home now because he had to call the medical examiner. He said the funeral home will have to get the body from the medical examiner. She said she had the mortuary for the funeral home. The Police asked what time they were coming to the facility. Police said they could start heading towards the facility. He said he was sorry for their loss. The police continued with CNA C and she stated CR#8 was cold to the touch and that CR#8 got hit on the left side of the temple and that was where the blood was coming from. LVN E heard that the iron tire on the bed was where CR#8 hit. Before he hit the ground he hit a metal piece that was attached to the bed. Police called the medical examiner at 5:36 a.m. LVN E stated he just spoke with CR#8's family member. LVN E told the police CR#8 was a full code. Police stated the facility staff did not hear CR#8 fall. Police was observed asking LVN E to print CR#8's physician orders. Observation did not reveal any other nurses printing any paperwork or assisting LVN E with anything. Observation revealed the police had the SILK test and the police said he would give it to the medical examiner. Case number (deidentified) Record review of Police body camera on [DATE] at 6:02 a.m. Resident observed laying on his back with both arms across his chest. Observation revealed blood at the head of roommates bed. Police observed walking down the hallway towards the Nurse Station. LVN E stated the roommate was walking in the hallway right now. The police stated the room and CR#8's body needed to be cleaned and he said the room smelled. They have to clean that room and they are going to come get the body. Police stated CR#8 peed in the bed. Police asked LVN E to call the family member at 6:05 a.m. CNA C was heard saying that CR#8 continued to raise the bed up and mess with the bed remote. The police said the family member could not come look at the body like that. The police spoke with the family member and said the body will be transported and they will not be able to see the body right now and the family member was already in the car right now. He said he could not let them see the body like this. (deidentified) for Medical Examiner and the number is (Deidentified). Police instructed them to say case in regards to her father and the medical examiner is [NAME], [NAME]. The police said he could not let them see the body like this. They will pick the body up in the next 30 minutes. Record review of police body camera video dated [DATE] at 6:26 a.m. revealed 911 Police instructing LVN E tell to write specifics on the report stating CR#8 had a hole in the right temple of the head at 6:26 a.m. Police officer was heard asking how was CR#8's body was so close to the other bed (roommates bed) in the room. LVN E stated the foot of CR#8's bed was always up. LVN E was heard saying the bed was all the way up when he found CR#8. LVN E stated when he went into the room LVN E put the bed down low. CR#8 was found on his side. The black thing on the edge of the bed is metal and this is where CR #8's head was found. LVN E stated CR#8 liked to move his bed and his bed was moved all the way by the roommates bed. Observation revealed Police said he had the staff to remove roommate out of the room. CR #8 body's was observed on the floor with both of his arms across his chest. Observation of CR#8's room on the video did not reveal a crash cart, [NAME] bag and no other staff assisting LVN E. Observation of the body camera video revealed Police was heard asking how he can lift the bed up and he was heard asking for CR#8's bed remote. Observation revealed blood on the floor by roommates bed. Record review of County EMS date of Service [DATE] with primary role: Medic Transport, Paramedic, Ambulance Response Info: Nature of Call: Cardiac Arrest/Death, Patient found: On floor, Initial Patient Acuity: Dead without Resuscitation Efforts (Black) .(means dead without resuscitation efforts) Disposition: Type of Service 911 Response (Scene) Outcome: Dead at Scene- No Resuscitation Attempted- No Transport Barriers to Care: None noted Scene Delay: None/No Delay Times: Injury: 4:19 a.m. on [DATE] PSAP (Public Safety Answering Point): 4:34 a.m. on [DATE] Dispatch Notify: 4:34 a.m. [DATE] Received: 4:34 a.m. [DATE] Dispatch: 4:36 a.m. [DATE] En route: 4:37 a.m. [DATE] At scene: 4:42 a.m. [DATE] At Patient: 4:46 a.m. [DATE] In service: 5:09 a.m. [DATE] Body Area: Assessments and Comments: Body Area: Assessments and comments Airway Patent Breathing Absent Circulation Pulses-Carotid-Absent (0) Blood/Fluid loss ,d+[DATE] ml Pulses-Femoral-Absent Head Laceration External/Skin Cold: Dry Mental Status Unresponsive Neurological Not done Primary Impression: Death Secondary Impressions: Cardiac Arrest Cardiac Arrest Cardiac Arrest: Yes, Prior to EMS Arrival Arrest Etiology: Cardiac (Presumed) Resuscitation Attempted: Not Attempted-Considered Futile Arrest Witnessed by: Not witnessed Discontinued Reason: Obvious signs of death Patient Dead on Arrival: yes Pronounced Dead By: First Responder (Fire, Law, EMS) Time of Cardiac Arrest [DATE] 4:34 a.m. End of Cardiac Arrest Event: Expired in the field [DATE] at 4:48 a.m. Medic responded emergent for a 911 request for a cardiac arrest. Medic responded without delay from the station. Medic arrived on scene to find a [AGE] year-old male lying supine on the floor with signs of rigor mortis. The patient is apneic and pulseless. The nursing staff stated that they last saw the patient normal was around 2:00 a.m. The nursing staff stated that they found the patient on the floor and immediately called 911. The patient skin is cold and dry. The patient's jaw is stiff and unable to be moved. The patient's pupils are fixed and unreactive. The 4-lead (shows electrical activity of the heart) was applied to the patient. The patient was in asystole (heart stopped beating). The patient is DOA per protocol at 4:45 a.m. Scene was left with [PD]. Medic returned back in service. Record review of City Police Department Event Report dated [DATE] at 4:34 a.m. revealed, Call received [DATE] at 4:34 a.m. Call routed [DATE] at 4:34 a.m. Call take finished [DATE] 4:34 a.m. 1st Dispatch [DATE] 4:36 a.m. 1st En-Route [DATE] 4:36 a.m. 1st Arrive [DATE] 4:53 a.m. Last Clear [DATE] 7:14 a.m. Record review of Police Department Incident/Investigation Report dated [DATE] at 4:34 a.m., time reported [DATE] at 4:34 a.m. revealed: Crime Incident(s) Dead On Arrival Narrative: On [Wednesday] [DATE], at approximately 4:34 a.m., .Officers were dispatched to [facility]. A death investigation and a report was completed. On [Wednesday] [DATE], at approximately 0434 hours [4:34 a.m.], .a Police Officer for the City .was dispatched to [facility]. Upon arrival, I made contact with the on duty nurse who was identified as LVN E, The deceased male was identified as [CR#8], [ethnicity, gender, date of birth], .The CNA who was taking care of the deceased male was identified as [CNA C][ethnicity, gender, date of birth]. [CNA C], stated she went to [CR#8's], Room on [DATE] at approximately 10pm to check on him and she noticed he was doing fine. [CNA C], stated when she went to go check back on [CR#8], on [DATE], at approximately 2AM, she noticed he was alive. [CNA C], stated she left the room and returned at approximately 4AM on [DATE] and that`s when she noticed that [CR#8] had fallen out of his bed and struck the right side of his forehead on the ground. [CNA C] stated when she noticed [CR#8] was on the ground, She asked [LVN E] to come help her lift him up off the ground. [CNA C] stated when they touched [CR#8], he was already cold to the touch .medic 6:08 a.m. arrived on location and called the time of death on [DATE] at 4:46 AM. I asked [CNA C] how often they are supposed to check on their patient and she stated every two hours. I was advised by [LVN E] that [CR#8], was not on hospice. [LVN E] provided me with [CR#8's] doctor information, but he did not make contact with him while I was on location. While in the room, I did not notice any foul play. [CR#8`s] body was cold to the touch. There was blood on the right side of his bed. I observed [CR#8] to have a knot on the right side of his forehead. Photos of the room were taken of his body and the injury. [CR#8] was diagnose with the following, unspecified dementia, unspecified osteoarthritis, hypertension, benign prostatic, insomnia, constipation, cachexia, overactive bladder, major depression, and hallucination. The next of kin [CR#8's family member] [ethnicity, gender, date of birth], was notified of the death and was also advised that [CR#8's] body`s will be transported to the .Medical Examiner`s. Body car arrived on location on [DATE] at approximately 06:39 a.m. hours to transport the body to the .County Medical Examiner`s Office .Medical examiner ., provided me with their case number (deidentified)and took custody of [CR#8`s] body. The body bag zip tie sealed number was #(deidentified). While on scene, audio and video was recorded on my Utility body camera and in car camera in unit 2522. Record review of voice recording from 911 call made by LVN E revealed: he stated the address to the facility and that they find a patient by the bedside it looks like he has fallen from the bed he is unresponsive. He is in [room number, side of room letter]. He is not breathing. He is [AGE] years old, he is not breathing I checked. Record review of 29 photographs taken on [DATE] of CR#8 and CR#8's room by First Responders revealed a large amount of blood on the floor and bed wheel of the (resident's) roommate. The blood was both smeared and puddled. CR#8 was observed laying at the end of his own bed with his feet towards the door. His arms were resting on his chest. HE was wearing socks and a gown. A puddle of blood was on the floor by his head. CR#8's eyes were open, mouth was closed. CR#8 was observed with a wound (appeared to be a hole) to right side of his head above his eye. The bed was observed to have 3 stacked pillows at the head of the bed. The pictures revealed the head of CR#8's bed was lower than the foot of the bed. One photograph revealed the bed was in a low lying position, head of bed lower than the foot of bed. A separate photo of the bed revealed the bed was in a raised position, the head of bed was lower than the foot of bed. Call light was attached to CR#8's) and roommates bed. Observation revealed there was a small amount of blood on the roommates call light cord. There was no blood visible on CR#8's bed. In a telephone interview on [DATE] at 1:25 p.m. with CNA C she stated she worked the night shift in the Memory Care Unit from 10pm-6am and had been working on the unit for a year. CNA C said when she arrived to work on [DATE] at 10:00pm she made rounds on the residents and that CR#8 was sleeping in bed with the bed in low position with no concerns identified. She said she made rounds on the residents every 2 hours going in the resident's room making sure they were breathing and doing okay. CNA C said she made rounds again at 12:00am and 2:00am with CR#8 continuing to rest quietly in bed with bed in low position and bed had not been moved. She said when she went to check on CR#8 again at 4:00a.m., she found CR#8 on the floor in his room with his head somewhat under his roommate's bed and thought resident was resting on his left side but was not certain but resident (CR#8) was not responding when she started calling his name. CNA C said resident bed was still in the low position and the bed had not been moved. She said she did not see any blood at that time and ran out of the room to get the nurse. CNA C said when the nurse got to the room and turned resident on his back, she could see a lot of blood coming from his head and was not sure which side it was coming from. CNA C said LVN E went and called 911 while she stayed with CR#8 and after LVN E called 911, he came back and began CPR on CR#8. She said CR#8 could walk and dress himself always rearranging stuff in his room such as his table. CNA C said CR#8 did have the behavior of liking to play with the bed remote a lot raising the bed in the highest position or raising the head or foot of bed putting in different positions. CNA C said CR#8 did not like his roommate always saying get him out of here, but never witnessed him and the roommate getting in any physical altercations. CNA C said she had heard that on the day shift they may have had words at one time but that was hearsay. She said CR#8's roommate could walk but at the time of the incident, CR#8's roommate slept through the whole incident. In an interview on [DATE] at 10:37 a.m. with the DON she stated she spoke with LVN E when he called her and said CNA C on night shift was making rounds and went to assess CR#8 she noticed CR#8 was unresponsive. The DON stated LVN E said he started CPR, called 911 and 911 worked on CR#8 and 911 pronounced CR#8 deceased . The DON stated CR#8 would try to walk but use the wheelchair sometime. In an interview on [DATE] at 10:49 a.m. with CNA C she stated she found CR#8 and she let the LVN E know. CNA C stated she called CR#8's name and he was laying on his side on the floor halfway by his roommate's bed. CNA C stated she did not touch CR#8. She stated there was blood when the LVN E moved CR#8. She stated there was no fall mat and the bed was at the lowest level. She stated she saw CR#8 at 10 p.m., 12 a.m., 2 a.m. and 4 a.m. She stated she saw CR#8 at 2 a.m. sleeping, and she did not have to change him. CNA C stated she called LVN E and he came into the room and called CR#8's name. She stated LVN E touched CR#8 and moved him and that is when they saw the blood on CR#8's head. She stated she did not remember if LVN E stated CR#8 was cold or warm and LVN E touched CR#8's chest. CNA C stated LVN E called 911 with crash cart (carries instruments for CPR) and started performing CPR. She stated LVN E did chest compressions and the [NAME] bag (used to deliver positive pressure ventilation for respiratory support in CPR) and the CNA D came and CNA C let 911 in. CNA C stated she did not go back in the room. CNA C stated she could not explain the CPR process LVN E carried out. CNA C stated CR#8's roommate was in the room in bed and she did not pay attention to him when she found CR#8. CNA C stated at 2 a.m. CR#8's roommate was sleeping. She stated she saw LVN E with the [NAME] bag but not what he was doing with it because she ran to the front. She stated she saw chest compressions. In an interview and Record review on [DATE] at 11:54 a.m. with the DON of CR#8's clinical records revealed CNA C did rounds at 1:11 a.m. on [DATE] and CNA C went to do her other rounds at 4 a.m. and that is when CNA C found the resident (CR#8). The DON stated CNA C said 911 found CR#8 and worked on him for a good while. The DON stated LVN E called her when 911 was at the facility and said what happened. She stated LVN E called her back with bad news 35 minutes later and said 911 said they could not stabilize CR#8. The DON stated she could not answer whether CR#8 should be cold or warm when a resident died as far as time. The DON stated she could not say if a resident had a fall if he should be warm or not. She stated they do not do mouth to mouth anymore since Covid, now they put the bag ([NAME]) over the mouth and the bag is pushing the air in. She stated you do not have to have the resident's mouth open when using the [NAME] bag, it's a cuff that goes over mouth and nose so they are still getting the air in the mouth and nose. The DON stated LVN E stated 911 worked on CR#8 at the facility and she got 2 calls from LVN E. She stated LVN E called her back and said 911 will not take him (CR#8) and they would go ahead and pronounce CR#8. The DON stated she was not at the facility, and she was going by what was relayed to her. In an interview on [DATE] at 12:19 p.m. with LVN E he stated on [DATE] at first CR#8 was in bed the last time they saw him was 2 a.m. and around 4:15 a.m. LVN E stated he was giving meds and CNA C started changing the residents. He stated CNA C went to CR#8's room to change him and when she entered the room CNA C came out running and calling his name. LVN E stated he asked what was going on and CNA C said come, come, it looks like [CR#8] fell out of his bed and they found CR#8 between his bed and his roommate's bed because CR#8 pushed his bed close to his roommate's bed. LVN E stated CR#8's bed was able to move. CR#8 was lying on his right side and CR#8's forehead was against the head of his roommate's bed on the tire. LVN E stated CR#8's head came straight down on the tire. LVN E stated when he saw that he touched CR#8, he realized CR#8 was unconscious. He stated since CR#8 was between the beds, LVN E tried to push the bed back but it was all the way up and the bed was not going down. LVN E stated he and CNA C tried to push the bed to give them space to put CR#8 down. LVN E stated they were trying to start CPR and CR#8 was unconscious and bleeding from the head, so he ran to call 911, called a code blue for the nurses to come and help him and he started CPR. LVN E stated he kept doing the CPR and other nurses came printing the paperwork and doing other things. LVN E stated between the beds it was impossible to do the CPR because he was practically sitting on the bed doing the CPR and he was not comfortable, and he knew he was not doing it right and there was little space in between. LVN E stated he and CNA C decided to move CR#8 from that place and put him in another space and then 911 came and found them on that spot. LVN E stated 911 asked if they moved CR#8 and they said yes, they had to move him because the beds were so tight together and it was impossible to do CPR. LVN E stated CR#8's eyes were closed and he was still bleeding from the head. LVN E stated CR#8 was becoming cold, but the bleeding was still present, and that means there is circulation going on. LVN E stated you cannot evaluate with your eyes. He stated CR#8 started being cold, even when they moved him there was bleeding in the head and it was still coming out. He stated CR#8's mouth was opening at that time and the lady (LVN B) was doing the [NAME] bag while he did CPR. He stated he did chest compressions until 911 came and they came in less than 5 min. LVN E stated when 911 came, they plugged all their machines on him and started the process to bring CR#8 back and in a couple tries 911 said no, he (CR#8) was gone and after 15 minutes they called it. He stated CR#8 played with his bed remote a lot. He stated CR#8 played with the bed remote a lot because it was on the side of his bed. He stated you can just push the bed even with 1 foot and the bed would move and he stated the bed was all the way up. He stated he was sure CR#8 did it himself. LVN E stated there were no rails on CR#8's bed, he was not a fall risk, and there was no floor mat. LVN E stated CR#8 was able to get up and go to the bathroom. He stated they found CR#8's bed at different positions sometimes. LVN E stated CR#8 was so close to the roommate's bed that the head of CR#8's bed was almost touching the head of the roommate's bed. He stated he never said 911 would take CR#8, but they asked for all his paperwork like they usually did when they take the residents. He said they never found CR#8's bed so close to the roommate's bed and sometimes they put the remote far away but CR#8 was so smart he would feel for the remote on the side of the bed. LVN E stated maybe CNA C did not look at the time that she checked CR#8 because the last time she documented was 1:13 am. He stated since then he checks the residents every 45 minutes. He stated in Memory care they could say it was a quiet night, but in the next second thin [TRUNCATED]

Based on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (CR#1) of 9 residents reviewed for accidents, hazards, and supervision. -The facility failed to safely transfer CR #1 when the Wound Care Nurse used a Hoyer lift and left her in the air unattended for about 45 minutes until CR #1's family member alerted LVN A. -The facility failed to adequately supervise CR #1 who was cognitively impaired when the Wound Care Nurse positioned her on her side and left her unattended after wound care resulting in an unwitnessed fall. -The facility failed to thoroughly document 3-day neuro checks to monitor CR #1 after her fall. -The facility failed to adequately document and notify the physician of CR#1's fall. -The facility failed to complete an Incident Report and investigation on the fall. An Immediate Jeopardy (IJ) was identified on 07/28/23. The IJ template was provided to the facility on [DATE] at 5:25 p.m. While the IJ was removed on 08/5/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been trained on accidents and supervision, neglect, safe transfer, fall prevention, and adequate monitoring. These failures placed residents at risk for accidents and supervision, risk for falls, unsafe transfers, no safety interventions, improper use Hoyer lifts, no fall prevention measures causing pain, lower quality of life, falls with unknown harm and death. Findings included: CR #1 CR #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with malignant neoplasm of rectosigmoid junction (cancer between the sigmoid colon and rectum), fistula of vagina to large intestine (feces coming through the vagina), chronic pain syndrome, muscle weakness, muscle wasting and atrophy (decrease in size and wasting of muscle tissue), anxiety disorder, idiopathic peripheral autonomic neuropathy, encephalopathy (damage to the peripheral nerves), hypertension, bacteremia (bacteria in the blood), fracture of fifth lumbar vertebra, and fracture of lumbosacral spine and pelvis. Record review of CR #1's Care Plan dated 2/22/23 revealed CR#1 has a diagnosis of cancer and was at risk of increased weakness, weight loss, pain, depression, tiredness, death as evidenced by, receiving anticoagulant therapy and was at risk for increased bleeding, bruising, etc., bowel and bladder incontinence and was at risk for skin breakdown as evidenced by cognitive impairment, ADL self-care deficits and was at risk for further decline in ADL functioning and injury as evidenced by disease process with interventions being provide extensive assistance of (#2 support persons) for bed mobility, toileting/incontinent care and transfers. CR#1 complained of increased pain and was at risk for further episodes of increased pain/discomfort and injury with interventions/tasks to give pain medication, treatments, relaxation modalities, provide pressure reducing and positioning devices as needed. CR#1 was at risk for falls and injuries with goal to be free from falls and injuries over the next 90 days dated/revised on 2/22/23, risk for pressure wounds with interventions/tasks to assist with incontinent care, perform weekly skin checks, provide pressure reducing device for bed and wheelchair . Record review of Resident #1's Quarterly MDS dated [DATE] revealed Cognitive Pattern BIMS Summary Score was 00 indicating severe impairment. CR#1's functional status revealed walk in room and corridor, locomotion on/off unit did not occur, bed mobility, dressing, personal hygiene was extensive assistance with 2- person assisting, transfer was activity occurred once or twice with 2-person assisting and bathing, and she was totally dependent for bathing with 2-person assist. Record review of CR#1's family members text message to CR#1's family member dated April 27, 2023, at 5:16 p.m. revealed, Painful [CR#1] was suspended by a lift to keep her off the bed while they put blow up mattress on her bed to help with bed sores. I was trying to hold her head up the whole time by bracing my leg up on the metal part of the bed and stacking pillows on to my knee to it touched [CR#1's] head. Awful but not torture. Her legs were dangling and that was hurting so once the Nurse left, I stacked pillows until they reached under her leg. The Nurse came back and argued with me that the bed wouldn't fill with air with the pillows, and I said the man said the bed would inflate regardless and she said, he didn't say that and then said, well if you want it (air mattress) to never inflate and her stay dangling forever and walked out. The mattress filled with air just fine and I'm so thankful I was here. They would have left her neck/head with no support just dangling like, her legs, if I hadn't had been here. I do thank God for that. I can't even begin to understand what she would have gone through. I talked to the Dr. today and he did up one of her pain patch meds. I told him she's still not on Hospice because she is Medicaid pending but with Palliative Care, we're trying to keep her comfortable and she isn't comfortable. So at least a little more pain meds but it still isn't enough. Record review of CR#1 family member text message to CR#1's family member dated 4/27/23 at 7:06 p.m. revealed, I forgot to tell you they forgot [CR#1] and left her dangling .I was told the mattress would take 20 min to fill so after 30 min the mattress felt full and read normal. I waited another 15 minutes then headed to the Nurse Station. Finally, the Nurse came and lowered the sling on to the bed. She could have been there for hours. Record review of CR#1's progress notes dated 4/27/23 revealed no facility notes (documentation) regarding CR#1 being left dangling on a Hoyer lift without staff present. Record review of LVN A's text message to NP dated 5/10/23 at 1:33 p.m. revealed, Good morning just letting you know that [CR#1] fell from her bed, no injuries vital signs ok, she stated that she was trying to sit on the wheelchair and NP response revealed Ok thanks. Record review of CR#1 progress notes dated 5/10/23 at 1:34 p.m. by LVN A revealed, Resident fell from the bed, no injuries, vital sign ok, RP, NP all notified, Neuro check in progress. Record review of CR#1's Neurological Evaluation Flow Sheet dated 5/10/23 revealed: Eyes Open to: Spontaneously, to Speech, To Pain, None was not documented on 5/10/23 at 1:30 p.m., 1:45 p.m., 2 p.m., 2:15 p.m., 2:30 p.m., 2:45 p.m., 3 p.m. 4 p.m., 5 p.m., 6 p.m. 5/10/23 documented once during the shift 6 p.m. to 6 a.m. level 2 pain, 5/11/23 was not documented for pain at all. 5/12/23 at 2 p.m. and 8 p.m. documented 4 for spontaneously. 5/13/23 at 6 (unknown a.m. or p.m.) documented 4 for spontaneously Record review of CR #1's SBAR (Change of Condition) dated 5/10/23 at 4:17 p.m. revealed, Resident fell out of bed, no injuries, position lying left arm .Resident fell out of bed with no injuries noted, vitals sign completed and correct, neuro check in progress .Recommendation monitor vital signs, x-ray/ultrasound/ekg, other . Record review of CR#1's family member text message to CR#1's family member dated 5/10/23 at 9:48 p.m. revealed, Poor [CR#1] fell off her bed today between 12 and 1 PM, right before I got there .The Nurse said they checked her out and she seemed to be ok. After talking to the Nurse, a while to try to see how it could have happened, I found out that the Wound Nurse had just changed her bandage and I'm sure left her on her stomach because she needed the aide to change the diaper, but they all know if can take up to hours for an Aide to show up. Also, she left the bed as high as it goes up and she claims the aide was coming. Anyway, I told the Nurse that it hurts [CR#1] to lay on her stomach and being close to the edge of the bed managed to try to turn over and went off the bed. I told the Nurse to tell the Wound Nurse not to leave [CR#1] close to the edge or on her stomach. [CR#1] seemed to be really scared of anyone coming up to her except me .She (CR#1) said my head hurts then my body hurts, etc. I told her I know she fell on the floor because the stupid Nurse and it won't happen again. She kept saying help me help me off and on for the whole time I was there .I felt so bad for her. After I got there, she said don't leave .I checked her head while I was lightly rubbing her face and head and didn't feel any lumps. Praying she didn't break anything. The Nurse said they would check her out every day for 3 days. Record review of CR#1's Physician note dated 5/18/23 revealed, Uncontrolled pain, Patient currently on palliative care services, responsible party does not want any aggressive care, patient has a history of probable metastatic cancer, is on multiple pain medications, patient reported to be in uncontrolled pain at times as per her responsible party. Patient is currently not able to swallow medications. Hospice services not available due to insurance issues. Review of systems general: unreliable due to patients lethargy .bedbound, ulcers on bilateral buttocks .Uncontrolled, patient is currently on palliative services, patient appropriate for hospice services, hospice services not available due to insurance issues., patient currently on scheduled fentanyl 50 mcg patch per hour, methadone 10 mg p.o. daily, also Norco scheduled, pain reported to be uncontrolled, patient not able to take medications by mouth, have ordered sublingual morphine, 10 mg every 4 hours as needed for pain .Lethargy Patient has not been eating for several days, patient's responsible party does not want aggressive measures, continue with palliative care, goals of care palliative. Decline in condition expected due to patients' severe comorbidities. Continue with palliative care and symptoms control as much as possible. Pharmacy Orders: Morphine concentrate 100 mg/5ml (20 mg/ml) oral solution- Take 1/2 ml under tongue every four hours as needed for pain . In an interview on 7/26/23 at 11:30 a.m. with LVN A she stated the CNA came and called her on 5/10/23 at around 12 p.m. and she found CR #1 on the floor. LVN A stated she assessed CR #1, and she was fine, and they checked on her for 3 days. She stated she notified the NP and CR #1's family member. LVN A explained CNA A was going to take care of CR #1's roommate and she found CR #1 on the floor. Record review of CR#1's clinical records and interview with LVN A revealed CR #1 did not have any x-rays or labs completed after CR#1's fall on 5/10/23. In an interview on 7/26/23 at 12:14 p.m. the Wound Care Nurse stated the wound care doctor started taking care of CR #1 for pressure sores on 4/24/23 when he saw CR #1 for the first time. The Wound Care Nurse stated she stated working at the facility in March 2023. The Wound Care Nurse stated CR #1 passed away while at the facility on May 31, 2023. The Wound Care nurse stated when CR #1 got the wounds she would tell the staff to get the air mattress. She stated CR #1 got the air mattress on 4/25/23 after seeing the wounds. She stated by the time she got back to see CR #1 the air mattress was already on. The Wound Care Nurse stated CNA A had CR #1 most of the time and the nurse over her was LVN A. The Wound Care Nurse stated she went back the next day and CR #1 was already on it. Wound Care Nurse stated she did not recall the details of the day CR #1 got the air mattress because they had to use the Hoyer lift and put CR #1 up and put the mattress on and the CNA stayed with her. The Wound Care Nurse stated it took about 10 minutes and she told the CNA once it pumps up a little, although it was not finished just put CR #1 on and it would be enough cushion. The Wound Care Nurse stated she left the CNA that had her for that day stayed with the resident and they used pillows to help to hold her feet up and put a pillow at her back. The Wound Care Nurse stated she told the CNA (unknown) that she did not need to wait that long, and she thinks CR #1's family member came into the room. The Wound Care Nurse stated she left CR #1's room and the CNA was there. The Wound Care Nurse stated she could not recall what day, she did not even document about it. The Wound Care Nurse stated she finished CR#1's wound care and she let the CNA know she needed to be cleaned up. She stated she went out to tell the CNA (CNA A) that CR#1 needed to be cleaned up and CR#1 had fallen out of her bed. The Wound Care Nurse stated CR#1 rolled out of the bed from being on her side. She stated the facility had little rails and CR#1 was laying on her side because she had stool and the Wound Care Nurse did not want to put her back in the stool and she put pillows behind CR#1's back and positioned her. The Wound Care Nurse stated she did not document CR#1's fall. The Wound Care Nurse did check CR#1's clinical record and she stated that she does not see any notes about CR#1's fall on 5/10/23. The Wound Care Nurse stated CR#1 did not have any injuries. The Wound Care Nurse stated she was told CR#1 had fallen but by the time she got into the room they had already picked her up. She stated CR#1 was found on her right side on the floor with her back on the bed. The Wound Care Nurse stated there was no blood, no wound, and the wound dressing was intact. The Wound Care Nurse stated CR #1's bed did not go all the way down but was the lowest that it could go. She stated she did not know if the facility reported the fall, she did not have injury and she thought they reported when there was injury. She stated normally they determine when a resident needs an air mattress when they have an injury anywhere from the back down. The Wound Care Nurse stated the back, the buttocks, or the back of legs even if it there were no pressure wounds and that was when they determine the resident can have an air mattress. In an interview on 7/26/23 at 3:31 p.m. CR#1's Family member stated everyday she showed up at the facility CR#1 was left wet all night long and they would change the resident once a shift. CR#1's Family member stated when the facility finally got around to giving CR#1 an air mattress, the Wound Care Nurse and maintenance came, and she was in the room. CR#1's Family member stated there was no CNA in the room when the air mattress was being installed. CR#1 stated the Wound Care Nurse hooked CR#1 to the Hoyer lift and lifted her up to wait for the air mattress to fill up. CR#1's family member stated the Wound Care Nurse and maintenance left her in the room and CR#1 was on the Hoyer Lift in pain and she tried to put pillows to help her. She stated it was the time right before the night shift and everybody was already gone. CR#1's Family member stated she asked LVN A to come look and LVN A said Oh, I can put that back down and she said she cannot believe they left her (CR#1) like that. CR#1's Family member stated she even made the comment I can't believe they left her like this. She stated the maintenance person put the mattress up and it was the Wound Care Nurse and maintenance who were in the room. CR#1's family member stated she made it to the facility while they were lifting her up out of the bed with the Hoyer Lift. She stated CR#1's head was not lifted up. CR#1's Family member stated LVN A was also the one that told her that CR#1 had fallen out the bed about an hour after she arrived at the facility. She stated LVN A told her the Wound Care Nurse left her (CR#1) on her side and the bed was all the way up which made it a harder fall. CR#1's Family member stated CR#1 was really hurting, especially the next day. She stated CR#1 could have easily broken something on the inside. She stated if the facility had not left CR#1 in urine and poop she would not have had a wound. She stated during the day she did change CR#1 because she always found CR#1 dirty. She stated she would go and ask for help and it take them hours to come to change CR#1. She stated, pee and poop burns, so she changed CR#1 herself, but that did not have anything to do with why the facility did not change her at night. She stated she pushed the call button, and no one came, and CR#1 would say get her out of here. In an interview on 7/26/23 at 4:05 p.m. the Maintenance Assistant stated he helped a lot of residents and did not remember helping with CR#1. The Maintenance Assistant stated he takes the air mattress in the resident's room and put it on the bed. He stated he straps the air mattress down and set up the pump. He stated the air mattress has 3 straps, and he secures it to the bed, turns the air pump on and plug it in and that was all he does. The Maintenance Assistant stated its takes about 30 minutes to an hour to air up the air mattress. He stated they should not put a resident down on an air mattress after 10 min because it is not fully inflated. He stated he does not stay in the room to wait for the air mattress to inflate. In an interview and Record review on 7/26/23 beginning at 4:20 p.m. LVN A stated CR#1's family member came and asked her to come look for a little bit, but she did not know it was so urgent. LVN A stated when she went to CR#1's room, she was in the Hoyer lift. She stated Maintenance was already gone. LVN A stated she was sorry she did not know it was something she could do because she thought it was a maintenance issue. She stated CR#1 was in the Hoyer lift and she was in the air, so she put CR#1 down into the bed and took the Hoyer lift. She stated she did not know who did that and put CR#1 in that position that day (4/27/23). She stated no one else was in the room. LVN A stated it was CR#1, her family member and her in the room. LVN A stated at the time CR#1's family member came to her and reported, it took about 10 to 15 minutes that CR#1's family member waited for her to come to the room. She stated before that she did not know how long CR#1 had been up in the Hoyer lift. LVN A stated the air mattress was fully inflated. LVN A stated she worked the 6 a.m. to 6 p.m. shift on 4/27/23. LVN A stated when CR#1 had her fall there were multiple pillows in her bed and she was dirty because the CNA was going to her room to change her. LVN A stated the bed was in normal position and they assessed CR#1 for 3 days with no injuries. LVN A reviewed CR#1's clinical record and she stated the Doctor did not order labs or x-rays. In an interview on 7/26/23 at 5:06 p.m. the DON stated there were different times when it is appropriate for an air mattress. She stated it was not necessary that the resident is bed bound that a resident receives an air mattress. The DON stated they have to look at the patient and the situation of the patient and they look at every individual case. The DON stated they normally do full body assessments upon admission and then weekly unless there is a new occurrence. The DON said she would have to know all the details about the resident to see why they have 3 pressure sores that big overnight. She stated the procedures for Hoyer lift transfer can be done by one person or two. She stated she does not believe that someone left the resident with a family member hooked to a Hoyer lift. She said she would hate to believe that would happen. In an interview on 7/27/23 at 12:15 p.m. the Wound Care Nurse stated CR#1 was being put on air mattress and CR#1 was positioned over the bed on Hoyer Lift a few inches above the bed. She stated she did CR#1's wound care and she left her on her side because she had stool. The Wound Care Nurse stated CR#1 had a brief on and the stool was in the brief, so she left to call the CNA. The Wound Care Nurse stated she called the CNA to come, and she went to see another patient. The Wound Care Nurse stated she was not aware that CR#1 was a 2 person assist. The Wound Care Nurse stated she was in bed, and she positioned CR#1 on her side to do the wound. In an interview on 7/28/23 at 12:03 p.m. the NP stated CR#1 had cancer, she was very sick, CR#1 was by CR#1's bed side, and CR#1 was unable to go to hospice. The NP stated she did not recall CR#1 having a fall and would have to look at the chart. The NP stated CR#1 had wounds that were being taken care of by wound care team. The NP stated she thought they did weekly skin assessments, and she gives wound care orders if she is notified. In an interview and Record review on 7/28/23 beginning at 12:21 p.m. the DON stated she was not working at the facility when CR#1 was at the facility. The DON stated she started working at the facility on July 3, 2023, and CR#1 has a fall on 5/10/23. The DON stated CR#1 had a fall out of bed no injuries, vital signs, neuro checks and the RP/NP were informed. The DON stated she did not see an assessment for CR#1. She stated the facility did a change of condition so that was considered an assessment and it said CR#1 fell out the bed. The DON stated the change in condition revealed the NP was informed and stated to start neuro checks and it did say x-ray. The DON completed a record review of CR#1's clinical records and she did not see the x-rays for 5/10/23. The DON stated the only circumstance a resident should be left alone on a Hoyer lift was in an extreme emergency when you go to the door and scream for a nurse. She stated CR#1 should not have been left alone when hooked up to a Hoyer lift unless it was a 911 emergency situation. The DON stated CR#1 should not have been left for 45 minutes. In an interview on 7/28/23 at 2:50 p.m. the Administrator stated she did not recall who CR#1 was. She stated they discuss all of their incidents in the morning meeting. She stated she did not make a report to the State because there was no injury. She stated the nurse should do an incident report. She stated if the unwitnessed fall required a transfer out of the facility, then she would begin her investigation. In a telephone interview on 8/1/23 at 1:18 p.m. the NP stated on 5/10/23 the nurse said there was no visible trauma and CR#1 was able to move her extremities, and there was no hematoma. She stated she did not remember what the nurse (LVN A) told her. The NP stated she only went by what was documented, and she saw a lot of patients. The NP stated if the nurse says the fall was unwitnessed then it was unwitnessed, then she would assess the patient and tell her that if the patient did not have injuries, then start neuro assessments. She stated if there was a change in condition within 72 hours, they would do something else. The NP stated the Doctor saw CR#1 on 5/9/23. She stated there was no definite time that they send patients out after a fall. The NP stated CR#1 could not tell her about her pain, but the nurses were taking care of CR#1. She stated the CNAs would pay attention and say CR#1 was grimacing more after a fall, then they would report. She stated if it was not documented then it did not occur when asked if the nurse informed her if there was a bruise on CR#1's head or body. The NP stated if it was not documented, there was an error of omission. The NP stated from her assessment and interview with the nurse (LVN A) she did not see an indication for diagnostics. She stated there was no change in condition and CR#1 had a terminal disease that CR#1's family member did not want treated. The NP stated Cr#1 was already on morphine; multiple pain meds, and a fentanyl patch and CR#1 was consistently being covered with pain meds. The NP stated death was imminent given her terminal disease and there was no increased pain. She stated the pain meds were efficient. The NP asked, Would an x-ray have made more of a difference than a neurological assessment that was being carried out. In an interview on 8/2/23 at 10:25 a.m. LVN C stated she had worked with CR#1. She stated she was not here when CR#1 fell , but she was total care and unable to move by herself. She stated when they have a resident that has an unwitnessed fall, she lets the resident stay in the position and she would let the nurse know. LVN C stated she would take CR#1's vital signs, carry out her neuro checks to do their assessments and observations, take vitals and assess for pain, try to carry out range of motion to rule out fracture. She would notify her supervisor, Unit manager, call the doctor and the family member. She stated they put the resident back in bed after and they continue to monitor. She stated she would have completed the SBAR for change in condition and the questions on the SBAR are what happened, her opinion, should the patient be sent out. Whatever action she would take is based on the Doctor's order and that they use to fill out the SBAR. She stated most of the time they send the patient for an x-ray order. LVN C stated the doctor's do not say no about an x-ray because they are their eyes of the doctor. She stated most of the time they get an x-ray stat order. LVN C stated the doctor sends them out sometimes, but the doctor's do not say no. LVN C stated CR#1 was alert and oriented x2 and was able to tell them she was in pain, up to a point and she was taking pain meds. She stated she was not lucid very much and was not able to communicate a lot, but she still made sense. LVN C stated before she does the SBAR, she would have spoken with the doctor already and that was the priority. She stated CR#1 was in a lot of pain because she had a big tumor on her neck. She stated as long as they left CR#1 alone in a state of rest she had no pain, but when they touched her, she had pain. If a resident is on anticoagulant, she would have sent the resident out of the building if they had an unwitnessed fall. LVN C stated CR#1 started morphine on 5/18/23 according to the Medication Administration Record. In an interview and record review on 8/2/23 at 10:56 a.m. Unit Manager A stated when there is an unwitnessed fall, she does an assessment to make sure the resident was ok and she does a quick assessment to make sure there are no injuries and no pain. Unit Manager A stated she does range of motion and a complete body assessment of all, checks for injuries, does neuro checks, SBAR, a risk assessment, nurse note, notify the doctor, family/RP, DON, and Administrator. She stated she documents the neuro checks on a neuro check list, does vitals on the neuro checks every 15 minutes for the first hour, every half an hour for the 2nd hour, every hour after the 2nd hour, every 4 hours after that, and then its every 8 hours and every day for 4 days. She stated if the patient does not have any injuries, they monitor them (the resident) and chart on them (the neuro checks) daily. Unit Manager A stated the Doctor, and the RP was notified. She stated she does the SBAR at the same time when she speaks with the Doctor/NP, and she likes to get the exact times. She stated the SBAR asks them some of the same questions, it asks the time you talk to the Doctor and the orders, and it asks the same question about when they speak with the RP and what their reaction was. Unit Manager A stated they document the SBAR with what they get from the Doctor and the nurse note will have the same information from the SBAR. She stated if the fall was unwitnessed, they are supposed to write it there because it asks them the question. She stated if the Doctor did not order an x-ray, you don't check that. She stated on the SBAR they put what the Doctor said to do, and they always follow what the Doctor says to do. She stated if x-ray was ordered then they call the x-ray company. She stated it was up to the Doctor to make the decision to send the resident out or not. Unit Manager A stated they offered CR#1 nourishment, and pain meds and sometimes she took it and sometimes she did not. She stated around 5/18/23 CR#1 started having more pain and that was when she started getting morphine. Unit Manager A stated she was not here when CR#1 had the fall. In an interview on 8/2/23 at 11:27 a.m. CNA A stated she took care of CR#1. She stated CR #1 was not really eating, she moaned a lot, so she tried to give her a sip to drink and food but every now and then she took a bite. CNA A stated she was here at the facility when CR#1 had her fall on 5/10/23. She stated she found CR#1 on the floor, and she told the nurse (LVN A) she needed help getting CR#1 back in the bed. CNA A stated when she found CR#1, she was on the side of the bed on her stomach. CNA A stated CR#1 was laying with her head on the floor on the side by the door. CNA A stated CR#1 did not have a fall mat. She stated she did not notice any blood. She stated CR#1 barely did say anything, she did not hardly talk. CNA A stated she would not have been able to tell if CR#1 had more pain at that time. She stated LVN A assessed CR#1. She said she could not remember noticing if CR#1 had any bruises or not. She stated the wound care nurse did not come to tell her that CR#1 was on her side or that she (CR#1) needed changing. CNA A stated she heard the Wound Care Nurse was looking for her, but it was too late then. CNA A stated CR#1 did not have any rails and she did not recall any pillows around CR#1. CNA A stated she was surprised CR#1 was on the floor because she was not able to move herself around the bed. She stated for CR#1 to be on the floor that means she was in a position she should not have been in because CR#1 could not move. CNA A stated when LVN A came she looked at her and checked to see if she was ok. She stated LVN A checked CR#1's head and looked at her whole body to make sure she was ok. CNA A stated she could not remember if LVN A moved CR#1 legs or not. CNA A stated in the position she was in; it was likely that CR#1 hit her head on the floor. CNA stated she did not remember CR#1 getting an air mattress. She stated she would never have left CR#1 on a Hoyer lift. CNA A stated it takes 2 staff to put a resident on Hoyer lift and CR#1 needed 2 people to help her with ADL's and bed mobility because she could not move. CNA A stated CR#1 just laid there in the bed like she did not want to be bothered. She stated sometimes CR#1 would moan when she (CNA A) moved her around in the bed and she did not want to be touched on. She stated when she started working with CR#1 she already had the pressure sores. CNA A stated she saw CR#1's wounds but she did not know how many there were because she just saw one (1) big one. In an interview on 8/2/23 at 12:44 p.m. the NP said she did not order x-rays and CR#1's Family member did not want anything done. She stated she ordered neuro checks, they looked at CR#1, did she become unresponsive at this time within 72 hours. The NP stated CR#1's family member did not want anything done. She stated CR#1 was on palliative care heading towards Hospice. She stated, We are talking about someone who is terminal illness who the POA did not want anything invasive. She stated there was no increased pain level, she was on fentanyl, the doctor increased the morphine out of compassion not because she fell . She said they assess the patient; she knew that she was on anticoagulants. She stated she did not recall if she was in the building on 5/12/23. In an interview on 8/3/23 at 10:16 a.m. LVN A stated when CNA A called her on 5/10/23, she was in another room taking care of another resident and when she got there, CR#1 was trying to grab with both hands holding the edge of the bed. She stated before that she never tried to get up out of the bed. She stated she did the SBAR, started a neuro check and she did not have to call the family member because the sister came to the facility that day. LVN A stated she let the NP know and he told her to keep checking on CR#1 for 20 min. She stated she sent a text to the NP, and she told NP she found CR#1 and she fell out of the bed with no injury, she completed vital signs its ok. LVN A said CR#1said she was trying to sit on the wheelchair, and she replied, ok thanks. LVN A stated the bed was not up and there were at least 4 or 5 pillows on the bed. She stated CR#1 should not have been left on her side. LVN A stated on the SBAR they fill out the vital sign, the r [TRUNCATED]

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 (CR#8) of 9 residents reviewed for advanced directives. - The facility failed to ensure that CR#8 received CPR in accordance with professional standards of practice on [DATE]. -The facility failed to immediately initiate CPR on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. -The facility failed to immediately contact Emergency Services on [DATE] at 4:19 a.m. when CR#8 was found unresponsive. EMS was contacted on [DATE] at 4:34 a.m. (15-minute delay). An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 2:34 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not an Immediate Jeopardy because all staff had not been effectively trained on CPR, calling the code, and immediately contacting Emergency Medical Services and evaluate the effectiveness of the corrective systems. These failures could place residents who are a full code-status (everything that is done to keep a person alive) at risk of death. Findings include: Record review of CR#8's face sheet dated [DATE] revealed CR #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with dementia, unspecified severity, with other behavioral disturbance, osteoarthritis, hypertension, benign prostatic hyperplasia (prostate gland enlarged, but not cancerous) with lower urinary tract symptoms, insomnia, cachexia (wasting syndrome), overactive bladder, major depressive disorder, recurrent, severe with psychotic symptoms and hallucinations. Record review of CR#8's Care Plan dated [DATE] revealed, CR#8 had delusions and was at risk for injury with interventions to report delusions in the clinical record, notify MD of changes in behavior, psychiatric consult as needed. CR#8 resident in Memory Care Unit for impaired cognition secondary to diagnosis of dementia, elopement risk, wandering with interventions to call resident by name when giving care, explain procedures, keep environment free of possible hazards .He also took psychotropic medication and was at risk for adverse reactions and episodes of driven behavior as evidenced by taking anti-psychotic with interventions to give medication as ordered, monitor each behavioral episode for frequency, intensity, duration and document in the clinical record .He was at risk for falls and injuries as evidenced by unsteady gait, confusion with interventions to anticipate needs, provide prompt assistance, assure lighting is adequate and areas are free of clutter, ensure call light is in reach and answer promptly, keep frequently used items at resident bedside, monitor for incontinent episodes-provide peri care as indicated and therapy to screen resident. Evaluate/treat per order. Self care deficits was identified with interventions to anticipate needs-provide prompt assistance, ensure light is within reach and answer in a timely manner, provide (extensive) assistance of (,d+[DATE] support persons for bed mobility, provide extensive assistance of (,d+[DATE] support persons) for transfers and provide (Supervision/Set up) assistance of (,d+[DATE] support persons for eating and staff to monitor for tolerance of intake, provide total assistance of (1 support persons) for toileting/incontinent care and provide privacy and maintain dignity. CR#8 was identified for being at risk for wandering as evidenced by dementia/Alzheimer's and was full code. Record review of CR#8's MDS assessment dated [DATE] revealed a BIMS Summary score of 3 indicating severe cognitive impairment, no behaviors exhibited, verbal behavior, the functional status revealed bed mobility, transfer, locomotion off the unit, dressing, toilet use and personal hygiene were extensive assistance with one person physical assist and limited assistance for walking in room and corridor, and locomotion on unit. Record review of CR#8's physician orders revealed CR#8 did not have a DNR. Observation: Behaviors, target behaviors (Hallucinations, Aggression, Wandering, Depressive Feature) every shift Monitor resident for presence of behaviors. Document yes or no to whether behaviors were observed? Notify MD as needed for behaviors. Started on [DATE]. Observation: Pain-observe every shift. If pain present, complete pain flow sheet and treat trying non-pharmacologic interventions prior to medicating if appropriate. Document in the PN's. every shift. Started on [DATE]. Amlodipine Besylate oral tablet 5 mg (Amlodipine Besylate) give 5 mg by mouth one time a day related to essential (primary) hypertension (110) Hold for sbp <110, dbp <60, pulse <60. Started on [DATE]. Aricept Oral tablet 10 mg (Donepezil Hydrocholoride) Give 0.5 tablet by mouth one time a day for dementia started on [DATE]. Gemtesa Oral tablet 75 mg (vibegron) give 1 tablet by mouth one time a day related to overactive bladder started on [DATE]. Megestrol Acetate oral suspension 400 mg/10ml (Megestrol Acetate) give 10 ml by mouth two times a day for loss of appetite started on [DATE]. Memantine HCl oral tablet 10 mg (Memantine HCl) give 10 mg by mouth two times a day for dementia started on [DATE]. ProAir HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 1 inhalation inhale orally every 6 hours as needed for COPD started on [DATE]. ProMod Oral Liquid (Nutritional Supplements) give 30 ml by mouth three times a day related to unspecified protein-calorie malnutrition started on [DATE]. Tylenol Oral tablet 325 mg (Acetaminophen) give 2 tablets by mouth every 6 hours as needed for OA related to unspecified osteoarthritis started on [DATE]. Record review of CR#8's Physical Therapy PT Evaluation & Plan of Treatment started on [DATE] revealed: Patient will have increase strength of trunk rotators and abdominals to [DATE] to be able to do all bed mobility with CGA x 1 (Target [DATE]) Baseline strength of trunk rotators and abdominals ,d+[DATE], able to do all bed mobility with minimum assistance of staff. Assessment Summary Clinical impressions: Patient presents with clinical impairments consisting of decreased strength of trunk rotators, abdominal and both LE, pain on both knees and thighs, decreased endurance, impaired dynamic standing balance. Reason for Skilled Services Skilled Patient services are warranted to analyze gait pattern, analyze/instruct in home exercise program, assess functional abilities, decrease complaints of pain, develop and instruct in restorative nursing program, enhance fall recovery abilities, enhance rehab potential, establish and instruct in compensatory strategies, facilitate anticipatory reactions .gait, increase LE ROM and strength, minimize falls, promote safety awareness . Record review of CR#8's Facility Provider Investigation Report dated [DATE] and reported to the State on [DATE] at 1:50 p.m. revealed Incident Category Death on [DATE] at 6 a.m. in resident's room. CR#8 functional assistance was total assistance in Memory Care. CR#8 was independently ambulatory, not interviewable, no capacity to make informed decisions and not wearing a wander guard at time of incident. Description of the allegations: Allegedly while the CNA was making her rounds she observed the resident lying on the floor in his room unresponsive. The assessment was on [DATE] at 6 a.m. Name and title of person who completed assessment was LVN E, with the description of assessment: Description of assessment including extent of injuries. Provide details of any physical harm, pain, or mental anguish including serious bodily injury, other injuries including but not limited to measurements, location, color of bruises, scratches, lacerations, fractures, changes in resident's behavior that is different from the normal baseline. LVN E immediately assessed the resident (CR#8) noting bleeding from the right side of the forehead, resident unresponsive CPR initiated and 911 was called. The incident was reported to the police and CPR initiated, notification to DON, Administrator, staff in-service initiated on rounds, supervision, fall prevention. Investigation Summary: Based on the information provided this investigation, while making AM rounds the CNA observed the resident lying on the floor in his room unresponsive. Per the CNA, she started her rounds at 10:00 p.m. the resident was in bed resting. Rounds were made again at 12:00 a.m. and then at 2 am, resident was resting in bed. When the CNA made rounds at 4 AM she noted the resident lying on the floor. She went into the room, called his name but did not get a response. The CNA immediately notified the Charge Nurse of her findings. The Charge Nurse immediately assessed the resident noting blood on the right side of his forehead and resident unresponsive. CPR was initiated and 911 was called. Resident continued to be unresponsive and was pronounced by the EMS. As a result of the incident, the facility could not rule out a cardiac or neurological event prior to falling. The family and physician were notified. The investigation findings were inconclusive. Record review of Fall assessment dated [DATE] at 5:53 a.m. with incident description: The CNA made her regular round at 10:25pm, 2 am. Then started her morning job at 4 am. When she went in there and found the resident on the floor unresponsive. Immediate Action Taken: She run and called me. I came in and observed resident on the floor by the bed side. Resident was bleeding from the head and was unresponsive. CPR initiated. 911 called. Injury type: laceration, Injury location: top of scalp, mobility: wheelchair bound. Record review of police body camera dated [DATE] at 4:58 a.m. revealed Paramedic stated the facility staff said they last saw CR#8 at 2 a.m. and he was okay and at 4:34 a.m. they were rounding and found CR#8. Observation of CR#8's room did not reveal a crash cart, nothing on the floor, no [NAME] bag observed. The police stated you can still see the blood right there. The Paramedic stated some facilities have a bed alarm. Police asked did the resident pee and pointed to something on the floor and EMS said they have no idea what that was on the floor. The paramedic stated he did not know what the facility policy was. Police officer was heard asking the facility for CR#8's paperwork and observation revealed LVN E was still trying to get the face sheet. LVN E stated at 2 a.m. CR#8 was still in bed and at around 4 am. LVN E stated they decided to start their morning job. The Police officer was observed asking LVN E did they have something for when residents fell out the bed, and LVN E stated the facility did not have anything. Observation revealed the Nurses station and there were no other nurses assisting LVN E at this time printing paperwork. Observation of CR#8's room in the video did not reveal a crash cart out or an ambu bag at the nurses station. LVN E was observed printing all CR#8's paperwork for the paramedic and the police. LVN E stated all the facility had was the call light that the resident may use when they need help. LVN E stated the CNA found CR#8 and CR#8 was diagnosed with dementia. LVN E was observed printing out the face sheet for the police officer. LVN E stated there was no DNR on record for CR#8 and he was full code. LVN E stated the full code was the first thing he checked. LVN E told the police officer that nursing homes did not allow bedrails. LVN E stated bedrails were considered a restraint. The police was heard asking for the paperwork and saying the facility smelled like urine. Observation revealed the police was saying something and they muted the body camera. LVN E stated CR#8 raised the bed and CR#8 fell out of the bed. The police stated CR#8 bled for a minute and the police said they probably could have saved him [CR#8]. Police was heard asking LVN E if anybody walked down that aisle and LVN E said no body walked down that aisle. The police asked if LVN E called his boss. LVN E said he would call his boss at 5:07 a.m. to tell his boss. The police officer stated he did not know what the cause of death would be because CR#8 fell . LVN E could be heard stating that 911 was at the facility and they were working with CR#8 and police was heard asking what did LVN E's boss say. LVN E stated the paramedics called the death at 4:46 a.m. LVN E was heard calling the family at 5:12 a.m. The police asked was CR#8's family member's coming to the facility and if they stayed far. The police officer asked where the family member's were coming from and she said she was not too far. Police asked how long it would take to get here and if they had a funeral home in mind. She said they need to get all the paperwork and call the funeral home. Police said the funeral home could not get the body yet because he needed to call the Medical Examiner. The family member said they would come after they get the paperwork for the funeral home. LVN E was heard telling the family member to wait until she got to the facility to call the funeral home. LVN E told the police he just spoke with the Director but said it was the DON. LVN E stated CR#8's doctor does not sign the death certificate in a situation like this. The police asked for the doctor information. The police said CR#8's room smells. The police asked LVN E to call for CNA C. LVN E was heard calling for CNA C to come. The police asked CNA C what happened and she stated the first time she rounded to see the residents was around 10 p.m. CNA C stated they check the resident's every 2 hours and her next round was around 2 a.m. and he was laying in bed face up. CNA C stated at 2 a.m. CR#8 had been in the room fumbling around and picking stuff of the floor. CNA C stated after 4 a.m. she saw CR#8 on the floor and ran back out the room. CNA C stated she kind of touched CR#8 and said LVN E went into the room and she saw CR#8's blood. She stated when she saw CR#8, he was facing on the side downward. She said the bed was not high when she went into the room. She grabbed LVN E and LVN E touched CR#8. On [DATE] at 5:26 a.m. CR#8's family member spoke with the police and he told her they could not call the funeral home now because he had to call the medical examiner. He said the funeral home will have to get the body from the medical examiner. She said she had the mortuary for the funeral home. The Police asked what time they were coming to the facility. Police said they could start heading towards the facility. He said he was sorry for their loss. The police continued with CNA C and she stated CR#8 was cold to the touch and that CR#8 got hit on the left side of the temple and that was where the blood was coming from. LVN E heard that the iron tire on the bed was where CR#8 hit. Before he hit the ground he hit a metal piece that was attached to the bed. Police called the medical examiner at 5:36 a.m. LVN E stated he just spoke with CR#8's family member. LVN E told the police CR#8 was a full code. Police stated the facility staff did not hear CR#8 fall. Police was observed asking LVN E to print CR#8's physician orders. Observation did not reveal any other nurses printing any paperwork or assisting LVN E with anything. Observation revealed the police had the SILK test and the police said he would give it to the medical examiner. Case number (deidentified). Record review of Police body camera on [DATE] at 6:02 a.m. Resident observed laying on his back with both arms across his chest. Observation revealed blood at the head of roommates bed. Police observed walking down the hallway towards the Nurse Station. LVN E stated the roommate was walking in the hallway right now. The police stated the room and CR#8's body needed to be cleaned and he said the room smelled. They have to clean that room and they are going to come get the body. Police stated CR#8 peed in the bed. Police asked LVN E to call the family member at 6:05 a.m. CNA C was heard saying that CR#8 continued to raise the bed up and mess with the bed remote. The police said the family member could not come look at the body like that. The police spoke with the family member and said the body will be transported and they will not be able to see the body right now and the family member was already in the car right now. He said he could not let them see the body like this. (Deidentified) for Medical Examiner and the number is (deidentified). Police instructed them to say case in regards to her father and the medical examiner is (deidentified )The police said he could not let them see the body like this. They will pick the body up in the next 30 minutes. Record review of police body camera video dated [DATE] at 6:26 a.m. revealed 911 Police instructing LVN E tell to write specifics on the report stating CR#8 had a hole in the right temple of the head at 6:26 a.m. Police officer was heard asking how was CR#8's body was so close to the other bed (roommates bed) in the room. LVN E stated the foot of CR#8's bed was always up. LVN E was heard saying the bed was all the way up when he found CR#8. LVN E stated when he went into the room LVN E put the bed down low. CR#8 was found on his side. The black thing on the edge of the bed is metal and this is where CR #8's head was found. LVN E stated CR#8 liked to move his bed and his bed was moved all the way by the roommates bed. Observation revealed Police said he had the staff to remove roommate out of the room. CR #8 body's was observed on the floor with both of his arms across his chest. Observation of CR#8's room on the video did not reveal a crash cart, [NAME] bag and no other staff assisting LVN E. Observation of the body camera video revealed Police was heard asking how he can lift the bed up and he was heard asking for CR#8's bed remote. Observation revealed blood on the floor by roommates bed. Record review of County EMS date of Service [DATE] with primary role: Medic Transport, Paramedic, Ambulance Response Info: Nature of Call: Cardiac Arrest/Death, Patient found: On floor, Initial Patient Acuity: Dead without Resuscitation Efforts (Black) .(means dead without resuscitation efforts) Disposition: Type of Service 911 Response (Scene) Outcome: Dead at Scene- No Resuscitation Attempted- No Transport Barriers to Care: None noted Scene Delay: None/No Delay Times: Injury: 4:19 a.m. on [DATE] PSAP (Public Safety Answering Point): 4:34 a.m. on [DATE] Dispatch Notify: 4:34 a.m. [DATE] Received: 4:34 a.m. [DATE] Dispatch: 4:36 a.m. [DATE] En route: 4:37 a.m. [DATE] At scene: 4:42 a.m. [DATE] At Patient: 4:46 a.m. [DATE] In service: 5:09 a.m. [DATE] [DATE] 4:46 a.m. Body Area: Assessments and Comments: Body Area: Assessments and comments Airway Patent Breathing Absent Circulation Pulses-Carotid-Absent (0) Blood/Fluid loss ,d+[DATE] ml Pulses-Femoral-Absent Head Laceration External/Skin Cold: Dry Mental Status Unresponsive Neurological Not done Primary Impression: Death Secondary Impressions: Cardiac Arrest Cardiac Arrest Cardiac Arrest: Yes, Prior to EMS Arrival Arrest Etiology: Cardiac (Presumed) Resuscitation Attempted: Not Attempted-Considered Futile Arrest Witnessed by: Not witnessed Discontinued Reason: Obvious signs of death Patient Dead on Arrival: yes Pronounced Dead By: First Responder (Fire, Law, EMS) Time of Cardiac Arrest [DATE] 4:34 a.m. End of Cardiac Arrest Event: Expired in the field [DATE] at 4:48 a.m. Medic responded emergent for a 911 request for a cardiac arrest. Medic responded without delay from the station. Medic arrived on scene to find a [AGE] year-old male lying supine on the floor with signs of rigor mortis. The patient is apneic and pulseless. The nursing staff stated that they last saw the patient normal was around 2:00 a.m. The nursing staff stated that they found the patient on the floor and immediately called 911. The patient skin is cold and dry. The patient's jaw is stiff and unable to be moved. The patient's pupils are fixed and unreactive. The 4-lead (shows electrical activity of the heart) was applied to the patient. The patient was in asystole (heart stopped beating). The patient is DOA per protocol at 4:45 a.m. Scene was left with [PD]. Medic returned back in service. Record review of City Police Department Event Report dated [DATE] at 4:34 a.m. revealed, Call received [DATE] at 4:34 a.m. Call routed [DATE] at 4:34 a.m. Call take finished [DATE] 4:34 a.m. 1st Dispatch [DATE] 4:36 a.m. 1st En-Route [DATE] 4:36 a.m. 1st Arrive [DATE] 4:53 a.m. Last Clear [DATE] 7:14 a.m. Record review of Police Department Incident/Investigation Report dated [DATE] at 4:34 a.m., time reported [DATE] at 4:34 a.m. revealed: Crime Incident(s) Dead On Arrival Narrative: On [Wednesday] [DATE], at approximately 4:34 a.m., .Officers were dispatched to [facility]. A death investigation and a report was completed. On [Wednesday] [DATE], at approximately 0434 hours [4:34 a.m.], .a Police Officer for the City .was dispatched to [facility]. Upon arrival, I made contact with the on duty nurse who was identified as LVN E, The deceased male was identified as [CR#8], [ethnicity, gender, date of birth], .The CNA who was taking care of the deceased male was identified as [CNA C][ethnicity, gender, date of birth]. [CNA C], stated she went to [CR#8's], Room on [DATE] at approximately 10pm to check on him and she noticed he was doing fine. [CNA C], stated when she went to go check back on [CR#8], on [DATE], at approximately 2AM, she noticed he was alive. [CNA C], stated she left the room and returned at approximately 4AM on [DATE] and that`s when she noticed that [CR#8] had fallen out of his bed and struck the right side of his forehead on the ground. [CNA C] stated when she noticed [CR#8] was on the ground, She asked [LVN E] to come help her lift him up off the ground. [CNA C] stated when they touched [CR#8], he was already cold to the touch .medic 6:08 a.m. arrived on location and called the time of death on [DATE] at 4:46 AM. I asked [CNA C] how often they are supposed to check on their patient and she stated every two hours. I was advised by [LVN E] that [CR#8], was not on hospice. [LVN E] provided me with [CR#8's] doctor information, but he did not make contact with him while I was on location. While in the room, I did not notice any foul play. [CR#8`s] body was cold to the touch. There was blood on the right side of his bed. I observed [CR#8] to have a knot on the right side of his forehead. Photos of the room were taken of his body and the injury. [CR#8] was diagnose with the following, unspecified dementia, unspecified osteoarthritis, hypertension, benign prostatic, insomnia, constipation, cachexia, overactive bladder, major depression, and hallucination. The next of kin [CR#8's family member] [ethnicity, gender, date of birth], was notified of the death and was also advised that [CR#8's] body`s will be transported to the .Medical Examiner`s. Body car arrived on location on [DATE] at approximately 06:39 a.m. hours to transport the body to the .County Medical Examiner`s Office .Medical examiner ., provided me with their case number [case number] and took custody of [CR#8`s] body. The body bag zip tie sealed number was [number]. While on scene, audio and video was recorded on my Utility body camera and in car camera in unit 2522. Record review of 911 call made by LVN E he stated the address to the facility and that they find a patient by the bedside it looks like he has fallen from the bed he is unresponsive. He is in [room number, side of room letter]. He is not breathing. He is [AGE] years old, he is not breathing I checked. Record review of 29 photographs taken on [DATE] of CR#8 and CR#8's room by First Responders revealed a large amount of blood on the floor and bed wheel of the (resident's) roommate. The blood was both smeared and puddled. CR#8 was observed laying at the end of his own bed with his feet towards the door. His arms were resting on his chest. HE was wearing socks and a gown. A puddle of blood was on the floor by his head. CR#8's eyes were open, mouth was closed. CR#8 was observed with a wound (appeared to be a hole) to right side of his head above his eye. The bed was observed to have 3 stacked pillows at the head of the bed. The pictures revealed the head of CR#8's bed was lower than the foot of the bed. One photograph revealed the bed was in a low lying position, head of bed lower than the foot of bed. A separate photo of the bed revealed the bed was in a raised position, the head of bed was lower than the foot of bed. Call light was attached to CR#8's) and roommates bed. Observation revealed there was a small amount of blood on the roommates call light cord. There was no blood visible on CR#8's bed. Record review of National Library of Medicine, Methods of Estimation of Time Since Death written by Rijen Shrestha; Tanuj Kanchan; Kewal [NAME] dated [DATE] reveaeld, Rigor mortis is the post-mortem stiffening of muscles caused by the depletion of adenosine triphosphate (ATP) from the muscles, which is necessary for the breakdown of actin-myosin filaments in the muscle fibers. Actin and myosin are components of the muscle fiber and form a bond during contraction. The cessation of oxygen supply causes the stoppage of aerobic respiration in the cells and leads to a lack of ATP production. Rigor mortis starts immediately after death and is usually seen in a sequence known as the march of rigor and Nysten's Law. While rigor mortis develops simultaneously in all muscle tissue in the body, voluntary and involuntary, the size of the muscle determines the perceptibility of changes by the examiner. Smaller muscles over the face - around the eyes, around the mouth, etc. are the muscles where rigor mortis first appears, followed by rigor mortis of the muscles in the hands and upper limbs, and finally appears in the large muscles of the lower limbs. Rigor mortis appears approximately 2 hours after death in the muscles of the face, progresses to the limbs over the next few hours, completing between 6 to 8 hours after death.[10] Rigor mortis then stays for another 12 hours (till 24 hours after death) and then disappears. In a telephone interview on [DATE] at 1:25 p.m. with CNA C she stated she worked the night shift in the Memory Care Unit from 10pm-6am and had been working on the unit for a year. CNA C said when she arrived to work on [DATE] at 10:00pm she made rounds on the residents and that CR#8 was sleeping in bed with the bed in low position with no concerns identified. She said she made rounds on the residents every 2 hours going in the resident's room making sure they were breathing and doing okay. CNA C said she made rounds again at 12:00am and 2:00am with CR#8 continuing to rest quietly in bed with bed in low position and bed had not been moved. She said when she went to check on CR#8 again at 4:00a.m., she found CR#8 on the floor in his room with his head somewhat under his roommate's bed and thought resident was resting on his left side but was not certain but resident (CR#8) was not responding when she started calling his name. CNA C said resident bed was still in the low position and the bed had not been moved. She said she did not see any blood at that time and ran out of the room to get the nurse. CNA C said when the nurse got to the room and turned resident on his back, she could see a lot of blood coming from his head and was not sure which side it was coming from. CNA C said LVN E went and called 911 while she stayed with CR#8 and after LVN E called 911, he came back and began CPR on CR#8. She said CR#8 could walk and dress himself always rearranging stuff in his room such as his table. CNA C said CR#8 did have the behavior of liking to play with the bed remote a lot raising the bed in the highest position or raising the head or foot of bed putting in different positions. CNA C said CR#8 did not like his roommate always saying get him out of here, but never witnessed him and the roommate getting in any physical altercations. CNA C said she had heard that on the day shift they may have had words at one time but that was here say. She said CR#8's roommate could walk but at the time of the incident, CR#8's roommate slept through the whole incident. In an interview on [DATE] at 11 a.m. with LVN F she stated she came in on [DATE] and walked in on the situation with CR#8 and allowed LVN E and EMS to take care of his passing. LVN F stated CR#8 passed on the night shift and when she walked in CR#8 was laying with his head toward his roommate's bed in the middle aisle between the bed and the chest of drawers. She stated the police officer was standing here and there was a lot of chaos on the floor and she was late due to traffic. LVN F stated the officer asked her if she knew anything. She stated when she came into CR#8's room, the bed was to the floor and the resident was laying on the floor. In an interview on [DATE] at 10:37 a.m. with the DON she stated she spoke with LVN E when he called her and said CNA C on night shift was making rounds and went to assess CR#8 she noticed CR#8 was unresponsive. The DON stated LVN E said he started CPR, called 911 and 911 worked on CR#8 and 911 pronounced CR#8 deceased . The DON stated CR#8 would try to walk but use the wheelchair sometime. In an interview on [DATE] on 11:29 a.m. with CNA E she stated she assisted CR#8 with showers and he was sometimes confused. She stated CR#8 would say things that were not true and he was always on the wheelchair. She stated sometimes CR#8 would just lay on the bed and on the day of his shower, she gave CR#8 limited assistance to transfer to the wheelchair and take him to the shower. CNA E stated sometimes CR#8 tried to stand up from the wheelchair and she assisted him to sit. In an interview on [DATE] at 10:49 a.m. with CNA C she stated she found CR#8 and she let the LVN E know. CNA C stated she called CR#8's name and he was laying on his side on the floor halfway by his roommate's bed. CNA C stated she did not touch CR#8. She stated there was blood when the LVN E moved CR#8. She stated there was no fall mat and the bed was at the lowest level. She stated she saw CR#8 at 10 p.m., 12 a.m., 2 a.m. and 4 a.m. She stated she saw CR#8 at 2 a.m. sleeping, and she did not have to change him. CNA C stated she called LVN E and he came into the room and called CR#8's name. She stated LVN E touched CR#8 and moved him and that is when they saw the blood on CR#8's head. She stated she did not remember if LVN E stated CR#8 was cold or warm and LVN E touched CR#8's chest. CNA C stated LVN E called 911 with crash cart (carries instruments for CPR) and started performing CPR. She stated LVN E did chest compressions and the [NAME] bag (used to deliver positive pressure ventilation for respiratory support in CPR) and the CNA D came and CNA C let 911 in. CNA C stated she did not go back in the room. CNA C stated she could not explain the CPR process LVN E carried out. CNA C stated CR#8's roommate was in the room in bed and she did not pay attention to him when she found CR#8. CNA C stated at 2 a.m. CR#8's roommate was sleeping. She stated she saw LVN E with the [NAME] bag but not what he was doing with it because she ran to the front. She stated she saw chest compressions. In an interview and Record review on [DATE] at 11:54 a.m. with the DON of CR#8's clinical records revealed CNA C did rounds at 1:11 a.m. on [DATE] and CNA C went to do her other rounds at 4 a.m. and that is when CNA C found the residen [TRUNCATED]

Based on observation, interview and record review, facility failed to ensure residents received treatment and care in accordance with professional standards of practice for Seven (7) residents (CR #1, CR#2, Residents #3, #4, #5, #6, and #7) of seven (7) residents reviewed for quality of care. 1. The facility failed to provide weekly skin assessment for CR #1 who was non- ambulatory and bed bound. 2. The facility failed to identify onset of CR #1's three large unstageable pressure ulcer and initiate intervention. 3. Facility failed to follow physician orders and treat pressure wound for CR #1, #2 and Residents #3, #4, #5, #6, #7, for multiple days. 4. The facility failed to provide education to their nurses regarding wound care and documentation, and nurses responsibility to do wound care when the treatment nurse was not in the facility. 5. Facility failed to obtain physician order before applying wound care treatment (Santyl and betadine) on CR #2 An Immediate Jeopardy (IJ) was identified on 07/28/2023. The IJ template was provided to the facility on [DATE] at 5:25pm. While the IJ was removed on 08/05/2023 at 3:50pm, the facility remained out of compliance at a severity of isolated actual harm that is not immediate jeopardy with a scope of pattern due to failure occurred to multiple residents over multiple days and the facility's need to evaluate the effectiveness of the corrective systems. These deficiencies could expose residents to low quality of care, wound deterioration, worsening of condition, infection, sepsis, and hospitalization . Findings included: CR #1 Review of face sheet revealed CR #1 was [AGE] years old female admitted to the facility on [DATE]. Her diagnoses were malignant neoplasm of rectosigmoid junction, fistula of vagina to large intestine, chronic pain, UTI (Urinary Tract Infection), fracture of lumbosacral spine and pelvis, and Hypertension, muscle wasting, lack of coordination, anxiety disorder, peripheral autonomic neuropathy, and encephalopathy. Review of skin assessment during admission on 01/29/2023 reveal CR #1 only had redness under her bilateral breast. Record review of facility weekly skin assessment for the month of February and March 2023 revealed there were no skin assessments done for CR #1 in the months of February and March 2023. Further review revealed there were no weekly skin assessment for CR#1 in the month of April 2023, until April 24th when three wounds were first identified. The skin assessment on 04/24/2023 revealed the following: - Wound #1 was acquired in the facility, first observation, size was (length x width x height) 7.5cm x 5.3cm x 0.0cm. Wound #1 was identified as pressure wound at the right buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage, no odor, peri-wound tissue was described to have redness and wound edges well defined. Stage of the wound was not documented, - Wound #2 acquired in the facility, first observation, size was (length x width x height) 5.5cm x 2.5cm x 0.0cm. wound #2 was identified as pressure wound at the left buttock, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, moderate drainage and no odor, peri-wound tissue was described having redness and wound edges well defined. Stage of the wound was not documented, - Wound #3 acquired in the facility, first observation, size was (length x width x height) 9.0cm x 0.8cm x 0.0cm. wound #3 was identified as pressure wound at the right ischium, necrotic tissue present, dry, thick adherent devitalized necrotic tissue 70%, no drainage and odor, peri-wound tissue was described as normal and wound edges well defined. Stage of the wound was not documented, Record review of progress note revealed CR #1 refused to be weighed on 02/06/2023. CR #1refused vital signs and medications multiple times, she also refused feeding and diaper change in the month of March and April 2023. However, there was no documentation of CR#1 or family member refusing skin assessment prior to 04/24/2023. Review of MDS dated [DATE] revealed CR #1 was identified as a resident who was at risk for pressure ulcers/injuries. Review of MDS dated [DATE] section M0300 revealed CR #1 had pressure ulcers. Review of care plan with close date 07/26/2023 revealed CR #1 had pressure wound. stage 4 buttock and DTI (Deep Tissue Injury) to the right ischium. Review of physician order dated 04/24/2023 revealed the following: - Left Buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. - Right buttocks Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. - Right Ischium Unstageable DTI: Cleanse with normal saline, pat dry, apply house barrier cream daily. Review of Wound Care Doctor's initial evaluation note dated 04/24/2023 revealed: - Site 1 was documented as unstageable (due to necrosis) of the right buttock full thickness. Wound size (L x W x D): 7.5cm x 5.3 x not measurable. - Site 2 was documented as unstageable (due to necrosis) of the left buttock full thickness. Wound size (L x W x D): 5.5cm x 2.5 x not measurable. - Site 3 was documented as unstageable DTI of the right buttock partial thickness. Wound size (L x W x D): 9cm x 0.8 x not measurable. Review of Treatment Administration Record for the month of April and May 2023 revealed there were no documentation of wound care provided to CR#1 on the following dates: 4/25/23, 4/26/23, 4/30/23, 5/5/23, 5/7/23, 5/14/23. Review of Wound Care Doctor's note dated 05/12/2023 revealed CR #1's wound Site 1 Stage 4 pressure wound of the right buttock full thickness became coalesced (merged) with Left buttock wound to form one large wound with new wound size. Wound Size (L x W x D): 12 x 18.5 x 1.5 cm; Surface Area: 222.00 cm^2; Exudate: Light Serous; Thick adherent devitalized necrotic tissue: 60 % Granulation tissue: 30 %; Other viable tissues: 10 % (Dermis, Bone, Fascia) Wound progress: Deteriorated On 7/26/23 at 11:10am in an interview with the Wound Care Nurse she sated the assigned nurse or whoever was taking care of CR #1 identified that CR #1 had 3 pressure sore areas. She stated the wounds were unstageable to right buttock measuring 7.5cm x 3.5cm, unstageable left buttock and it was 5.5cm x 2.5cm and the third site was an unstageable DTI on the right buttocks 9.0cm x 0.8cm. She stated the Wound Care Doctor saw CR #1 on 4/24/2023. She stated the wounds were debrided by the Wound Care Doctor. The Wound Care Nurse stated before CR #1 passed away at the facility due to her end-of-life condition. She stated the wounds merged and became one as CR #1's condition worsened. She also stated she always did wound care for all residents when she (Wound Care Nurse) came to the building. She said she always had a lot to do, but sometimes she got someone to help her so she could catch up with her documentations. She stated she might have missed to document for some days, but she was not sure. On 7/27/2023 at 2:48pm during interview with CNA F, she stated CR #1 was in room [ROOM NUMBER], she stated she did not take care of CR #1 often because they rotated shift and assignment, she stated sometimes she might not have CR #1 assigned to her. CNA F stated the last time she took care of CR #1 had been a while and she did not see any skin breakdown on CR #1. CNA F stated that CR #1's sister was not allowing them to do many things for CR #1. She stated the sister would say CR #1 was hurting and the sister would change CR #1 by herself most of the time. CNA F said sometimes the sister would call for help to change CR #1. CNA F stated whenever she changed resident or reposition resident, she always assessed residents' skin. On 7/27/2023 at 3:01pm in an interview with CNA G, she stated she never had the opportunity to take care of CR #1 because she was always assigned to the other side of the hall. CNA G stated she assessed residents every time she saw them or when she changed /clean them, and she would tell the nurse if she saw anything like new wound or changes to existing wounds. On 07/27/2023 at 3:23pm in an interview with LVN A, she stated she knew CR #1, she stated at the time CR #1 was in the facility the sister to CR #1 was always at the bedside and the sister she was always preventing the staffs from taking care of the resident. LVN A stated CR #1's sister would tell them not to disturb CR #1 because the sister stated CR#1 was in a lot of pain. She stated CR #1 had a lot going on with her, LVN A said CR #1 had cancer and hospice was recommended for CR#1, but CR #1 was not able to get on hospice because of CR#1's insurance. On 07/28/2023 at 11:54am in an interview with LVN B she said she worked night shift, she said by the time she arrived on shift, the wound care nurse must have done the dressing. She said if the dressing comes off, she would re-do the dressing. She said most of the time resident's sister was at bed side and refusing care for CR #1. She stated they did weekly skin assessment on all residents; however, the sister was not allowing care for CR #1. On 08/06/2023 at 2:47pm in an interview with CR#1's family member she stated she came to the facility every day, and she would text what was happening every day to other family members. CR#1's family member stated CR#1 would call her crying saying she was burning because they would not change her brief. She stated when she got there, CR#1 was still dirty many times. She stated the staff would come in and say they were going to get someone to help them, and they would not come back. She stated on 4/24/23 that was the first time she saw the wound nurse. She stated she asked the Wound Care Nurse for an air mattress, and maybe 2 or 3 days later they still had not provided the air mattress. She stated CR#1 did not get the air mattress the day the Wound Care Nurse found the wound. CR#1's family member stated the next day on 4/25/23, they brought the air mattress to CR#1's room and it sat on the floor for 2 days not aired up. CR#1's family member stated the Wound Care Nurse took pictures, measured the wounds, and put gauze on it. CR #2 Review of face sheet revealed CR #2 was [AGE] years old male admitted to the facility on [DATE] with diagnoses of pressure ulcers, osteomyelitis of sacral pressure ulcer, multiple fractures ribs, end stage renal disease, type 2 diabetes mellitus, functional quadriplegia, metabolic encephalopathy, acquired absence of the left leg below the knee, and peripheral vascular disease. Review of admission assessment dated [DATE] revealed CR #2 was admitted with multiple wounds identified as pressure injury at the sacrum and right heel, wound at the left stump, scrotum, right lower extremity, groin, and redness at the chest. Review of CR #2's baseline care plan dated 07/21/2023 reveal there was no intervention initiated for wounds. Review of physician orders dated 07/23/2023 revealed CR #2 had the following pressure wound care orders: - Right Ischium Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Vashe moist gauze sponge cover with gauze island dressing daily. - Sacrum Unstageable: Cleanse with normal saline, pat dry, apply Santyl + Dakins moist gauze sponge cover with gauze island dressing daily. - Bilateral Buttocks maceration: Cleanse with normal saline, pat dry apply maceration cover with gauze + island dressing daily. Review of Treatment Administration Record dated 07/23/2023 revealed a documentation of wound care for CR#2. Further review revealed there were no other documentation of wound care for CR#2 for 7/21/2023, 7/22/2023 at the time of his admission to the facility on [DATE]. On 07/26/2023 at 11:19am during interview with the Wound Care Nurse, she stated she assessed CR #2 and performed wound care for CR #2 on Friday 07/21/2023. Wound Care Nurse stated CR #2 was admitted on Thursday 07/20/2023, but Friday 07/21/2023 was the first day she saw CR #2, and at that time she was trying to reach out to the wound care company to give them a doctor who would cover for their Wound Care Doctor, because the Wound Care Doctor was on vacation. She stated but she did not hear back from the company on that Friday. She stated she also called the PCP (Primary Care Provider) for CR #2 but she could not get hold of anyone. The Wound Care Nurse said she did not want to leave the wound undone, and she did not want to leave the patient without dressing the wound. She said she took care of the wound, she cleaned the wound at the sacrum and applied Santyl to it because it had a slough, she stated the wound at the knee had necrotic tissue and she applied betadine to it. She stated CR#2's bottom had maceration and she put zinc oxide and cover all the wounds. The Wound Care Nurse stated she applied the same care, the same thing in the wound order. Surveyor asked how she could have used same wound supply in the order, because there was no wound care order given at that time. The wound Care Nurse responded that, based on her experience as a nurse, and based on the preference of the Wound Care Doctor, she knew that the Wound Care Doctor would use exactly what she used for the patient. She said she did not come to work on Saturday, but on Sunday when she came to work, she was able to reach out to the patient's primary care doctors Nurse Practitioner who gave order for the wound care. She stated that she (Wound Care Nurse) was the one who suggested the specifics of the wound care order for the nurse practitioner of which the nurse practitioner agreed. She said, I reached out to her, described everything and I said this will be a good order for the sacrum, and if you approve it, if you don't, you can give me something different. She stated the Nurse Practitioner agreed with the order. She stated she used Santyl for the sacrum and vashe moist, said she used Santyl because the sacrum wound had 90% slough. She said the stump and heel, had necrotic tissue and she used betadine on it. She stated the wound at the ischium had hard slough and she put Santyl on it with calcium alginate and covered it up. The Wound Care Nurse said CR #2 had maceration all around his bottom all the way to his anus, the Wound Care Nurse stated she put zinc oxide on the wound and covered them up. The Wound Care Nurse stated on the Friday she used those wound care supplies based on her experience with the Wound Care Doctor. She stated some other Doctors might use Medi-honey, but the wound Care Doctor never used Medi-honey, she said the Wound Care Doctor would use Santyl instead of Medi-Honey, and that was why she used it. She stated CR #2 was sent to hospital on Monday 07/24/2023 upon request by the family. On 07/26/2023 at 2:02pm, in an interview with LVN G. She stated she remembered the patient was brought in at her closing time and she only received the patient into the room and did a quick note on the resident. She stated the oncoming night nurse was the one who did the admission assessment on the patient. She stated she did not know anything regarding CR #2. On 07/26/2023 at 4:01pm in an interview with the Wound Care Nurse. She stated she was wrong by using the treatment (Santyl, betadine, Calcium alginate, and Zinc oxide) on CR #2's wound without Doctor's order. She stated she could have done the basic treatment of cleaning the wound with normal saline and covering it up. She stated she felt passion for the resident (CR #2) because the resident had multiple wounds and she did not want to leave his wound uncared for. On 07/26/2023 at 4:29pm, in an interview with LVN K, she said she started working at the facility about three weeks ago. She said she remembered CR #2 had wound in multiple locations including sacrum, because she saw it during the admission assessment. She stated she did not do anything to the wounds because the dressing was intact and did not require dressing change or reinforcement. She stated all the wounds were wrapped. She stated, honestly I did not see any order for wound care and it did not come to her mind to call the physician for wound care order. She stated she probably did not remember to call because she did not need to do the wound care that night. She said maybe if she had needed to do the wound care, she would have remembered to call for the order. She stated if there was no wound order and patient would not get timely wound care, and it might not be safe for the patient because of risk for infection. Resident #3 Review of face sheet revealed Resident #3 was a 54- year- old male initially admitted to the facility on [DATE]. Current admitted was 6/12/2023 with diagnoses of cerebral infarction, traumatic hemorrhage of cerebrum, quadriplegia, contracture, hypokalemia, Atherosclerotic heart disease, metabolic encephalopathy. Review of care plan dated 08/07/2023 revealed Resident #3 has multiple pressure wounds. Sites of the wounds were identified at sacrum, right plantar foot, left ischium, right Ischium, right calf, right and left posterior shoulder, and right lateral ankle. Review of MDS dated [DATE] section M0300 revealed Resident #3 has multiple pressure wounds. Review of physician order revealed the following orders: - Sacrum Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/19/2023. - Left Ischium Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order date: On 5/15/2023 - Right Ischium Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/15/2023 - Left Posterior Shoulder Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order date: 5/19/2023 - Right Posterior Shoulder Stage 4: Cleanse with normal saline, pat dry, apply Vashe moist gauze sponge cover with gauze + island dressing daily. Order Date: 5/15/2023. - Right Plantar Foot Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Order Date: 05/15/2023 - Right Calf Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Order Date: 5/15/2023 - Right Lateral Ankle Stage 3: Cleanse with normal saline, pat dry apply Calcium Alginate cover with gauze + Island dressing daily. Order Date: 7/14/2023. Review of Treatment Administration Record (TAR) for the months of April through July 2023 revealed there were no wound care documented in the TAR for Resident #3 on the following days: 7/2/23, 7/16/23, 7/22/23, 6/17/23, 6/18/23, 6/19/23, 6/25/23, 6/30/23 5/27/23, 5/29/23, 5/31/23, 4/15/23, 4/16/23, and 4/23/23. Review of progress notes revealed no documentation of wound care provided to Resident #3 on these dates: 7/2/23, 7/16/23, 7/22/23, 6/17/23, 6/18/23, 6/19/23, 6/25/23, 6/30/23 5/27/23, 5/29/23, 5/31/23, 4/15/23, 4/16/23, and 4/23/23. Review of Wound Care Doctor's note dated 07/20/2023 revealed the following on Resident #3's wound: - Stage 4 pressure wound sacrum full thickness Wound Size (L x W x D): 6 x 5.5 x 0.5 cm; Surface Area: 33.00 cm^2 Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the right, plantar foot full thickness. Wound Size (L x W x D): 1 x 0.5 x 0.3 cm; Surface Area: 0.50 cm^2; Exudate: Moderate Serous, Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the right ischium full thickness Wound Size (L x W x D): 6.5 x 7 x 1.5 cm; Surface Area: 45.50 cm^2 Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 4 pressure wound of the left, posterior shoulder full thickness Wound Size (L x W x D): 7 x 8 x 0.5 cm; Surface Area: 56.00 cm^2 Exudate: Moderate Serous; Slough: 20 %; Granulation tissue: 80 % Wound progress: Not Improved - Stage 3 pressure wound of the right, lateral ankle full thickness Wound Size (L x W x D): 3 x 2 x 0.2 cm; Surface Area: 6.00 cm^2 Exudate: Moderate Serous; Granulation tissue: 100 % Wound progress: Not Improved On 07/25/2023 at 1:23pm, surveyor observed and interviewed Resident #3, he said he got wound care daily most of the time, and he got wound care yesterday (07/24/2023) by the treatment nurse, but he stated he had not gotten wound care today (07/25/2023), he said he probably would not get any treatment today because he thought the Wound Care Nurse was not in the building. He said whenever he did not get wound care, he would know that the Wound Care Nurse was not in the building that day. When asked about the specific days in the past that he did not get wound care as a result of the wound care nurse not in the building, Resident #3 could not recall specifically. However, he stated he knew if he had not seen the wound care nurse by this time of the day, he would know that the wound care nurse was not in the building. Resident #4 Review of face sheet revealed Resident #4 was a [AGE] year old male who was initially admitted to the facility on [DATE]. His current admission was on 07/16/2023. His diagnoses included cerebral infarction, Hemiplegia and hemiparesis, heart failure, dysphagia, acute respiratory failure, and pulmonary hypertension. Review of care plan dated 07/17/2023 revealed Resident #4 had multiple pressure wound identified as Left heel, Right heel, left ankle, and left lateral foot. Review of MDS dated [DATE] section M0300 revealed Resident #4 had pressure wounds. Section C revealed resident had significant cognitive impairment. Review of physician order revealed the following: - Sacrum Stage 4: Cleanse with normal saline, pat dry, pack with Dakins moist gauze roll(kerlix) cover with gauze + island dressing daily. Order Date: 05/30/2023. - Left Heel DTI: Cleanse with normal saline, pat dry, apply Skin Prep Daily. Order Date: 4/01/2023 - Leg Medial leg Stage 3: Cleanse with normal saline, pat dry, apply Calcium Alginate cover with gauze + island dressing daily. Order Date: 4/19/2023. Review of Treatment Administration Record revealed there were no documentation of wound care provided for Resident #4 on the following days: 7/22/23, 7/24/23, 6/3/23, 6/4/23, 5/4/23, 5/5/23, 5/10/23, 5/14/23, and 4/16/23. Review of progress note revealed there were no documentation of wound care provided to Resident #4 on the following dates: 7/22/23, 7/24/23, 6/3/23, 6/4/23, 5/4/23, 5/5/23, 5/10/23, 5/14/23, and 4/16/23. Resident #5 Review of face sheet revealed Resident #5 was a [AGE] years old male who was initially admitted to the facility on [DATE] with the diagnoses of intellectual disabilities, Acute respiratory failure, pneumonia, constipation, and developmental disorders of speech. Review of care plan dated 06/29/2023 revealed Resident #5 has pressure wounds and at risk for further skin break down, infection, worsening of existing pressure wounds, and developing new pressure wound formation. Review of MDS dated [DATE] section M0300 revealed Resident #5 has pressure wounds. Section C revealed resident had significant cognitive impairment. Review of physician order dated 05/12/2023 revealed the following: - Left Hip Stage: Cleanse with normal Saline, pat dry apply Collagen Powder + Vashe moist gauze sponge sterile cover with gauze + island dressing daily. - Right Hip Stage: Cleanse with normal Saline, pat dry apply Collagen Powder + Vashe moist gauze sponge sterile cover with gauze + island dressing daily. Review of TAR revealed there were no documentation of wound care performed for Resident #5 on the following days: 7/16/23, 7/22/23, 6/3/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23, 5/7/23, 5/13/23, 5/17/23, 5/29/23, 4/16/23, 4/17/23. Review of progress note revealed there were no wound care provided for Resident #5 on 7/16/23, 7/22/23, 6/3/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23, 5/7/23, 5/13/23, 5/17/23, 5/29/23, 4/16/23, and 4/17/23. Resident #6 Review of face sheet revealed Resident #6 was an [AGE] years old female admitted to the facility on [DATE] with diagnosis of multiple Sclerosis, Chronic kidney disease, cataract, essential hypertension. Review of care plan dated revealed Resident #6 had pressure wound Review of MDS dated [DATE] revealed Resident #6 had pressure wound. Review of Treatment Administration record revealed there was no documentation of wound care for Resident #6 on the following days: 7/2/23, 7/16/23, 7/22/23, 6/16/23, 6/17/23, 6/18/23, 6/25/23. Review of Physician order dated 06/06/2023 revealed Sacrum Unstageable: cleanse with normal saline, pat dry, apply Santyl + Calcium Alginate cover with gauze + island dressing daily. Review of progress note revealed there were no wound care provided for Resident #6 on 7/2/23, 7/16/23, 7/22/23, 6/16/23, 6/17/23, 6/18/23, and 6/25/23. Resident #7 Review of face sheet revealed Resident #7 was a [AGE] year old female who was admitted to the facility on [DATE]. Her diagnoses included Hemiplegia and Hemiparesis, cerebral infarction, pressure ulcers, metabolic encephalopathy, neuro muscular dysfunction of bladder, immunodeficiency, and essential primary hypertension. Review of MDS dated [DATE] revealed Resident #7 had pressure wounds. Section C revealed resident had significant cognitive impairment. Review of care plan dated 06/01/2023 revealed Resident #7 had pressure wounds Review of physician order dated 05/19/2023 revealed order Sacrum Stage 4: Cleanse with normal saline, pat dry, apply Collagen Powder + Calcium Alginate cover with gauze + island dressing daily. Review of Treatment Administration Record revealed there were no documentation of wound care for Resident #7 on the following dates: 7/22/23, 6/17/23, 6/18/23, 6/19/23, 5/5/23, 5/7/23, 5/14/23, 5/18/23. On 07/25/2023 at 12:08pm in an interview with Charge Nurse A on the hallway at 300 hall, Charge Nurse A was observed standing by the medication cart. She stated that the wound Care Nurse was at the other side of the building, in the 400 hall. On 07/25/2023 at 12:12 pm, in an interview with LVN G in the 400 hall, she said the wound care nurse had not been to that side of the building. She said the Wound Care Nurse should be in the 300 hall because the Wound Care Nurse had never been to the 400 hall that day and she had not seen the Wound Care Nurse today (7/25/2023). Surveyor asked who would be responsible for wound care if the Wound Care Nurse was not in the building. LVN G said she thought the Wound Care Nurse was at the other side in the 300 hall. She said she was new and did not know the practice in the facility when the Wound Care Nurse was not in the building, she said she did not know what the process was, and she did not know who was responsible to do the wound care if the wound care nurse was not in the building. LVN G said as far as she knew, the facility always has someone to do the wound every day. She said since the time she started working at the facility she never did wound care. Surveyor asked what she would do if she had a new admission with wound when the treatment nurse was not in the building. She said she was new in the facility, she said she just started working about three weeks ago and she had never had many resident admissions and she never had to deal with a wound on admission either. LVN G said at the time she was hired about three weeks ago, she was made to understand that the facility would always have somebody to take care of wounds, and that she would not have to worry about doing wound care. She also said she was not trained or receive in-service yet about wound care at the facility. On 07/25/2023 at 12:40pm in an interview with Charge Nurse A, surveyor asked about the wound Care Nurse. When the Surveyor told her that they wound care nurse was not at the other side of the building, she said well let me go and ask. Then she said she was not aware that the wound care nurse was not in the building today. She stated that if the Wound Care Nurse was not in the building, the nurses on the floor would be responsible to do the wound care. Surveyor asked how they (floor Nurses) would know when the wound care nurse was not in the building, then she said they (Unit Managers, DON) would tell them anytime the treatment nurse not in the building, she stated but today she had not heard if the treatment nurse was not in the building, and she said she had not seen the treatment nurse yes. She said, let me go and find out and she walked away. On 07/26/2023 at 2:07pm, in an interview with LVN G, she said yesterday (07/25/2023) the DON trained her in an in-service about the expectation that the nurses were responsible to perform wound care if the wound care nurse was not in the building. She stated prior to yesterday (7/25/2023) nobody had ever told her, but she said, I know it now from yesterday when the DON told me. On 07/26/2023 at 3:17pm in an interview with LVN J, she stated she was the nurse who took care of CR #2, Resident #5 and #6 on Saturday 07/22/2023, she said she started working at the facility around May 2023. She said she did not work at the facility very often, but she remembered taking care of CR #2 on Saturday 7/22/2023 but she did not remember if CR #2 had any wound. She stated she did not usually do wound care, she said only if wound dressing came off during diaper change, she would do the dressing. She said usually she did not deal with wound care, and she would not know if any resident had any wound unless she was told - she said if she admitted any resident, she would do skin assessment and that way she would see if the resident had any wound. She said if the CNAs noticed anything like new skin breakdown, they would notify her. She said she worked night shift, and at night she generally did not do wound assessment. She stated she was not aware if wound care was performed for CR #2 or not. She stated her understanding was that the wound care nurse during the day would always take care of all residents' wounds. She said they have full time day nurse who do the wound care every day and she stated the nurse on the day shift had the responsibility to do wound care. she stated with that being said, whether they do the wound or not, it got nothing to do with me she said the full time Wound Care Nurse was the one responsible as far as dressing change for all residents. She said if the dressing falls off while the CNAs change diaper, she would do (change) the dressing. She stated she did not work at the facility often and she said, I have never at one time been told that I had to do wound care. or if the nurses on the floor were responsible to do wound care when the Wound Care Nurse was not in the building, she stated if there is any rules like that I have never been told. On 7/26/2023 at 5:13pm during interview with the DON, she stated nurses were supposed to do weekly assessment, wound care and document wound care in the TAR as soon as possible. She stated the expectation was to obtain physician's order before wound care treatment and follow the order. She stated all assessments and treatments should be documented in the Point Click Care. She stated lack of documentation was not acceptable, as this could result in incomplete record and affect decision made on residents' care. The DON also stated nurses on the floor were responsible for doing wound care and documenting it when the Wound Care Nurse was not in the building. She stated she was sorry that there was no timely communication with the nurses yesterday 7/25/2023 when the Wound Care Nurse was not in the building. She said, please put that on me,

Based on observation, interview, and record review the facility failed to ensure that resident environment remains free of accident hazards, and each resident receives adequate monitoring and supervision to prevent elopement for 1 of 4 (Resident #1) residents reviewed for elopement. The facility failed to ensure Resident #1 was provided adequate monitoring and supervision to prevent Resident #1's elopement from the facility. Resident #1 eloped from the secured unit of the facility on 12/04/2021. Resident #1 was found walking on a busy highway many miles away from the facility by the law enforcement 3 days later. The facility failed to ensure the exit gate on the secured unit courtyard was latched and secured to prevent elopement and safety. An Immediate Jeopardy (IJ) situation was determined to have existed on 12/4/21. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. These failures could place residents on the secured unit at risk of elopement that could possibly result in serious injury or death. Findings Included: Resident #1 Record review of Resident #1's admission MDS dated [DATE] revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included dementia without behavior, type 2 diabetes mellitus with [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] of native coronary artery without [CONDITION(S)] pectoris, constipation, unspecified vitamin deficiency, [CONDITION(S)], convulsion, protein calorie malnutrition, psychoactive substance abuse, repeated falls, hypercalcemia, pain, gastro [CONDITION(S)] reflux disease. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 04 indicating the resident was severely impaired for cognition. For Behavior the resident was coded has having no verbal or physical behavior and no wandering behavior. For Activities of daily living the resident was coded for: Bed mobility and toilet use as needing Supervision with one person physically assisted, For transfer, dressing and hygiene the resident was coded as limited assistance with one person physically assisted, for bathing he was coded as needing physical help with one person assisted and for eating, he was coded as needing supervision with set up only. For bowel and bladder, he was coded as frequently incontinent bowel and bladder. Record review of Resident #1's care plan initiated 11/03/2021 deemed the resident to be at risk of wandering/elopement as evidence as ambulatory and had a diagnosis of dementia. Care plan was revised on 12/6/2021 to address Resident#1's actual elopement on 12/04/2021. Further record review revealed that any resident in the courtyard will be accompanied by a staff member also screeches will be installed on all exit door to alert the staff when the exit doors were opened. Record review of Resident #1's nurses notes dated 12/04/2021 at 7:41 PM, written LVN documented that Resident #1's where abouts were unknown and staff had actively began searching the facility for the resident but to no avail. Responsibility Party and Nurse Practitioner was notified that the resident was not on the unit or any unit in the facility. In an interview with CNA B on 12/07/2021 at 1:20 PM, she said she saw Resident #1 on 12/4/2021 at the beginning of her shift at 2:00PM sitting in the corner and at around 3:30 PM he was walking on the unit. She said at about 4:30 PM she was looking for him and could not find him and she reported it to the charge nurse. She said prior to Resident #1's elopement they were checking residents every two hours but now they are doing hourly checks. She said residents in the courtyard will have a staff watching them even when they are not smoking. In an interview with RN A on 12/07/2021 at 10:15 AM she said she was the Charge Nurse on the secured unit on 12/4/2021 and had seen Resident #1 at about 4:00 PM sitting in the activity area. She said he did not display any unusual behavior during her observation. At about 4:30 PM on 12/4/2021 CNA B reported to her that Resident#1 was not on the unit. She said they call CODE D to inform other unit managers and lock the facility down and started searching for Resident #1, she said, they could not find him. She said they searched everywhere but could not find the resident. In an interview with LVN A on 12/07/2021 at 9:30 AM he said Resident #1 was not admitted to the facility for a long time. He said Resident #1 was a very quiet resident and he never displayed any aggressive behavior and never attempted to leave the facility. He further stated he never tried to leave the facility with any visitors, so this was very surprising when they told him he was missing on 12/4/2021. In an interview with the DON on 12/07/2021 at 9:43 AM she said she had in-serviced the staff regarding elopement monitoring and smoking policies on 12/6/2021. She said she was also in-serviced staff on doing hourly checks and document it to ensure that it was done. Further interview revealed that all checks should be documented. She said that prior to the elopement, residents were checked every two hours but now they are doing hourly checks. She said t all residents in the courtyard will always have a staff watching them even when they are not smoking. She said prior to Resident #1's elopement he did not display any behavior of exit seeking. She said he was always very quiet and did not even follow a staff to the exit door. She said he never displayed any behavior of aggression. Record review revealed that hourly checks log dated 12/05/2021 to 12/9/2021 documented that hourly checks were done. Record review that training was completed on 12/09/2021. In an interview with the Administrator on 12/7/2021 at 4:30 PM, he said he was called about the elopement on 12/4/2021 and arrived at the facility between 6:30 PM and 7:00 PM. He said on arrival he started checking all the exit doors and gates. He said he checked the exit gate off the secured unit and realized it was open. He said when he realized it was open and could not lock, he used a zip tie to temporarily secure the gate. He said on 12/05/2021 the maintenance crew came in and repaired the gate. He said the malfunctioning of the gate was possibly due to electricity flash around 4:30 PM due to the [NAME] on 12/04/2021 and could possibly be the exit/escape route for Resident #1 although no one saw him going through the gate. Record review of the nurse's notes dated 12/07/2021 at 4:20 AM by LVN C documented that Resident #1's vitals on assessment was blood pressure 130/86, pulse 92, temperature 98.5, O2 stat 98 (RA) respiration19 and Blood sugar 147. Resident #1 was alert x 1 and skin intact. Resident#1 was sent to the hospital for evaluation on 12/07/2021. In an interview on 12/7/2021 at 3:00PM with LVN C revealed that Resident #1 was returned to the facility by the police on 12/07/2021 at 4:30 am. She said the resident was alert but confused and had no visible marks or bruises. She said the police told her they saw him walking on belt was 8. She said she assessed the resident and call 911 but they refused to take him stating it was not an emergency. She said the resident was sent to the hospital at about 7:00am that that morning for evaluation. Record of the hospital evaluation report dated 12/07/2021 revealed that Resident #1 was admitted to the hospital for evaluation. Further record revealed diagnoses of altered mental status and unspecified altered mental type. He had no injury and he was medically cleared to return to the facility. Observation of Resident #1 on 12/7/2021 at 3:30 PM revealed Resident #1 in bed he was alert but confused. Resident #1 was clean with no offensive odor. No visible marks or bruises observed. Attempt to interview Resident #1 but was unsuccessful due to his confusion, he was unable to say what happened and where he went. Observation on 12/02/2021 at 11:47 AM revealed the exit gate to the secured unit to be locked. There was also a Zip tie to the exit gate. Further observation at 11:50 AM revealed no alarm to the exit door from the secure unit to the courtyard. In an interview on 12/7/2021 at 11:50 AM with Maintenance D she said they were checking the exit gate daily. She said the last time the exit gate was checked prior to the elopement was on 12/03/2021 and the gate was working properly. She said after they fixed the malfunctioning gate on 12/05/2021 and they did hourly monitoring to ensure the gate was working properly and they will continue to do daily checks to ensure no malfunctioning of the gates or doors. She was questioned about the zip tie and she said it was for extra precaution. She also stated that there was no alarm to the exit door from the secured unit to the courtyard, because the courtyard was secured, and the side gate was always lock and not an exit. She said for the gate only opens when there was a fire drill and they pull the alarm. Said there was a code to that gate and only the DON Maintenance and the Administrator has the code. Interview with the DON on 12/8/2021 on 2:00 PM she said she was in-servicing staff on daily checking regarding the side gates and exit entrances. She said they have ordered screeches (alarm device) to alert staff if a resident goes through the door or the gate and if the gate was opened. Record review revealed the screeches were ordered on 12/08/2021 installed on 12/9/2021. Interview with the Administrator on 12/8/2021 at 3:00 PM he said that he ordered some screeches to put on the exit doors to alert staff when the exit doors were opened. He said when the alarm (screeches) goes off staff are expected to check the outside gates and inside the unit to ensure no resident was missing. In an interview on 12/10/2021 at 11:55PM with the Administrator he said that they had gotten the screeches and he had them installed. He said the one to the side gate was temporary as they were waiting for a water-resistant screech to come in. He said as soon as it comes in, he will replace it the permanent one. Observation on 12/10/2021 at 12:05 PM revealed that all exit doors on all unit had screeches on them. They were tested and the alarm went off and the sound was audible. The door from the secured unit to the courtyard had screeches on it and it was audible when the door opens. Further observation at 1:30PM revealed two residents in the courtyard and there was a staff on the outside with them. Further interviews conducted on 12/08/2021 with the staff on all three units revealed they were in-serviced on the screeches. They were also able to explain how they worked what they were expected to do when alarm alerts them. Record review of Nursing Policies and Procedures dated 8/2019 titled Elopement read in part . Policy: It is the policy of this facility is to safely and timely redirect residents to a safe environment. A prompt investigation and search will be conducted if a resident is considered missing. The facility will determine a signal code to designate a missing resident. Immediate Action Taken The facility always needs to train staff on effective supervision and monitoring of secured unit residents. Actions taken include: Record review of the QAPI dated 12/6/2021 Occurrence: 1. Resident exited property a. All main exit doors were locked b. Gate in the courtyard appears to be malfunctioning. Electricity flash around 4:30pm due to [NAME]. c. No clear indication to confirm exit location or direction. 2. Resident did not exit through main doors or window. (observation on 12/07/2021 of windows revealed they couldn't open wide enough for a person to go through). Conclusion: Resident did exit property, route not confirmed, but likely from the gate door that was dislodged during power [NAME] around 4:30pm. Door secure on 12/4/2021 and repairs done on 12/5/2021. On 12/06/2021 Staff were re-educated on elopement policy, visual checks, emergency notification. Hourly checks were done on12/5/2021 to ensure functionality of gate and daily checks to be done. Gate was observed to have zip ties on it on 12/7/2021. Gate is working properly on 12/07/2021. On 12/07/2021 the Administrator said he ordered a device that will alarm if the gate malfunctions. Invoice of purchase was provided and reviewed. Staff should always be with residents when they go into the gated courtyard. After a storm the Maintenance Director or nurses will check the gates to ensure they are working. They will continue to do daily gate checks to ensure there are no malfunction issues. Ongoing education will be done to ensure that no resident leaves the building.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for one resident (CR #1) of five residents reviewed for accidents and supervision. The facility failed to ensure adequate supervision for CR #1 was provided after the resident showed exit seeking behaviors on [DATE] and attempted to elope multiple times on [DATE] and [DATE]. CR #1 was found unresponsive approximately one mile from the facility. Resident #1 expired at the hospital within 12 hours of the elopement . The failure resulted in CR #1 eloping from the facility. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with potential for more than minimal harm, due to the need to evaluate the effectiveness of the corrective systems. Findings include: Record review of the Admission Record for CR #1 revealed a [AGE] year old male admitted to the facility on [DATE]. CR #1 had diagnoses which included, but were not limited to, Alzheimer's disease, muscle weakness, and hypertension (high blood pressure). He resided on the secure unit. Record review of the MDS assessment, dated [DATE], revealed CR #1 scored '3' on the BIMS, indicative of severe cognitive impairment. The MDS reflected the resident exhibited wandering behaviors. CR #1 was able to walk with supervision. Record review of the Care Plan for CR #1, dated [DATE], revealed staff was to maintain CR #1's safety during increased episodes of wandering. The staff was to observe and document the resident's location frequently . The Care Plan reflected if CR #1 attempted to exit the facility, the IDT , physician, and family were to be notified. Record review of the electronic chart for CR #1 revealed one Wandering Risk Assessment, dated [DATE]. The score reflected CR #1 was high risk for wandering. Record review of the Nurses Note, dated [DATE] at 7:24 p.m., revealed CR #1 was an exit seeker, and he was at high risk for elopement . Record review of a Nurses Note, dated [DATE] at 6:07 a.m., revealed CR #1 attempted to exit through doors, setting alarms off. The nurses note was entered by LVN D . Record review of the Nurses Note, dated [DATE] at 12:09 a.m. revealed CR #1 attempted elope 'multiple times' during the shift. The nurses note reflected the resident should be monitored closely . The nurses note was entered by LVN D. Record review of a Nurses Note, dated [DATE] at 9:45 p.m., revealed CR #1 exhibited exit-seeking behaviors, and was redirected to his room. The nurses note reflected .will continue to monitor resident for any changes. The nurses note was entered by LVN D. Record review of a late entry Nurses Note, dated [DATE] at 11:09 a.m., revealed CR #1 was observed by staff at 1:00 a.m At 1:37 a.m. the RCS (RCS E ) assigned to the hall reported CR #1 was missing. The nurses note reflected the resident was found at 2:00 a.m. and was transported to the hospital . Record review of the facility investigation revealed CR #1 expired at the hospital on [DATE], within 12 hours of the elopement. Record review of CR #1's local hospital records dated [DATE] read in part, Consultation .Supportive Medicine Consult Note .History of Present Illness XXX[AGE] year old male with hisotry of DM (Diabetes Mellitus), [CONDITION(S)] (Hypertension), dementia presents after being found down outside his center with SDH (Subdural Hematoma) with MLS, tSAH, facial fractures, with minimal intracranial blood flow. Per report, patient eloped from his memory care center last night and was found later on the side of the road. Patrient brought to MHH (Hospital) with oxygen saturation in 30s in extremis, CPR (Cardiopulmonary Resuscitation) performed, intubated emergently with above imaging. EMERGENCY DEPARTMENT PROVIDER DOCUMENTATION .Date & Time [DATE] 02:41 (a.m.) .History of Present Illness .The patient presents with altered mental status. The onset is unknown. The degree at present is severe. Risk factors consist of diabetes mellitus and head trauma. Associated symptoms: left scalp hematoma. [AGE] year old male with PMHx (Past Medical History of DM, [CONDITION(S)], and Alzheimer's, presents to the ED (Emergency Department) via HFD for evaluation of altered mental status onset unknown. Condition is severe. Per EMS (Emergency Medical Services), patient eloped from his nursing home around 0100 (1:00 a.m.) and was found unresponsive on the side of the road with a left sided scalp hematoma by a bystander. EMS placed him on a nasal cannula and reported that his respiratory rate had slowed in route. They also reported that they gave 10 of [MEDICATION(S)] for a BP (blood pressure) of 240. Per nursing home staff, patient was last normal 2 hours ago. HPI/ROS is limited secondary to altered mental status. On arrival he is minimally responsive and will only grimace to pain on the left side. upon transfer to our monitors he was noted to have an oxygen saturation of ,d+[DATE]% on arrival with slow respirations.IMPRESSION .2. Acute subdural hematomas along both cerebral convexities as well as the interhemispheric fissure and along the bilateral tentorium as above described. 3. Acute subarachnoid hemorrhage is seen involving both frontal lobes with small hemorrhagic contusions suspected along the anterior inferior margins of both frontal lobes. Milder acute subarachnoid hemorrhage is seen in both parietal lobes. 4. Right to left mass effect and midline shift estimated at 8 mm at the level of the septum pellucidum. 5. Acute nondisplaced tomildly displaced fractures involving the left parietal bone, left frontal bone, and a small portion of the right parietal bone. 6. Acute mildly inferiorly impacted fracture involving the right superior orbital wall associated with mild induration and stranding in the right retrobulbar fat suggesting mild intraorbital injury. Mild right proptosis is also present. The right globe is other wise intact. 7. Suspect acute nondisplaced fractures involving the left superior orbital wall and a portion of the left lateral orbital wall. Observation on [DATE] at 5:25 p.m. revealed the facility did not have a fence which enclosed the secured unit. CR #1's former room was at the end of a hallway. Observation revealed a window screen on the ground. The facility was located next to a busy four lane divided street. Observation on [DATE] at 12:14 p.m. revealed CR #1's former room had an air conditioning unit under the window which could have been used to assist the elopement. The window was approximately four feet wide, with one panel that, when opened fully, created an opening large enough for the elopement. The facility had since limited the window opening to prevent future elopement . Interview on [DATE] at 5:15 p.m. with the Administrator revealed CR #1 eloped from the facility through the window in his room. He said the windows did not have limiters on them at the time, but limiters have since been installed . Interview on [DATE] at 12:40 p.m. with LVN D revealed the residents on the secure unit were checked on every two hours, but some required every one-hour checks . She said the checks were not documented . She said the last time she saw CR #1 was on [DATE] at 12:30 a.m. She said RCS E was on break , then reported the resident was missing at 1:37 a.m. LVN D said she had been sitting at the nurses' station while RCS E was on break. She said she did not check on CR #1 . Interview on [DATE] at 3:15 p.m. with the Administrator revealed the residents on the secured unit were checked on every two hours . He said there was a 30-minute gap between when CR #1 was observed and when he was discovered to be missing at 1:37 a.m. on [DATE]. He said the resident was found by a citizen, who called 911. He did not know the identity of that citizen. Interview on [DATE] at 3:25 p.m. with the DON revealed she did not think that a resident would elope through a window. She said she spoke with the nurses and instructed them to do more rounding. The DON stated she did not provide staff with specific times to complete rounds. She said she created a form for the nurses to document hourly checks. She said the form was created after the elopement . Interview via telephone on [DATE] at 6:20 p.m. with the family member of CR #1 revealed the resident was taken to the hospital with severe head injury. He was placed on life support and later expired. Interview on [DATE] at 12:20 p.m. with LVN G, the secure unit Charge Nurse, revealed the DON told her to increase checks on the residents but provided no specifics. She said CR #1 was able to walk independently. She said when the resident's family member visited, he would try to leave with her . Interview on [DATE] at 12:40 p.m. with the DON revealed she conducted an in-service to increase supervision, but it did not establish timeframes for checking on residents with increased exit-seeking behaviors. Interview via telephone on [DATE] at 1:)05 p.m. with RCS F revealed she worked the night of CR #1's elopement. She was assigned to the other side of the unit. She said she thought RCS E never left the unit , and she did not check on the residents on that side. She said CR #1 would try to exit. Interview on [DATE] at 1:40 a.m. with the DON revealed she did not in-service the staff regarding informing the other staff when they go on break. Interview via telephone on [DATE] at 4:35 a.m. with LVN D revealed the facility had an in-service about increased supervision, but she was not in attendance. She said they should do a head count every 15 minutes, go to the rooms, check the beds, windows. In the lock-down [secure] unit we don't have time. Record review of the form created on [DATE] revealed hourly increments from for the nurse and the RCS to initial. The form did not reflect what the staff was initialing for. This was determined to be an Immediate Jeopardy (IJ) on [DATE] at 1:10 p.m. The Administrator and the DON were notified. The Administrator was provided with the IJ template on [DATE] at 1:10 p.m. The following Plan of Removal submitted by the facility was accepted on [DATE] : Alleged Deficient Practice The facility failed to ensure Resident #1, who had numerous elopement attempts, received adequate supervision to prevent a fatal accident. AND The facility failed to ensure Resident #1 was provided services that were necessary to prevent physical harm. Corrective Action 1. Window limiters were placed on all resident room windows in the memory care unit by maintenance staff on [DATE]. 2. Staffing pattern and needs were reviewed by Administrator and DON to ensure proper staffing levels for memory care unit [DATE]. It was determined that no one had called out of the shift and that the staffing level was adequate for the needs of the residents for the shift . 3. In-services: a. All disciplines of staff were educated by ADON on [DATE] related to the Elopement policy, monitoring residents for elopement signs and exit door seeking, report to supervisor if you notice a resident is missing, pay attention to your surroundings b. All disciplines of staff were educated by ADON on [DATE] related to ensuring doors and windows remain closed, check your back when entering/exiting secured unit, ensure memory unit door latches and working properly. c. Communication of going on breaks was conducted by DON on [DATE]. d. Licensed staff were educated by ADON on [DATE] to notify MD with increase in exit seeking behaviors and when repeated attempts to exit cannot be redirected with other interventions. e. Licensed staff were re-educated by ADON on [DATE] to notify family with new order changes related to elopement risk monitoring f. Clinical staff were educated by ADON on [DATE] that nurse will provide documentation form to complete based on MD orders for monitoring and form to be passed to next individual for consistency in monitoring. g. IDT was educated to be involved and assist with diversional activities during increase elopement periods. Education was conducted by Administrator on [DATE]. 4. Staff education per above will be completed prior to them returning to work for their next shift. 5. MDS nurse and nursing administration were re-educated on care plan review/updates when new occurrences of increased elopement risk. Education was completed by Administrator on [DATE]. 6. An assessment was completed by Administrator on [DATE] to assess the physical site of the secured unit for concerns relating to elopement risks to residents. 7. An environmental assessment was completed to ensure doors were locking properly and windows have limiters in place. This assessment was completed on [DATE] by the Administrator. 8. DON and nurse managers to assess staffing levels based on staffing needs and resident acuity as needed . Identification of Others Resident #1 is deceased All residents at the facility have the potential of being affected by this alleged deficient practice An elopement risk assessment audit was completed on [DATE] by DON, ADON and Unit Managers for all residents related to wandering risk. All residents had a revised assessment completed. Care plans for those identified as high risk were reviewed and updated by DON on [DATE]. Monitoring for implementation of the POR: Observation revealed staff were provided in-services as they began their shift . Interview on [DATE] at 3:10 p.m. with the MDS Coordinator revealed she received the in-service. She said staff observing a resident who is exit-seeking must alert the Charge Nurse. The Charge Nurse calls the physician and gets an order to monitor. It's documented on the 24- hour report, then discussed in the meeting . The Care Plan is then updated. Interviews with four CNAs from the 6:00 a.m. to 2:00 p.m. shift revealed they had been in-serviced, and they were able to answer questions regarding the updated procedures. Interviews with three CNAs from the 2:00 p.m. to 10:00 p.m. shift revealed they had been in-serviced, and they were able to answer questions regarding the updated procedures . Interviews with two CNAs from the 10:00 p.m. to 6:00 a.m. shift revealed they had been in-serviced, and they were able to answer questions regarding the updated procedures . Interviews with two 6:00 a.m. to 6:00 p.m. shift and one 6:00 p.m. to 6:00 a.m. Charge Nurses revealed they had been in-serviced and were able to answer questions regarding the updated procedures . Record review of an in-service, dated [DATE], entitled POR education - IDT revealed the Therapy Director, Business Office Manager, Dietary Manager, MDS Coordinator, Activities Director, Maintenance Director, and Social Worker attended . Record review of an in-service, dated [DATE], entitled Lunch Break revealed 32 staff signed as receiving the in-service . Record review of the newly implemented Critical Behavior Monitoring Log revealed the physician could order safety checks for residents as often as every fifteen minutes . Record review of individual Inservice Plans revealed the items listed in #3 a - 3 g in the POR were presented to the staff. Record review of the Care Plans for Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, and Resident #12 revealed the Care Plans were current and/or updated . The Administrator and the DON were notified the IJ was removed on [DATE] at 7:15 a.m. The facility remained out of compliance at a severity level of actual harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review , the facility failed to ensure residents reviewed were provided care based on the comprehensive assessment of the residents received treatments and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of five residents (CR #2) reviewed for Quality of Care. 1. The facility failed to ensure wound care was provided for -CR #2's post-surgical wound according to physician orders. This failure resulted in CR #2's toes having to be amputated, and placed residents at risk for delay of wound healing. Findings Include: Record review of the Admission Record for CR #2 revealed a [AGE] year and old female who was originally admitted on [DATE], then readmitted to the facility on [DATE] . CR #2's had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS assessment for CR #2, dated 06/10/21, revealed a BIMS score of '15,' indicative of intact cognition. The MDS reflected CR #2 did not resist care. CR #2 required extensive assist from 2 persons for bed mobility. She did not walk during the 7-day look-back period. The MDS reflected the resident had one pressure sore and one surgical wound, which were present upon readmission. Record review of the Care Plan, dated 06/07/21, for CR #2 revealed an identified concern of the left foot surgical wound. The Care Plan reflected Perform treatments per order . Record review of CR #2's Weekly Wound Observation sheet, dated 06/09/21, revealed the left foot surgical site was documented to be 1.5 x 3.0 x 0.3 cm. with no inflammation present. Record review of CR #2's most recent Weekly Wound Observation sheet, dated 06/18/21, revealed the left foot surgical site was documented to be 2.0 x 4.0 x 0.3 cm. with no inflammation present. Record review of the June 2021 TAR revealed CR #2 had an order, dated 06/04/21, to clean the surgical wound with NS, pat dry, then apply a wet-to-dry dressing twice daily until a wound vac was available. Record review of the June 2021 TAR revealed an order, dated 06/12/21, reflected CR #2 was to be provided a wound vac, and the dressing was to be changed every three days. From 06/12/21 at 8:00 p.m. to 06/14/21, no wound care treatment was provided . Record review of the June 2021 TAR reflected the wound vac was provided on 06/14/21, and the dressing was changed on 06/18/21, four days later, one day beyond the time ordered . Record review of the June 2021 TAR revealed an order, dated 06/18/21, reflected CR #2's surgical wound was to be cleansed with NS or wound cleanser, pat dry, then Santyl and alginate calcium were to be applied, and covered with a dry dressing daily . Record review of the June 2021 TAR for CR #2 revealed LVN B initialed she provided wound care for CR #2 on 06/21/21 and 06/22/21 . Record review of the June 2021 TAR for CR #2 revealed LVN A initialed he had provided wound care for CR #2 on 06/19/21 and 06/20/21. Record review of the hospital Emergency Department to Hospital Admission record, dated 06/25/21, for CR #2 revealed her left dorsalis pedis (top of foot) was palpable (detected via touch). CR #2 underwent a left foot trans metatarsal (removal of the five long bones between the ankle and toes, including the toes) amputation on 06/25/21. Interview on 09/15/21 at 3:35 p.m. via telephone with CR #2 revealed she was originally admitted to the facility following an amputation of one toe of her left foot. She said the facility was not consistent with the dressing changes and were not proficient with use of the wound vac (negative pressure wound treatment device). She said when she went to her follow-up appointment with the surgeon , he said the wound appeared to be infected. He sent her directly to the hospital . CR #2 had the remainder of her toes on the left foot amputated as the result of infection. Interview on 09/15/21 at 5:15 p.m. with the DON revealed she said the facility has 4 or 5 wound vacs in house. She said when one was ordered, it would be initiated right away. She said CR #2 came from the hospital with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview via telephone on 09/20/21 at 12:51 p.m. with LVN B revealed the wound vac would not seal properly, and the error warning kept beeping . She said when she observed the wound It didn't look good. She said it was the only time she recalled seeing the wound. She said she did not recall providing the treatments on 06/21/21 and 06/22/21. Interview on 09/20/21 at 1:00 p.m. with LVN A revealed he did not remember anything about CR #2. He did not recall anyone having a wound vac, and he did not recall any resident requiring wound care for a toe amputation . Telephone interview on 09/21/21 at 10:20 a.m. with the Surgeon revealed he had concerns with the surgical wound on CR #2's left foot. He said the wound was not healing. He voiced concern the wound vac was not being used, and other dressings were being used. He sent her directly to the Emergency Department. He subsequently had to amputate the remainder of the toes on CR #2's left foot . The surgeon said CR #2 did have some underlying vascular issues, but the inadequate wound care caused the deterioration of the foot to occur faster. Record review of the facility Nursing Policies and Procedures Subject: Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eight residents reviewed for quality of care. -The facility failed to assess and treat Resident #1's right eye when it was found swollen and red. -The facility failed to follow Resident #1's antibiotic order for his right eye as prescribed by his ophthalmologist in April 2020. Resident #1 had surgery on 4/16/20 for enucleation (removal) of right eye. These failures could affect all residents and place them at risk of decreaased quality of care and negative outcomes. Findings Include: Record review of the face sheet for Resident #1 revealed an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation of Resident #1 on 8/21/20 at 12:15 pm, revealed Resident #1 in the Barrington unit. He was well groomed and sitting in his wheelchair. He parked his wheelchair, stood up to put his sweater and hat on and sat back down. Surveyor waved to him saying hi resident waved back and smiled at surveyor. His right eye was shut. There was no visible scaring or bruising around his eye. Record review of Resident #1's progress notes dated 12/16/19 written by RN C revealed a note that read, his right eye is swollen and reddened. Informed np. Waiting for reply.plz follow up. Further review of Resident #1's progress notes revealed no other documentation related to this note. Further review of Resident #1's progress notes dated 04/12/20 written by LVN A revealed a note that read in part, .Resident was observed with swelling, bloody and pus like drainage from the ( R ) eye .NP ordered to be transferred to .hospital . Record review of the SBAR for Resident #1 dated 04/12/20 completed by LVN A read in part, .swelling, bloody and pus like drainage was observed from the R eye .NP was notified .911 was called . Record review of Resident #1's hospital, after visit summary dated 04/12/20 read in part, [DIAGNOSES REDACTED].abrasion of right cornea .medications .Moxifloxacin 0.5% ophthalmic solution ( used to treat eye infections), administer 1 drop to the right eye 4 times a day for 7 days . Record review of Resident #1's physician order [REDACTED].patient given a prescription for Moxifloxacin ophthalmic solution to be used (1 drop into R eye every hour) . Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's MAR/TAR for April 2020 revealed he was given Moxifloxacin 0.5% ophthalmic solution, administer 1 drop to the right eye 4 times a day on 4/13/20 and 4/14/20 (he was in the hospital after that date). Record review of Resident #1's progress notes for April 2020 revealed no documentation to reflect any communication with the physician or Local Eye Specialist to verify orders for his Moxifloxacin. Record review of Resident #1's medical file revealed that he was sent to the hospital on [DATE] and returned to the facility on the same day (4/12/20). Record review of Resident #1's hospital records dated 4/16/20 read in part, .[DIAGNOSES REDACTED].acute bacterial [MEDICAL CONDITION] of right eye .right endophthalmia (inflammation in the tissue within the eye ball) .plan enucleation right eye .in our best medical judgement, this surgery is emergent/urgent .there is significant medical risk of patient deterioration if this surgery is not urgently performed .the patient and family voiced understanding and gave their consent to proceed . Further review of the hospital records, did not reveal a discharge summary. Record review of Resident #1's care plan initiated on 4/22/20 read in part, the resident has impaired visual function .interventions .arrange and follow up with eye care practitioner as required .monitor/document/report any s/sx of acute eye problems . There was no care plan to address his visual function prior to 4/22/20. Record review of Resident #1's significant change in status MDS assessment dated [DATE] revealed his BIMS was 9 indicating that he was moderately impaired. Further review of the section for vision revealed that he was coded as moderately impaired in vision. Phone Interview with RN C on 5/28/20 at 12:21 pm, she said she was a full time RN at the facility. When asked if she remembered Resident #1, she said she did. Surveyor read the note dated 12/16/19 to her and asked if she remembered writing that note or anything about Resident #1 during that time frame. She said, No I am sorry, it was so long time ago I can't remember anything. She said she did recall Resident #1 being on an eye drop but could not remember which one it was. She apologized for not being able to remember anything else. When asked if she thought she did any follow up after this note, she said she could not remember and if she did not document then that probably meant she did not. She said they were supposed to notify the RP and follow up with the physician in situations like this note. Interview with DON and ADON on 8/11/20 at 11:15 am, when asked regarding the note on 12/16/19 the DON said, there should have been a follow up, it should have been addressed. They said the family should have been notified and there should have been more documentation regarding the issue. It should not have been left like that, some type of follow up should have been made. They agreed that since there was no further documentation, they could not tell if anything was done regarding the issue. When asked about the Moxifloaxin, the DON said the facility should have called and got clarification on the order. When there are 2 different orders like that, we need to get clarification. DON was asked if anything was mentioned on the 24 hour log regarding the resident's eyes, she said that she would check but does not believe there was. Phone interview with the Clinical Consultant with the Local Eye Specialist on 8/11/20 at 1:00 pm, when asked about the order that was written for Resident #1 on 04/12/20 by the Ophthalmologist, she said based on the pictures that the family member of Resident #1 had sent to them and concerns from the facility the Doctor did want for Resident #1 to be on Moxifloxacin drops and for those drops to be put in every hour until seen by his primary Ophthalmologist. She said this was communicated to the facility verbally and she also sent the email stating this to the facility. She said she had communicated everything with the facility. She said she even let the NP know because the NP had called her to confirm the drops Resident #1 needed to be on before and after his surgery. Phone interview with NP on 8/12/20 at 1:15 pm, she said the only time she could remember the facility calling her regarding Resident #1's eyes was in April. She said when they notified her of the eye issues, she gave order to send him out to the hospital. She said that was the only time they had ever contacted her regarding his eyes. She said she did not recall communicating with the Local Eye Specialist regarding his eye drops but the facility should follow whatever order is given by the Resident's Ophthalmologist because he was the specialist. Record review of the facility's policy for change in condition communication revised on 06/19 read in part, .notify the physician of the change in medical condition .the nurse will document all assessments and change in the .resident's condition on the medical record .if the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified .The Medical Director will provide medical orders as necessary to treat the patient's condition .residents family member will be notified of any change in condition . Record review of the facility's policy for Physician orders [REDACTED].the qualified licensed nurse reviews orders from the transfer record from an acute care hospital or other entity .a call is placed to the physician to confirm the orders and request any additional orders as needed .

Based on observation, interview, and record review, the facility failed to ensure two resident (Resident #5 and Resident #10) of five residents reviewed for pressure sores was provided the necessary care and services to ensure a resident who entered the facility with pressure sores received the necessary treatments and services to promote healing, prevent infection, and prevent new sores from developing. - The facility failed to assess, measure, and treat Resident #5 ' s Stage IV sacral wound. His wound had drainage and a foul smell. He had a drainage-saturated dressing in his disposable brief that was 4 days old. - Facility failed to assess and treat Resident #5 ' s bilateral untageable heels wounds. The resident had dressings on both lower extremeties that were 7 days old and were dated before his admission to the facility. - The Wound Care Nurse was unaware of Resident #5 ' s Stage IV pressure sore. - The facility failed to transcribe the sacral wound care order to the MAR and TAR for Resident #5. - The facility failed to provide wound care for Resident #10's bilateral knees and failed to use devices between his legs to avoid further decline and breakdown. An Immediate Jeopardy (IJ) was identified on 09/7/16. While the IJ was lowered on 09/11/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The failure affected two residents and placed the other 14 residents with pressure sores at risk of worsening and infections of pressure sores, and at risk of developing new pressure sore areas. Findings Included: Resident #5: Record view of Resident #5 ' s hospital transfer form revealed he was [AGE] year old male admitted to the long term care facility on 09/01/16 with [DIAGNOSES REDACTED]. Further review of the form revealed a body diagram indicating the resident had a pressure ulcer Stage IV on the sacrum and unstageable pressure ulcers on bilateral heels. Form section titled dressings and bandages revealed in part: bilateral heel wounds, clean with NS, pat dry, put iodosorb gel, dry Kerlix .sacral wound, clean with NS, pat dry, wet to dry gauze, cover with abdominal dressing and secure with medipro. Record review of the facility clinical record and electronic record revealed no admission skin assessment, no interim care plan and no MDS for Resident #5. Record review of the Nursing Admission Data Collection Report, dated 09/02/16, revealed the resident was admitted due to a Stage 4 sacral wound, exhibited limited range-of-motion to all extremeties and was totally dependent with assistance from staff for bed mobility. The report revealed the resident had a Stage 4 Sacral Wound, Bilateral Foor (sic) Eschar. There was no description or measurements of any of the wounds on the report. Record review of the multidisciplinary Progress Notes revealed only nurses notes and no notes from any other discipline. The nurse note dated 09/02/16 at 3:36 a.m. revealed in part Resident is on contact isolation for E-coli (Escherichia coli bacteria). The note did not reflect the location of the infection. Further review of the note revealed that admission orders [REDACTED]. Record review of the nurses ' notes from 09/02/16 to 09/06/16 reveal no documentation that the resident was assessed by a NP or physician. Observation on 09/07/16 at 9:26 a.m. revealed Resident #5 to be in a room on the 400 Hall. He was in the bed located in the center of the room. He had no roommate. Licensed Vocational Nurse (LVN) M accompanied the surveyor to the room. LVN M identified herself as the facility Treatment Nurse. LVN M donned gloves and adjusted the resident ' s covers to expose the resident ' s lower extremities. The resident had Podus boots on both legs. Both lower legs were wrapped in gauze that were dated 08/31 at 1630 (4:30 p.m.). The initials ' JW ' were observed on the dressings. LVN M confirmed the information, then said, I don ' t do his dressings. The Charge Nurse does. Further observation revealed Resident #5 turned onto his right side. An uncovered open wound area of approximately 10 centimeters (cm) in diameter, with approximately 2 cm depth on his sacral area. There was a saturated dressing in the disposable brief dated 09/04/16. The entire visible surface of the brief was saturated with bloody drainage. Observation revealed the resident had an indwelling catheter. When asked why the resident was on isolation, LVN M answered, I don ' t know. Charge nurses are responsible for skin assessments. This is my first time with this resident. Observation on 09/07/16 at 9:35 a.m. revealed Resident #5 to be lying in bed, watching television. The resident provided verbal consent for the surveyor to observe treatment, but did not verbalize anything else. He had limited use of his upper extremeties. Observation and interview on 09/07/16 at 9:37 a.m. revealed NP N was sitting at a table in the lobby of the unit. LVN W asked NP N for an order for [REDACTED]. NP N then told them, It ' s in the wound. The surveyor asked NP N, LVN V, and LVN M if there were any wound care orders for Resident #5 ' s sacral area. LVN M looked in the clinical paper chart and said, There ' s none in the chart. Continued observation revealed LVN M search the computer chart of Resident #5. The search revealed an order dated 09/02/16 that revealed in part Stage 4 sacral pressure ulcer (ESBL) in the urine and wound). Bilateral Heel wounds, Left Calf-clean with NS (Normal Saline), pat dry, Iodosorb Gel, dry Kerlix and gauze tape. Sacral wound-clean with NS, pat dry, wet to dry gauze, cover with ABD (absorbant pad), secure with medipre (tape). In an interview on 09/07/16 at 9:43 a.m., LVN W said When an admission comes in, the Charge Nurse was responsible for a head to toe assessment. If there ' s a wound, I get a wound consult. Record review on 09/07/16 at 9:55 a.m., LVN M presented the Medication Administration Record (MAR) for Resident #5, which included Treatments. Review revealed no treatment schedule for the sacral area, and therefore, no documentation to reflect treatments were conducted. The MAR revealed Collagenese Ointment 250 unit/gm (gram). Apply to eschar on the heels topically one time a day for wound care. The date was 09/02/16. The box for 09/06/16 was initialed by LVN V as being administered. In an interview on 09/07/16 at 9:55 a.m., regarding Resident #5's heels wouds ,LVN V said The Aide held his leg up. Gauze wrap. I put it there. At that time the surveyor asked LVN V to observe Resident #5 ' s dressings. Observation revealed LVN V enter the room without an isolation gown, don gloves, adjust the linens, and look at the dressings on the resident ' s legs. LVN V verified the date of 08/31, and the initials ' JW . When asked who ' s initials they were, LVN V answered, I have no idea. LVN V then said she pulled the gauze wrap back slightly (demonstrated) and said I put ointment on that. She exposed a linear scar on the resident ' s left calf area. When asked about the sacral wound, LVN V stated, I didn' t touch that at all. Record review of a nurse note dated 09/06/16 at 9:33 p.m., noted by LVN V revealed _____ (Resident #5) has been very combative today. The 2-10 RCS (Resident Care Specialist) tried on several different occasions to try and clean him up. I even went into the room with her to try to talk him into allowing us to clean him up. I am very concerned about the sacral wound that he has. The RCS said that when she changed him yesterday that it was very bloody and the diaper was saturated with his blood. He also refused his last 2 med passes. I am going to call the family to make them aware of the situation. In an interview on 09/07/16 at 10:15 a.m., NP T stated she would have been the person on call and who would have been notified if the resident refused treatment. She stated she had not been notified. She stated she knew Resident #5 from another facility. Observation on 09/07/16 at 10:27 a.m. revealed NP N and LVN M at the doorway of Resident #5 ' s room. NP N looked at the dressings on the legs, that were dated 08/31. The surveyor asked NP N if that was a problem. NP N answered, Yea. Continued observation revealed LVN M remove the gauze dressing from the left lower leg and foot. LVN M lifted the leg, and NP N observed the heel. Observation revealed an unstageable black area, of approximately 3 cm diameter. NP N said there was no open area. Continued observation revealed LVN M, without changing gloves, remove the gauze from the right leg and hold up the leg. NP N looked at the heel, and said, A little softer. A little open area. Overall about 2 cm in diameter. Eschar. Without changing gloves, LVN M assisted the resident onto his left side. Observation revealed an open area on the sacral area, of approximately 10 cm diameter. NP N said, Stage 4 with undermining .pink borders. Foul smell. He ' s on antibiotics. At no time was the wound measured. Observation on 09/07/16 at 10:37 a.m. revealed LVN V and LVN M in the room to provide wound care. LVN M provided incontinent care for the resident. LVN V assisted Resident #5 onto his right side. Observation revealed a dressing on the back of the resident ' s left leg. There was no date or initials on it. LVN M rolled up a pad and placed it in position behind the resident. LVN M cleaned the wound in a circular motion. Without changing gloves, LVN M packed the wound with Dakin ' s-soaked gauze. She then covered the area with a 4 inch by four inch gauze, and secured it with an island dressing. Without changing gloves, LVN M secured the resident ' s brief and adjusted the draw sheet. LVN M said, She (NP N) said paint this one (left heel) with [MEDICATION NAME] and this one (right heel) with Calcium Alginate. At no time was the wound measured. Record review of Resident #5's physician orders from 09/07/16 to 09/11/16 revealed no orders for the [MEDICATION NAME] and the Calcium Alginate. In an interview on 09/07/16 at 11:25 a.m., LVN M was asked why she did not measure the wounds. She stated the wounds were to be measured on Thursday (09/08/16) with the wound care doctor. In an interview on 09/07/16 at 12:15 p.m., the Director of Nursing (DON) said the Charge Nurse was responsible to perform a skin assessment upon admission. The DON said the Assessment should be in the Assessments section of the paper chart. Record review and interview on 09/07/ at 12:15 pm of the paper chart did not reveal any admission skin assessment for Resident #5. The DON was asked what complications could arise because of missed wound care treatments. She answered, It could get infected. The wound could get worse. The list of pressure sores submitted by the facility DON on 09/07/16 revealed sixteen residents had pressure sores. Resident #5 was not included on that list. In an interview on 09/07/16 at 2:50 p.m., LVN M, the wound care nurse, said she was at the facility on 09/05/16 and 09/06/16, and 09/07/16, and that no one had informed her Resident #5 had wounds prior to the surveyor inquiry. In an interview via telephone with RN C on 09/07/16 at 4:25 p.m., she said she conducted a treatment on Resident #5 ' s wounds. She stated, Yes, I did the sacral wound. Two CNAs (Certified Nurse Aide) turned him and I did wound stage 4. I did both days. When asked if she conducted treatment on both heels, RN C said Yes. I did all the dressings. I wrote the date/name. When asked what initials she scribed, she answered CHIZO. The surveyor then informed RN C that the dressings on both legs, when observed on 09/07/16 were dated 08/31/16 with the initials JW. RN C then said, Oh, on that patient I did the sacral. The way we do it on weekends is the mornings does the ' A ' bed, and the evening does the ' B ' bed. In the morning it was soiled so I did it and passed it to the evening nurse. Record Review of the September 2016 Medication (Treatment) Administration Record (TAR) for Resident #5 revealed an order for [REDACTED]. The TAR reflected the initials of RN C on 09/03/16 and 09/04/16. When asked about signing the treatment sheet for the heel treatments, RN C said, Hmm. I don ' t know if they had it for the morning shift. I was going through the computer. I don' t know if it was set in the morning. I saw order for sacral wound. Review of the TAR revealed no treatment order for the sacral wound. Resident #10: Record review of the Admission Record for Resident #10 revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation on 09/07/16 at 11:40 a.m. revealed Resident #10 to be lying on his bed. LVN V accompanied the surveyor into the room. The resident appeared to have bilateralcontractures to the lower extremities. There was no padding between the resident ' s knees. Observation revealed an open area on the medial left knee, of approximately one centimeter (cm) diameter, with superficial depth. The medial right knee exhibited an open area, of approximately 1.5 cm diameter, with superficial depth. There were no dressings on either open area, or observed in the linens. LVN V stated regarding the opened skin areas, Probably from his knees being together. LVN V said Resident #10 was receiving Hospice services, and that the Hospice service did the weekly skin assessments. Record review of a Wound Care Specialist Initial Evaluation for Resident #10 dated 06/09/16 revealed At the request of Dr. _____, this [AGE] year old male was seen and evaluated today. He presents with a stage 3 pressure wound on his left, medial knee of at least 1 days duration. There is light serous exudate. There is no indication of pain with this condition. The Evaluation revealed the resident had the Stage 3 pressure sore on the left knee that measured 2.5 x 1.7 x 0.2 centimeters (cm). The Evaluation revealed the resident had a Stage 3 pressure wound on the right knee, which measured 2 x 2 x 0.2 cm. Record review of a Physician ' s Telephone Order for Resident #10 dated 07/06/16 revealed W/c (wound care) sacral and bilat (bilateral) knees per facility protocol. Record review of the Wound Care Specialist Evaluation for Resident #10 dated 07/28/16 revealed the Left knee wound measured 1 x 0.5 x 0.1 cm. The Right knee wound measured 0.5 x 0.3 x 0.2 cm. Record review of the multidisciplinary Progress Notes from 07/31/16 to present revealed no documentation of wounds on the knees after 08/14/16. The progress notes dated 08/14/16 at 10:54 a.m. revealed resident was already on his bed on taking over shift. I went to the room, do head to toe assessment (sic) on the resident .still have the existing wound to buttock area . The progress note did not reflect the resident had open areas on the knees. In an interview on 09/07/16 at 12:12 p.m., RN Z said the wound care and dressing changes to Resident #10 ' s knees were to be conducted every two days. She stated she was not the Charge Nurse for that unit. In an interview on 09/07/16 at 12:30 p.m., LVN I, the unit Charge Nurse, said _____ (LVN M) is the wound care nurse. She stated she was unaware Resident #10 ' s knees had no dressings. In an interview on 09/07/16 at 12:37 p.m., LVN M stated she was informed by LVN V about 30 minutes ago that the dressings on Resident #10 were not on the knees. She said no other staff had informed her. In an interview on 09/08/16 at 9:40 a.m., LVN D stated that Resident #10 had been up in the wheelchair on the previous day, and was transferred to bed just prior to the observation of no pillow between his knees. Observation on 09/08/16 at 9:42 a.m. revealed Resident #10 to be lying in his bed. LVN I was asked to adjust the linens for observation of the resident ' s lower extremities. There was no pillow or padding between the knees. Review of the facility policy entitled Wound Care/Treatment Guidelines (revised 09/2015) revealed XII. There must be a specific order for the treatment. XIII. Documentation of the treatment should be done immediately after the treatment. XIV. The care plan should reflect the current status of the wound and appropriate goals. On 09/07/16 at 5:35 p.m., the Administrator, the DON, and the Corporate RN were informed that an Immediate Jeopardy (IJ) situation was identified. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 09/08/16 at 11:08 am. After three revisions the plan was accepted on 09/09/16 at 11:40 am. The POR read in part: .On September 7, 2016 the resident identified as having no dressing changes since 8/31/16 has had a dressing change . wound care doctor here in facility at 9:30am on September 8, 2016 and assessed the sacral wound. The resident had a head to toe skin assessment and all dressings changed/dated on September 7, 2016. The resident identified without a knee dressing also had skin assessment completed and knee dressing applied on September 7, 2016. On September 7, 2016 the DON/ADON and charge nurses did a complete skin assessment on all facility residents to look for new skin breakdown or issues, which included residents at risk for skin breakdown and residents with orders for dressing changes. This audit will be complete by September 8, 2016 by 12 noon. The audit revealed no new skin problems. On September 7, 2016 Pressure Ulcer prevention education was conducted by the DON with all nurses. Staff will not be able to work until they receive the training. The content included: · Timely dressing changes when ordered. · The risk associated with development of a pressure ulcer if not treated. · The importance of monitoring resident with wounds and orders for dressing changes. · The importance of communication of Certified Nursing to nurses regarding the status of dressings. · · The importance of licensed nurses using assistive devices for the prevention of new pressure ulcers. On September 8, 2016 the CNA were educated by the DON regarding the importance of using assistive devices for those with contractures and reporting skin issues. This education will be completed by 2pm on September 9, 2016. Staff will not be allowed to work until they receive this education. Quality Assessment and Assurance Committee: On September 7, 2016 an ad hoc subcommittee of Quality Assessment Performance Improvement Committee (QAPI) met to discuss and approve the plan . The plan was monitored from 09/08/16 to 09/11/16 by surveyors with the following results: Facility staff, including CNAs, Nurses, and Nursing Management from all shifts were interviewed for effectiveness of in-services regarding Wound care, skin issues preventive measures, assessments and repositioning. Record review of in-services done by DON with all nursing staff on the morning evening, and night shift dated 09/07/16 on the following: 1) How to do a head to toe skin assessment with return demonstration 2) Preventive skin care measurements Record review on of in-service done by the DON with staff on all three shifts with the CNA ' s (morning, evening, and nights) date 09/08/16 on the following: -Positioning & Alignment (assisting devices, wedges, pillows , positioning devices) Record review of a Physician's Telephone Order for Resident #5 dated 09/07/16 (no time) revealed Wound consult Dx (diagnosis): Sacral and Bil (bilateral) heel wound. On 09/07/16 at 5:50 p.m., the DON presented a Nursing Admission Data Collection form for Resident #5. The form reflected Effective Date: 09/01/16 12:00 (prior to the resident ' s admission.) The form revealed Stage 4 sacral wound, bilateral foor (sic) eschar. There were no measurements on the assessment. The form revealed Stage IV - Full thickness tissue loss with exposed bone, tendon, or muscle. Slough of eschar may be present on some parts of the wound bed. Often include undermining and tunneling. On 09/07/16 at 5:50 p.m., the DON presented a Care Plan for Resident #5. The earliest dated reflected for any skin issues was 09/06/16. The Goal was reflected as Resident ' s wound will show signs of healing with area decreasing in overall size and depth by next review. The Date Initiated was 09/07/16. The Intervention was Provide wound care and treatment/preventative skin care per order. Observation on 09/08/16 at 10:32 a.m. revealed Physician X, the Wound Care Physician, was at the facility. He stated he had just completed the assessment of Resident #5. He stated the resident had a Stage 4 pressure ulcer on the sacral area, that appeared to be clean. He stated the resident exhibited areas on both heels that would be treated with topical agents. He did not have the measurements with him, but stated they would be included in the Progress Note. Record review of the Wound Care Specialist Evaluation dated 09/08/16 revealed Physician X evaluated the resident at the request of the Attending Physician. The Evaluation revealed Stage 4 Pressure Wound Sacrum. The size was measured as 7.5 cm x 7 cm x 1.5 cm., with moderate serous exudate. The Wound Progress was reflected as Improved, but there was no reflection of comparison data, such as date. Review of the paper and computer charts since admission on 09/02/16 revealed no baseline measurements. Interview on 09/09/16 at 3:00pm with the DON saying she think that the reason a IJ has occurred was because when the surveyors came into the facility they felt the facility could have done something better than what the facility was doing. The DON said the IJ could have been prevented by reviewing the processes in the system making sure the facility tools were being used properly; tools such as quality assurance, training, and in-servicing staff to make sure they completely understand how to use the systems that have been put in place. Interview on 09/09/16 at 4:15 p.m. the Administrator said she ensures that the DON was doing her job by having consultants that come to the facility on a monthly basis and do a performance review on different systems such as skin, weights, dietary, and other standard things. The Administrator said the facility have start up meetings every morning, Quality Assurance monthly and weekly, reports and audits holding the DON accountable for these topics. The Administrator said she feels that and IJ had occurred in the facility because ya ' ll feel that we may not have been doing things as well as we could have done things like what you said the IJ was for . The Administrator said she prevent neglect by using tools such as in-service, education, policy and procedures. We have physical things such as supplies, medication, food etc. The facility Administrator and DON were informed that the IJ was lowered on 09/11/16 at 12:15 pm. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The list of pressure sores submitted by the facility DON on 09/07/16 revealed sixteen residents had pressure sores.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 10 residents reviewed for quality of care. (CR #1) - The facility failed to recognize and asses CR #1, who was receiving the medication [MEDICATION NAME] (anticoagulant), when he began showing signs of change in condition, increased confusion after a un-witnessed fall on 08/28/16. - CR #1 was not sent to the hospital until 9 hours after the fall. -CR #1 passed away in the hospital on [DATE] due to [MEDICAL CONDITION] related to the fall. An Immediate Jeopardy (IJ) was identified on 09/07/16. While the IJ was lowered on 09/11/16 the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. This failure affected one discharged resident whose needs were not met and placed the other 6 residents who are receiving anticoagulant therapy at risk of not being provided with appropriate and timely medical intervention resulting in uncontrolled bleeding, hospitalization and death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set assessment dated [DATE] revealed that CR #1 ' BIMS (Brief Interview for Mental Status) was a 13, indicating he had no cognitive deficit. Further review of the MDS revealed that CR #1 required extensive assistance of two people for bed mobility, transfers and dressing. He required extensive assistance of one person for locomotion in the unit, eating and toilet use. The resident used a wheelchair. Record review of CR #1 care plan date initiated 07/18/2016 revised on 07/18/16 revealed that CR #1 was receiving anticoagulant therapy([MEDICATION NAME]) related to [MEDICAL CONDITION] Fibrillation. Interventions included to observe/document/report as needed reactions of anticoagulant therapy such as lethargy and sudden changes in mental status. Record review of CR #1 Physician order [REDACTED]. Record review of SBAR Communication Form on CR #1 done by LVN-E dated 08/28/16 at 6:50 a.m. revealed that CR #1 had an un-witnessed fall. It was also noted that the resident had mental status changes with increase in confusion, needs more assistance with ADLs, and weakness or [MEDICAL CONDITION]. Under Question: Is the resident taking [MEDICATION NAME]/[MEDICATION NAME], the nurse marked yes. Further review of the form revealed that CR #1 was noted on the floor trying to get back on the low bed on his knees. Nurse LVN-E asked CR #1 what happened, CR #1 stated, I wanted to go to the bathroom . Under section: Mental Status changes (compared to baseline, check all that you observe), increased confusion was checked. Interview on 09/07/2016 at 4:15 p.m. RN-C said she worked the 6 am-2pm shift. She said it was reported to her in change of shift report on 08/28/16 by LVN-E that CR #1 was found on the floor near his bed on his knees saying he was going back to bed. LVN E reported to her that she called the physician but he never returned her call. RN C said she immediately went to check on CR #1 and observed CR #1 ' s knees with bruising but no open skin areas. RN-C said resident was alert and oriented and answering questions asked appropriately. RN-C said that she called the Physician to notify him of the un-witnessed fall and bruising on the knees but she did not tell him that CR #1 was taking the medication [MEDICATION NAME] or that the SBAR Communication Form indicated CR #1 exhibited mental status changes with increase in confusion after the fall. RN-C said that the Physician only gave orders to obtain X-Rays of the knees. Record review of CR #1 Radiology Report of X-Rays of bilateral knees dated 08/28/16 results: The knee joint is in alignment, but there is narrowing of the join space due to mild [MEDICAL CONDITION] changes. Conclusion: Mild [MEDICAL CONDITION] of the right and left knee. Interview on 09/07/2016 at 12:00 p.m. with the DON saying with a resident involved in an un-witnessed fall, she would do a head to toe assessment along with neurological checks and vital signs. The DON said if resident exhibited signs of increase in confusion, she would call the Physician to get an order to transfer the resident out to the hospital. The DON said she was shocked to hear later that CR #1 had passed away. Interview on 09/08/16 at 11:12 a.m. with LVN-E regarding the un-witnessed fall of CR #1 saying it was around 5:00 a.m. when the CNA-B informed her of CR #1 was on the floor. LVN-E said she observed CR #1 kneeling on the floor and she began an assessment and noted that resident had a skin tear on right knee but denied of any pain. LVN-E said resident was assisted back to bed with the help of her and CNA-B. LVN-E said she attempted to notify the Physician around 5:45 a.m. but did not get a response back. She said that she then called CR #1 ' s family member and after that she called the Administrator. LVN-E said she completed the SBAR and she was not sure if the nurse on the next shift communicated to the physician that the resident was taking [MEDICATION NAME]. Interview on 09/09/16 at 12:05 p.m. with RN-F he said he worked the 2pm-10 pm shift. He said he arrived to work on 08/28/2016 at 2:00 p.m. he received shift report that CR #1 had an un-witnessed fall in the early a.m. around 4:00 a.m. and was told by RN-C that CR #1 was stable. RN-F said that after receiving report he went to CR #1 room and observed CR #1 resting in bed no distress noted. RN-F said around 3:34 p.m. he went back to check on CR #1 and observed that his respirations were labored at a rate of 48 breaths per minute and he was disoriented. RN-F said he placed a call to the Physician immediately reporting the condition of the resident and requesting orders to transfer CR #1 to the hospital. Physician orders [REDACTED].#1 to the hospital. The resident was transferred to the VA hospital on [DATE] at 4:30 p.m. In further interview with RN-F on 09/09/16 at 12:05 pm regarding the use of the SBAR Communication form he said SBAR was used when there was a change in a resident condition from the norm and example wound be a fall, decrease level of consciousness, etc. RN-F said a resident who was on [MEDICATION NAME] and had an un-witnessed fall exhibiting increase in confusion using the SBAR tool may be experiencing some bleeding on the brain and that he would report findings to the Physician immediately to transfer resident to a higher level of care. Record review of the nurses notes for CR #1 revealed that RN C and RN F only documented one time each during their shifts: 08/28/16 at 10:19 am. Note read in part: .on taking over the night nurse, report was given that pt was found on floor .call was placed to NP .who gave order for X ray . The note completed by RN C did not documented that the nurse assessed the resident at that time. -8/28/16 at 7:48 pm. the note reveaeled in part: .the resident was met in bed, very lethargic and weak .inability to respond to questions .the patient was transported to VA at 4:30 pm . The note was completed by RN-F Interview on 09/09/16 at 9:40 a.m. the DON said the facility SBAR Communication Form was used in the facility only when there was a change in the resident condition and the Nursing staff had been in-serviced on how to use the form. The DON said the SBAR Communication Form was a tool to help the nurses paint a picture to the Doctor about the current condition of that particular resident. Record review of facility SBAR Communication Form 2014 read in part: . Before Calling the Physician/NP/PA -Have relevant information available when reporting (recent progress notes, labs, primary diagnosis, if resident was on [MEDICATION NAME] or other anticoagulants, lab results, and mental status evaluation) . On 09/07/16 at 5:35 p.m., the Administrator, the DON, and the Corporate RN were informed that an Immediate Jeopardy (IJ) situation was identified. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 09/08/16 at 11:08 am. After three revisions the plan was accepted on 09/09/16 at 11:40 am. The POR read in part: . The survey team identified that the facility failed to provide prompt interventions for a resident that had an unwitnessed fall while on [MEDICATION NAME]. This resident had an unwitnessed fall on August 28, 2016, and was sent to the emergency room the same day. On September 7, 2016, the DON/ADON educated all nurses on the importance of notifying physician when resident have a unwitnessed fall and making sure to include all pertinent information, including the use of [MEDICATION NAME], to help assist the physician with making a decision regarding the plan of care for the resident. All nurses will notify the Administrator and DON when there an unwitnessed fall for immediate guidance and follow up. The education will be completed by September 8, 2016 at 10pm. Staff will not be allowed to work until they receive the education. On September 8, 2016 the DON/ADON educated all CNA regarding the importance of notifying the charge nurse when a resident falls. This education will be completed by 2pm on September 9, 2016. Staff will not be allowed to work until they receive this education. Don/designee will review all residents with falls who are on [MEDICATION NAME] during the morning startup meeting to assure appropriate notifications was done with respect to the family and the physician. The DON/designee will validate the notification was made and appropriate follow up was completed. The DON/designee will assess and review all residents on [MEDICATION NAME] who have fallen to ensure no issues have occurred. All residents on [MEDICATION NAME] were identified on September 8, 2016 by 10am. Quality Assessment Performance Improvement Committee: On September 7, 2016 an ad hoc subcommittee of the Quality Assessment Performance Improvement (QAPI) met to discuss and approve the plan . The plan was monitored from 09/08/16 to 09/11/16 by surveyors with the following results: Facility staff, including CNAs, Nurses, and Nursing Management from all shifts were interviewed for effectiveness of in-services regarding falls, neglect, reporting changes in condition and use of blood thinners to the physicians. Record review of in-services done by DON with all nursing staff on the morning evening, and night shift dated 09/07/16 on the following: 1) Notification of MD after a fall of a resident taking [MEDICATION NAME] 2) Assessments and falls Record review of in-service done by the DON with staff on all three shifts with the CNA ' s (morning, evening, and nights) date 09/08/16 on the following: 1) Reporting to charge nurse when a resident falls and changes in condition Interview on 09/09/16 at 3:00pm with the DON saying she think that the reason a IJ has occurred was because when the surveyors came into the facility they felt the facility could have done something better than what the facility was doing. The DON said the IJ could have been prevented by reviewing the processes in the system making sure the facility tools were being used properly; tools such as quality assurance, training, and in-servicing staff to make sure they completely understand how to use the systems that have been put in place. Interview on 09/09/16 at 4:15 p.m. with the Administrator she said CR #1 ' s un-witnessed fall was not reported to the State because they did not feel it was reportable and that she followed the grid and regulation letter to determine her decision. The surveyor then asked the Administrator for a copy of the grid. The Administrator replied, well it is on the DADS website . The Administrator said she ensures that the DON was doing her job by having consultants that come to the facility on a monthly basis and do a performance review on different systems such as skin, weights, dietary, and other standard things. The Administrator said the facility have start up meetings every morning, Quality Assurance monthly and weekly, reports and audits holding the DON accountable for these topics. The Administrator said she feels that and IJ had occurred in the facility because yall feel that we may not have been doing things as well as we could have done things like what you said the IJ was for . The Administrator said she prevent neglect by using tools such as in-service, education, policy and procedures. We have physical things such as supplies, medication, food etc. The facility Administrator and DON were informed that the IJ was lowered on 09/11/16 at 12:15 pm. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. The DON identified 6 residents in the facility who were on anticoagulant therapy.

Based on observation, interview and record review, the Administrator and DON failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents reviewed for quality of care. (Resident #5, #10 and CR #1) The Administrator failed: - to supervise the Director of Nursing to ensure she was monitoring and training the nursing staff to provide accurate skin assessments, and provide wound care as per physician orders. --supervise the DON to ensure that nursing staff was trained in recognizing and reporting changes in condition after falls for residents on anticoagulants medications. -The DON failed to: -train and supervise the nursing staff to ensure they were providing care to include accurate skin assessments, and provided wound care as per physician orders. - train and supervise the nursing staff to ensure they were able to recognize and report changes in condition after falls for residents on anticoagulants medications. An Immediate Jeopardy (IJ) was identified on 09/7/16. While the IJ was lowered on 09/11/16, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failure affected three residents and placed 100 other residents at risk of a decline in their quality of care and quality of life. Findings include: Resident #5: Record view of Resident #5 ' s hospital transfer form dated 09/01/16 revealed he was [AGE] year old male admitted to the long term care facility on 09/01/16 with [DIAGNOSES REDACTED]. Further review of the form revealed a body diagram indicating the resident had a pressure ulcer Stage IV on the sacrum and unstageable pressure ulcers on bilateral heels. Form section titled dressings and bandages revealed in part: bilateral heel wounds, clean with NS, pat dry, put iodosorb gel, dry Kerlix .sacral wound, clean with NS, pat dry, wet to dry gauze, cover with abdominal dressing and secure with medipro. Record review of the facility clinical record and electronic record revealed no admission nursing assessment, no interim care plan and no MDS for Resident #5. Record review of the nurses ' notes from 09/02/16 to 09/06/16 reveal no documentation that the resident was assessed by a NP or physician. Observation on 09/07/16 at 9:26 a.m. revealed Resident #5 to be in a room on the 400 Hall. He was in the bed located in the center of the room. He had no roommate. Licensed Vocational Nurse (LVN) M accompanied the surveyor to the room. LVN M identified herself as the facility Treatment Nurse. Observation revealed LVN M donned gloves and adjusted the resident ' s covers to expose the resident ' s lower extremities. Observation at that time revealed the resident had Podus boots on both legs. Both lower legs were wrapped in gauze that were dated 08/31 at 1630 (4:30 p.m.). The initials ' JW ' were observed on the dressings. LVN M confirmed the information, then said, I don ' t do his dressings. The Charge Nurse does. Further observation revealed Resident #5 turned onto his right side. Observation revealed an uncovered open wound area of approximately 10 centimeters (cm) in diameter, with approximately 2 cm depth on his sacral area. There was a saturated dressing in the disposable brief dated 09/04/16. The entire visible surface of the brief was saturated with bloody drainage. Observation revealed the resident had an indwelling catheter. When asked why the resident was on isolation, LVN M answered, I don ' t know. Charge nurses are responsible for skin assessments. This is my first time with this resident. In an interview on 09/07/16 at 12:15 p.m., the Director of Nursing (DON) said the Charge Nurse was responsible to perform a skin assessment upon admission. The DON said the Assessment should be in the Assessments section of the paper chart. Record review of the paper chart did not reveal any admission skin assessment for Resident #5. The DON was asked what complications could arise because of missed wound care treatments. She answered, It could get infected. The wound could get worse. The list of pressure sores submitted by the facility DON on 09/07/16 revealed sixteen residents had pressure sores. Resident #5 was not included on that list. In an interview on 09/07/16 at 2:50 p.m., LVN M, the wound care nurse, said she was at the facility on 09/05/16 and 09/06/16, and 09/07/16, and that no one had informed her Resident #5 had wounds prior to the surveyor inquiry. Resident #10: Record review of the Admission Record for Resident #10, dated 07/01/16, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation on 09/07/16 at 11:40 a.m. revealed Resident #10 to be lying on his bed. LVN V accompanied the surveyor into the room. Observation revealed the resident appeared to have bilateral limited range-of -motion to the lower extremities. There was no padding between the resident ' s knees. Observation revealed an open area on the medial left knee, of approximately one centimeter (cm) diameter, with superficial depth. The medial right knee exhibited an open area, of approximately 1.5 cm diameter, with superficial depth. There were no dressings on either open area, or observed in the linens. LVN V stated regarding the opened skin areas, Probably from his knees being together. LVN V said Resident #10 was receiving Hospice services, and that the Hospice service did the weekly skin assessments. Record review of a Wound Care Specialist Initial Evaluation for Resident #10 dated 06/09/16 revealed At the request of Dr. _____, this [AGE] year old male was seen and evaluated today. He presents with a stage 3 pressure wound on his left, medial knee of at least 1 days duration. There is light serous exudate. There is no indication of pain with this condition. The Evaluation revealed the resident had the Stage 3 pressure sore on the left knee that measured 2.5 x 1.7 x 0.2 centimeters (cm). The Evaluation revealed the resident had a Stage 3 pressure wound on the right knee, which measured 2 x 2 x 0.2 cm. Record review of a Physician ' s Telephone Order for Resident #10 dated 07/06/16 revealed W/c (wound care) sacral and bilat (bilateral) knees per facility protocol. Record review of the Wound Care Specialist Evaluation for Resident #10 dated 07/28/16 revealed the Left knee wound measured 1 x 0.5 x 0.1 cm. The Right knee wound measured 0.5 x 0.3 x 0.2 cm. Record review of the multidisciplinary Progress Notes from 07/31/16 to present revealed no documentation of wounds on the knees after 08/14/16. The progress notes dated 08/14/16 at 10:54 a.m. revealed resident was already on his bed on taking over shift. I went to the room, do head to toe assessment (sic) on the resident .still have the existing wound to buttock area . The progress note did not reflect the resident had open areas on the knees. CR #1: Record review of CR #1 face sheet revealed a [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1 care plan date initiated 07/18/2016 revised on 07/18/16 revealed that CR #1 was receiving anticoagulant therapy([MEDICATION NAME]) related to [MEDICAL CONDITION] Fibrillation. Interventions included to observe/document/report as needed reactions of anticoagulant therapy such as lethargy and sudden changes in mental status. Record review of CR #1 Physician order [REDACTED]. Record review of SBAR Communication Form on CR #1 done by LVN-E dated 08/28/16 at 6:50 a.m. revealed that CR #1 had an un-witnessed fall. It was also noted that the resident had mental status changes with increase in confusion, needs more assistance with ADLs, and weakness or [MEDICAL CONDITION]. Under Question: Is the resident taking [MEDICATION NAME]/[MEDICATION NAME], the nurse marked yes. Further review of the form revealed that CR #1 was noted on the floor trying to get back on the low bed on his knees. Nurse LVN-E asked CR #1 what happened, CR #1 stated, I wanted to go to the bathroom . Under section: Mental Status changes (compared to baseline, check all that you observe), increased confusion was checked. Interview on 09/07/2016 at 4:15 p.m. RN-C said she worked the 6 am-2pm shift. She said it was reported to her in change of shift report on 08/28/16 by LVN-E that CR #1 was found on the floor near his bed on his knees saying he was going back to bed. LVN E reported to her that she called the physician but he never returned her call. RN C said she immediately went to check on CR #1 and observed CR #1 ' s knees with bruising but no open skin areas. RN-C said resident was alert and oriented and answering questions asked appropriately. RN-C said that she called the Physician to notify him of the un-witnessed fall and bruising on the knees but she did not tell him that CR #1 was taking the medication [MEDICATION NAME] or that the SBAR Communication Form indicated CR #1 exhibited mental status changes with increase in confusion after the fall. RN-C said that the Physician only gave orders to obtain X-Rays of the knees. Interview on 09/07/2016 at 12:00 p.m. with the DON saying with a resident involved in an un-witnessed fall, she would do a head to toe assessment along with neurological checks and vital signs. The DON said if resident exhibited signs of increase in confusion, she would call the Physician to get an order to transfer the resident out to the hospital. The DON said she was shocked to hear later that CR #1 had passed away. Interview on 09/09/16 at 12:05 p.m. with RN-F saying when arriving to work on 09/28/2016 at 2:00 p.m. he received shift that CR #1 had an un-witnessed fall in the early a.m. around 4:00 a.m. and was told by RN-C that CR #1 was stable. RN-F said that after receiving report he went to CR #1 room and observed CR #1 resting in bed no distress noted. RN-F said around 3:34 p.m. he went back to check on CR #1 and observed that his respirations were labored at a rate of 48 breaths per minute and he was disoriented. RN-F said he placed a call to the Physician immediately reporting the condition of the resident and requesting orders to transfer CR #1 to the hospital. Physician orders [REDACTED].#1 to the hospital. The resident was transferred to the VA hospital on [DATE] at 4:30 p.m. Record review of the hospital records for CR #1 revealed that he was admitted to the hospital on [DATE]. The records read in part: .was found down in the SNF and admitted with right occipital contusion .his [MEDICATION NAME] hemorrhage are likely traumatic, secondary to his fall . Further review of the hospital record revealed that the resident passed away on 09/01/16 after the family decided to extubate him and place him on comfort care. In further interview with RN-F on 09/09/16 at 12:05 pm regarding the use of the SBAR Communication form he said SBAR was used when there was a change in a resident condition from the norm and example wound be a fall, decrease level of consciousness, etc. RN-F said a resident who was on [MEDICATION NAME] and had an un-witnessed fall exhibiting increase in confusion using the SBAR tool may be experiencing some bleeding on the brain and that he would report findings to the Physician immediately to transfer resident to a higher level of care. Interview on 09/08/16 at 11:12 a.m. with LVN-E regarding the un-witnessed fall of CR #1 saying it was around 5:00 a.m. when the CNA-B informed her of CR #1 was on the floor. LVN-E said she observed CR #1 kneeling on the floor and she began an assessment and noted that resident had a skin tear on right knee but denied of any pain. LVN-E said resident was assisted back to bed with the help of her and CNA-B. LVN-E said she attempted to notify the Physician around 5:45 a.m. but did not get a response back. She said that she then called CR #1 ' s family member and after that she called the Administrator. LVN-E said she completed the SBAR and she was not sure if the nurse on the next shift communicated to the physician that the resident was taking [MEDICATION NAME]. Interview on 09/09/16 at 9:40 a.m. with the DON saying the reason why CR #1 fall was not on the Incident/ Accident Log was because for some reason the computer system would not let her log it in. The DON said she does the tracking for falls in the facility. The DON said the facility SBAR Communication Form was used in the facility only when there was a change in the resident condition and the Nursing staff had been in-serviced on how to use the form. The DON said the SBAR Communication Form was a tool to help the nurses paint a picture to the Doctor about the current condition of that particular resident. On 09/07/16 at 5:35 p.m., the Administrator, the DON, and the Corporate RN were informed that an Immediate Jeopardy (IJ) situation was identified. A Plan of Removal (POR) was requested at that time. A POR for the IJ was submitted on 09/08/16 at 11:08 am. After three revisions the plan was accepted on 09/09/16 at 11:40 am. The POR read in part: .On September 7, 2016 the resident identified as having no dressing changes since 8/31/16 has had a dressing change. Dr. Wolfe, wound care doctor here in facility at 9:30am on September 8, 2016 and assessed the sacral wound. The resident had a head to toe skin assessment and all dressings changed/dated on September 7, 2016. The resident identified without a knee dressing also had skin assessment completed and knee dressing applied on September 7, 2016. On September 7, 2016 the DON/ADON and charge nurses did a complete skin assessment on all facility residents to look for new skin breakdown or issues, which included residents at risk for skin breakdown and residents with orders for dressing changes. This audit will be complete by September 8, 2016 by 12 noon. The audit revealed no new skin problems. On September 7, 2016 Pressure Ulcer prevention education was conducted by the DON with all nurses. Staff will not be able to work until they receive the training. The content included: · Timely dressing changes when ordered. · The risk associated with development of a pressure ulcer if not treated. · The importance of monitoring resident with wounds and orders for dressing changes. · The importance of communication of Certified Nursing to nurses regarding the status of dressings. · · The importance of licensed nurses using assistive devices for the prevention of new pressure ulcers. On September 8, 2016 the CNA were educated by the DON regarding the importance of using assistive devices for those with contractures and reporting skin issues. This education will be completed by 2pm on September 9, 2016. Staff will not be allowed to work until they receive this education. Quality Assessment and Assurance Committee: . The survey team identified that the facility failed to provide prompt interventions for a resident that had an unwitnessed fall while on [MEDICATION NAME]. This resident had an unwitnessed fall on August 28, 2016, and was sent to the emergency room the same day. On September 7, 2016, the DON/ADON educated all nurses on the importance of notifying physician when resident have a unwitnessed fall and making sure to include all pertinent information, including the use of [MEDICATION NAME], to help assist the physician with making a decision regarding the plan of care for the resident. All nurses will notify the Administrator and DON when there an unwitnessed fall for immediate guidance and follow up. The education will be completed by September 8, 2016 at 10pm. Staff will not be allowed to work until they receive the education. On September 8, 2016 the DON/ADON educated all CNA regarding the importance of notifying the charge nurse when a resident falls. This education will be completed by 2pm on September 9, 2016. Staff will not be allowed to work until they receive this education. Don/designee will review all residents with falls who are on [MEDICATION NAME] during the morning startup meeting to assure appropriate notifications was done with respect to the family and the physician. The DON/designee will validate the notification was made and appropriate follow up was completed. The DON/designee will assess and review all residents on [MEDICATION NAME] who have fallen to ensure no issues have occurred. All residents on [MEDICATION NAME] were identified on September 8, 2016 by 10am. Quality Assessment Performance Improvement Committee: On September 7, 2016 an ad hoc subcommittee of the Quality Assessment Performance Improvement (QAPI) met to discuss and approve the plan . The plan was monitored from 09/08/16 to 09/11/16 by surveyors with the following results: Facility staff, including CNAs, Nurses, and Nursing Management from all shifts were interviewed for effectiveness of in-services regarding wound care, repositioning, wound prevention and assessments. Record review of in-services done by DON with all nursing staff on the morning evening, and night shift dated 09/07/16 on the following: Record review on of in-service done by the DON with staff on all three shifts with the CNA ' s (morning, evening, and nights) date 09/08/16 on the following: 1) Reporting to charge nurse when a resident falls and changes in condition Interview on 09/09/16 at 3:00pm with the DON saying she think that the reason a IJ has occurred was because when the surveyors came into the facility they felt the facility could have done something better than what the facility was doing. The DON said the IJ could have been prevented by reviewing the processes in the system making sure the facility tools were being used properly; tools such as quality assurance, training, and in-servicing staff to make sure they completely understand how to use the systems that have been put in place. Interview on 09/09/16 at 4:15 p.m. with the Administrator she said CR #1 ' s un-witnessed fall was not reported to the State because they did not feel it was reportable and that she followed the grid and regulation letter to determine her decision. The surveyor then asked the Administrator for a copy of the grid. The Administrator replied, well it is on the DADS website . The Administrator said she ensures that the DON was doing her job by having consultants that come to the facility on a monthly basis and do a performance review on different systems such as skin, weights, dietary, and other standard things. The Administrator said the facility have start up meetings every morning, Quality Assurance monthly and weekly, reports and audits holding the DON accountable for these topics. The Administrator said she feels that and IJ had occurred in the facility because yall feel that we may not have been doing things as well as we could have done things like what you said the IJ was for . The Administrator said she prevent neglect by using tools such as in-service, education, policy and procedures. We have physical things such as supplies, medication, food etc. The facility Administrator and DON were informed that the IJ was lowered on 09/11/16 at 12:15 pm. the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of isolated as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. According to the facility form CMS 672 the facility census was 102.

Based on interview and record review the facility failed to provide necessary care, proper assessments, and timely interventions to attain the highest practicable mental and physical well-being for 1 of 9 residents (CR# 1) reviewed for care. On 6/11/14 CR# 1, who was severely impaired for cognition, and agitated, was left unattended in the dining room during breakfast. CR# 1 was later found on the floor. After breakfast, CR# 1 exhibited sign of pain by grimacing and holding her right arm. Staff had been administering pain medication for three days without further evaluation of the arm. CR # 1 was identified with dislocation and fracture to her right shoulder on 6/13/14 and was transferred to the hospital where it was discovered she had multiple fracture to her right shoulder and her right hip and had to undergo corrective surgeries. This failure affected 1 resident and placed 112 residents in the facility of risk of not receiving timely assessments, medical care and services, which could have a negative impact on their health and wellbeing. Findings include: Intake # 0 and 4 CR#1 Record review of CR# 1 face sheet revealed an [AGE] year old year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1 ' s MDS dated [DATE] revealed the resident was severely impaired for cognition , required extensive assistance for all ADLs and had no history, risk or actual falls since admission. Record review of CR#1 ' s physician order dated 5/18/14 revealed admission to hospice due to end stage dementia. Record review of CR # 1 ' s care plan (not dated) revealed resident had ADL self-care performance deficit related to Dementia and confusion. Goal and approaches were outlined. Further review of the care plan (not dated) revealed the resident had impaired cognitive function/dementia or impaired thought processes related to short term memory loss, long term memory loss and Dementia. Further review of a care plan for falls (not dated) revealed high risk for falls related to unaware of safety needs, confusion, poor communication/comprehension, gait /balance problems and incontinence. Goal and approaches were outlined. Record review of CR# 1's incident/accident investigation follow up dated 6/11/14 revealed resident was observed on the floor in the dining room area in supine position. Investigation summary revealed the resident was agitated, attempting to self-ambulate out of the wheel chair prior to taking her to dining room. Past intervention attempted- chair alarm in place at all times, Recommendation- Continue visual monitoring. Record review of CR # 1's nursing notes dated 6/11/14 at 11:32 A.M., revealed the resident was assisted by two aides from floor to wheelchair, able to move lower extremities without pain, grimacing and holding right arm. Record review of CR # 1's nursing notes dated 6/11/14 at 12:04 P.M., revealed in part: " resident observed on the floor in the dining area in supine position , chair alarm buzzing... Assess while on the floor, moves all bilateral legs without pain, grimacing when passive range of motion was done to right arm, inspected affected arm , no change in skin areas, no evidence of swelling noted, medicated with as needed pain medication with effect after an hour. Record review of CR # 1's nursing notes dated 6/11/14 at 3:28 P.M., revealed the resident was observed sitting in the day area with slight swelling and discoloration surfacing to right upper cheeks, Neuro checks in progress, place a call to hospice nurse awaiting call back. Record review of CR # 1 ' s nursing notes dated 6/11/14 at 9:39 P.M., revealed resident was seen and examined by hospice nurse on this shift, orders given to monitor closely for any change and apply ice to the right cheek as tolerated per residents for swelling, resident cooperative with care , ate 50% of dinner. Was calmer and relaxed this shift. Record review of CR #1's nurses notes dated 06/12/14 at 9:44 P.M revealed: "monitoring today to prevent any new falls. Resident has not tried to self ambulate during shift." Record review of CR# 1 ' s MAR indicated [REDACTED]. This medication was administered as follows: 6/11/14 at 8:30 A.M., 12:30 P.M., and 4:30 P.M. 6/12/14 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. 6/13/14 at 9:00 A.M., and 1:00 P.M. Record review of the provider investigation report submitted to DADS and dated 06/13/14 revealed that on 06/11/14 at 9:00 A.M the resident was found in the dining room floor. The report stated that staff and other residents were in the dining room at the time of the incident, but that no one witness the fall. The report indicated that the resident was assessed by the charge nurse and was then assisted back to the wheelchair and she continued to eat breakfast. CR #1 was sent to the hospital on 06-13-14 due to dislocation and [MEDICAL CONDITION] arm. Record review of CR # 1 ' s nursing notes dated 6/13/14 at 9:43 A.M., revealed resident had a fall on 6/11/14, upper right arm noted with discoloration, right hand slightly swollen , not able to lift right arm at this time. X-ray was ordered and taken at 10:28 A.M. CR# 1 was transferred to the hospital on [DATE]. Record review CR# 1 ' s X-ray result dated 6/13/14 at 11:55 A.M., revealed right shoulder dislocation and fracture. Interview on 6/26/14 at 12:15 P.M., with CNA # 1 she said she was assigned CR# 1 on 6/11/14 morning shift. She said the resident was agitated in the morning before breakfast , she was saying she did not want to eat breakfast. CNA #1 said that she took the resident to the dining room and she continued to attempt to get up , CNA# 1 said she redirected the resident about 4 times but she continued to attempt to stand up. CNA# 1 said she left to bring other residents to the dining room for breakfast. She said there should have been another aide in the dining room before she left. She did not know who and where the aide was. CNA # 1 said she believed the aide (unknown) was at the other end of the dining room. CNA #1 said she was coming into the dining room when she saw CR# 1 on the floor lying on her back. She called the charge nurse who came in and assessed her. CNA # 1 said she left the resident in the dining room because she had to assist other residents to the dining room for breakfast. Interview on 6/26/14 at 9:30 A.M., with RN # 1 who was the charge nurse on duty on the morning of 6/11/14, she said the aides were taking residents in and out of the dining room for breakfast the day of the incident. Aide (unknown) told her CR# 1 was on the floor. RN # 1 said she went in there and the resident was lying on her back facing up, she said the resident moved all extremities, so she was transferred back to her chair and she ate some breakfast. After breakfast, RN # 1 said she noted CR# 1 was grimacing and holding her right arm, she told the medication aide to give her pain medication. RN # 1 said the resident was given showers daily. RN # 1 said she expected the aides to stay with agitated residents and to call the nurse ' s attention if residents could not be re-directed. RN # 1 gave no reason as to why CR #1's grimacing and holding of her right arm was not further evaluated for possible fracture after the fall on 6/11/14. Interview on 6/26/14 at 12:10 P.M., MA # 1 said she medicated CR# 1 following her fall on 6/11/4 as instructed by RN# 1. MA # 1 said CR # 1 was subsequently medicated daily because each time she checked her for pain, the resident exhibited signs of discomfort which was not her normal state. She said CR #1 was unable to tell she was in pain but her body language did. She said she offered CR # 1 as needed medication form 6/11/13 to 6/13/14 before she was transferred out. Record review of CR# 1 ' s as needed pain Medication Administration Record [REDACTED] 6/11/14 at 8:30 A.M.,pain level of 4 ( hurts even more) with facial grimacing, she was medicated and pain level was 2 ( hurts little bit ) after medication. 6/11/14 at 12:30 P.M., pain level of 4 with facial grimacing, she was medicated and pain level was 3 (hurts little more) after. 6/11/14 at 4:30 P.M., facial pain level was 2 with verbal complaints of pain presence. Pain level after medication was 1. (No hurt). Further review of pain assessment record revealed the resident continued to show and verbalize pain from 6/12/14 through 6/13/14; level up to 5 (hurts a whole lot on 6/13/14 at 9 am) and was getting two tablets of Tylenol 325 mg. Interview on 6/26/14 at 12:15 P.M., LVN # 1 said an aide reported on the morning of 6/13/14 that the resident's right arm was swollen with bruise noted to the upper right arm and she was unable to assist with her AM care as usual. LVN # 1 said she assessed the resident and called her physician for X-ray orders since she was notified of previous fall on 6/11/14. LVN # 1 said the result showed a fracture with dislocation of right shoulder. CR# 1 was sent to hospital on [DATE]. LVN # 1 said she did not notice signs of pain, discomfort or bruises on the resident prior to 06/13/14. She said that a hospice aide gave the resident a bed bath on 6/12/14 and did not report any injures. LVN # 1 however said that on 6/13/14 , a hospice aide came in to give CR#1 a shower. She said that when the resident was sent to the hospital the hospice aide said CR# 1 told her she did not look well yesterday, but she did not report that to any facility staff . Interview on 6/26/14 at 11:38 A.M., with the ADON regarding her expectation regarding leaving residents unattended in the dining room. She expressed an agitated resident should be monitored and the nurse should be notified when re-direction was ineffective. The ADON said she was told CR #1 had a chair alarm on at the time of the fall but was unsure how staff in the dining room or around did not hear the alarm go off. The ADON said the staff interviewed did not recall CR # 1 showing any bruising, signs of pain or discomfort. She said that she was not aware if the resident was assessed and medicated with as needed pain medication by MA # 1. The ADON said she was unsure as to why further evaluations were not done following the resident ' s grimacing and holding of her right hand. The ADON agreed staff should have done more evaluations after the fall since CR# 1 ' s cognition was severely impaired due to end stage dementia. Interview on 6/26/14 at 1:02 P.M., the Administrator said she called the incident to the State due the family ' s concerns and conducted an investigation to include interview with staff. She said no staff admitted observing anything usual on CR# 1. She said the resident was monitored and care was provided until 6/13/14 when her right hand swelling was noted. Staff contacted the resident physician immediately. The Administrator said that CR #1's family reported that the resident had additional fractures to include a [MEDICAL CONDITION] and was still in the hospital. Interview with CR# 1 ' s family on 06/26/14 at 3:38 P.M. and again on 6/30/14 at 10:02 A.M., revealed CR# 1 had multiple surgeries on 6/14/14 for a right shoulder dislocation and a fracture repair and partial hip replacement on 6/18/14. Resident was still in the hospital as her health continued to deteriorate. Record review of witness statement by LVN # 2 (not dated) revealed that on 6/11/14, 2-10 shift. " CR# 1 had a fall in AM. Thus discoloration noted on right cheek and slight rise in the areas. Hospice nurse came between 6-7 pm and was told the resident was in bed, she turned to her saying she did not see the discoloration to the cheek , I (LVN # 2) wnet in to the room with hospice nurse and showed her the area, hospice nurse said " this is Hematoma " LVN # 2 asked the hospice nurse if she needed to assess the resident further but hospice nurse said CR#1 appears to be sleeping calm now showed no sign of discomfort " . Further record review of the facilitys' documentation revealed no additional information indicating that either the hospice nurse or LVN # 2 assessed the resident on the evening of 6/11/14. There was no evidence that the resident was assessed on 6/12/14. Facility staff found bruise and swelling to right hand on 6/13/14. X-ray was not ordered until 6/13/14 despite the resident exhibiting pain to right arm. CR#1 ' s physician was not notified of continued pain presence (ineffective pain control). Further review of the facility policy on pain management revised August 2012 revealed " the goal of pain management program is that pain is identified and treated effectively and consistently. The licensed nurse will implement a Medication Administration Record [REDACTED]. Record review of facility policy on fall management revised 2012 revealed " falling star is a visual identifier /reminder program for staff to recognize and be aware of residents determined to be at risk. Visual identifier will assist the facility staff as well as family and visitors to identify those residents that are at risk of falls and to respond accordingly when the resident demonstrates a behavior that may be associated with impending fall " . Facility census dated 6/26/14 listed 112 residents.

Based on interview and record review, the facility failed to implement its written polices and procedures to prohibited neglect of 1 of 9 residents (CR#1) reviewed for care provided: On 6/11/14 CR# 1, who was severely impaired for cognition, and agitated, was left unattended in the dining room during breakfast. CR# 1 was later found on the floor. After breakfast, CR# 1 exhibited sign of pain by grimacing and holding her right arm. Staff had been administering pain medication for three days without further evaluation of the arm. CR # 1 was identified with dislocation and fracture to her right shoulder on 6/13/14 and was transferred to the hospital where it was discovered she had multiple fracture to her right shoulder and her right hip and had to undergo corrective surgeries. This failure affected CR# 1 and placed 112 residents at risk of not receiving services needed and /or prompt transfers when a decline and/or a change in their health status were identified which could cause medical decline. Intake # 0 and 4 Findings include: Record review of CR# 1 face sheet revealed an [AGE] year old year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1 ' s MDS dated [DATE] revealed the resident was severely impaired for cognition , required extensive assistance for all ADLs and had no history, risk or actual falls since admission. Record review of CR#1 ' s physician order [REDACTED]. Record review of CR # 1 ' s care plan (not dated) revealed resident had ADL self-care performance deficit related to Dementia and confusion. Goal and approaches were outlined. Further review of the care plan (not dated) revealed the resident had impaired cognitive function/dementia or impaired thought processes related to short term memory loss, long term memory loss and Dementia. Further review of a care plan for falls (not dated) revealed high risk for falls related to unaware of safety needs, confusion, poor communication/comprehension, gait /balance problems and incontinence. Goal and approaches were outlined. Record review of CR# 1's incident/accident investigation follow up dated 6/11/14 revealed resident was observed on the floor in the dining room area in supine position. Investigation summary revealed the resident was agitated, attempting to self-ambulate out of the wheel chair prior to taking her to dining room. Past intervention attempted- chair alarm in place at all times, Recommendation- Continue visual monitoring. Record review of CR # 1's nursing notes dated 6/11/14 at 11:32 A.M., revealed the resident was assisted by two aides from floor to wheelchair, able to move lower extremities without pain, grimacing and holding right arm. Record review of CR # 1's nursing notes dated 6/11/14 at 12:04 P.M., revealed in part: " resident observed on the floor in the dining area in supine position , chair alarm buzzing... Assess while on the floor, moves all bilateral legs without pain, grimacing when passive range of motion was done to right arm, inspected affected arm , no change in skin areas, no evidence of swelling noted, medicated with as needed pain medication with effect after an hour. Record review of CR # 1's nursing notes dated 6/11/14 at 3:28 P.M., revealed the resident was observed sitting in the day area with slight swelling and discoloration surfacing to right upper cheeks, Neuro checks in progress, place a call to hospice nurse awaiting call back. Record review of CR # 1 ' s nursing notes dated 6/11/14 at 9:39 P.M., revealed resident was seen and examined by hospice nurse on this shift, orders given to monitor closely for any change and apply ice to the right cheek as tolerated per residents for swelling, resident cooperative with care , ate 50% of dinner. Was calmer and relaxed this shift. Record review of CR #1's nurses notes dated 06/12/14 at 9:44 P.M revealed: "monitoring today to prevent any new falls. Resident has not tried to self ambulate during shift." Record review of CR# 1 ' s MAR indicated [REDACTED]. This medication was administered as follows: 6/11/14 at 8:30 A.M., 12:30 P.M., and 4:30 P.M. 6/12/14 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. 6/13/14 at 9:00 A.M., and 1:00 P.M. Record review of the provider investigation report submitted to DADS and dated 06/13/14 revealed that on 06/11/14 at 9:00 A.M the resident was found in the dining room floor. The report stated that staff and other residents were in the dining room at the time of the incident, but that no one witness the fall. The report indicated that the resident was assessed by the charge nurse and was then assisted back to the wheelchair and she continued to eat breakfast. CR #1 was sent to the hospital on 06-13-14 due to dislocation and [MEDICAL CONDITION] arm. Record review of CR # 1 ' s nursing notes dated 6/13/14 at 9:43 A.M., revealed resident had a fall on 6/11/14, upper right arm noted with discoloration, right hand slightly swollen , not able to lift right arm at this time. X-ray was ordered and taken at 10:28 A.M. CR# 1 was transferred to the hospital on [DATE]. Record review CR# 1 ' s X-ray result dated 6/13/14 at 11:55 A.M., revealed right shoulder dislocation and fracture. Interview on 6/26/14 at 12:15 P.M., with CNA # 1 she said she was assigned CR# 1 on 6/11/14 morning shift. She said the resident was agitated in the morning before breakfast , she was saying she did not want to eat breakfast. CNA #1 said that she took the resident to the dining room and she continued to attempt to get up , CNA# 1 said she redirected the resident about 4 times but she continued to attempt to stand up. CNA# 1 said she left to bring other residents to the dining room for breakfast. She said there should have been another aide in the dining room before she left. She did not know who and where the aide was. CNA # 1 said she believed the aide (unknown) was at the other end of the dining room. CNA #1 said she was coming into the dining room when she saw CR# 1 on the floor lying on her back. She called the charge nurse who came in and assessed her. CNA # 1 said she left the resident in the dining room because she had to assist other residents to the dining room for breakfast. Interview on 6/26/14 at 9:30 A.M., with RN # 1 who was the charge nurse on duty on the morning of 6/11/14, she said the aides were taking residents in and out of the dining room for breakfast the day of the incident. Aide (unknown) told her CR# 1 was on the floor. RN # 1 said she went in there and the resident was lying on her back facing up, she said the resident moved all extremities, so she was transferred back to her chair and she ate some breakfast. After breakfast, RN # 1 said she noted CR# 1 was grimacing and holding her right arm, she told the medication aide to give her pain medication. RN # 1 said the resident was given showers daily. RN # 1 said she expected the aides to stay with agitated residents and to call the nurse ' s attention if residents could not be re-directed. RN # 1 gave no reason as to why CR #1's grimacing and holding of her right arm was not further evaluated for possible fracture after the fall on 6/11/14. Interview on 6/26/14 at 12:10 P.M., MA # 1 said she medicated CR# 1 following her fall on 6/11/4 as instructed by RN# 1. MA # 1 said CR # 1 was subsequently medicated daily because each time she checked her for pain, the resident exhibited signs of discomfort which was not her normal state. She said CR #1 was unable to tell she was in pain but her body language did. She said she offered CR # 1 as needed medication form 6/11/13 to 6/13/14 before she was transferred out. Record review of CR# 1 ' s as needed pain Medication Administration Record [REDACTED] 6/11/14 at 8:30 A.M.,pain level of 4 ( hurts even more) with facial grimacing, she was medicated and pain level was 2 ( hurts little bit ) after medication. 6/11/14 at 12:30 P.M., pain level of 4 with facial grimacing, she was medicated and pain level was 3 (hurts little more) after. 6/11/14 at 4:30 P.M., facial pain level was 2 with verbal complaints of pain presence. Pain level after medication was 1. (No hurt). Further review of pain assessment record revealed the resident continued to show and verbalize pain from 6/12/14 through 6/13/14; level up to 5 (hurts a whole lot on 6/13/14 at 9 am) and was getting two tablets of Tylenol 325 mg. Interview on 6/26/14 at 12:15 P.M., LVN # 1 said an aide reported on the morning of 6/13/14 that the resident's right arm was swollen with bruise noted to the upper right arm and she was unable to assist with her AM care as usual. LVN # 1 said she assessed the resident and called her physician for X-ray orders since she was notified of previous fall on 6/11/14. LVN # 1 said the result showed a fracture with dislocation of right shoulder. CR# 1 was sent to hospital on [DATE]. LVN # 1 said she did not notice signs of pain, discomfort or bruises on the resident prior to 06/13/14. She said that a hospice aide gave the resident a bed bath on 6/12/14 and did not report any injures. LVN # 1 however said that on 6/13/14 , a hospice aide came in to give CR#1 a shower. She said that when the resident was sent to the hospital the hospice aide said CR# 1 told her she did not look well yesterday, but she did not report that to any facility staff . Interview on 6/26/14 at 11:38 A.M., with the ADON regarding her expectation regarding leaving residents unattended in the dining room. She expressed an agitated resident should be monitored and the nurse should be notified when re-direction was ineffective. The ADON said she was told CR #1 had a chair alarm on at the time of the fall but was unsure how staff in the dining room or around did not hear the alarm go off. The ADON said the staff interviewed did not recall CR # 1 showing any bruising, signs of pain or discomfort. She said that she was not aware if the resident was assessed and medicated with as needed pain medication by MA # 1. The ADON said she was unsure as to why further evaluations were not done following the resident ' s grimacing and holding of her right hand. The ADON agreed staff should have done more evaluations after the fall since CR# 1 ' s cognition was severely impaired due to end stage dementia. Interview on 6/26/14 at 1:02 P.M., the Administrator said she called the incident to the State due the family ' s concerns and conducted an investigation to include interview with staff. She said no staff admitted observing anything usual on CR# 1. She said the resident was monitored and care was provided until 6/13/14 when her right hand swelling was noted. Staff contacted the resident physician immediately. The Administrator said that CR #1's family reported that the resident had additional fractures to include a [MEDICAL CONDITION] and was still in the hospital. Interview with CR# 1 ' s family on 06/26/14 at 3:38 P.M. and again on 6/30/14 at 10:02 A.M., revealed CR# 1 had multiple surgeries on 6/14/14 for a right shoulder dislocation and a fracture repair and partial hip replacement on 6/18/14. Resident was still in the hospital as her health continued to deteriorate. Record review of witness statement by LVN # 2 (not dated) revealed that on 6/11/14, 2-10 shift. " CR# 1 had a fall in AM. Thus discoloration noted on right cheek and slight rise in the areas. Hospice nurse came between 6-7 pm and was told the resident was in bed, she turned to her saying she did not see the discoloration to the cheek , I (LVN # 2) wnet in to the room with hospice nurse and showed her the area, hospice nurse said " this is Hematoma " LVN # 2 asked the hospice nurse if she needed to assess the resident further but hospice nurse said CR#1 appears to be sleeping calm now showed no sign of discomfort " . Further record review of the facilitys' documentation revealed no additional information indicating that either the hospice nurse or LVN # 2 assessed the resident on the evening of 6/11/14. Record review of the facility ' s policy on Abuse and Neglect prohibition revised June 2013 revealed " Each resident has the right to be free from mistreatment, neglect abuse ,involuntary seclusion, injuries of unknown origin and misappropriation of property. Policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect " . Facility census dated 6/26/14 listed 112 residents.

Based on interview and record review, the facility failed to follow/implement their written policies and procedures that prohibit the neglect of resident 1 of 9 residents (CR #1) reviewed for abuse and neglect. On 6/11/14 CR# 1, who was severely impaired for cognition, and agitated, was left unattended in the dining room during breakfast. CR# 1 was later found on the floor. After breakfast, CR# 1 exhibited sign of pain by grimacing and holding her right arm. Staff had been administering pain medication for three days without further evaluation of the arm. CR # 1 was identified with dislocation and fracture to her right shoulder on 6/13/14 and was transferred to the hospital where it was discovered she had multiple fracture to her right shoulder and her right hip and had to undergo corrective surgeries. This failure affected CR# 1 was left in the facility for three days following a fall without further evaluations.CR#1 had multiple fractures to Right shoulder and right hip and had to undergo corrective surgeries and placed 112 residents at increased risk of neglect , decline in health status. Findings include: Intake # 0 and 4 CR#1 Record review of the facility ' s policy on Abuse and Neglect prohibition revised June 2013 revealed " Each resident has the right to be free from mistreatment, neglect abuse ,involuntary seclusion, injuries of unknown origin and misappropriation of property. Policy defined neglect as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown origin may occur as a result of neglect " . Record review of CR# 1 face sheet revealed an [AGE] year old year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of CR# 1 ' s MDS dated [DATE] revealed the resident was severely impaired for cognition , required extensive assistance for all ADLs and had no history, risk or actual falls since admission. Record review of CR#1 ' s physician order [REDACTED]. Record review of CR # 1 ' s care plan (not dated) revealed resident had ADL self-care performance deficit related to Dementia and confusion. Goal and approaches were outlined. Further review of the care plan (not dated) revealed the resident had impaired cognitive function/dementia or impaired thought processes related to short term memory loss, long term memory loss and Dementia. Further review of a care plan for falls (not dated) revealed high risk for falls related to unaware of safety needs, confusion, poor communication/comprehension, gait /balance problems and incontinence. Goal and approaches were outlined. Record review of CR# 1's incident/accident investigation follow up dated 6/11/14 revealed resident was observed on the floor in the dining room area in supine position. Investigation summary revealed the resident was agitated, attempting to self-ambulate out of the wheel chair prior to taking her to dining room. Past intervention attempted- chair alarm in place at all times, Recommendation- Continue visual monitoring. Record review of CR # 1's nursing notes dated 6/11/14 at 11:32 A.M., revealed the resident was assisted by two aides from floor to wheelchair, able to move lower extremities without pain, grimacing and holding right arm. Record review of CR # 1's nursing notes dated 6/11/14 at 12:04 P.M., revealed in part: " resident observed on the floor in the dining area in supine position , chair alarm buzzing... Assess while on the floor, moves all bilateral legs without pain, grimacing when passive range of motion was done to right arm, inspected affected arm , no change in skin areas, no evidence of swelling noted, medicated with as needed pain medication with effect after an hour. Record review of CR # 1's nursing notes dated 6/11/14 at 3:28 P.M., revealed the resident was observed sitting in the day area with slight swelling and discoloration surfacing to right upper cheeks, Neuro checks in progress, place a call to hospice nurse awaiting call back. Record review of CR # 1 ' s nursing notes dated 6/11/14 at 9:39 P.M., revealed resident was seen and examined by hospice nurse on this shift, orders given to monitor closely for any change and apply ice to the right cheek as tolerated per residents for swelling, resident cooperative with care , ate 50% of dinner. Was calmer and relaxed this shift. Record review of CR #1's nurses notes dated 06/12/14 at 9:44 P.M revealed: "monitoring today to prevent any new falls. Resident has not tried to self ambulate during shift." Record review of CR# 1 ' s MAR indicated [REDACTED]. This medication was administered as follows: 6/11/14 at 8:30 A.M., 12:30 P.M., and 4:30 P.M. 6/12/14 at 9:00 A.M., 1:00 P.M., and 5:00 P.M. 6/13/14 at 9:00 A.M., and 1:00 P.M. Record review of the provider investigation report submitted to DADS and dated 06/13/14 revealed that on 06/11/14 at 9:00 A.M the resident was found in the dining room floor. The report stated that staff and other residents were in the dining room at the time of the incident, but that no one witness the fall. The report indicated that the resident was assessed by the charge nurse and was then assisted back to the wheelchair and she continued to eat breakfast. CR #1 was sent to the hospital on 06-13-14 due to dislocation and [MEDICAL CONDITION] arm. Record review of CR # 1 ' s nursing notes dated 6/13/14 at 9:43 A.M., revealed resident had a fall on 6/11/14, upper right arm noted with discoloration, right hand slightly swollen , not able to lift right arm at this time. X-ray was ordered and taken at 10:28 A.M. CR# 1 was transferred to the hospital on [DATE]. Record review CR# 1 ' s X-ray result dated 6/13/14 at 11:55 A.M., revealed right shoulder dislocation and fracture. Interview on 6/26/14 at 12:15 P.M., with CNA # 1 she said she was assigned CR# 1 on 6/11/14 morning shift. She said the resident was agitated in the morning before breakfast , she was saying she did not want to eat breakfast. CNA #1 said that she took the resident to the dining room and she continued to attempt to get up , CNA# 1 said she redirected the resident about 4 times but she continued to attempt to stand up. CNA# 1 said she left to bring other residents to the dining room for breakfast. She said there should have been another aide in the dining room before she left. She did not know who and where the aide was. CNA # 1 said she believed the aide (unknown) was at the other end of the dining room. CNA #1 said she was coming into the dining room when she saw CR# 1 on the floor lying on her back. She called the charge nurse who came in and assessed her. CNA # 1 said she left the resident in the dining room because she had to assist other residents to the dining room for breakfast. Interview on 6/26/14 at 9:30 A.M., with RN # 1 who was the charge nurse on duty on the morning of 6/11/14, she said the aides were taking residents in and out of the dining room for breakfast the day of the incident. Aide (unknown) told her CR# 1 was on the floor. RN # 1 said she went in there and the resident was lying on her back facing up, she said the resident moved all extremities, so she was transferred back to her chair and she ate some breakfast. After breakfast, RN # 1 said she noted CR# 1 was grimacing and holding her right arm, she told the medication aide to give her pain medication. RN # 1 said the resident was given showers daily. RN # 1 said she expected the aides to stay with agitated residents and to call the nurse ' s attention if residents could not be re-directed. RN # 1 gave no reason as to why CR #1's grimacing and holding of her right arm was not further evaluated for possible fracture after the fall on 6/11/14. Interview on 6/26/14 at 12:10 P.M., MA # 1 said she medicated CR# 1 following her fall on 6/11/4 as instructed by RN# 1. MA # 1 said CR # 1 was subsequently medicated daily because each time she checked her for pain, the resident exhibited signs of discomfort which was not her normal state. She said CR #1 was unable to tell she was in pain but her body language did. She said she offered CR # 1 as needed medication form 6/11/13 to 6/13/14 before she was transferred out. Record review of CR# 1 ' s as needed pain Medication Administration Record [REDACTED] 6/11/14 at 8:30 A.M.,pain level of 4 ( hurts even more) with facial grimacing, she was medicated and pain level was 2 ( hurts little bit ) after medication. 6/11/14 at 12:30 P.M., pain level of 4 with facial grimacing, she was medicated and pain level was 3 (hurts little more) after. 6/11/14 at 4:30 P.M., facial pain level was 2 with verbal complaints of pain presence. Pain level after medication was 1. (No hurt). Further review of pain assessment record revealed the resident continued to show and verbalize pain from 6/12/14 through 6/13/14; level up to 5 (hurts a whole lot on 6/13/14 at 9 am) and was getting two tablets of Tylenol 325 mg. Interview on 6/26/14 at 12:15 P.M., LVN # 1 said an aide reported on the morning of 6/13/14 that the resident's right arm was swollen with bruise noted to the upper right arm and she was unable to assist with her AM care as usual. LVN # 1 said she assessed the resident and called her physician for X-ray orders since she was notified of previous fall on 6/11/14. LVN # 1 said the result showed a fracture with dislocation of right shoulder. CR# 1 was sent to hospital on [DATE]. LVN # 1 said she did not notice signs of pain, discomfort or bruises on the resident prior to 06/13/14. She said that a hospice aide gave the resident a bed bath on 6/12/14 and did not report any injures. LVN # 1 however said that on 6/13/14 , a hospice aide came in to give CR#1 a shower. She said that when the resident was sent to the hospital the hospice aide said CR# 1 told her she did not look well yesterday, but she did not report that to any facility staff . Interview on 6/26/14 at 11:38 A.M., with the ADON regarding her expectation regarding leaving residents unattended in the dining room. She expressed an agitated resident should be monitored and the nurse should be notified when re-direction was ineffective. The ADON said she was told CR #1 had a chair alarm on at the time of the fall but was unsure how staff in the dining room or around did not hear the alarm go off. The ADON said the staff interviewed did not recall CR # 1 showing any bruising, signs of pain or discomfort. She said that she was not aware if the resident was assessed and medicated with as needed pain medication by MA # 1. The ADON said she was unsure as to why further evaluations were not done following the resident ' s grimacing and holding of her right hand. The ADON agreed staff should have done more evaluations after the fall since CR# 1 ' s cognition was severely impaired due to end stage dementia. Interview on 6/26/14 at 1:02 P.M., the Administrator said she called the incident to the State due the family ' s concerns and conducted an investigation to include interview with staff. She said no staff admitted observing anything usual on CR# 1. She said the resident was monitored and care was provided until 6/13/14 when her right hand swelling was noted. Staff contacted the resident physician immediately. The Administrator said that CR #1's family reported that the resident had additional fractures to include a [MEDICAL CONDITION] and was still in the hospital. Interview with CR# 1 ' s family on 06/26/14 at 3:38 P.M. and again on 6/30/14 at 10:02 A.M., revealed CR# 1 had multiple surgeries on 6/14/14 for a right shoulder dislocation and a fracture repair and partial hip replacement on 6/18/14. Resident was still in the hospital as her health continued to deteriorate. Record review of witness statement by LVN # 2 (not dated) revealed that on 6/11/14, 2-10 shift. " CR# 1 had a fall in AM. Thus discoloration noted on right cheek and slight rise in the areas. Hospice nurse came between 6-7 pm and was told the resident was in bed, she turned to her saying she did not see the discoloration to the cheek , I (LVN # 2) wnet in to the room with hospice nurse and showed her the area, hospice nurse said " this is Hematoma " LVN # 2 asked the hospice nurse if she needed to assess the resident further but hospice nurse said CR#1 appears to be sleeping calm now showed no sign of discomfort " . Further record review of the facilitys' documentation revealed no additional information indicating that either the hospice nurse or LVN # 2 assessed the resident on the evening of 6/11/14. Facility census dated 6/26/14 listed 112 residents.

Based on interview and record review the facility failed to ensure 1 of 23 residents (Resident #12) reviewed for pain assessment received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident #12 had a Stage III pressure ulcer, was receiving daily wound treatment and was not being assessed for pain and was not receiving any pain medications. This failure affected 1 resident and placed 13 other residents with pressure ulcers at risk of a diminish quality of life, increased risk for pain and delcine in overall well-being. Findings include: Resident #12 Record review of Resident #12's face sheet revealed a [AGE] year old female with an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #12's Admission MDS assessment dated [DATE] revealed that Resident #12 was totally dependent on staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #12 was also incontinent of bowel and bladder. Further record review of the MDS Assessment revealed that under Section M, Resident #12 had a Stage III Pressure Ulcer. Further review of Section J revealed resident had no pain. Record review of Resident #12's care plan dated 03/20/14 revealed that the resident had the potential for pain due to [MEDICAL CONDITION]. The care plan did not address the risk for pain due to Stage III pressure sore to the sacral area. Further review of a care plan dated 03/31/14 revealed that the resident had a Stage IV Pressure ulcer. Further review of the approaches included in the care plan revealed no mention of pain assessments before or after treatment and no mention of the use of pain medication. Record review of Resident #12's MAR for April 2014 revealed an order for [REDACTED]. There was no other order for pain medication for the resident. Record review of a Head to Toe Skin Check dated 05/07/14 revealed documentation of the Stage III pressure ulcer to the sacral area. Observation on 05/07/14 at 10:30 a.m. of LVN A providing pressure sore treatment for [REDACTED]. Further observation revealed Resident #12 was unable to express her pain verbally to the staff. During an interview on 05/08/14 at 10:10 a.m. LVN P about pain medication for Resident #12 she stated she was going to look in the MAR to see what was order. She look at the MAR and said that nothing was ordered for pain so she did not get any pain medication before her wound treatments. In an interview on 05/08/14 at 10:20 am, the DON said that the staff was supposed to anticipate pain for Resident #12 since she had a Stage III pressure sore and was not able to voice her pain. At that point the DON instructed LVN P to contact Resident #12's doctor for him to prescribe pain medication for Resident #12. In an interview with the MDS Coordinator on 05/08/14 at 11:30 a.m. she stated that pain assessment of a resident was based on the residents expression of pain by groaning, grimacing or verbally. At that point she was asked about the residents who were unable to voice pain. The MDS Coordinator did not answer. CMs 672 revealed there where 14 residents with pressure sores.