Every finding on record at Park View Care Center

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan of weekly skin assessments was implemented. This failure could place the residents at risk of pressure wounds not being addressed as soon as they develop. Findings include:Record review of Resident #2's Face Sheet, dated 08/11/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses of a history of falls and lack of coordination. Record review of Resident #1's Face Sheet, dated 08/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses of Type 2 diabetes (low insulin) and reduced mobility. Record review of Resident #1's Quarterly MDS Assessment, dated 06/19/26, reflected the resident had a BIMS of 15 (intact cognitive response). The resident had an active diagnosis of Type 2 diabetes. Record review of Resident #1's Quarterly Comprehensive Care Plan, dated 06/19/26, reflected the resident had a diagnosis of Type 2 diabetes and it included an intervention of weekly skin assessments. Record review of the Resident #1's skin assessments for July and August 2026 revealed skin assessments only completed on 07/23/26 and 08/15/26. During an observation and interview on 08/28/26 at 11:14am, Resident #1 was observed at the hospital. The resident was admitted to the ICU unit on 08/21/26. Resident #1 was observed to be intubated and could not be interviewed or wounds assessed. An interview with an RN at the hospital revealed the resident was admitted with a stage 2 pressure injury to the spine/coccyx, a stage 1 pressure injury to the scrotum, and deep tissue injury to the left leg. Photos of the wounds were reviewed on the nurse's computer. The hospital records indicated no wounds upon admission on [DATE], but the wounds being observed on 08/26/26. During an interview on 08/28/26 at 10:00 a.m., the Wound Care Nurse stated Resident #1 had skin assessment completed on 07/23/26, and she observed a skin tear on his scrotum and coccyx. She stated the wounds were to be assessed weekly to ensure the wounds were not getting worse. She stated it was the charge nurse's responsibility to conduct weekly skin assessments and alert her if there were wounds observed. She stated the resident was diabetic and required weekly skin assessments to ensure he did not have any new wounds. During an interview on 08/28/26 at 10:50 a.m., ADON L was informed of Resident #1 having an intervention for weekly skin assessments and records revealing the resident only having an assessment on 07/23/26 for the month of July and on 08/15/26 for the month of August. She stated the resident should have had weekly skin assessments completed by the charge nurse, and if there were any concerns, an assessment form should be completed. She stated if the weekly skin assessments were not completed, they would not be able to determine if the resident acquired new wounds or if wounds were improving or getting worse. She stated it was the ADON and DON's responsibility to ensure the nurses were documenting skin assessments and it was usually done when the resident received his showers. During an interview on 08/28/26 at 1:13 p.m., the DON was informed of Resident #1's care plan revealing the resident was a diabetic and an intervention was for the resident to receive weekly skin assessments. She was informed of the resident records revealing only having skin assessments on 07/23/26 for the month of July and on 08/15/26 for the month of August. She stated the resident should have received weekly skin assessments from the weekly charge nurse. She stated Resident #1 did not have a wound prior to being discharged to the hospital on [DATE]. She stated the nurse on duty at the time of the Resident's discharge to the hospital, should have completed a skin assessment prior to the discharge. She stated if the resident did not receive weekly skin assessments, they could have skin breakdown going unnoticed. During an interview on 08/28/26 at 1:50 p.m., LVN R, stated she completed a skin assessment of Resident #1 on 08/21/26; however, she had forgotten to document it. She stated the resident did not have any wounds prior to discharging to the hospital on [DATE]. She stated it should have been documented in the nurses notes. Record review of facility's policy, Comprehensive Care Plans, dated 2/10/2021, reflected It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

Based on interviews, observations, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #1) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #1 received his scheduled showers for July and August 2026. This failure could place the residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.Findings included: Record review of Resident #1's Face Sheet, dated 08/28/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis of need for assistance with personal care. Record review of Resident #1's Quarterly MDS Assessment, dated 06/19/26, reflected the resident had a BIMS of 15 (intact cognitive response). The MDS Assessment reflected the resident dependent on helper for showering and bathing. Record review of Resident #1's Quarterly Comprehensive Care Plan, dated 06/19/26, reflected the resident had an ADL self-care performance deficit. The care plan revealed an intervention which included the resident required an assist of two nursing staff for bathing. There was no mentioning of the resident refusing showers or bed baths. Record review of Resident #1's Progress notes for the month of July and August 2026, reflected no documentation of the resident refusing showers/bed baths. progress notes revealed the resident was discharged to the hospital on [DATE]. Record review of the facility's shower sheet book for July and August 2026 revealed the following shower sheets for Resident #1: 07/08/26 (bed bath); 07/10/26 (refused); 07/13/26 (bed bath); 07/15/26 (no indication of bed bath or shower); 07/20/26 (bed bath); 08/14/26 (bed bath). During an interview on 08/28/26 at 10:27 a.m., Resident #1's Care Conference Person stated Resident #1 was observed at the hospital on [DATE] and he looked like a bum. She stated he looked very dirty, he was unshaven, and his hair was dirty. During an observation and interview on 08/28/26 at 11:14 a.m., Resident #1 was observed at the hospital. The resident was admitted to the ICU unit on 08/21/26. Resident #1 was observed to be intubated and could not be interviewed. The resident did not have an odor and appeared clean. The nurse on duty could not recall the initial appearance of the resident upon admission to the hospital for respiratory concerns. During an interview on 08/28/26 at 11:00 a.m., ADON L stated the CNAs were to complete shower sheets on all residents when they were scheduled for their showers and the nurses were to sign off on the forms during the shift the resident was scheduled to receive their shower. She stated at that time the nurses were to also indicate if there were any changes to the resident's skin condition. She stated Resident #1 was scheduled for showers in the evenings on Monday, Wednesday, and Friday. She was informed of Resident #1 only having shower sheets on file for the dates previously referenced, and she stated it was the ADONs and the nurse's responsibility to ensure the residents were receiving their scheduled showers. She stated if the resident did not receive his scheduled showers, they would not be able to detect if the resident had any new skin issues. She stated the evening staff responsible for the resident's showers were unavailable for interview. During an interview on 08/28/26 at 1:13 p.m., the DON was informed of Resident #1 having only shower sheets for 07/08/26, 07/10/26, 07/13/26, 07/15/26, 07/20/26, 08/14/26. She stated the CNAs were to complete shower sheets for the residents and the nurse on duty was responsible for signing off on them and then have the shower sheet placed in the binder. She stated she was not sure why the resident only had a limited amount of shower sheets on file. She stated if it was not documented, it was not done. She stated if the resident did not receive his scheduled showers, he could have skin breakdown. Record review of the facility's policy, Resident Showers, dated 2/11/2022, reflected It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per shower schedule

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (#11) of 5 resident rooms (room [ROOM NUMBER]B) reviewed for accidents and hazards. The facility failed to ensure that a mechanical lift was locked when not in use in room [ROOM NUMBER]B. This failure could place residents, visitors and staff at risk of falls and/or injuries.Findings include: Record review of the quarterly MDS assessment dated [DATE] revealed Resident #11 was a [AGE] year-old male admitted to the facility on [DATE], readmitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infraction (hemiplegia is the total paralysis of one entire side of the body, while hemiparesis is mild to moderate muscle weakness on one side). Resident #11 had impairment on one side for his upper and lower extremities. Resident #11 was not able to walk. Resident #11's MDS revealed his moderate cognitive impairment with a BIMS score of 11. Observation of room [ROOM NUMBER]B on 07/30/26 at 10:25 a.m. revealed an unlocked and unsecured mechanical lift. During an interview on 7/30/26 at 10:35 a.m., LVN C stated that she was unaware of a mechanical lift in room [ROOM NUMBER]B on 07/30/2026. LVN C stated she could not state why the mechanical lift was left unattended and unlocked. LVN C stated all mechanical lifts were to always be locked and secure when they were not in use. LVN C stated that she would ensure that the mechanical lift was removed from room and placed in the storage room when not in use. LVN C stated that harm could be caused to anyone when a mechanical lift was unlocked, which included accidents and falls due to the unlocked and unsecured mechanical lift being moved and rolled. She stated that someone could be harmed by having a serious fall with injuries, such as someone's foot getting caught in the mechanical lift. LVN C stated that she had in-service training on mechanical lift usage in July 2026. During an interview on 07/30/2026 at 2:00 p.m., CNA B stated that she had been employed at the facility for three years. CNA B stated that she was the aide who used the mechanical lift in room [ROOM NUMBER]B. CNA B stated that she used the mechanical lift on the resident in bed A. CNA B stated that she could not state the reason the mechanical lift was left unattended and was unaware that it was unlocked. CNA B stated that the facility policy was when the mechanical lift was not in use it was to be placed in a storage room and locked. CNA B stated that a mechanical lift should not be left unattended in a resident's room. CNA B stated that the risk to residents and/or staff if left unattended and unlocked was that someone could trip and cause an injury. During an interview on 07/30/26 at 2:14 p.m., the DON stated that she had been employed at the facility for 11 months. The DON stated that she was unaware that a mechanical lift was parked inside room [ROOM NUMBER]B unlocked and unsecured on 07/30/26. The DON stated that her expectation for all staff at the facility was to ensure that all mechanical lifts in the facility were to be locked and secured when they were parked and not in use. The DON stated that all staff have been educated and trained on the proper usage and safety of mechanical lifts, which included always locking and always securing them. The DON stated that she could not recall when all staff received their last in-service training on mechanical lifts. The DON stated that she will reeducate staff with in-service training on mechanical lift safety and storage. The DON stated the facility designated area for storage for the mechanical lifts were in a storage room. The DON stated there was a risk of anyone in the facility to be injured due to an unlocked and unsecured mechanical lift. She stated the risk was that the resident and/or staff could bump against the unlocked mechanical lift and cause an accident. Record review of facility Transfer and Hoyer in-service dated 06/30/2026 covered Hoyers should be locked and stored appropriately when not in use.

Based on observation, interview and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Residents #10) of 5 residents reviewed for call lights. The facility failed to ensure Residents #10's call lights were answered in a timely manner. This failure could place residents at risk for decreased quality of life, self-worth and dignity.Findings included:Record review of the quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of central cord syndrome at unspecified of cervical spinal cord (common form of an incomplete spinal cord injury in the neck). Resident #10 was dependent on staff for toileting hygiene, upper and lower body dressing and personal hygiene. Resident #10's MDS revealed his cognitive function was completely intact with a BIMS score of 15.During an interview on 07/29/26 at 10:48 a.m., Resident #10 revealed he did have to wait a long time. Resident #10 stated that he requested a brief change at 8:00 a.m. but took so long for a staff member to come that he left the room for a smoke break at 9:00 a.m. Resident #10 stated that he did not have any skin breakdown. Resident #10 stated that he was able to use the restroom on his own but required a new brief as urine had gotten on it and wanted a new one. Resident #10 stated that his aide today was CNA A and nurse was RN D.Observation on 07/29/26 at 11:16 a.m., Resident #10 pressed his call light. State surveyor stayed in Resident #10 room until 11:57 a.m. Resident #10 call light remained on. CNA A entered Resident #10's room [ROOM NUMBER] minutes later at 12:11 p.m.Observation on 07/29/26 at 12:08 p.m., RN D exited a resident room, walked to the south nurses' station, then returned to the hall that Resident #10 resided on, RN D did not respond to the call light.During an interview on 07/29/26 at 2:15 p.m., CNA A stated that she had been employed at the facility for five years. CNA A stated that she was the aide for the south side of the building. CNA A stated that she was not aware that a call light took 55 minutes to answer as anyone in the building could answer a call light. CNA A stated that a call light was to be answered within five minutes. CNA A stated that no one should have to wait 55 minutes to be assisted with care and that could lead to skin breakdown. CNA A revealed if you could not assist the resident, you were supposed to go and get a staff member who could. CNA A stated that she received in-service on call light response two weeks ago.During an interview on 07/29/26 at 2:29 p.m., RN D stated that he had been employed at the facility for three months. RN D stated that he was the charge nurse for the south side of the building. RN D stated that he was unaware that a call light did not get answered for 55 minutes. RN D stated that he could not provide why it took 55 minutes to answer a resident call light. RN D stated that he had a call light response in-service. RN D stated that call light response should be prompt and prompt meant less than 15 minutes. RN D stated that the risk to residents when call lights were not answered promptly could lead to skin breakdown, emotional neglect.During an interview on 07/30/26 at 2:14 p.m., the DON stated that she had been employed at the facility for 11 months. The DON stated she expected her staff to answer call lights timely. The DON said that she wanted all staff to answer call lights and if they could not take care of the problem, they needed to get someone who could. The DON said the call light should never stay on longer than five to seven minutes and anything over that time was too long. The DON said there was no reason that the staff should not answer the call lights. The DON stated that the risk of call lights not being answered was lack of patient care, needs weren't attended to, decline of quality of life, safety concerns, falls, or skin breakdowns.Record review of facility in-service on Customer Service dated 07/06/26 through 07/08/26 covered Call System, Residents. Record review of the facilities June Grievance log revealed no issues with call light response time. Review of the Policy and Procedure Call System, Residents dated 09/2022, revised 01/2025, .Residents are provided with a means to call staff for assistance through communication that directly calls a staff member or a centralized workstation.6. Calls for assistance are answered timely

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, recognizing each resident's individuality for one (Resident #1) of seven residents reviewed for resident rights. 1. The facility failed to ensure Resident #1 was adequately dressed, on Tuesday 07/14/26 at 5:10 am. He was sitting behind the south nurses station counter, in a Geri chair, and only had on shorts and a white towel over his chest with no shirt on. 2. The facility failed to ensure Resident #1 was adequately dressed, on Tuesday 07/14/26 at 5:36 pm. He was sitting behind the nurses' station counter in a Geri chair, and was asleep with a blue hospital gown on. These failures could affect residents who required assistance with activities of daily living and could place them at risk of embarrassment and shame, which could result in decreased self-worth, mood, and psycho-social well-being. The findings included:Record review of Resident #1's admission MDS assessment dated [DATE] revealed, revealed a [AGE] year-old male who admitted [DATE], his (SAMS) Staff Assessment for Mental Status score was a 03 (moderately impaired). He used a wheelchair and was dependent with all ADL care, including upper and lower dressing and he was always incontinent with bowel and bladder. He had medically complex conditions with diagnoses: anemia (low iron), hypertension (high blood pressure), hyperlipidemia (high levels of fat in blood), seizure disorder/epilepsy (uncontrollable electrical surge in brain), malnutrition (deficient in nutrient intake). And anxiety (excessive worry), depression (persistent sadness), respiratory failure (not able to supply oxygen to the blood), metabolic encephalopathy (brain malfunction), dysphagia (difficulty swallowing), other psychoactive substance abuse (use of alcohol, recreation drugs with mental health), need for assistance with personal care, gastrostomy status (feeding tube). Record review of Resident #1's Care Plan dated 06/30/26 revealed, Resident had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner, he had a communication problem related to traumatic brain injury, potential for falls, required the use of a feeding tube and was at risk for aspiration, weight loss and dehydration. Resident had impaired cognitive function/dementia or impaired thought process related to head injury. Record review of Resident #1's Care Plan dated Tuesday 07/14/26 revealed, he had a behavior problem, with attempts to take clothing off - Goal Resident will have fewer episodes by review date - Interventions: administer medications as ordered, monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs, assist the resident with developing more appropriate methods of coping and interacting. Interview and observation on 07/14/26 at 5:10 am, revealed Resident #1 was sitting in a Geri chair at the nurse's station. He was awake looking around, and had no shirt on and had a white towel across his chest. Resident #1 had on shorts and a white pillow sheet was on the floor. LVN A was standing by the south nurses station, he stated he was the charge nurse. Additionally, LVN A said Resident #1 liked to try and pull on his gastric tube and tried to get out of bed, so they kept him at the nurses station to keep him from hurting himself. He stated Resident #1 liked to throw things on the floor and said he was not sure where his shirt was and would get his CNA to check on him and get him a shirt.Observation on 07/14/26 at 5:36 pm, Resident #1 was sitting in a Geri chair at the south nurses' station. He was asleep and had on a blue hospital gown. Interview and observation on 07/14/26 at 5:37 pm, revealed LVN B was standing at the nurses' station counter and Resident #1 was sitting in the Geri-chair with a blue hospital gown on. She stated the facility did not have any clothes for Resident #1, and that his family member had not brought any up for him to wear so they put the hospital gowns on him. She stated Resident #1 had been at this facility for two months, and they had to keep him at the nurses' station every day because he tried to get out of the bed every 15 to 20 minutes. She stated Resident #1 was also a fall risk, and she could get him some clothes from the laundry's lost and found department, until his family member brought some in. Interview on 07/14/26 at 5:42 pm, the DON stated Resident #1 got very restless and removed his gastric tube, but he was usually clothed. She stated the CNAs ensured he had on clothes, and she was not aware of him having on a hospital gown at the nursing station today 07/14/26. She said she would talk to the staff about going to the lost and found for clothes, until his family brought some in. She stated she was not sure and would check to see if they care planned his behaviors of throwing clothes and things on the floor. Interview on 07/14/26 at 6:10 pm, the Administrator stated she was not aware of Resident #1 wearing a hospital gown at the nurse's station today, 07/14/26. She stated she knew he had to be monitored closely because he had behaviors, and she would address the way he was dressed with the nursing staff.Observation on 07/14/26 at 6:27 pm, Resident #1 was at the south nurse's station, he was sitting in a Geri chair with a 3-button dark blue shirt and a grey blanket across his lap. He was awake, appeared calm, and was not taking his clothes off or throwing anything on the floor. Record Review of the facility's Resident Rights policy dated 01/01/25 revealed, Policy: The facility will inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Policy Explanation and Compliance Guidelines: .4. Respect and dignity. The resident has a right to be treated with respect and dignity.

Based on observation, interview, and record review the facility failed to ensure that residents had the right to be free from abuse for 3 (Resident #1, Resident #2, Resident #3) of 7 residents and 3 staff members reviewed for abuse.The facility failed to ensure that Resident #1 was supervised while in the facility.The facility failed to keep staff and residents free from accidents and hazards due to Resident #1's physical and aggressive behaviors. Resident #1 was the aggressor in 5 altercations involving 2 (Resident #2 and Resident #3) residents. As a result Resident #2 preferred to stay in her room to avoid any confrontations with Resident #1. Resident #2 expressed that did not feel safe and started the transfer process to a different facility. This failure could place residents at risk for severe and long-lasting impact for physical, psychological and emotional wellbeing.Record review of Resident #1's Face sheet printed 07/08/26 reflected, she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's diagnoses included: schizophrenia (a chronic, severe brain disorder that causes psychosis, including hallucinations and delusions), major depressive disorder (a serious mental health condition defined by a persistent low mood and a profound loss of interest in daily activities), anxiety, bipolar disorder (a mental health condition characterized by extreme, unpredictable shifts in mood, energy, and activity levels), and current episode manic severe with psychotic features (an extreme mood elevation, dangerous impulsivity, and a complete break from reality). Record review of Resident #1's Care Plan reflected, the facility's Interdisciplinary Team (IDT) determined Resident #1 was PASRR positive. Resident #1 had a behavior problem as evidenced by: behaviors affecting others by physical impulsive behaviors when dx of Schizophrenic episodes began to appear and interfere with care. Behavioral Problem: history of physical and verbal aggression toward others. Resident #1 refused medications, had suicidal dreams, refused follow-up doctor appointments and ADL care. Record review of Resident #1's MDS indicated his BIMS was a 06, severely cognitively impaired. Resident #1 is diagnosed with hallucinations and delusions. Record review of Resident #1's nurses notes on 03/09/26 at 6:10 AM written by LVN F revealed: The writer knocked on resident door to administer the 0500 medication, resident ran out of the room and pursued this nurse, resident picked up the laptop and threw it at this nurse and pursued this nurse with the water pitcher and threw it at this nurse. Record review of Resident #1's nurses notes on 03/09/26 at 7:20 AM written by LVN F revealed: The laptop thrown at this nurse is broken and no longer functions. Record review of Resident #1's nurses notes on 03/09/26 at 3:05 PM written by ADON revealed: resident has been walking around facility most of the day talking, cursing aloud to self, speaking in different voices, no aggressive behaviors noted this day. Record review of Resident #1's nurses notes on 03/09/26 at 2:54 PM written by RN B revealed: When MED-AIDE is passing medication to the another resident, resident walk around med-aide and throw the medication and other properties, Med-aide is trying to protect medication and other properties but resident is attacking on her, and scratch her in her left upper shoulder and threw all the medication. this nurse gave first aid to the MED-Aide. Record review of Resident #1's nurses notes on 06/29/26 at 7:06 PM written by RN B revealed: This nurse was notified by kitchen staff that the resident requesting a sandwich, the resident was informed that snacks are provided by the nursing staff and was instructed to obtain the sandwich from the nurse. The resident became aggressive and hit the kitchen staff member in her face. This nurse went to talk with resident but the resident walked away to the smoke zone area. Notified to DON, [Psych Services], [NP E] and this nurse call family member but nobody responded, send a voice message to call back. The resident continued to be monitored and if still show the aggressive behavior then call 911. Record review of Resident #1's nurses notes on 06/29/26 at 7:21 PM written by RN B revealed: This nurse assessed the kitchen staff, she said that She is fine. Record review of Resident #1's nurses notes on 06/29/26 at 7:21 PM written by LPN G revealed: Called to smoking patio per north station ADON. A resident on south station reported that [Resident #1] slapped another resident [Resident #3] in the face. [Resident #3] also stated that she slapped him. No injuries observed, he denies any pain or discomfort. Administrator immediately notified. Resident placed on 1:1 supervision until further notice. Spoke with [Psych Services], MD. She stated that she would be here this morning to evaluate resident. [NP F], [NP E], also notified and she stated she would also be here today to evaluate. Record review of Resident #1's nurses notes on 07/06/26 at 3:00 PM written by LPN D revealed: Another resident reported that this resident spat on her arms, Administrator, [NP E], DON and family was notified. [NP E] said, will be here tomorrow to talk to the resident. Record review of Resident #1's MAR from January 2026 - July 08. 2026 revealed all medications were refused. Record review of Resident #2's Face sheet printed 07/08/26 reflected, she was a 45-year- old female admitted to the facility on [DATE]. Resident #2's diagnoses included: conversion disorder with seizures or convulsions, anxiety, PTSD, major depressive disorder (a serious mental health condition defined by a persistent low mood and a profound loss of interest in daily activities), and alcohol liver disease. Record review of Resident #2's Care Plan reflected, [Resident #2] had mood problems. Record review of Resident #2's MDS indicated his BIMS was a 15, her cognition and memory are completely intact. Record review of Resident #2's nurses notes revealed:On 07/06/26, Resident #1 spat on Resident #2. Record review of Resident #3's Face sheet printed 07/08/26 reflected, he was a [AGE] year-old male admitted to the facility on [DATE]. Resident #3's diagnoses included: hemiplegia (complete paralysis) and hemiparesis (severe weakness) on the left non-dominant side result from damage to the right hemisphere of the brain, cerebral infarction (occurs when a blood vessel supplying the brain is blocked or narrowed), major depressive disorder (a serious mental health condition defined by a persistent low mood and a profound loss of interest in daily activities), and acute pulmonary edema (a life-threatening medical emergency where sudden fluid accumulation in the lungs' air sacs severely impairs breathing and oxygen exchange). Record review of Resident #3's MDS indicated his BIMS was a 09, moderate cognitive impairment. Record review of Resident #3's nurses notes revealed:On 06/30/26, Resident #1 slapped on Resident #3. Resident #3 denied any pain and there were no injuries. During an interview with Resident #2 on 07/07/26 at, she stated on 07/04/26 12:43 PM, Resident #1 pointed her finger at her and told her that she was going to kill her. Resident #2 stated she notified the Administrator on 07/04/26 and nothing was done. Resident #2 stated on 07/06/26, Resident #1 spat on her and she notified staff. Resident #2 stated she was told by staff to notify LE and file a police report about the incident with Resident #1. Resident #2 stated she telephoned 911 and when LE came to the facility she decided not to press legal charges against Resident #1 for spitting on her. Resident #2 stated on 07/08/26, she spoke with the Administrator and was told that the facility could not do anything about having Resident #1 moved to another hallway or discharged from the facility. Resident #2 stated the Administrator told her there was nothing the facility could do about Resident #1's behaviors and the situation. Resident #2 stated the facility staff gave her the option to change rooms but felt like she had been at the facility for 3 years and assigned her current room for about the same timeframe. Resident #2 stated she would have preferred Resident 1 to move rooms being they were on the same hallway and their rooms were directly across from each other. She stated she was scheduled to have surgery at the end of the month and did not want to move her room so close to her surgery date. Resident #2 stated staff at the facility gave her the option to change facilities due to her concerns regarding not feeling safe with Resident #1 still on the same hallway and at the same facility as herself. Resident #2 stated she met with the Social Worker and she started the transfer process. Resident #2 stated after she submitted a facility transfer from the facility, Resident #1 approached her and asked her when she was leaving the facility. Resident #2 stated she did not feel safe with being on the same hallway as Resident #1. Resident #2 stated she preferred to stay in her room so that there would not be anymore confrontations with Resident #1. Resident #2 stated she told the Administrator and staff she did not feel safe at the facility and she received no response from anyone. Resident #1 stated she was offered by staff to change rooms, but she refused due to wanting to be in the same room prior to her planned surgery at the end of the month. Resident #2 stated Resident #1 is nice and pleasant when she is on her psych medications, but when she is not on her psych medications, she talks to herself and is loud and physically aggressive with everyone. Resident #2 stated Resident #1 had been physical with other staff and residents and the facility has done nothing. Resident #2 stated she had been at the facility for 3 years and Resident #1 had been at the facility for a couple of months. During an interview on 07/07/26 at 12:55 PM. with Resident #3, he stated on the day of the incident with Resident #1, she slapped him on his face and the incident was unprovoked. Resident #3 stated he did not have any injuries. Resident #3 stated he preferred to stay away from Resident #1 because of her history of aggressive behaviors with staff and residents and avoids her at all costs. He stated when he was in the community, he observed Resident #1 speaking to herself and wandering up and down the hallways throughout the facility. Resident #3 stated if Resident #1 comes near him, he will just turn his wheelchair around and go the opposite direction as Resident #1. Resident #3 stated he felt safe with Resident #1 at the facility. During an attempted interview and observation of Resident #1 on 07/07/26 at 1:14 PM, she was sitting on her bed in her room and was talking loudly and asking questions to herself and answered the questions in a different tone and voice. Resident #1 was unable to answer the questions during the interview due to speaking loudly. Surveyor exited Resident #1's room and she began to walk behind this Surveyor and speaking loudly and followed this Surveyor from her room into the hallway. During an interview on 07/07/26 at 4:56 PM, Dietary Aide A stated on 06/29/26, Resident #1 opened the kitchen door and requested a sandwich. Dietary Aide A said she told Resident #1 she needed to have a staff member sign a document stating she requested kitchen staff to make a sandwich for her. Dietary Aide A said when she told Resident #1 the same response a second time Resident #1 slapped her on the left cheek. Dietary Aide A stated she reported to the nursing staff about the incident and was told that the facility could not do anything with the residents behavior. Dietary Aide A stated she went to the doctor on the following day due to having redness to her left cheek and although she experienced some pain to her left cheek area, there were no injuries noted by the doctor. During an interview on 07/08/26 at 1:09 PM with CNA C, she stated she had been employed at the facility for about 9 years. She stated during her shift on 03/09/26, she was the Medication Aide on duty on Resident #1's hallway . She stated Resident #1 pills had refused her medications in the past. CNA C stated she was standing beside her Medication Cart outside of Resident #1's room and walked down the hall to provide another resident their medication. CNA C stated Resident #1 wandered up and down the halls in the facility talking to herself, which was a common occurrence. She stated Resident #1 saw her and approached her and she stated scratched her on her upper arm, near her shoulder and Resident #1 walked away. CNA C stated [Resident #1] had refused her medications for several months. CNA C stated she believed [Resident #1] approached her at the Medication Cart because she thought she was trying to give her some medication. CNA C stated Resident #1 had a few incidents involving other staff and residents. CNA C stated the scratch from [Resident #1] caused some bleeding to her upper arm, but there were no serious injuries. She stated she felt safe at the facility and no residents had told her that they did not feel uncomfortable or unsafe at the facility with Resident #1 at the facility. During an interview with the Administrator on 07/08/26 at 2:48 PM, she stated she had been employed at the facility since November 2025 She stated Resident #1 had been at the facility for several years and was her own RP. She stated the facility is currently in the process of obtaining a guardian for Resident #1 due to her current mental status and having the right mind frame to make her own decisions. The Administrator stated [Resident #2] was diagnosed with schizophrenia with hallucinations and delusions and bipolar. She stated [Resident #1] had 2 Emergency contacts who were FM's and they were aware of the situation with [Resident #1] and were mind boggled (to feel completely overwhelmed, astonished, or confused by something that is extremely difficult to comprehend or imagine) on what to do for [Resident #1] and were supportive of any recommendations of care. The Administrator stated [Resident #2] received regular scheduled Psych visits with NP E, which the notes stated the resident was not a danger to herself or others. The Administrator stated [Resident #2] had 2 incidents involving 2 residents [Resident #3], which was physical and there were no injuries. The Administrator stated the incident involving {Resident #1] and [Resident #2] occurred when [Resident #1] slapped [Resident #3] on the face. She stated [Resident #2] had 2 incidents which involved [Resident #2]. She stated the first incident with [Resident #2] occurred when she was off duty. During that incident [Resident #2] stated [Resident #1] told her that she was, going to kill her. She stated she met with [Resident #2] and told her that [Resident #1] directly did not tell her, I am going to kill you. The Administrator stated all of the incidents involving Resident #1 and Resident #2 were unwitnessed. The Administrator stated she told [Resident #2] that [Resident #1] had been heard on some occasions speaking to herself and telling an imaginary person that she, was going to kill them. She stated the second incident that involved both residents [Resident #1 and Resident #2] occurred when [Resident #1] allegedly spat on [Resident #2], which was unwitnessed. She stated she met with Resident #2after second incident and she was never told by Resident #2 that she did not feel safe at the facility due to Resident #1's behaviors. She stated she offered Resident #2 a room change, but she denied. She stated Resident #1 could not be moved to another room due her being confused and if she moved her to another room, it was more than likely that Resident #1 would return to her old room on the same hallway as Resident #2. She stated [Resident #1] had to be in her own room due to her behaviors and mental status and the facility currently did not have any empty rooms. She stated there were 3 incidents involving staff [Dietary Aide A, CNA C, and LVN F] and there were no injuries. The Administrator stated [Resident #1's] incident involving [Dietary Aide A] occurred when the resident went to the kitchen and requested a sandwich. She stated the facility changed food venders while she was on Leave. She stated when she returned, she did not know that the new vendor requested the kitchen staff to have a form filled out and completed by the nursing staff if a resident requested food items, such as sandwiches. She stated she was not aware of the new vendors requirement until the incident occurred, in which Resident #1 slapped Dietary Aide A on her face. She stated she told the kitchen staff that their food vendor worked for the facility and not to use the form. The Administrator stated, she [Dietary Aide A] should have just given [Resident #1] the damn sandwich. She stated she stated she told all staff if any residents wanted a sandwich, they should just give them the sandwich and the form from the food vendor should no longer be utilized. She stated [Dietary Aide A did not receive any injuries after being slapped in the face by Resident #1. The Administrator stated the incident that involved Resident #1 and LVN F occurred when the resident walked up to LVN F and slapped the computer off the table which caused it to break. The Administrator stated the incident that involved Resident #1 and [CNA C occurred when the resident walked up to CNA C and scratched her on her arm. The Administrator stated she did not feel there were potential risks or harm to Resident #2 or any other residents and staff with Resident #1 being supervised to prevent further or future accidents and hazards. She stated Resident #1 had not taken her psych medications and other medications for 6 months and the facility could not make the resident take her medications because that was her Resident Rights. The Administrator stated after each incident that involved [Resident #1], the facility placedthe resident] on 72-hour supervision with staff after each incident. The 72-hour supervision included 15-minute checks on [Resident #1]. She stated [Resident #1] also was sent a referral with Psych Services and there were no new recommendations. She stated the facility could not submit for a transfer/discharge for [Resident #1] because, 'no facility would take her because of her Clinical Notes, which the facility had to divulge. The Administrator did not provide the potential risks and stated there was no harm to any residents and/or staff with Resident #1 being supervised to prevent further or future accidents and hazards. During an interview on 07/08/2026 at 3:01 PM with the Social Worker, she stated she had been employed at the facility for 1 year. SW stated she was aware of the incidents involving Resident #1 and 2 residents [Resident #2, and Resident #3]. SW stated she was aware of the incidents involving 3 staff members [Dietary Aide A, CNA C, and LVN F]. the SWstated for the past couple of months Resident #1 had been observed walking throughout the hallways in the facility and speaking to herself. She said she had not observed any verbal or physical aggression towards herself or anyone else. The SW stated she was surprised after hearing from other staff and residents about the incidents that involved [Resident #1] that involved residents and staff. The SW stated Resident #2 mentioned the previous week to her that she did not feel safe at the facility and [Resident #2] spoke with the nursing staff and Administrator and told all parties that she wanted to be transferred to another facility. The SW stated she met with Resident #2 and began the process for her to be transferred to another facility. The SW stated she asked [Resident #2] if she wanted to change rooms in between the transfer. She stated she spoke with another facility and [Resident #2] was approved for a transfer. The SW stated Resident #2 told her that she wanted to hold off on the transfer until her scheduled surgery at the end of the month. The SW stated after all the incidents involving [Resident #2], the staff placed the resident on 15-minute observations by staff. The SW stated the staff are very good at de-escalating the situations when [Resident #1] was the aggressorin the facility related incidents, which included residents and staff. The SW stated she felt that there were no concerns regarding staff having the skill to supervise the residents at the facility. The SW stated she was unaware of any serious injuries to staff or residents caused by [Resident #2]. The SW stated no residents voiced their concerns to her regarding their safety at the facility other than [Resident #2]. The SW stated she did not feel there were any risks or harm any residents and/or staff with [Resident #1] being supervised to prevent further or future accidents and hazards. The DON was unavailable for interviews on 07/07/26 and 07/08/26 due to being on Leave for an undetermined timeframe. Attempted telephone calls to NP E, LPN D, RN B and LPN G were unsuccessful. A voicemail message was left for each with no returned calls prior to exit on 07/08/26. Record review of the facility's policy, Abuse, Neglect and Exploitation, updated 09/06/2024, reflected: Policy:It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.Definitions:. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Policy Explanation and Compliance Guidelines:1. The facility provides resident protection that include:a) Prevention/prohibit resident abuse, neglect, and exploitation and misappropriation of resident property;b) Investigation of all allegations listed above andc) Training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; andd) QAPI program includes review and evaluation of all allegations resident abuse, neglect, and exploitation and misappropriation of resident property.2. The facility's Abuse Prevention Coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.3. The facility provides ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written III. Prevention of Abuse, Neglect and ExploitationThe facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves:. B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is suspected or identified by:1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents.2. Review and evaluation of like instances to determine if the appropriate actions to correct noncompliance was taken and documented. E. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment.F. Monitoring the ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.G. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions.H. Provide residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed.J. The licensed nurses are assigned the responsibility of supervision of staff to identify behaviors that may be perceived or actual abuse, neglect, or misappropriation.IV. Identification of Abuse, Neglect and ExploitationA. The facility assists staff to understand the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:1. Resident, staff, or family report of abuse2. Physical marks such as bruises or patterned appearances such as a handprint, belt, or ring mark on a resident's body3. Physical injury of a resident, of unknown source.5. Verbal abuse of a resident overheard6. Physical abuse of a resident observed7. Psychological abuse of a resident observed8. Failure to provide care needs such as comfort, safety.10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame.VI. Protection of ResidentThe facility makes efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:A. Responding immediately to protect the alleged victim and integrity of the investigation.B. Physical exam of the alleged victim for any sign of injury such asa. physical harm,b. pain,c. mental anguish, ord. emotional distress including a psychosocial assessment if needed.C. Increased supervision of the alleged victim and residents.D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.E. Protection from retaliation.F. Providing emotional support and counseling to the resident during and after the investigation, as needed.G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. Record review of the facility's policy, Resident Rights, dated 02/23/2016, reflected: .Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.Exercise of rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights. 4. Respect and dignity. The resident has a right to be treated with respect and dignity.5. Self-determination. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to:a. The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.c. The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.d. The resident has a right to receive visitors of his or her choosing at the time of his or herchoosing, subject to the resident's right to deny visitation when applicable, and in a manner, that does not impose on the rights of another resident.e. The resident has a right to organize and participate in resident groups in the facility.f. The resident has a right to participate in family groups.g. The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) or other residents in the facility.h. The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.i. The resident has a right to choose to or refuse to perform services for the facility and the facility must not require a resident to perform services for the facility. The resident may perform services for the facility if he or she chooses.8. Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Record review of the facility's policy, Discharge Planning, updated 12/06/2016, reflected: Anticipated Outcome:The resident will receive medically-related social services means services provided by the facility's staff to assist residents in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. Including discharge planning services (e.g., helping to place a resident on a waiting list for community congregate living, arranging intake for home care services for residents returning home, assisting with transfer arrangements to other facilities) .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 2 of 3 nurses' station (North Station and Central Station) and 2 of 3 dining rooms (North Dining Room and Central Dining Room), for 2 of 8 residents (Resident #1 and Resident #4) reviewed for pest control. 1. The facility failed to ensure the North Station nurses' desk and North Dining Room were free from flies. 2. The facility failed to ensure the Central Station nurses' desk and Central Hall dining room were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.Findings included:1. During an observation of North Station on 05/27/26 at 9:22 AM, Resident #1 had flies circling in his room and landing on his personal items. Resident #1 was not able to be interviewed due to cognitive impairment.During an observation of North Station nurses' desk on 05/27/26 at 11:40 AM, there were flies circling and landing on the desk and then flying to the hall.Record review of the facility's pest control binder revealed the following: 03/03/26 - Location (Interior, Resident Room) - Issues Flies room [ROOM NUMBER],15c 04/14/26 - Location (Interior, Resident Room) 25, 23, 22, 21, 20, 19, 18, 17, 16, 15, 14, 12, 11, 10, 13,9, 64, 63, 62, 52, 51, 41, 40, 39, 38, 35, 34, 33, 32, 30, 81, 80, 77, and 72 During an interview on 05/27/26 at 11:12 AM, Housekeeper A stated he was assigned to the North station. He stated no residents complain about flies. He stated when he saw pests, he reported to his director and to the Maintenance Director. He stated Maintenance was responsible for following up on the complaints. He stated pest control was at the facility every week.During an interview on 05/27/26 at 1:13 PM, Nurse Aide B revealed he worked at the facility for seven months. He stated there was a constant issue with flies because the doors were opened frequently for residents to go out to smoke, which led to the flies entering residents' rooms and circling around. He stated he had not had residents complain about flies. He stated he would report the concerns to Maintenance, and he would write the report in the book, pest control log. He stated pest control visited weekly.During an interview on 05/27/26 at 03:31 PM, the Maintenance Supervisor revealed he noticed flies in various areas in the facility. He stated the flies were coming in due to the rain and the doors being opened frequently for residents going to and from the smoking patio. He stated pest control had been at the facility for their weekly visits , and they treated for pests and flies. He stated pest control applied traps and treated outdoor and indoor areas. The Maintenance Supervisor stated other than being a pest control issue they were irritating, and the risk would be contamination. During an interview on 05/27/23 at 3:58 PM, the Administrator revealed she was not aware of flies in the building. The Administrator stated all staff were aware that if they saw pests or flies, they were supposed to document it in the pest control log. She stated the maintenance department was responsible for notifying the pest control company. She said the pest control company was at the facility every week. The Administrator stated the flies were irritating.2. During an observation and interview on 05/27/26 at 10:49 AM, a fly was flying around the room and landed on Resident #4 while he was in his bed on the Central Hall. He stated the flies bothered him and had gotten worse, but there was nothing he could do about it. Resident #4 said he assumed they came in through the door that went to the smoking area. He stated they were everywhere. He stated he would shoo at them when they landed on him or near him. During an observation on 05/27/26 between 12:46 PM and 12:52 PM, three flies were flying around the Central Hall dining room during the lunch meal service. During an interview on 05/27/26 at 12:39 PM, MA F stated she saw a few flies at the nurses' station but not in resident rooms. She said the flies were bad in the summertime and came in when they opened the doors for residents who smoked. She stated if she saw any pests she was supposed to write it in the log book for Maintenance, so pest control could come out. She stated flies could bite residents, and the residents could find them annoying. During an interview on 05/27/26 at 1:43 PM, RN D stated flies were seen all over and about three flew in every time they opened the door. She said she wrote it down in the Maintenance log, and they contacted pest control. She stated the risk to residents was that the flies were disgusting and could carry germs.Record review of the facility's Pest Control policy, dated May 2020, reflected: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, that is flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations

Based on observation, interview, and record review , the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 8 residents (Resident #2 and Resident #3) reviewed for environmental conditions.The facility failed to ensure the privacy curtains for Resident #2 and Resident #3 were maintained in a clean and sanitary manner free of dried vomit. This failure could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. Findings included:During an observation and interview on 05/27/26 at 11:12 AM, the privacy curtain in Resident #2's and Resident #3's room had several areas with a dried black substance. Resident #3 stated it was from when his roommate, Resident #2, vomited and had been like that for the past couple of days. He stated he told the nurse and maintenance. He stated he had to get housekeeping to come change the curtain. During an interview on 05/27/26 at 1:38 PM, [NAME] C stated he just finished cleaning Resident #2's and #3's room. He stated the privacy curtain had been changed before he cleaned the room. He stated if he saw stains he would tell his supervisor that it needed to be changed. He stated housekeeping was supposed to check the curtains daily. He said it was important to make sure they were clean for the health of residents. During an interview on 05/27/26 at 1:43 PM, RN D stated the black substance on the privacy curtain was vomit. She stated it happened yesterday, and she used bleach wipes to try to clean it up. She said she assumed a CNA told housekeeping the curtain got soiled and needed to be changed. She said she could not remember who the aides were. She stated she did not tell housekeeping that the curtain was soiled. She said the risk to the residents would be germs. During an interview on 05/27/26 at 1:59 PM, CNA E stated she noticed the black stains on the curtain and said it had happened yesterday. She stated the Maintenance Director was fixing sprinklers and probably had not gotten around to changing it, and she stated she did not remember if she reported to anyone that the curtain needed to be changed. She stated she remembered using bleach wipes to clean up the stains. She stated the risk to the resident would be germs and cross contamination. During an interview on 05/27/26 at 2:48 PM, the DON stated Resident #2's and Resident #3's privacy curtain should have been changed and she expected staff to notify housekeeping right away. She said the risk to the resident would be infection control and would not be homelike. During an interview on 05/27/26 at 3:13 PM, the Maintenance Director stated housekeeping was responsible for changing the privacy curtains and the only thing Maintenance did was adjust the tracks. During an interview on 05/27/26 at 3:20 PM, the Environmental Services Director stated his department and Maintenance was responsible for changing the privacy curtains when they were stained. He stated he kept some available in the linen closet if something happened when housekeeping was not there. He said Resident #2's and Resident #3's privacy curtain was changed earlier today (05/27/26) around 1:00 PM when one of the residents mentioned it to him and said his roommate threw up. He stated he was not notified by any staff the privacy curtain needed to be changed. He stated no resident should have to experience having soiled or bodily fluids on the curtain and it was unhealthy. During an interview on 05/27/26 at 3:55 PM, the Administrator stated housekeeping was responsible for changing privacy curtains and they were to be changed when soiled. She stated Resident #2's and #3's privacy curtain should have been changed and should have been reported by nursing staff to housekeeping to change it. She said the risk to the residents was that it was an infection control issue and not a clean and homelike environment.Record review of the facility's Resident Rights policy, dated 02/20/21, reflected that: .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations, interviews, and record reviews, 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 4 of 15 residents (Residents # 1,2,3, and 4) reviewed for infection control when CNAs A, B, C, and D were serving meals. During lunch meal delivery to Hall 100 CNAs A, B, C, and D delivered trays to Residents #1,2,3, and 4, without using hand sanitizer. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. Findings included: Observation on 03/05/26 at 12:19 PM, revealed:- CNA-A and CNA-B knocking on doors prior to entering the rooms and taking meal trays into the rooms, they were not observed sanitizing their hands prior to passing out meals to Resident #1 and Resident #2. -At 12:23 PM, CNA-C walked out of the shower room and started helping to pass out the meals without sanitizing her hands -At 12:25 PM, CNA-C moved to the adjoining hall, pulled on her pants then continued to push the meals down the hallway, then she delivered a food tray to Resident #3.-At 12:27 PM, CNA-C handed a meal tray to CNA-D who was passing by, and she took the meal into the room of Resident #4, CNA-D did not sanitize her hands prior to receiving the tray . Record review of the face sheet dated 03/05/26 for Resident #1 reflected he was a [AGE] year-old-male admitted to the facility on [DATE]. He was diagnosed with traumatic subarachnoid hemorrhage (bleeding into the space surrounding the brain caused by trauma, commonly from falls or accidents), major depressive disorder (a common severe mental health condition characterized by persistent sadness), and anxiety disorder (mental health conditions characterized by persistent, excessive fear or worry that interferes with daily life). Record review of a care plan dated 01/13/26 for Resident #1 reflected he had a focus on ADL self-care performance deficit and was at risk of not having his needs met in a timely manner. The goal was to maintain a sense of dignity by being clean, dry, odor free, and well groomed. Interventions for eating was set up assist of one. Record review of the Quarterly MDS dated [DATE] for Resident #1 reflected his functional abilities eating for self-care indicated he needed setup or clean-up assistance, the helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity. He had a BIMS score of 15 indicated he was cognitively intact. Interview with Resident #1 on 03/05/26 at 12:28 PM, revealed he had never noticed if the staff washed their hands when they brought his meals. He stated clean hands were important because dirty hands on a person's food could make the person sick. He stated that he had not been sick with a virus.Record review of the face sheet dated 03/05/26 for Resident #2 reflected he was a [AGE] year-old-male admitted to the facility on [DATE]. He was diagnosed with dementia (umbrella term for a progressive decline in memory, thinking, and behavior), peripheral vascular disease (a slow progressive circulation disorder characterized by narrowing, blockage, or spasms in blood vessels outside the heart and brain), schizophrenia (chronic, severe brain disorder), major depressive disorder (a common severe mental health condition characterized by persistent sadness, loss of interest, low energy), and hypertension (a chronic condition where blood forces against artery walls).Record review of a care plan dated 06/03/26 for Resident #2 reflected he had a focus on ADL self-care performance deficit r/t dementia. The goal was to maintain a sense of dignity by being clean, dry, odor free, and well groomed. Interventions for eating was to be set up and supervision. Record review of a Quarterly MDS dated [DATE] for Resident #2 reflected his functional abilities eating for self-care indicated he completed the activity independently with no assistance from a helper. He had a BIMS score of 15 indicating he was cognitively intact. In an interview on 03/05/26 at 12:36 PM, Resident #2 stated he did not know if the staff had sanitized their hands before bringing his food into his room. He stated the staff did not wash their hands before leaving his room. He stated cleaning hands was important. He stated he had not had any sicknesses.Record review of the face sheet dated 03/05/26 for Resident #3 reflected he was a [AGE] year-old-male admitted to the facility 11/18/25. He was diagnosed with dementia (umbrella term for a progressive decline in memory, thinking, and behavior), paranoid schizophrenia (a chronic brain disorder characterized by intense, irrational paranoia, auditory hallucinations), encephalopathy (a general term for brain dysfunction, damage, or disease caused by infections), anxiety disorder anxiety disorder (mental health conditions characterized by persistent, excessive fear or worry that interferes with daily life), hypertension (a chronic condition where blood forces against artery walls), and respiratory failure (a critical, potentially life threatening condition where the lungs cannot adequately provide oxygen to the blood or remove carbon dioxide). Record review of a care plan dated 12/09/26 for Resident #3 reflected a focus was that he was at risk for infection/signs and symptoms of viral respiratory infection, the goal was that Resident #3 would not exhibit signs/symptoms of viral respiratory infection through next review date. The interventions were to educate staff, resident, family, and visitors of signs and symptoms of infections and precautions. Record review of a Quarterly MDS dated [DATE] for Resident #3 reflected his functional abilities eating for self-care indicated he needed setup or clean-up assistance, the helper sets up or cleans up; resident completes activity. He had a BIMS score of 11 indicating he was moderately impaired. In an attempted interview on 03/05/26 at 1:10 PM, with Resident #3 in his room, he was asked if he enjoyed his lunch, he did not respond, his eyes were observed to be closed. Record review of the face sheet dated 03/05/26 for Resident #4 reflected she was a [AGE] year-old-female admitted to the facility 01/22/26 diagnosed with type 2 diabetes (a chronic condition where the body resists insulin or fails to produce enough), severe sepsis (a life-threatening medical emergency occurring when an infection causes widespread inflammation), schizophrenia disorder (a chronic severe brain disorder), cognitive communication deficit (impairment in communication), bipolar disorder (a mental health condition characterized by extreme mood swings, altering between high-energy manic/hypomanic episodes). Record review of a care plan dated 01/30/26 for Resident #4 reflected a focus that she was at risk of infection/signs and symptoms of viral respiratory infection. Her goal was that she would not exhibit signs/symptoms of viral respiratory infection through the next review date. The interventions were to educate staff, resident, family and visitors of signs and symptoms of infections and precautions. Record review of Comprehensive MDS dated [DATE] for Resident #4 reflected her functional abilities eating for self-care indicated she needed setup or clean-up assistance, the helper sets up or cleans up; resident completes activity. She had a BIMS score of 15 indicating she was cognitively intact.In an attempted interview on 03/05/26 at 1:15 PM, Resident #4 stated her lunch was great, when asked if she noticed if the staff had washed or sanitized their hands, she replied she liked the investigator's shoes. Resident #4 was asked what she ate for lunch, she responded that she wanted to buy some shoes.In an interview on 03/05/26 at 1:38 PM, CNA-D stated they were supposed to have hand sanitizer in their pocket, she stated she was not the person who passed out the trays. She stated that she was walking down the hall when CNA-C gave her the tray to take into the room. She stated she took the tray in the room and sat it down. She stated that she thought there were hand sanitizer containers on the halls, but she would have to check to make sure. She stated that she thought the housekeepers were responsible for making sure hand sanitizer was available for them to use. She stated that she should use hand sanitizer and wash hands to keep down infection and that was why it should be done at every interaction with residents. She stated that the residents had been placed at risk of infection, cross contamination and transferring of bacteria. In an interview on 03/05/26 at 2:02 PM, CNA-A stated she did not use hand sanitizer when she passed out the meal trays. She stated that the hand sanitizer stations in the hall did not work. She stated that she told the nurses at the nursing station that there was not any hand sanitizer, but she never received any to use. She stated that she did not remember the name of the nurse she told. She stated that she had received infection control in-service, but she did not remember the date. She stated that the residents had been at risk of her passing an infection to them when she did not sanitize her hands. In an interview on 03/05/26 at 2:56 PM, the DON stated she had recently completed an infection control in-service with the staff, but she could not remember the date. She stated that she could not remember if all of the staff had completed the in-service. She stated that she tried to complete the in-services quarterly, as needed, and at the yearly conferences. She stated that all staff should have hand sanitizer available at all times when they were working in the halls. She stated that she thought all of the staff had hand sanitizer. She stated that she was new to the facility and was not sure if there were sanitizer receptacles located in the halls. She denied staff had told her there was not hand sanitizer available. She stated that when the staff did not sanitize their hands they placed the residents at risk of transmission of infection. She stated best practice for the staff was to sanitize before all interactions with residents and going and coming in/out of the room. In a telephone interview on 03/05/26 at 3:08 PM, CNA-C stated there was no hand sanitizer in the hall where she was working. She stated if there was hand sanitizer the containers would be mostly empty. She stated that she usually washed her hands when she passed out the trays and when she picked up the trays. She stated that it had been a few months since she had an in-service on infection control. She stated that she had washed her hands before she left out of the shower room, so she did not see a need to have to sanitize her hands. She stated the residents were at risk of transmission of infection when she did not sanitize her hands. She denied she had told anyone there was no hand sanitizer available.In an interview on 03/05/26 at 5:48 PM, the Administrator stated that the expectation was that all the CNAs would practice good hand hygiene, and to notify her that there was no hand sanitizer available. She stated if staff would have notified her she would have notified housekeeping that hand sanitizer was needed in the halls. She stated housekeeping was managed by an outside vender and she would ensure they were notified that the hand sanitizer stations needed to be filled. She stated that the residents had been at risk of getting sick with infection or a UTI. Record review of infection control and prevention in-service dated 1/5/26 reflected, The purpose for this policy is to reduce the spread of infections by the use of evidenced based techniques established infection control policies and procedures. It is the policy to use precautions to reduce the risk and prevent transmission of infectious agents.Record review of hand hygiene police dated 11/12/17 reflected, Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy explanation and compliance guidelines:1. Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also known as alcohol-based hand rub.2. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.

Based on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchenThe facility failed to ensure the seal on the walk-in freezer door was replaced properly.These failures could place residents at risk of not having essential equipment maintained and in working order. Findings included:Observation on 02/10/2026 at 8:55 AM, revealed ice buildup was accumulated along the door frame, threshold, and floor of the walk-in freezer. Interview on 02/12/2026 at 9:58 AM, the Dietary Manager stated Maintenance was responsible for ensuring the freezer was clean. She stated she noticed the ice buildup 3 months ago and someone put a new seal, but it was not done properly. She said the risk was someone could trip and fall. The Dietary Manager said kitchen staff had a communication book for repairs and the Maintenance Director would come to check. Observation on 02/12/2026 at 10:13 AM, revealed ice buildup was still accumulated along the door frame and threshold of the walk-in freezer.Interview on 02/12/2026 at 11:57 AM, the Maintenance Director said the freezer was functioning properly and the seal had been replaced in November. He said it was important to ensure the freezer was working to protect food and prevent illness and the ice could be a hazard to employees.Interview on 02/12/2026 at 4:38 PM, the Administrator stated she expected kitchen staff to report to the Maintenance Director and herself if major repairs were needed including the freezer, stove, or dishwasher. She stated if the freezer was not working it could affect the quality of the food if the temperature got out of range. Record review of Maintenance Work Order Log, dated November 2020, reflected that the seal around the freezer was resolved on 11/20/25.Record review of the U.S. FDA Food Code 2022 revealed, .4-501.11 Good Repair and Proper Adjustment.(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.(B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications.

Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters. (Dumpsters #1, #2, and #3)1. The facility failed to ensure the doors were completely shut on dumpster #1 2. The facility failed to ensure the lids were closed on dumpsters #1 and #3.3. The facility failed to ensure used incontinent briefs and other garbage were not on the ground surrounding the dumpsters. These failures could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals. Findings included:Observation of the dumpster area on 02/10/2026 at 9:12 AM, revealed the following:- both doors were open on dumpster #1 exposing trash, - Used incontinent briefs, and a clear trash bag with soiled incontinent briefs was lying on the ground next to dumpster #1,- Dumpsters #1 and #3's lids were not closed. Interview on 02/12/2026 at 9:58 AM, the Dietary Manager stated kitchen and environmental services staff were responsible for taking trash outside. She stated the dumpster doors were supposed to be closed, and the area should be clean. She stated if not, it could look bad, be unsanitary and could bring pests. Interview on 02/12/2026 at 3:08 PM, the Environmental Services Manager stated floor techs were responsible for taking trash to the dumpsters. He stated the doors should be closed and trash picked up. He stated if not, it could bring pests and trash could fly around. Interview on 02/12/2026 at 4:38 PM, the Administrator stated floor techs were responsible for taking trash outside and for the surrounding area. She said the dumpster doors should be closed all the way and trash should be picked up and if not it could bring rodents .The facility did not provide a policy on garbage and refuse disposal.

Based on interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.The facility failed to ensure the dishwasher's chemical concentration and temperatures were logged.These failures could place residents at risk of foodborne illness.Findings included: Observation and interview on 02/12/26 at 8:59 AM, Dietary Staff M ran a cycle of the dishwasher and used a test strip to check the chemical sanitizer. She stated she checked the temperature and chemicals once a day before washing dishes . The test strip was dark purple and read 100 parts per million and was within the correct concentration of 50 to 100 parts per million. Record review of facility's Low-Temperature Dish machine Sanitizer Log for February 2026, revealed no water temperature or chemical concentration checks for the following dates:- 02/03/26 - evening- 02/04/26 - midday and evening- 02/05/26 - midday and evening- 02/06/26 - midday and evening- 02/07/26 - morning, midday and evening- 02/08/26 - morning, midday and evening- 02/09/26 - midday and evening.Interview on 02/12/26 at 9:58 AM, the Dietary Manager stated staff were supposed to check the dishwasher 3 times a day and record it on the log to disinfect and make sure dishes were clean. She stated she or the Assistant Manager would train staff on that procedure. The Dietary Manager stated she checked the dishwasher in the morning herself, and the Assistant Manager ran it at night. When asked about the blanks on the log, she stated she did not see the log and there were 2 days when the dishwasher was down. She said they did not use the log when it was down.Interview on 02/12/26 at 11:57 AM, the Maintenance Director stated the dishwasher was out of service last week. He said kitchen staff noticed it was not working, and he was able to fix it the same day. He said he purchased some drain covers to collect food and to keep silverware from getting in there. The Maintenance Director said it was important to ensure the dishwasher was working so dishes would get properly cleaned and sanitized and to prevent food borne illness. Interview on 02/12/2026 at 4:38 PM, the Administrator stated she expected kitchen staff to report to the Maintenance Director and herself if major repairs were needed including the freezer, stove, or dishwasher. She stated if the dishwasher was not working or chemicals were not being checked there was potential for unsanitary dishes. Record review of Maintenance Work Order Logs, from November 2025 to February 2026 did not have dishwasher listed. Record review of the facility policy titled Ware Washing dated 7/2022 revealed the following: The purpose of ware washing is to clean and sanitize utensils and equipment used during the preparation and service of food form the dietary department. Proper ware washing is an essential component in the prevention of food borne illnesses.Procedure.3. Dish Machine temperatures (wash and rinse) will be observed and recorded on the Dish Machine Temperature Log before starting the ware washing process after each meal. For low temperature machines the chemical sanitizer strength will be tested and recorded as well.2. Low temperature Dish Machines.b. chemical: Chorine Sanitizer = 50-100 ppm (parts per million).

Based on interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #72) reviewed for dialysis documentation. The facility failed to ensure nurses documented ongoing assessments of Resident #72's condition and monitoring complications before and after dialysis treatments. This deficient practice could place residents at risk of complications from dialysis due to the lack of documentation between the facility and dialysis center in the event of a medical event. Findings include: Record review of Resident #72's face sheet, dated 02/12/2026, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE]. Resident #72's admitting diagnoses included End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids); Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (is a common, progressive nerve damage condition causing pain, burning, tingling, or numbness typically starting in the feet and hands); Dependence on Renal Dialysis (patients who require dialysis treatment for chronic kidney disease or acute kidney injury). Record review of Resident #72's quarterly MDS, dated [DATE], revealed his BIMS Score was 15, which indicated the resident's memory intact. Resident #72's cognitive abilities were within a normal range. Resident #72 could make independent decisions regarding her care. Record review of care plan undated, revealed in part Resident #72 needed hemodialysis r/t renal failure every Monday, Wednesday, and Friday. Resident #72 would have no complications from dialysis through the review date. Monitor dialysis dressing and change as ordered; Report abnormal bleeding to physician. Monitor for possible complications such as shortness of breath, peripheral edema, chest, pain, elevated blood pressure, dry itchy skin, nausea and vomiting, or bleeding at access site. Record review of Resident #72's Dialysis Communication Forms revealed, dates 05/07/2025 and 02/09/2026, were fully completed from 2 dialysis treatments. Dialysis Communication Forms revealed dates 10/27/2025, 11/03/2025,11/05/2025, 11/07/2025, 11/10/2025, 12/15/2025, 01/03/2026, 01/28/2026, 02/02/2026, and 02/06/2026 were not fully completed with missing documentation. Resident #72 did not complain about any complications from missing documentation. No complications noted in resident's file. Interview on 02/12/2026 at 4:15 PM, the DON revealed the completed Dialysis Communication Records were to be completed and kept in a binder for each dialysis resident. The DON said the ADONs monitor these forms, she said her expectation is to have the charge nurse contact the Dialysis Center and request the Dialysis Communication Record if not returned with the resident. The charge nurse was supposed to complete the form and send with resident to the dialysis center. The risk of not having the completed form for the dialysis resident is potentially an order can be missed or a change that may have occurred at dialysis center was not communicated back to facility. Charge nurses are to check resident's vitals before resident leave for dialysis and upon the resident's return. The DON stated training would be provided to all nurses r/t the Dialysis Communication Records. In an interview on 02/12/2026 at 4:39 PM, the Administrator revealed her expectations are for charge nurses to complete the Dialysis Communication Record, send with resident to dialysis, review form upon resident's return from dialysis. Forms are to be kept in a notebook for resident at nurse's station. Record review of the facility's policy Dialysis - General Guidelines and Management revised 01/01/2024 revealed in part, It is the policy of this home that dialysis residents will receive dialysis service as per physician orders and will be monitored accordingly. Prior to dialysis treatments, assess vitals, edema, access site, mental status, complaints of pain/discomfort, blood sugar (if ordered) and administer meds as directed by the dialysis center.

Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 5 residents (Resident #86) reviewed for restorative care. The facility failed to obtain a physician order and care plan for the use of a splint for Resident #86's left hand contracture (a permanent tightening of the muscles).This failure could place residents at risk of increased contractures, not receiving care and services to maintain their highest level of well-being and decline. Findings include:Findings include: Record review of Resident #86's annual MDS assessment, dated 11/24/25, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #86's diagnoses included cerebrovascular accident (loss of blood flow to part of the brain), encephalopathy (disturbance of brain function), contracture (a permanent tightening of the muscles), cognitive communication deficit, and muscle wasting and atrophy (loss of muscle tissue). Resident #86's BIMS score was 14 which indicated his cognition was intact. The MDS Section GG - Functional Abilities indicated functional limitation in range of motion upper extremity (shoulder, elbow, wrist, hand). The MDS Section O - Special Treatments, Procedures, and Programs indicated no use of a splint or brace assistance. Record review of Resident #86's Care Plan, revised 07/17/25, reflected Focus: ADLs: [Resident #86] has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to: left side hemiplegia (paralysis)/hemiparesis (weakness)/contracture. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Provide shower, shave, oral care, hair care, and nail care per schedule and when needed. The care plan did not address the use of a splint. Record review of Resident #86's physician orders revealed no orders for the use of a splint. Observation and interview on 02/10/26 at 11:28 AM revealed Resident #86 in bed. Observed Resident #86's left hand to be contracted, and resident did not have a splint on. Resident #86 stated at some point he was using a splint for his left hand but then for a while staff stopped putting it on. Resident #86 stated he could not recall the last time he had a splint on. Observations on 02/10/26 from 1:20 PM through 4:30 PM revealed Resident #86 had a splint on his left hand. Observation on 02/11/26 at 12:15 PM revealed Resident #86 was observed in the dining room, and he had a splint on his left hand. Observation on 02/12/26 at 11:14 AM revealed Resident #86 to be in the dining room. Resident #86 did not have a splint on his left hand. Observation on 02/12/26 at 1:21 PM revealed Resident #86 had a splint on his left hand. Interview on 02/12/26 at 1:28 PM, CNA P revealed she was the CNA assigned to Resident #86. She stated Resident #86's left hand was contracted and required the use of a splint. CNA P stated the nurses apply the splint on Resident #86. She stated the splint is put on every day when the resident allowed them to put it on. Interview on 02/12/26 at 1:40 PM, RN Q revealed she was the nurse assigned to Resident #86. She stated Resident #86 had a contracted left hand and required the use of a splint. RN Q stated whoever gets the resident up and ready for the day was responsible for putting on the splint. She stated she was the one who applied the splint on Resident #86 today (02/12/26). RN Q stated a physician order was needed for the use of a splint. She stated she was aware Resident #86 had no physician order for the splint; however, she still applied it because she knew he used it. RN Q stated there was no potential risk for putting the splint on without a physician order; however, for any treatment provided to a resident a physician order needed to be obtained first. RN Q stated contractures, and any use of a device should be care planned. RN Q reviewed Resident #86's care plan and stated resident's left-hand contracture and the use of the splint was not care planned. She stated each department was responsible for care plans, and the clinical team went over the care plans during morning meetings. RN Q stated the potential risk of not care planning the use of the splint would be staff not knowing the correct treatment to provide to the resident. Interview on 02/12/26 at 3:37 PM, ADON H revealed she was the ADON assigned to Resident #86. She stated Resident #86's left hand was contracted. She stated therapy would usually put on a splint on him, but resident was not compliant with it. ADON H stated she had not seen Resident #86 with a splint on. She stated she was not aware nursing staff were applying the splint on Resident #86. She stated she was not aware Resident #86 did not have a physician order for the splint. She stated before starting any treatment, nurses needed to make sure a physician order was obtained. ADON H stated the potential risk of not having a physician order for the use of a splint would be staff not knowing when to put on and take off the splint. She stated the therapy department was responsible for providing an order for the use of a splint. ADON H stated contractures, and the use of any device should be care planned. ADON H stated she was not aware Resident #86 was not care planned for the use of the splint. She stated each department was responsible for the care plan. She stated therapy department was responsible for contractures. ADON H stated the potential risk of not care planning the use of splint/devices would be staff not able to follow up or monitor treatment. Interview on 02/12/26 at 3:54 PM the DON revealed Resident #86 did not require the use of a splint. She stated she had never been told Resident #86 needed a splint. The DON stated she was not aware her staff were putting a splint on Resident #86's left hand. She stated the expectation was for therapy to evaluate, assess the resident for any contractures and obtain an order. The DON stated once the resident was assessed, then therapy must educate the staff on how to put on and remove the splint. She stated her expectations were for nurses to obtain a physician order before putting on the splint. The DON stated the potential risk of putting on a splint without a physician order would be skin integrity. The DON stated contractures needed to be care planned, and she stated she was not aware it was not. She stated therapy was responsible for care planning contractures and the use of a splint. The DON stated the potential risk of not care planning contractures or the use of a splint would be staff not able to monitor. Interview on 02/12/26 at 4:03 PM, Occupational Therapy revealed she had not worked with Resident #86 in a while. She stated on Tuesday 02/10/26 the staff assigned to Resident #86 came into the therapy room looking for a splint. She stated staff were notified that Resident #86 had a splint in his room, which was located. Occupational Therapy stated that since Resident #86 was not receiving any therapy from them it was the responsibility of the nurses to put on the splint. She stated the Occupational Therapist that provided Resident #86 services was on leave and she was not sure of what recommendations were given for the use of the splint. Occupational Therapy stated Resident #86 had a paper order for the use of the splint and it was provided to ADON H and had ADON H signed the form showing that it was provided to her. She stated from what she recalled nurses were trained in how to put on and remove the splint on Resident #86. Occupational Therapy stated they no longer had the original paper order for the use of the splint. She stated the MDS Coordinators were responsible for care plans. Interview on 02/12/26 at 4:12 PM, the MDS Coordinator revealed each department was responsible for care planning each service provided to a resident. She stated contractures should be care planned and therapy was responsible for care planning contractures or the use of any device. Follow up interview on 02/12/26 at 4:20 PM, ADON H revealed she was never provided with a paper order from therapy. Interview on 02/12/26 at 4:35 PM, the Administrator revealed nurses were responsible for obtaining physician orders for the use of a splint. She stated the expectation was for therapy to not put any equipment on a resident without being evaluated and assessed first. If the resident was appropriate for the use of a splint, then therapy should train all nurses on the use of the equipment. The Administrator stated therapy had not provided any physician form to the nursing staff and was she not aware Resident #86 required the use of a splint. She stated there was a potential risk of not having a physician order for the use of a splint; however, she did not know exactly. Record review of facility Contracture Management policy, dated 2/1/25, reflected the following: Policy: The purpose of this Contracture Management Policy is to provide a framework for preventing, identifying, and managing contractures in long-term care residents. This policy outlines the responsibilities of caregivers, the procedures for assessment and intervention, and the documentation requirements. Interdisciplinary Notes: Ensure that interdisciplinary notes from nurses, therapists, and physicians are included in the resident's medical record, reflecting the collaborative approach to contracture management.

Based on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 4 of 32 residents (Residents #12, #27, #81, and #86) reviewed for ADL care. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Residents #12, #27, #81, and #86. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties. Findings included:Record review of Resident #12's admission Record, dated 02/12/2026, revealed a [AGE] year-old female with original admission date of 07/02/2025 with a diagnosis of hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting left non-dominant side. Record review of Resident #12's admission MDS, dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Record review of Resident #12's care plan, dated 07/02/2025 and revised on 11/16/2025, revealed Resident #12 had an ADL Self-care Performance Deficit and was at risk of not having their needs met in a timely manner. Resident #12's performance deficit was related to CVA (stroke) w/L hemiplegia. Interventions included ADL assistance as required, and Resident #12 was dependent for ADLs. Observation on 02/10/2026 at 10:47 AM revealed Resident #12's left hand was in a splint. Observation and interview on 02/12/2026 at 12:38 PM revealed Resident #12's nails on both hands were long, approximately between 1/4 to 1/2 an inch. She stated she wanted them cut.Record review of Resident #27's admission Record, dated 02/12/2026, revealed a [AGE] year-old male with an original admission date of 10/17/2025. Resident #27's diagnoses included unspecified dementia (memory loss and cognitive decline without a specific cause), Type 2 Diabetes (a disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels) and Spina Bifida (a condition when the spine and spinal cord do not close properly in early pregnancy).Record review of Resident #27's Quarterly MDS, dated [DATE], revealed a BIMS score of 13, indicating intact cognition. Record review of Resident #27's care plan, dated 10/17/25 and revised on 01/15/2026, revealed Resident #27 had an ADL Self Care Performance Deficit and was at risk of not having their needs met in a timely manner. Resident #27's performance deficit was related to Spina bifida. Interventions included ADL assistance as required. Bathing: total assist, provide shower, shave, oral care, hair care and nail care per schedule and when needed. Observation and interview on 02/10/2026 at 10:56 AM revealed Resident #27's nails on his left hand appeared clean except for the thumb nail, and his right hand had a black and brown substance underneath all nails. The nails measured approximately 1/8 to 1/4 inch past the nail bed. Resident #27 stated he wanted his nails cut. Observation and interview on 02/12/2026 at 12:43 PM revealed in Resident #27's room, CNA N stated Resident #27's nails were long and she noticed the dirt underneath. She stated CNAs did not cut nails unless the nurse asked them to. She stated residents could scratch themselves and could be at risk of infections if nails were not trimmed and clean.Interview on 02/12/2026 at 1:07 PM revealed RN O stated nurses and CNAs do nail care, however if the resident was diabetic, they preferred CNAs not. She stated nail care was not scheduled but done as needed. RN O said if not done there could be injuries, residents could scratch themselves or a risk of infection.Record review of Resident #81's Face Sheet, dated 02/11/26, reflected a [AGE] year-old male who admitted to the facility on [DATE], and readmitted on [DATE].Record review of Resident #81's Quarterly MDS, dated [DATE], reflected the resident had diagnoses that included: Cerebral Infarction with hemiplegia (Stroke resulting in paralysis of one side of body), lack of coordination, need for assistance with personal care, muscle weakness, Diabetes Mellitus (chronic condition in which the body does not regulate blood sugar levels), Dementia (decline in memory and thinking skills), and Hypertension (high blood pressure). The MDS reflected Resident #81 had a BIMS score of 11, indicating moderate cognitive impairment. The MDS also reflected Resident #81 was frequently incontinent of bowel and bladder. Record review of Resident #81's Care Plan, revised 01/15/26, revealed the resident had an ADL self-care performance deficit with interventions to provide shower, oral care, and nail care per schedule and when needed. The Care Plan also revealed the resident had a diagnosis of diabetes with interventions to monitor skin for redness and infection, and the resident was noted to have fragile skin and was at risk for skin tears with an intervention to keep skin clean, dry, and to use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surfaces. Record review of Resident #81's Order summary report, dated 02/12/26 revealed the following orders: May be seen for evaluation and treatment of mycotic nail care and debridement (treatment of a fungal nail infection where the thick, damaged, or infected nail is removed). may consult podiatrist. Record review revealed no physician orders for fingernail care. Record review of Resident #81's progress notes revealed no documentation of refusal of fingernail care. Observation and interview on 02/10/26 at 10:09 AM revealed Resident #81 had long fingernails on both his hands, ranging approximately 1/4 - 1/2 inch long with rough edges and dark debris underneath. Resident #81 stated he did not like his fingernails long and wanted them shorter. He stated he did not remember when they were last cut. Observation and interview on 02/11/26 at 12:16 PM revealed Resident #81 lying in bed. Resident #81 stated he got a shower yesterday and did not receive nail care. Observation of both hands revealed all fingernails approximately 1/4 - 1/2 long with jagged sharp edges. Resident #81 stated he was still wanting his fingernails cut. Observation and interview on 02/12/26 at 10:41 AM revealed Resident #81's fingernails were long and there was a brown substance underneath them. Also, the edges of his nails were rough and uneven. Resident #81 stated he had told the nursing team he wanted them cut. Interview and observation on 02/12/26 at 11:40 AM with CNA D revealed she regularly worked with Resident #81. CNA D stated Resident #81 received daily showers and she had showered him on 02/11/26. During the interview, CNA D entered Resident #81's room and stated his nails were long and jagged. Resident #81 stated he wanted his nails cut. After leaving resident's room, CNA D stated she had not offered to cut his nails because she assumed he would tell her when he wanted them cut. CNA D stated she had not noticed his long nails. She stated Resident #81 had not refused nail care. CNA D stated it was her and the nurse's responsibility to ensure Resident #81's nails were cut. CNA D stated the nurse would cut Resident #81's nails since he was a diabetic. CNA D stated the risk of having long fingernails was they could scratch themselves or another resident. Interview on 02/12/26 at 1:02 PM with LVN E revealed she worked regularly with Resident #81. She stated the last time she checked Resident #81's fingernails was two weeks ago, and she did not notice them long. LVN E stated she was unsure who cut Resident #81's fingernails last. LVN E stated most of the time Resident #81 was sleeping and she did not want to bother him. LVN E stated she had observed Resident #81's fingernails and they were long. LVN E stated she was responsible for cutting Resident #81's nails. LVN E stated the risk of having long fingernails was an infection risk and residents could cut themselves. Interview on 02/12/26 at 1:43 PM with ADON F revealed she expected her staff to do nail care during all showers. ADON F stated she had not been aware of Resident #81 refusing any nail trims and there would be documentation if he had. ADON F stated she had not seen Resident #81 with long fingernails. She stated it was all staff's responsibility to ensure nail care was completed. ADON F stated the CNAs could notify the nurse. ADON F stated the nurses cut any diabetic nails. ADON F stated the risk of not performing nail care/trims was the resident could cut themselves, get debris underneath, and lead to infection control issues. Record review of Resident #86's annual MDS assessment, dated 11/24/25, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted [DATE]. Resident #86's diagnoses included cerebrovascular accident (loss of blood flow to part of the brain), encephalopathy (disturbance of brain function), contracture (a permanent tightening of the muscles), cognitive communication deficit, and muscle wasting and atrophy (loss of muscle tissue). Resident #86's BIMS score was 14 which indicated his cognition was intact. The MDS Section GG - Functional Abilities indicated the resident was dependent on 2 or more helpers to assist with personal hygiene. Record review of Resident #86's Care Plan, revised 07/17/25, reflected Focus: ADLs: [Resident #86] has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to: left side hemiplegia/hemiparesis/contracture. Goal: Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) through the next review date. Interventions: Provide shower, shave, oral care, hair care, and nail care per schedule and when needed.Observation and interview on 02/10/26 at 11:28 AM revealed Resident #86 was in his room lying in bed. Observed Resident #86's left hand to be contracted and thumb fingernail to be half an inch long and curling to the side. Resident #86 stated his right-hand fingernails were cut but not his left-hand fingernails. Resident #86 was unable to open his left hand but stated his other fingernails were long. Resident #86 stated he wanted his fingernails to be cut short. Observed CNA P entered the room and assisted with opening Resident #86's hand. Observed Resident #86's middle finger and ring finger nails to be 1/4 - 1/2 long. No open areas were noted. Interview on 02/12/26 at 1:28 PM, CNA P revealed she was the CNA assigned to Resident #86. She stated Resident #86 had long fingernails on his contracted hand. She stated she was not sure if Resident #86 refused contracted hand fingernails to be trimmed. CNA P stated the nurses were responsible for trimming resident's fingernails. Interview on 02/12/26 at 1:52 PM, RN Q revealed she was the nurse assigned to Resident #86. She stated she had seen Resident #86's contracted hand fingernails to be long. She stated Resident #86 was not a diabetic resident and his nails should be trimmed by either the CNAs or nurse. She stated that depending on the resident's mood, Resident #86 would allow them to cut his fingernails. RN Q stated the potential risk of having long nails while the hand was contracted could lead to fingernails digging into his hand and cause infection. Interview on 02/12/26 at 3:50 PM with the DON revealed all nursing staff were responsible for nail trims. The DON stated she was not aware if Resident #12, Resident #27, Resident #81, or Resident #86 were residents who refused nail trims. The DON stated she expected the nurses to keep nails trimmed and document any refusals. The DON stated the risk of having uncut fingernails was hurting themselves and skin integrity issues.Record review of facility Nail Care policy, revised 1/1/2025, reflected the following: Purpose: To provide for personal hygiene needs and prevent infection. NOTE: Precaution should be used when trimming nails of a resident with diabetes and should be done by a Licensed Nurse or Physician.Record review of the facility's policy, titled Activities of Daily Living, revised 1/1/2024 revealed the following: It is the policy of this home to assure residents have their activities of daily living met.

Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 32 residents (Residents #95, #86 and #14) and 1 of 3 shower rooms (Shower room [ROOM NUMBER]) reviewed for environmental conditions.1. The facility failed to ensure the privacy curtains for Residents #95, #86 and #14 were maintained in a clean and sanitary manner free of dried brown substances.2. The facility failed to ensure the walls in Shower room [ROOM NUMBER] were properly maintained and free of cracked and missing tiles. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. 1. Observation and interview on 02/10/26 at 10:55 AM of Resident #95's room revealed the privacy curtain had several dried brown substances on it. Resident #95 stated housekeeping cleaned her room; however, she could not recall the last time her privacy curtain was cleaned. Observation and interview on 02/10/26 at 11:28 AM of Resident #86's room revealed the privacy curtain had several dried brown substances on it. Resident #86 stated his room got cleaned but was not sure who cleaned the privacy curtains. Observation and interview on 02/10/26 at 1:30 PM of Resident #14's room revealed the privacy curtain had several dried brown substances on it. Resident #14 stated housekeeping cleaned her room; however, she could not recall the last time her privacy curtain was cleaned.Interview on 02/12/26 at 2:58 PM, Housekeeping R revealed if a privacy curtain needed to be changed or washed, she writes it down on a work log and provides it to Environmental Service Manager. She stated she had not had any resident complaint about privacy curtains being dirty. She stated she had observed privacy curtains with stains and would notify the Environmental Service Manger about it. Housekeeping R stated she was not aware of how often privacy curtains were washed. She stated everyone was responsible for reporting any dirty privacy curtains. She stated it was a biohazard for residents to have dirty privacy curtains. Interview on 02/12/26 at 3:14 PM, the Environmental Service Manager revealed everyone was responsible for notifying him when a privacy curtain needed to be washed. He stated most of the privacy curtains were stained and he had talked to the Administrator about a month ago about replacing the privacy curtains. He stated the privacy curtains were ordered; however, they were on back order. Environmental Service Manager stated he did not have any work-log pertaining to privacy curtains or keep a list of privacy curtains that needed to be washed. He stated the potential risk of not washing or removing stained privacy curtains would be germs/sanitation. Interview on 02/12/26 at 4:33 PM, the Administrator revealed housekeeping was responsible for removing and washing privacy curtains. She stated she had noticed several privacy curtains to be stained. She stated she had ordered new privacy curtains; however, they were in back order. She stated the privacy curtains were ordered either December 2025 or January 2026. She stated in the meantime her expectations were for housekeeping to continue to wash the privacy curtains. She stated it was unsanitary for the residents if privacy curtains were not cleaned. 2. Observation and interview on 02/12/26 at 12:09 PM in Shower room [ROOM NUMBER] revealed there were cracked wall tiles on a corner near the floor and 5 missing wall tiles where the wall met the floor. The Maintenance Director stated he had fixed those a few months ago and was not aware they were broken. He stated it was not homelike, and water could get into the wall if the tiles were not replaced. The Maintenance Director said his expectation was for staff to tell him of any repairs needed. He said he made environmental rounds and started with the most critical and fixed those before moving on to the next project. Interview on 02/12/26 at 3:50 PM, the DON stated she expected staff to let maintenance know if repairs were needed. She stated it would not be homelike, and residents could be at risk of injury or infections.Interview on 02/12/2026 at 4:38 PM, the Administrator stated she expected staff to report to Maintenance if repairs were needed. She stated the risk to residents could be mold, injury and it not being homelike. Record review of the facility's Resident Rights policy, dated 02/20/21 reflected that: .8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on interviews and record reviews, the facility failed to establish policies regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 2 residents (Residents #11 and #72) reviewed for smoking.The facility failed to ensure the quarterly smoking assessments were completed to determine Resident #11 and Resident #72 for capability and safety.This failure could place the residents at risk for unsafe smoking causing harm. Findings include:Record review of Resident #11's face sheet, dated 02/19/2026, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE]. Resident #11's admitting diagnoses included Unspecified Dementia, Unspecified Severity, without Behavioral Disturbances, Psychotic Disturbances, Mood Disturbances, and Anxiety (decline in cognitive functioning); Peripheral Vascular Disease (a slow-progressing condition involving narrowing blood vessels outside the heart - usually in the legs); and Schizophrenia, Unspecified (an individual experiencing significant psychotic symptoms, such as hallucinations, delusions, or disorganized behavior, that cause distress).Record review of Resident #11's quarterly MDS, dated [DATE], revealed his BIMS Score was 15, which indicated the resident's memory was intact. Resident #11's cognitive abilities were within a normal range. Resident #11 could make independent decisions regarding his ADL care.Record review of Resident #11's quarterly smoking assessments were completed 06/03/2023, 01/11/2024, 03/08/2024, 06/10/2024, and 09/10/2024. Quarterly smoking assessments have not been regularly completed. The smoking assessments currently completed by the nurse and social worker.Record review of Resident #72's face sheet, dated 02/12/2026, revealed resident was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE]. Resident #72's admitting diagnoses included End Stage Renal Disease (a condition in which the kidneys lose the ability to remove waste and balance fluids); Type 2 Diabetes Mellitus with Diabetic Polyneuropathy (is a common, progressive nerve damage condition causing pain, burning, tingling, or numbness typically starting in the feet and hands); Dependence on Renal Dialysis (patients who require dialysis treatment for chronic kidney disease or acute kidney injury); Acquired Absence of Right Upper Limb below elbow (amputation or loss of arm below the elbow ); Complete Traumatic Amputation of Right Hand at Wrist Level Subsequent Encounter (loss of right hand at wrist level).Record review of Resident #72's quarterly MDS, dated [DATE], revealed his BIMS Score was 15, which indicated the resident's memory intact. Resident #72's cognitive abilities were within a normal range. Resident #72 could make independent decisions regarding her care.Record review of Resident #72's quarterly smoking assessments were completed 12/29/23, 03/08/24, and 03/06/25. Quarterly smoking assessments had not been regularly completed.Interview on 02/11/2026 at 10:00 a.m. with Resident #72 revealed he does not go out to smoke much, but with no hands or arms below the elbows the staff must assist him with smoking. Resident #72 states the staff are good at helping him with smoking.Interview on 02/12/26 at 4:15 PM, the DON revealed the policy for smoking residents is a designated smoke aide is assigned to set with the residents during the designated smoke breaks. She stated she expected that smoking assessments be completed on admission, quarterly, and if a resident had a change in smoking status. She stated the nurse or Social Worker completed the assessments, and the care plan was implemented by Social Worker or Nurse related to smoking.Interview on 02/12/26 at 4:39 PM, the Administrator revealed her expectations related to resident smokers is assessments and care plans were to be completed at admission, quarterly, and if resident had a change in smoking status. The Administrator stated she expected the Social Worker to complete the smoking assessments.Record review of the facility's Smoking Policy revised 01/07/2025, reflected in part: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking. To evaluate a patient's ability to participate and exercise the privilege to smoke/Use smokeless Tobacco products while residing within the facility.Evaluate patients that smoke/use smokeless tobacco, utilizing the Smoking Evaluation/Smokeless Tobacco Tool: (a) upon admission; (b) quarterly(c) when a previous non-smoking patient takes up smoking or when a patient takes up the use of smokeless tobacco (d) if unsafe smoking practices are observed in a current smoker; or a smokeless Tobacco user can no longer manage the use of, or cleaning abilities (e) when a patient that smokes or uses smokeless Tobacco products has a significant change in medical condition. Request therapy screen as indicated. Education will be provided to the resident on the assessment and the facility's expectation of compliance with the smoking program. Residents who smoke/use smokeless tobacco, will sign a smoke agreement upon admission and will be required to follow rules and regulations.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #45) reviewed for infection control practicesThe facility failed to ensure CNA C performed hand hygiene prior to and during incontinence care for Resident #45. These failures could place residents at risk of cross-contamination and infections. Findings included: Record review of Resident #45's Face Sheet, dated 02/12/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. Record review of Resident #45's admission MDS, dated [DATE], reflected the resident's diagnoses included: Cerebral infarction (stroke caused by a blocked blood vessel in the brain), Degenerative disease of nervous system (disease that causes the brain or nerves to slowly break down over time), Hemiplegia (Paralysis on one side of the body), and aphasia (difficulty speaking). The MDS also reflected Resident #45's cognitive skills were severely impaired, indicating he was unable to make decisions. In addition, the MDS reflected that the resident was dependent on staff for all care, was incontinent of bowel and bladder, and had a feeding tube for nutrition. Record review of Resident #45's Care Plan, revised 01/13/26, reflected the resident had an ADL self-care deficit and required a total assist with all cares, was incontinent and required staff to check frequently for wetness, and required monitoring for signs of UTI. The Care Plan also reflected Resident #45 required tube feeding for nutrition, was on enhanced barrier precautions due to wounds, and required PPE for cares. Observation on 02/11/26 at 9:53 AM, revealed CNA C entered Resident #45's room, did not wash/sanitize her hands, and applied PPE (gown and gloves). Resident #45 was observed sitting in a wheelchair. CNA C closed the door, pulled the privacy curtain, and transferred Resident #45 into bed for wound care. CNA C checked Resident #45's brief which was observed to be wet. CNA C prepared incontinent care supplies on a clean barrier, unlatched Resident #45's brief, and cleaned the resident's perineal area. CNA C then assisted Resident #45 to turn onto his left side, used new wipes and cleaned the buttocks. CNA C rolled the soiled brief within itself and discarded it in the trash. Without performing hand hygiene or changing gloves, CNA C obtained a clean brief and placed it under Resident #45's buttocks, turned the resident onto his back, and secured the brief. CNA C then repositioned Resident #45 and removed her PPE, washed hands, and exited the room. CNA C did not perform hand hygiene prior to care and did not change gloves or perform hand hygiene prior to applying a clean brief during incontinence care. Interview on 02/12/26 at 12:39 PM, CNA C said she had been working at the facility for one month. CNA C stated hand hygiene should be performed anytime she entered or exited a resident's room. CNA C stated she forgot to wash her hands before putting gloves on prior to performing care on Resident #45. She stated she was also expected to change her gloves when going from the dirty brief to a clean one, or if the gloves were soiled. CNA C stated she was in a hurry to perform the care prior to wound care and forgot to change gloves or perform hand hygiene. CNA C stated she was educated on incontinent care and infection control when she was hired. She stated the risk of not changing gloves or performing hand hygiene was spreading bacteria. Interview on 02/12/26 at 12:44 PM, ADON B revealed she expected her staff to perform hand hygiene when entering or leaving a resident room. She stated she also expected all staff to change gloves and perform hand hygiene when soiled and between removing the soiled brief and applying a clean brief. ADON B stated she and the nurses were responsible for ensuring all CNAs were completing incontinent care appropriately. ADON B stated the risk of not changing gloves or performing hand hygiene was an infection control risk and could cause cross contamination. ADON B stated she was unsure when the last in-service was completed on incontinent care, but she stated all CNAs were trained on infection control and incontinent care upon hire and she performed regular rounds and completed 1:1 education when needed. Interview on 02/12/26 at 4:00 PM, the DON revealed she was the infection preventionist. The DON stated she expected her staff to change gloves and perform hand hygiene between the dirty and clean brief. She stated all staff were also expected to perform hand hygiene when entering and leaving a room. The DON stated it was her and the ADONs responsibility to ensure CNAs were properly performing incontinent care and infection control measures. The DON stated the risk of not performing hand hygiene and glove changes appropriately was potential introduction of bacteria. The DON stated all new hires get competencies completed, and the ADONs rounded to ensure care and infection control was properly performed. The DON stated she performed her own rounds and was going to start in-services and training for infection control. Interview on 02/12/26 at 4:35 PM, the Administrator revealed she expected her staff to perform hand hygiene when entering a resident's room prior to doing cares. The Administrator stated the risk of not performing hand hygiene appropriately could lead to infections. She stated it was all staff's responsibility to ensure infection control measures were completed. Record review of the facility's Hand Hygiene Policy, revised November 2022, reflected the following: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Record review of the facility's Nursing Procedure Manual titled, Incontinence Care, revised 02/14/20, reflected the following: .14. Remove linen/underpad and discard 15. Remove and discard gloves 16. Wash hands 17. Apply clean linen/underpad, brief or other incontinent products, as needed.

Based on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 11 residents (Resident #14) reviewed for enteral feeding.The facility failed to follow physician's orders of providing Resident #14 with her 16 hours of her enteral feeding intake from 02/10/26 to 02/11/26. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.Findings included:Record review of Resident #14's quarterly MDS assessment, dated 12/13/25, reflected the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted [DATE]. Resident #14's diagnoses included gastrostomy status (surgical opening (stoma) in the stomach), dysphagia (difficult swallowing) following cerebral infarction (stroke), malnutrition (lack of proper nutrition). Resident #14's BIMS score was 13 which indicated her cognition was intact. The MDS Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube and mechanically altered diet.Record review of Resident #14's care plan revised date 01/22/26 reflected: Focus: Feeding Tube: [Resident #14] requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Feeding tube is related to: Dysphagia. Goal: [Resident #14] will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date. Intervention: Administer tube feeding and water flushes as ordered. Monitor/document/report to the physician as needed for the following potential complications related to tube feedings: Fever, shortness of breath, abnormal breath/lung sounds, tube dislodged, signs/symptoms infection at site, tube malfunction, abdominal pain distension or tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, and signs and symptoms of dehydration.Record review of Resident #14's physician orders reflected: Enteral Feed Order every 24 hours for ENTERAL FEED - ARTIFICAL NUTRITION Jevity 1.5 cal for Enteral feed Continuous overnight feeds at 60 ml/hr x 16 hours 6pm-10am w/ 300 cc H2O flush q 4 hours Start Date 02/09/2026. Record review of Resident #14's February 2026 MAR revealed Enteral Feed Order every 24 hours for ENTERAL FEED - ARTIFICAL NUTRITION Jevity 1.5 cal for Enteral feed Continuous overnight feeds at 60 ml/hr x 16 hours 6pm-10am w/ 300 cc H2O flush q 4 hours -Start Date- 02/09/2026 1800 (6:00PM) revealed it was started on 02/10/25 at 1804 (6:04 PM) Observation and interview on 02/10/26 at 1:30 PM, Resident #14 was observed in her room lying in bed. Resident #14 stated she had a g-tube and she received her g-tube feedings at nights. Observed g-tube machine next to resident's bed, and g-tube was not on. Observation on 02/11/26 at 8:20 AM, revealed Resident #14 was sleeping. Observed formula bag to be dated 02/10/26. Resident #14's g-tube machine was turned off. Observation on 02/11/26 at 9:48 AM, revealed Resident #14 was sleeping. Resident #14's g-tube machine was turned off. Interview on 02/11/26 at 9:50 AM, RN G revealed she was the nurse assigned to Resident #14. She stated Resident #14 had a g-tube and received her feeding at night for 16 hours and to be disconnected at 8AM the following day. RN G stated she disconnected Resident #14 at 8:00 AM. She stated she reviewed Resident #14's physician orders before disconnecting her. Observed RN G reviewing Resident #14's physician orders and stated she was not aware that the physician orders had been changed on 02/09/26. She stated Resident #14 should had been disconnected at 10:00 AM instead of 8:00 AM. RN G stated she failed to follow physician orders. She stated there was no risk to the resident if she was disconnected from her feeding two hours prior to the ordered disconnection time. Interview on 02/12/26 at 10:04 AM, ADON H revealed she was the ADON assigned to Resident #14. She stated her expectations were for the nurses to always review physician orders prior to administering anything to a resident and not depend on the next person to notify them. She stated if a nurse needs clarification on an order they are expected to contact the doctor. ADON H stated RN G informed her about disconnecting Resident #14 two hours early. She stated each nurse was responsible for reviewing physician orders and it was her responsibility to ensure physician orders were being followed. ADON H stated the potential risk of not providing the correct feeding time could lead to malnutrition. Interview on 02/12/26 at 3:50 PM, the DON revealed she expected her nurses to follow the physician orders, provide the correct quantity and feeding time. She stated nurses should review the physician orders before disconnecting the resident from her feedings. She stated the nurses were responsible for putting in physician orders in the system and the ADONs were responsible for ensuring physician orders were being followed. The DON stated potential risk of not providing the correct feeding time could lead the resident to not get her calorie intake. Record review of facility Feeding Tube Administration, Nutrition and Care policy, revised 12/2012, reflected the following: Enteral feedings will be administered per physician order. Complications related to enteral feedings will be minimized through provision of proper care. Resident's receiving enteral feedings will receive adequate nutrition and fluid to meet their individual needs, to the extent possible in consideration of their clinical condition and wishes.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 medication rooms (North medication room) reviewed for pharmacy services. The facility failed to remove expired Bisacodyl suppositories, with an expiration date of 01/21/26 and Acetaminophen suppositories, with an expiration date of 01/09/26, from the North medication room refrigerator.This failure could place residents at risk of receiving medications that were ineffective. Findings included: Observation on 02/11/26 at 3:10 PM of the North medication room refrigerator with LVN A revealed four 10mg Bisacodyl suppositories (medication administered rectally to treat constipation) with an expiration date of 01/21/26, and 11- 650mg Acetaminophen suppositories (medication administered rectally for pain and fever reduction) with an expiration date of 01/09/26. Interview on 02/11/26 at 3:16 PM, LVN A stated the Bisacodyl suppositories expired on 01/21/26 and the Acetaminophen suppositories expired on 01/09/26. LVN A stated the managers oversaw and checked the medication room for expired medications, but she stated it was all nurses' responsibility to ensure there were no expired medications in the storage rooms. LVN A stated she checked the medication expiration date prior to administering any medications but did not routinely inspect the medication rooms for expired medications. LVN A stated by failing to remove expired medications, the medications could be administered, and the dose could be ineffective or cause an adverse reaction. Interview on 02/12/26 at 12:44 PM, ADON B revealed she expected the nurses to be reviewing and checking the medication room daily for expired medications. ADON B stated it was her and the nurse's responsibility to ensure all expired medications were removed. ADON B stated she checked the medication room most mornings for expired medications, and had checked it this week, but must had missed the expiration date on the suppositories. ADON B stated the risk of having expired medications was that they could be administered to residents and not function properly. Interview on 02/12/26 at 4:03 PM, the DON revealed she expected the nurses to check the medication rooms daily for expired medications. The DON also stated the ADONs were expected to conduct rounds of the medication rooms at least weekly to ensure there were no expired medications. The DON stated it was all nursing staff's responsibility to ensure there were no expired medications. The DON stated that no specific training on auditing the storage room for expired medications had been completed with the floor nurses since she started; however, nurses were expected to review the storage room for expired medications when retrieving medications and supplies. The DON stated the risk of having expired medications was that the medications could be administered and not be effective or have adverse effects . Record review of the facility's Medication Storage policy, dated 01/20/21 reflected the following: .8. Medication Carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy. 9. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with the facility policy.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted him on 07/10/25. This failure could place residents at risk for abuse. Review of Resident #1's admission Record, dated 07/15/25, reflected he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 06/04/25, reflected he had a BIMS score of 15 indicating no cognitive impairment. His active diagnoses included depression (a mood disorder that causes persistent feelings of sadness and loss of interest), heart failure (a condition where the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and coronary artery disease (a disease that is caused by plaque buildup in the arteries that block blood supply to the heart). Review of Resident #1's undated care plan did not reflect anything related to the incident with Resident #2 on 07/10/25.Review of Resident #1's Psych notes, dated 07/10/25 reflected the following: Services: Comments: Provider was contacted by nursing staff due to patient being agitated after an alleged altercaiton [sic] with another resident. Per staff report, the patient was the victim. Hours after the incident patient remains agitated.Review of Resident #1's Progress Notes reflected the following: -LVN A on 07/10/25 at 4:12 wrote: This nurse heard some noise coming from the north hallway, on getting there, resident was agitated, talking in a loud voice, this nurse tried to calm him down to get what the problem is.Resident [sic] alleged that a mal peer from another hall hit him on the face and gave him a little finger cut.This [sic] nurse calmed the resident a bit down for him to leave the scene, resident was asked to go to his own hallway and the other peer was put on one on one monitor to prevent further altercation. This nurse took residentout [sic] to the smoke patio and waited until resident calmed down Resident [sic] was advised to stay in his room after smoking to prevent further altercation.-LVN A on 07/10/25 at 5:43 PM wrote: This nurse went back to resident to f/u up [sic] on pain, resident denied pain at this time, [NP B] gave a new order to put TAO on the cut on the resident [sic] face for 3 days.-the SSD on 07/10/25 at 6:53 PM wrote: SSD, SS Assistant and Facility BOM met with [Resident #1] when he came into SSD's office stating ‘Another male resident just punched me in the face and the nurses are not doing anything about it.'With questioning, it was learned that the other male resident was laying in the floor in the dining room area like he prefers to do. [Resident #1] told him ‘Hey let me help you get up, people are about to be coming thru here to smoke and you will be in the way.' Another male resident laughed and taunted the situation and the male resident on the ground punched [Resident #1] on the left cheek bone. Area has a larger than quarter size purple bruise forming with 2 cut areas.SSD questioned resident if he would like an ice pack and he refused. Facility Admin- Abuse Coordinator and ADON were notified of resident's statements. IDT was already aware of situation, resident assessments have been initiated. Other male resident has been placed on 1 on 1 supervision.SSD, SS Assistant and BOM spoke at length with [Resident #1] due to him being worked up stating ‘The police are going to have to be called on me because I am going to take care of him for doing this. I don't care about going to jail.' [Resident #1] was educated on treating others the way he wants to be treated, facility rules for no aggression, what jail is like, how expensive it is to bond out, how much a fine could be, that this behavior would interrupt his desire to eventually move to another facility.Due to resident stating understanding in one breath and then returning to being worked up, [Psych NP] was notified. NP then spoke with Hallway Nurses where PRN Anxiety [sic] med Dr. Order was written.-the SSD on 07/11/25 at 4:17 PM wrote: SSD called [City Initials] PD Non-Emergency [phone number] and requested that a Patrol Unit be dispatched to [Facility Name] to meet with [Resident #1] in an attempt to speak with him, to get him to calm down after the physical altercation that he was in with another male resident yesterday. Interview on 07/16/25 at 8:45 AM with Resident #1 revealed he was lying in his bed watching TV. Resident #1 said Resident #2 was on the ground the other day and he was telling him he needed to get up. Resident #1 said he tried to help Resident #2 get up from the ground and then someone near them started talking back about something. Resident #1 said he turned his face to tell the other resident to be quiet and when he turned back to Resident #2, he punched him on the right side of his face. Resident #1 said it hurt and he was very upset about the situation, but he had calmed down since then. Resident #1 said he got a scratch on his face and had a bruise for a few days but it had since healed. Resident #1 said he felt safe in the facility and was not afraid of Resident #2. Resident #1 did not have any bruises or cuts to either side of his face. Review of Resident #2's admission Record, dated 07/15/25, reflected he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE].Review of Resident #2's Quarterly MDS Assessment, dated 05/06/25, reflected he did not have a BIMS score calculated. It was noted that Resident #2 had both short-term and long-term memory problems and had severely impaired cognitive skills for daily decision making. Resident #2's behaviors towards others included physical and wandering that had occurred for 1 to 3 days. His active diagnoses included Alzheimer's disease (a neurological disorder that slowly destroys memory and thinking skills, and the ability to carry out the simplest task), a stroke (happens when something prevents your brain from getting enough blood flow), non-alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problem's in one's abilities to perform daily tasks), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), and schizophrenia (a chronic mental health condition that affects how individuals think, feel, and behave).Review of Resident #2's undated care plan did not reflect anything related to the incident on 07/10/25.Review of Resident #2's Psych Visit Note, dated 07/14/25, reflected the following: The patient is being seen today for reevaluation of mood and to assess the need for ongoing 1:1 observation. Staff do not report and concerns [sic] or complaints. The patient has not had any aggressive behaviors for >48 hours.The patient is calm and nonverbal during today's encounter. Due to limited communication, he is unable to elaborate on thoughts or emotions or engage in meaningful conversation. There are no observable signs of sadness, depression, anxiety, panic, anger, or mood instability. No impulsive or aggressive behaviors were noted. There is no evidence of manic symptoms or perceptual disturbances. He is not exhibiting any behaviors or attitudes to suggest he poses a danger to himself or others. Based on observation, staff report, and chart review, the patient appears to be at his mental and emotional baseline and remains stable on the current treatment regimen. The case was discussed with the treatment team, and the decision was made to discontinue 1:1 observation.Review of Resident #2's Progress Notes reflected the following: -LVN C on 07/10/25 at 3:30 PM wrote: esident [sic] walking around the dining area and he hit [Resident #1] around the circle of the left eye, Resident separated and moved to his room and was assessed and noted no apparent injuries.The NP notified with new order to continue to monitor resident for altercation. The DON notified and [Resident #2's Family Member] notified. Resident not able to state what happened or how he hit the other resident when asked by this writer.Resident [sic] deniespain [sic] and discomfort.-RN D on 07/11/25 at 3:56 AM wrote: The resident is in bed resting. No distress or behavior noted on this shift.-LVN C on 07/11/25 at 11:02 PM wrote: Resident continue [sic] on 1:1 monitoring and resting quietly in bed.-RN D on 07/12/25 at 2:35 AM wrote: Ln [sic] bed resting. No behavior noed. [sic]-RN D on 07/13/25 at 2:43 AM wrote: The resident is on 1:1 monitoring for behavior. No behavior is noted at this time.-LVN E on 07/14/25 at 4:59 AM wrote: The resident continue [sic] on 1:1 monitoring for aggressive behavior, staff at the bedside, no behavior reported.Observation and attempted interview on 07/16/25 at 8:55 AM of Resident #2 revealed he was laying in his bed. Resident #2 was not able to answer any questions due to his condition as he just stared blankly at the surveyor. Interview on 07/15/25 at 3:21 PM with LVN A revealed he was at the nurse's station when he heard a noise and an ADON told him that's your patient so he went to find out what had happened. LVN A said by the time he got there, Resident #1 was explaining what happened but that he did not do anything to him. LVN A said he took Resident #1 away from the area and tried talking to him and telling him that Resident #2 did not know what he was doing or had done. LVN A said Resident #2 was placed on 1:1 since he wandered around the facility, and he stayed with Resident #1 for a while to make sure he was okay and calm. LVN A said Resident #1 was punched by Resident #2 and had suffered a little scratch to his face from it. LVN A said staff kept their eyes on Residents #1 and #2 after this. LVN A said he had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 9:28 AM with LVN C revealed she cared for Resident #2 who was very confused and wandered around the facility. LVN C said Resident #1 told her that Resident #2 had punched him in the dining room. LVN C said she redirected Resident #1 back to his room and tried to keep him calm since he was upset from the incident. LVN C said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 9:35 AM with LVN F revealed she cared for Resident #1 the next day and saw that his face was a little discolored on one side and was red. LVN F said he did not have any pain but did have a scratch to his face which did not require any treatment. LVN F said Resident #1 was very upset about the situation and needed to be calmed down. LVN F said she assured Resident #1 that Resident #2 would be kept away from him as he was being watched closely by staff. LVN F said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 10:37 AM with the ADON revealed she heard yelling in the dining room and when she went down there to see what happened, Resident #1 told her that Resident #2 had hit him. The ADON said the residents were separated away from each other and she saw that Resident #1 had a small scratch on his cheek that did not require treatment. The ADON said she had been in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 12:13 PM with the DON revealed Resident #1 was agitated but could be calmed down with redirection. The DON said Resident #2 had a BIMS of 0 and had no idea what happened and could not even say his name. The DON said Resident #2 hit Resident #1 who became very angry about what happened. The DON said both residents were separated from each other and Resident #2 was placed on 1:1 until the psych doctor could come and evaluate him. The DON said Resident #1 had a scratch to his face but that was his only injury. The DON said all staff were in-serviced and knew what to do regarding abuse/neglect and resident-to-resident altercations.Interview on 07/16/25 at 1:50 PM with the Administrator revealed Resident #2 was sitting on the floor, and which he was already care planned for that behavior. The Administrator said Resident #1 had leaned over and extended his hand to Resident #2 when another resident began to [NAME] the residents and make a lot of noise. The Administrator said Resident #2 was startled by this and reacted by striking Resident #1 on the face and mouth area. The Administrator said Resident #2 was upset by this and both residents were separated. The Administrator said Resident #2 walked away as if nothing had happened, but he was placed on 1:1 because he liked to wander. The Administrator said Resident #1 was very upset about the situation and would not let it go for days but has since calmed down. The Administrator said Resident #1 had a scratch to his lip but it had already healed since the incident happened. The Administrator said the facility completed safe surveys with other residents, in-serviced staff on abuse/neglect and resident-to-resident altercations. The Administrator said all residents had the right to be free from abuse and this situation was considered physical abuse. The Administrator said all staff had the responsibility to keep residents free from abuse. The Administrator said if residents were not free from abuse they could be fearful of others and this was their home and they should not be hurt by anyone.Review of the facility's provider investigation report, dated 07/15/25, reflected the following: Investigation Summary: [Resident #2] had no recollection of the incident immediately after the incident as the writer attempted to interview him. This same writer interviewed [Resident #1] who explained that he was trying to help [Resident #2] up from the ground and was hit on his cheek. When this writer asked him if another resident was yelling in the background, he stated he did not recall. This write informed him that [Resident #2] seemed to be startled by the other resident which may have caused him to hit [Resident #1]. [Resident #1] did not acknowledge if he understood or not. [Resident #2] does not have any negative outcome due to this incident. [Resident #2] initially was upset but seems much better now and continue s [sic] to participate in his normal activities.Facility Investigation Findings: Confirmed.Review of resident safe surveys, dated 07/11/25, revealed 12 were completed with no additional abuse allegations founded.Review of an in-service, titled Abuse and Neglect, dated 07/10/25, reflected 38 staff had been in-serviced.Review of the facility's policy, revised 09/06/24, and titled Abuse, Neglect and Exploitation reflected: III. Prevention of Abuse, Neglect and Exploitation.The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents.IV. Identification of Abuse, Neglect and Exploitation A. The facility assists staff to understand the different types of abuse- mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This included staff to resident abuse and certain resident to resident altercations.

Based on interviews and record reviews the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 struck him in the face on 02/18/25. This failure could place residents at risk of injury and anxiety. Findings included: Record review of Resident #1's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia, stroke, and amputation of left leg. Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 9 indicating moderate cognitive impairment. The MDS reflected Resident #1 had no issues with verbal or physical aggression. Record review of Resident #1's care plan, dated 11/20/24, reflected he had cognitive impairment, visual impairment, and ADL self-care deficit. Record review of Resident #2's undated Admission Record reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included a traumatic brain injury causing fluid buildup in the brain requiring drainage via a shunt. Schizoaffective disorder, drug abuse, and violent behavior. Record review of Resident #2's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating severe cognitive impairment. His Behavioral assessment reflected no behavioral issues. Record review of Resident #2's care plan, dated 12/19/24, reflected he had a cognitive impairment related to his brain injury, he had behavioral issues of name calling of staff, and he was on a psychotropic medication. Record review of Resident #2's Behavioral Monitoring for January and February 2025 reflected on 1/5/25 he made accusations towards another resident, and on 1/25 he made complaints about another resident. No physical aggression documented. Record review of the facility's Provider Investigation Report, completed by the Administrator on 02/19/25, reflected the following incident occurred on 02/18/25 at 11:00 AM: .While [Resident #1] was at the nurses' station eating a snack, [Resident #2] walked up to the nurses station to get a snack as well. [Resident #1] made a statement to [Resident #2] and [Resident #2] struck [Resident #1] on the left cheek with his closed fist .[Resident #1] had some redness to the left cheek area. Nurse applied ice to the affective [sic] area. [Resident #2] also had some ice to his right fist as a precautionary measure The residents were immediately separated and treated in their rooms which are on opposite ends of the hall. [Resident #1] states that he does not have any pain but stated that he did want to report this incident to the police. The physician was notified of hte incident as well as the responsible parties. Neither resident seemed to have been emotionally affected. [Resident #1] stated that he was not in any pain but an X-ray was ordered as a precautionary measure. The police were called regarding the incident as [Resident #1] requested [Resident #2] has a history of violent behavior. When this administrator interviewed him, he had no remorse for his actions. The police arrive at approximately 1 pm to interview both residents as well. The .Police Department took custody of [Resident #2] from the facility and took him to .Hospital for a mandatory detention for a mental health evaluation. He currently remains in a mandatory detention at the hospital and will not be returning to this facility. [Resident #1] states that he is doing fine. His X-ray results came back negative for any fractures. He has a new order for Ibuprofen 400 mg every 6 hours as needed. [Resident #1] did not have any negative outcomes from this incident and has limited recall of the incident as well It is confirmed that [Resident #2] struck [Resident #1]. [Resident #2] was escorted by police to [the local hospital] for a mandatory detention and has been discharged from the facility and is not eligible to return. [Resident #1] continues to do fine and has no complaints of pain or anything else. The staff members were re-educated on the facility abuse and neglect policy as well. Record review of the Radiology Patient Report for Resident #1, dated 02/18/25, reflected: .No orbital fracture is seen. No focal bone lesion is present. The paranasal sinuses are normally aerated. No soft tissue abnormally is seen Record review of Resident #2's Progress Notes, dated 02/18/25 1:38 PM, written by LVN A reflected: Resident [#2] came to nurse's station asking for a cup of ice. Other resident [#1] was sitting in his w/c at nurse's station with his snack on the counter where resident was standing. Other resident [#1] thought resident [#2] was about to take his snack and began saying No .no .no loudly. Resident [#2] then said F*** You! and hit other resident [#1] in the face with his fist, other resident [#1] fell out of wheelchair. Staff was tyring to get to the residents before it got to this point but it happened so quickly. Resident [#2] states I don't try to be mean, but people keep f***ing with me Resident [#2] was immediately escorted to his room by male CNA. Other resident [Resident #1] was immediately assessed for injuries Record review of the facility's In-Service Immediate Notification report, dated 02/18/25, reflected the facility provided staff with in-service training regarding abuse, neglect, and exploitation. Interview on 02/20/25 at 11:00 AM with LVN A revealed she was at the nurses' station when Resident #1 rolled up in his wheelchair to look at the snacks. Resident #2 walked up to the desk and stood in front of the snack tray. Resident #1 said no, no. no and Resident #2 turned and struck Resident #1 in the face with a closed fist. LVN-A stated she separated the residents to their rooms, placing Resident #2 on 1:1 supervision. Resident #1's right eye was red, and she applied ice to it. Resident #2 was given ice for his hand. She stated the DON and Administrator were notified. Interview on 02/20/25 at 11:05 AM with Resident #1 revealed he was trying to get a snack when Resident #2 blocked him. When he told him no to do that, Resident #2 punched him in the eye. Resident #1 stated he had never had an issue with Resident #2 prior, and now that he was gone he had no fear of concerns about his safety. Resident #1 stated he wanted to press charges because it wasn't right. Interview on 02/20/24 at 11:15 AM the DON stated since Resident #1 wanted to press charges the police department was called. After the police investigated, they placed Resident #2 in cuffs and took him away. The DON stated she did not know where Resident #2 had been taken until the hospital called the next morning to return the resident. The DON stated if the hospital had made medication changes, they had not given them enough time to take affect and she felt Resident #2 was still a risk to the other residents. She contacted corporate administration and they agreed the resident was a risk to other residents. An emergency discharge was initiated. The DON stated there had been no physical violence with Resident #2, he was only verbally 'grumpy with staff. She stated it had been noticed in the last few weeks after the resident had run out of cigarettes. The DON stated Resident #2's family had not responded to phone calls to bring him more cigarettes. She stated Resident #2 was started on a nicotine patch to help him out. Record review of the facility's Abuse, Neglect, and Exploitation policy, dated 09/06/24, reflected: It is the policy of this facility to provide protections for the health and welfare of each resident by developing policies and procedures that prohibit and prevent abuse, neglect, and exploitation. .VI. Protection of Resident The facility makes efforts to e sure all residents are protected from physical and psychosocial harms well as additional abuse. A Respond immediately to protect the alleged victim. B, Physical exam of the alleged victim for any sign of injury C. Increase supervision of the alleged victim and residents D. Room or staffing changes if necessary E. Protect from retaliation F. Provide emotional support and counseling to the resident .

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse per the policy when the Administrator verbally abused Resident #1 when he cursed at him during a conversation. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse. Findings included: Review of the facility's policy revised 09/06/24, and titled Abuse, Neglect and Exploitation reflected: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: 'Staff' includes employees .who provide care and services to residents .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .III. Prevention of Abuse, Neglect and Exploitation: The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment .B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents. 2. Review and evaluation of like instances to determine if the appropriate actions to correct noncompliance was taken and documented. Review of Resident #1's Admission Record, dated 09/17/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 07/03/24, reflected he had a BIMS score of 15 indicating no cognitive impairment. Review of Resident #1's active diagnoses included paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerve) and hyponatremia (a condition where the sodium level in your blood is too low). Review of Resident #1's care plan, dated 03/04/24, reflected the following: Focus: Verbal Behaviors: [Resident #1] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner .Interventions: Approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing cares, allow time for a response, and do not rush. Review of Resident #1's progress notes for September 2024 reflected the following: - 09/04/24 at 3:27 PM, SW A wrote: Resident is a 44 y/o male admitted to facility on 01/06/2023 from [Hospital B]. He remains alert, verbal and able to make his needs known. He has voiced the desire to transfer to a nursing home in the [city] area. Resident was denied by facilities in [city] area. Resident was informed that [SNF C] has accepted him. He stated he is willing to transfer to [SNF C] due to staff acts like they don't want him here Resident stated he will transfer to [SNF C] tomorrow because he was not happy here. He stated that he does not want to be anywhere he is not wanted. - 09/05/24 at 9:41 AM, SW A wrote: .Resident stated that he has to leave due to not feeling safe . Interview via phone on 09/17/24 at 10:03 AM with Resident #1 revealed he was no longer at the facility and was at a different facility now. Resident #1 said the Administrator cursed at him one day, and he had recorded the conversation. Resident #1 said he thought it was unnecessary that the Administrator cursed at him, and there was no way he was going to feel safe in the facility after being treated that way. Resident #1 said it made him very scared and that was why he left the facility. Resident #1 was not sure what day the Administrator cursed at him, but it was near the date he discharged from the facility. Listening to the audio recording provided by Resident #1 on 09/17/24 10:40 AM revealed the following: the audio recording began with static sounds and background noise of things happening and people talking. At the 35-second mark, there was a knock on a door. The following information was the dialogued conversation between the Administrator and Resident #1: Administrator: Do you not understand English? Resident #1: I understand, I understand perfect English. Administrator: This is such a crisis that I've got to stop dealing with the crisis so I can deal with you. Resident #1: What it is, Mr. [Administrator], I don't want anybody sitting up here lying on me, Mr. [Administrator]. Listen to me, sir. The only thing is it is very hot on that hallway and-. Administrator: It's not 81 degrees down there. Resident #1: Sir, sir, I just wanna be clear when I speak to you. Administrator: But when I speak to you, you don't listen to me. Resident #1- I'm just saying. Administrator: I don't have time for this right now. Resident #1: Well then let me- Administrator: No, I don't wanna let you have- Resident #1: Mr. [Administrator]. Administrator: I've gotta make half a dozen phone calls in the next five minutes- Resident #1: Okay, let me let this go real quick like- Administrator: Let it go Resident #1: Okay, let me go real quick. Administrator: It's not, the temperature down there is not a problem. Resident #1: Yes it is, but sir I don't want- Administrator: [unintelligible] [city name]. Resident #1: Listen, sir. Administrator: You're the only person who's come down here from that whole hallway that's complaining about the temperature. Resident #1: Sir, is [Resident #2] had a heat stroke the other day. Administrator: No, he didn't. Resident #1: Yes, he did. Administrator: No he didn't. You ain't a doctor. Resident #1: Okay. Administrator: Are you a doctor? Resident #1: That's an emergency. Administrator: Are you a doctor? Resident #1: That's not- Administrator: I don't have time Resident #1: Wait a minute, [Administrator] I need a- let me just say this and let it go they stole- Administrator: You don't gotta let it go. Resident #1: Yes I am, I am fixin' to let it go. Sir, they told you I did not have that fan in my room. Administrator: I don't care. Resident #1: It was on the hall. Administrator: Well then you don't get to determine where it goes. Resident #1: I didn't say- Administrator: You were. Resident #1: The whole hall is hot, sir. Administrator: Leave me alone. Resident #1: They told you that I did not have that fan in my room sir. I never had it in my room. It was. Administrator: I didn't say it was in your room. I said we had to have the fan. Period. I don't have time for this argument. And I don't- Resident #1: You say it sometimes; I feel special or something and I'm not. Administrator: You are; you do think you're special. Resident #1: No, the hall is hot sir. Administrator: You called me at 2:30 in the morning so I could get you a damn burrito warmed up. Resident #1: I hadn't eaten in 3 days, sir. Administrator: Because you choose not to. It's not part of your religion. Resident #1: Yes, it is. Administrator: There's not a religion that says you fast every other day. Resident #1: Yes its [unintelligible]fast. Yes it is sir, but- Administrator: I don't care. Resident #1: That's [unintelligible]- Administrator: You don't wanna be here and you wanna cause us problems every time you turn around. Resident #1: Sir. Administrator: Take to one of the places we found for you to go. Resident #1: Where? Who gave me- Administrator: We found a couple places for you to go, and you and you refused both of them Resident #1: Who, sir, who told me that. Ain't nobody came and told me nothin' like that Administrator: Aright, I'll find you a place to go and you can go there. I don't have time for this right now. Resident #1: This is how all our conversations go. Administrator: What do you not understand about I need to deal with this? This is a problem. Resident #1: Okay sir. That. But I just, I just don't appreciate no one lying on me. And lying to you on me. Sir I did not have that fan in my room. Administrator: But you said something about not having it moved. Resident #1: Because its hot. Administrator: Okay. Resident #1: Because its hot in there. Administrator: But it's not 80 degrees down there. Resident #1: But [Administrator] you got, you getting' all upset with me [Administrator]. I don't want this between us. Administrator: Well its between us because. Resident #1: I don't want this between us. Administrator: I tried to tell you to go- I don't have time to deal with this shit right now. Resident #1: but I didn't want nobody to lie to you and tell you I had the. Administrator: I don't give a fuck about that right now; excuse my French. Resident #1: Okay, sir, but Mr. [Administrator], Mr. [Administrator]. Administrator: Bye I gotta get deal with this. Resident #1: Okay but. Administrator: We're not okay. Resident #1: Why? Wait a minute. Administrator: Leave me alone. I gotta go deal with this if you don't mind. I've got people's lives down here and you're telling me that you you're making diagnoses on somebody that you don't know. Resident #1: That's what they told me. Administrator: Well, but you, you don't know. Resident #1: That's what they told me, but I don't know. Administrator: Well, but you don't know for sure or not. Resident #1: That's what they told me. Administrator: But you're spreading rumors about it in the entire facility. Resident #1: No, no I didn't. Administrator: Well you just told me. Resident #1: That's because, that's because you said ain't nobody complaining. Administrator: Well there hadn't been anybody complaining; not down there and I don't have a problem with any of the air conditioning units down there. Resident #1: Its hot down there but. Administrator: I'll have them turn it down. I don't have time for this. You're not listening to me at all you don't ever listen to me. Resident #1: Yes I am and I'm. Administrator: Let me go do my job. A door slams. Resident #1: See how he slammed the door on me. Audio stops. Interview on 09/18/24 at 10:40 AM with the DON revealed if a staff member cursed at or towards a resident during a conversation that was considered abuse. The DON said it was never appropriate for staff to curse at a resident. The DON said each staff member was responsible for how they responded to residents, and she expected them to be accountable for their own behavior. The DON said if a staff member cursed at a resident that could breed an environment of fear. The DON said any abuse should be reported to the Administrator immediately. Interview on 09/18/24 at 12:06 PM with the Administrator revealed he was the Abuse Coordinator, and all abuse was supposed to be reported to him. The Administrator said it was not relevant what he thought if something was abusive or not but how the individual felt about it who was spoken to in that manner. The Administrator said staff cursing at or towards a resident was considered abuse. The Administrator said he did not have any tolerance for staff cursing at or towards a resident. The Administrator said the purpose of residents being free from abuse was that the facility was their home, and they should have a safe and comfortable environment to live in. The Administrator said ultimately, he was responsible for ensuring all residents in the facility were free from abuse, but the staff helped to make sure that happened. The Administrator said if he found out that staff cursed at or towards a resident they would no longer work at the facility. The Administrator said he remembered having a conversation with Resident #1 about an A/C problem in the facility one day but did not recall cursing at the resident. The Administrator said he may have said I don't have time to deal with this shit towards the resident because he was trying to deal with a situation. The Administrator said it was not wrong for him to use that phrase because he was trying to make Resident #1 understand that he was not important right then because of other things going on. The Administrator said he did not remember using the f word and would have to hear the recording to determine if that was said and if it was him who said it but that was not acceptable to use towards the resident. Follow -up interview on 09/18/24 at 1:39 PM with the Administrator while he listened to the audio recording detailed above, he identified Resident #1 in the recording, and said he would not question that. The Administrator said he was not sure that was his voice in the recording, but he remembered having the conversation with Resident #1. The Administrator said he heard there were curse words used in the recording, but it could have been AI generated or someone used a phone app to say the words and used his voice. The Administrator said he was simply having a conversation with Resident #1 to make him understand what he was trying to do with dealing with the crisis. The Administrator said what he heard on the recording was not considered verbally abusive because he was trying to explain to Resident #1 in a language he could understand since the resident cursed a lot at staff. The Administrator said since Resident #1 interrupted him all the time the conversation in the recording was not considered abusive because it was with Resident #1. The Administrator said Resident #1 had tried several times that morning to talk to him because Resident #1 thought he was special when he had something he wanted to talk about it needed to be addressed right there and then. Interview on 09/18/24 at 3:00 PM with the Administrator and the DON revealed the Administrator said he never intended to abuse Resident #1. The Administrator said there was an allegation that Resident #1 was abused by him, so he was suspending himself and leaving the DON to complete the investigation. The Administrator said he was leaving the facility due to the suspension.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure the Administrator did not verbally abuse Resident #1 when he cursed at him during a conversation. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm. Findings included: Review of Resident #1's Admission Record, dated 09/17/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 07/03/24, reflected he had a BIMS score of 15 indicating no cognitive impairment. Review of Resident #1's active diagnoses included paraplegia (paralysis of the legs and lower body caused by a problem with the spinal cord or nerve) and hyponatremia (a condition where the sodium level in your blood is too low). Review of Resident #1's care plan, dated 03/04/24, reflected the following: Focus: Verbal Behaviors: [Resident #1] exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner .Interventions: Approach resident in a calm manner, call by name, speak slowly, and maintain eye contact. Talk while providing cares, allow time for a response, and do not rush. Review of Resident #1's progress notes for September 2024 reflected the following: - 09/04/24 at 3:27 PM, SW A wrote: Resident is a 44 y/o male admitted to facility on 01/06/2023 from [Hospital B]. He remains alert, verbal and able to make his needs known. He has voiced the desire to transfer to a nursing home in the [city] area. Resident was denied by facilities in [city] area. Resident was informed that [SNF C] has accepted him. He stated he is willing to transfer to [SNF C] due to staff acts like they don't want him here Resident stated he will transfer to [SNF C] tomorrow because he was not happy here. He stated that he does not want to be anywhere he is not wanted. - 09/05/24 at 9:41 AM, SW A wrote: .Resident stated that he has to leave due to not feeling safe . Interview via phone on 09/17/24 at 10:03 AM with Resident #1 revealed he was no longer at the facility and was at a different facility now. Resident #1 said the Administrator cursed at him one day, and he had recorded the conversation. Resident #1 said he thought it was unnecessary that the Administrator cursed at him, and there was no way he was going to feel safe in the facility after being treated that way. Resident #1 said it made him very scared and that was why he left the facility. Resident #1 was not sure what day the Administrator cursed at him, but it was near the date he discharged from the facility. Listening to the audio recording provided by Resident #1 on 09/17/24 10:40 AM revealed the following: the audio recording began with static sounds and background noise of things happening and people talking. At the 35-second mark, there was a knock on a door. The following information was the dialogued conversation between the Administrator and Resident #1: Administrator: Do you not understand English? Resident #1: I understand, I understand perfect English. Administrator: This is such a crisis that I've got to stop dealing with the crisis so I can deal with you. Resident #1: What it is, Mr. [Administrator], I don't want anybody sitting up here lying on me, Mr. [Administrator]. Listen to me, sir. The only thing is it is very hot on that hallway and-. Administrator: It's not 81 degrees down there. Resident #1: Sir, sir, I just wanna be clear when I speak to you. Administrator: But when I speak to you, you don't listen to me. Resident #1- I'm just saying. Administrator: I don't have time for this right now. Resident #1: Well then let me- Administrator: No, I don't wanna let you have- Resident #1: Mr. [Administrator]. Administrator: I've gotta make half a dozen phone calls in the next five minutes- Resident #1: Okay, let me let this go real quick like- Administrator: Let it go Resident #1: Okay, let me go real quick. Administrator: It's not, the temperature down there is not a problem. Resident #1: Yes it is, but sir I don't want- Administrator: [unintelligible] [city name]. Resident #1: Listen, sir. Administrator: You're the only person who's come down here from that whole hallway that's complaining about the temperature. Resident #1: Sir, is [Resident #2] had a heat stroke the other day. Administrator: No, he didn't. Resident #1: Yes, he did. Administrator: No he didn't. You ain't a doctor. Resident #1: Okay. Administrator: Are you a doctor? Resident #1: That's an emergency. Administrator: Are you a doctor? Resident #1: That's not- Administrator: I don't have time Resident #1: Wait a minute, [Administrator] I need a- let me just say this and let it go they stole- Administrator: You don't gotta let it go. Resident #1: Yes I am, I am fixin' to let it go. Sir, they told you I did not have that fan in my room. Administrator: I don't care. Resident #1: It was on the hall. Administrator: Well then you don't get to determine where it goes. Resident #1: I didn't say- Administrator: You were. Resident #1: The whole hall is hot, sir. Administrator: Leave me alone. Resident #1: They told you that I did not have that fan in my room sir. I never had it in my room. It was. Administrator: I didn't say it was in your room. I said we had to have the fan. Period. I don't have time for this argument. And I don't- Resident #1: You say it sometimes; I feel special or something and I'm not. Administrator: You are; you do think you're special. Resident #1: No, the hall is hot sir. Administrator: You called me at 2:30 in the morning so I could get you a damn burrito warmed up. Resident #1: I hadn't eaten in 3 days, sir. Administrator: Because you choose not to. It's not part of your religion. Resident #1: Yes, it is. Administrator: There's not a religion that says you fast every other day. Resident #1: Yes its [unintelligible]fast. Yes it is sir, but- Administrator: I don't care. Resident #1: That's [unintelligible]- Administrator: You don't wanna be here and you wanna cause us problems every time you turn around. Resident #1: Sir. Administrator: Take to one of the places we found for you to go. Resident #1: Where? Who gave me- Administrator: We found a couple places for you to go, and you and you refused both of them Resident #1: Who, sir, who told me that. Ain't nobody came and told me nothin' like that Administrator: Aright, I'll find you a place to go and you can go there. I don't have time for this right now. Resident #1: This is how all our conversations go. Administrator: What do you not understand about I need to deal with this? This is a problem. Resident #1: Okay sir. That. But I just, I just don't appreciate no one lying on me. And lying to you on me. Sir I did not have that fan in my room. Administrator: But you said something about not having it moved. Resident #1: Because its hot. Administrator: Okay. Resident #1: Because its hot in there. Administrator: But it's not 80 degrees down there. Resident #1: But [Administrator] you got, you getting' all upset with me [Administrator]. I don't want this between us. Administrator: Well its between us because. Resident #1: I don't want this between us. Administrator: I tried to tell you to go- I don't have time to deal with this shit right now. Resident #1: but I didn't want nobody to lie to you and tell you I had the. Administrator: I don't give a fuck about that right now; excuse my French. Resident #1: Okay, sir, but Mr. [Administrator], Mr. [Administrator]. Administrator: Bye I gotta get deal with this. Resident #1: Okay but. Administrator: We're not okay. Resident #1: Why? Wait a minute. Administrator: Leave me alone. I gotta go deal with this if you don't mind. I've got people's lives down here and you're telling me that you you're making diagnoses on somebody that you don't know. Resident #1: That's what they told me. Administrator: Well, but you, you don't know. Resident #1: That's what they told me, but I don't know. Administrator: Well, but you don't know for sure or not. Resident #1: That's what they told me. Administrator: But you're spreading rumors about it in the entire facility. Resident #1: No, no I didn't. Administrator: Well you just told me. Resident #1: That's because, that's because you said ain't nobody complaining. Administrator: Well there hadn't been anybody complaining; not down there and I don't have a problem with any of the air conditioning units down there. Resident #1: Its hot down there but. Administrator: I'll have them turn it down. I don't have time for this. You're not listening to me at all you don't ever listen to me. Resident #1: Yes I am and I'm. Administrator: Let me go do my job. A door slams. Resident #1: See how he slammed the door on me. Audio stops. Interview on 09/18/24 at 10:40 AM with the DON revealed if a staff member cursed at or towards a resident during a conversation that was considered abuse. The DON said it was never appropriate for staff to curse at a resident. The DON said each staff member was responsible for how they responded to residents, and she expected them to be accountable for their own behavior. The DON said if a staff member cursed at a resident that could breed an environment of fear. The DON said any abuse should be reported to the Administrator immediately. Interview on 09/18/24 at 12:06 PM with the Administrator revealed he was the Abuse Coordinator, and all abuse was supposed to be reported to him. The Administrator said it was not relevant what he thought if something was abusive or not but how the individual felt about it who was spoken to in that manner. The Administrator said staff cursing at or towards a resident was considered abuse. The Administrator said he did not have any tolerance for staff cursing at or towards a resident. The Administrator said the purpose of residents being free from abuse was that the facility was their home, and they should have a safe and comfortable environment to live in. The Administrator said ultimately, he was responsible for ensuring all residents in the facility were free from abuse, but the staff helped to make sure that happened. The Administrator said if he found out that staff cursed at or towards a resident they would no longer work at the facility. The Administrator said he remembered having a conversation with Resident #1 about an A/C problem in the facility one day but did not recall cursing at the resident. The Administrator said he may have said I don't have time to deal with this shit towards the resident because he was trying to deal with a situation. The Administrator said it was not wrong for him to use that phrase because he was trying to make Resident #1 understand that he was not important right then because of other things going on. The Administrator said he did not remember using the f word and would have to hear the recording to determine if that was said and if it was him who said it but that was not acceptable to use towards the resident. Follow -up interview on 09/18/24 at 1:39 PM with the Administrator while he listened to the audio recording detailed above, he identified Resident #1 in the recording, and said he would not question that. The Administrator said he was not sure that was his voice in the recording, but he remembered having the conversation with Resident #1. The Administrator said he heard there were curse words used in the recording, but it could have been AI generated or someone used a phone app to say the words and used his voice. The Administrator said he was simply having a conversation with Resident #1 to make him understand what he was trying to do with dealing with the crisis. The Administrator said what he heard on the recording was not considered verbally abusive because he was trying to explain to Resident #1 in a language he could understand since the resident cursed a lot at staff. The Administrator said since Resident #1 interrupted him all the time the conversation in the recording was not considered abusive because it was with Resident #1. The Administrator said Resident #1 had tried several times that morning to talk to him because Resident #1 thought he was special when he had something he wanted to talk about it needed to be addressed right there and then. Interview on 09/18/24 at 3:00 PM with the Administrator and the DON revealed the Administrator said he never intended to abuse Resident #1. The Administrator said there was an allegation that Resident #1 was abused by him, so he was suspending himself and leaving the DON to complete the investigation. The Administrator said he was leaving the facility due to the suspension. Review of the facility's policy, revised 09/06/24, and titled Abuse, Neglect and Exploitation reflected: Definitions: 'Staff' includes employees .who provide care and services to residents .'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .'Verbal Abuse' means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .III. Prevention of Abuse, Neglect and Exploitation: The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment .B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents. 2. Review and evaluation of like instances to determine if the appropriate actions to correct noncompliance was taken and documented.

Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to ensure Housekeeping Supervisor did not verbally abuse Resident #3 on 12/10/23. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #2's face sheet, dated 02/01/24, reflected the resident was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia and mood disorder), major depressive disorder (a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities), and vascular dementia (a type of dementia caused by conditions that damage blood vessels in the brain and interrupt the flow of blood and oxygen). Record review of Resident #2's quarterly MDS Assessment, dated 01/02/24, reflected she had a BIMS score of 07, which indicated severe cognitive impairment. Observation and interview on 02/01/24 at 9:15 AM with Resident #2 revealed she was lying in her bed with the blanket covering her head. Resident #2 said she originally did not remember the situation that occurred with the Housekeeping Supervisor in December 2023. Resident #2 said she then remembered the Housekeeping Supervisor called her a swamp ass rat and an ugly ass bitch. Resident #2 said it happened a long time ago and made her feel bad about herself because the Housekeeping Supervisor was being mean and hateful towards her. Resident #2 said she had not seen the Housekeeping Supervisor in a while because she was fired. In an interview on 02/01/24 at 12:17 PM with CNA F, she revealed she was at the facility on 12/10/23 and witnessed the situation between Resident #2 and the Housekeeping Supervisor. CNA F said she heard a lot of shouting and walked to the nurses' station and saw the Housekeeping Supervisor and Resident #2 arguing. CNA F said she heard Resident #2 cursing at the Housekeeping Supervisor and told her something like, I hope your mom dies. CNA F said the Housekeeping Supervisor told Resident #2 not to talk about her mom that way and said to her, I don't give a fuck about this job. You know what you are saying. You got me fucked up. CNA F said she was not sure why the Housekeeping Supervisor was talking to Resident #2 that way and considered it to be verbal abuse. CNA F said she attempted to intervene, and she encouraged Resident #2 to leave the area while Houskeeper G tried to get the Housekeeping Supervisor to also leave the area and reminded her she could not speak to Resident #2 in that way. CNA F said after the situation was over the Housekeeping Supervisor kept coming to the area where Resident #2 was talking crazy to her. CNA F stated she had to keep telling the Housekeeping Supervisor to stay away. CNA F said this was not out of character for the Housekeeping Supervisor because she always had an attitude and did not treat people well, but she had never been observed to be abusive towards residents before this incident. In an interview on 02/01/24 at 1:05 PM with Housekeeper G, she revealed she was in the laundry room on 12/10/23 when she heard a commotion and went to see what was happening. Houskeeper G said she saw the Housekeeping Supervisor going off and fussing with Resident #2. Housekeeper G said Resident #2 told her she only knocked one down, and the Housekeeping Supervisor told her she was tired of Resident #2 knocking the signs down and disrespecting her. Housekeeper G said she heard the Housekeeping Supervisor call Resident #2 a bitch and said to Resident #2, Fuck you bitch. Housekeeper G said she saw CNA F try to take Resident #2 away from the area and away from the Housekeeping Supervisor. Housekeeper G said the Housekeeping Supervisor was being abusive towards Resident #2 because staff could not curse residents out like that. In a telephone interview on 02/01/24 at 1:34 PM with the Housekeeping Supervisor, she revealed Resident #2 was cursing at her saying things like, fuck you bitch and stick something up your mom's pussy because all you want to do is fuck. The Housekeeping Supervisor said she asked Resident #2 not to talk to her like that and demanded respect from her because there were too many times Resident #2 did not respect her. The Housekeeping Supervisor said she did not curse at Resident #2 because she had more sense than that, and she knew that would be grounds for termination. In an interview on 02/01/24 at 2:23 PM with the Administrator, he revealed for some reason Resident #2 and the Housekeeping Supervisor got into a squabble on 12/10/23 that escalated where name calling and cussing at each other occurred. The Administrator said Resident #2 got into it with the Housekeeping Supervisor and cursed at her but then per two staff interviews (Housekeeper G and CNA F) the Housekeeping Supervisor said fuck you to Resident #2. The Administrator said the Housekeeping Supervisor should have walked away when Resident #2 kicked over the wet floor sign instead of name calling and cursing at Resident #2. The Administrator said the Housekeeping Supervisor was verbally abusive towards Resident #2 with what she said to her. The Administrator said he expected staff to not be abusive in any way towards residents. The Administrator said residents were supposed to be protected. The Administrator said he contacted the Housekeeping Supervisor's company and told them she was not allowed back in the building after 12/11/23 because of the verbal abuse incident with Resident #3. The Administrator said he reported the abuse to the State Survey Agency, completed an investigation, and in-serviced all staff regarding abuse and neglect. Record review of an undated letter with the third party company's logo and name on the top reflected: To Whom it my Concern- This letter is to state that [the Housekeeping Supervisor] has been terminated from [company name] since December 15, 2023, with a prior suspension. Record review of the facility's policy, dated 10/24/22, and titled Abuse, Neglect and Exploitation reflected: .III. Prevention of Abuse, Neglect and Exploitation; The facility will make every effort to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is suspected or identified by: 1. Taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring to resident or other residents

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure the necessary level of assistance was provided to safely care for Resident #1 during incontinence care. CNA B provided incontinence care without assistance, resulting in Resident #1 falling out of bed and dislocating her finger. This failure could place residents at risk for serious injuries or harm, decline in health, and decreased quality of life. Findings included: Review of Resident #1's MDS dated [DATE] reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included muscle wasting and atrophy of multiple sites and post-laminectomy syndrome (continued pain after back surgery). The resident had moderate cognitive impairment with a BIMS score of 11. She had impairment to her upper and lower extremities on both sides, and she required extensive assistance of two persons for bed mobility. Review of Resident #1's care plan initiated on 05/27/22 reflected the resident had an ADL self-care performance deficit related to muscle wasting and atrophy. Interventions included total assist two staff for bed mobility. Observation and interview on 09/07/23 at 11:58 AM with Resident #1 revealed she was in her room in bed watching a show on her phone. The resident had her fingers on her left hand taped together and there appeared to be a healing bruise to the right side of her head above her eye. The resident stated she had paralysis from her neck down. She stated the previous Friday, 09/01/23, CNA A was providing incontinent care alone and as she, Resident #1, was being turned on to her right side, she felt the top of body start to shift off the bed but CNA A was able to hold on to the lower part of the body, and other staff entered the room and adjusted her back on the bed before she fell . Resident #1 said she bumped her head on the windowsill. The resident further stated on the following day, 09/02/23, CNA B was providing incontinence care alone and as the resident was being turned on her right side, she began to feel like she was falling off the bed. Resident #1 began to yell at CNA B, but she fell out of bed and hit her head on the floor. The resident said she refused to go to the hospital but the facility did xrays of her arm/hand which showed she had dislocated her finger and the staff monitored her pain and vitals. Resident #1 revealed there was only 1 staff member providing care both days and that was common most times. Review of Resident #1's progress notes dated 09/01/23 revealed the following: Writer was at the nurses station when writer heard aide yelling 'help!!!' Upon entering room, writer observed resident lying on the side with head toward window seal and aide holding resident in attempt to keep from falling OOB. Action: Resident was assisted back up in bed properly Hematoma noted to Rt side of forehead. Resident denies pain. Review of the progress notes dated 09/02/23 revealed the following: .Heard Female Person Yell out, went to [Resident #1's room] Resident Face down on the Floor at the Window, Bed was positioned in the elevated position at crying and sobbing, CNA at Beside standing over Resident, assessed Resident, instructed Staff to place Sheet down and to roll Resident over onto the Sheet, Resident lifted the Bed by Staff x3, Resdient positioned for comfort. Resident states The Bed was 6 inches away from the Wall, and, she pushed me over too much, I felt that I was falling, and I told her, but, she couldn't hear me. Assessment completed, bruising and Swelling noted to the right Side of Face, right arm at Elbow/Forearm Junction, and to left Hand at Base of Index Finger, Ice applied to all affected Areas, Resident refused Pain Medication stating 'If I have to go to the ER, I don't want a lot of Medicine in my System' Review of Resident #1's xray of the left hand dated 09/02/23 revealed the following: Finding: Minimal subluxation [an incomplete or partial dislocation of a joint] at second proximal interphalangeal joint [finger joint in index finger] is noted. No other acute fracture or dislocation .Mild osteoarthritis at base of thumb Interview on 09/07/23 at 12:18 PM with CNA A revealed she was providing care to Resident #1 on 09/01/23, and the resident began to slip as she was turned on her right side but before the resident fell , she was able to hold on to the lower part of the resident's body. CNA A called for help and other staff entered the room and adjusted the resident in bed. CNA A further stated there should have been two people assisting with Resident #1's incontinence care. She admitted she did it alone because the resident needed to be changed, and she had looked for assistance but did not see anyone at that time. Interview on 09/07/23 at 12:14 PM with LVN C revealed on 09/01/23 she was at the nurses' station when she heard CNA A call for help. As she entered the room, she saw CNA A holding Resident #1 trying to keep from her from falling off the bed and the resident was assisted properly back in bed. LVN C stated during her assessment of the resident, she noticed a small bump on Resident #1's head. LVN C went on to say Resident #1 has always been a two person assist for incontinence care and she did not know only one person had been caring for her. Interview on 09/07/23 at 1:47 PM with CNA B revealed on 09/02/23, she answered Resident #1's call light because the resident needed to be changed. CNA B stated she did not normally work on that station where Resident #1 resided so she asked the resident if she could hold herself over and the resident said she just needed assistance being rolled over on her side. CNA B stated she was not aware Resident #1 was a two person assist and because the resident was alert and oriented, CNA B thought the resident would have let her know if she needed second staff member. CNA B further stated Resident #1 was telling her, grab my hand because the bed is moving but CNA B said she did not want to grab her left hand because it appeared to be her stroke side and she did not want to harm her. CNA B tried to grab Resident #1's leg but the resident fell on the floor on the wall side of the bed. CNA B called for help and the resident was assisted back into bed and the CNA was then told Resident #1 was a two person assist. Interview on 09/07/23 at 2:25 PM with RN D revealed on 09/02/23 she heard Resident #1 yell and when she went into the room, the resident was on the floor face down by the wall and she was crying. CNA B was heard saying it was not her fault and after the resident's assessment, she was noted with a bump on her head, arm, and base of her index finger of her left hand. Resident #1 refused to go to the hospital but allowed the x-rays to be in house. The x-ray results of her left forearm showed a dislocation of her index finger. RN D said Resident #1 required a person on each side of her bed for incontinence care for safety and she also said if a staff member was not sure if a resident required one or two people for care, they could look in the computer system or ask the charge nurse. Interview on 09/07/23 at 2:51 PM with LVN E revealed on 09/01/23 she heard yelling from Resident #1's room and when she entered, the resident was by the windowsill but the resident did not fall. She assisted the other staff members in repositioning Resident #1 back into bed. LVN E further stated Resident #1 required two staff members for care and if a staff member was not certain they could look in the computer system or ask the charge nurse. Review of the CNA's Kardex computer system revealed Resident #1 required total assist of two for bed mobility and transfers. Interview on 09/07/23 at 3:20 PM with the ADON revealed she had been made aware of Resident #1's fall and stated staff should not have provided care alone and needed two staff members. She said a second person was required to keep the resident safe or to keep her from rolling off the bed. The ADON said if a staff member was not sure if a resident required one or two staff members, they could look in the computer system or as the charge need of the resident's needs. Interview on 09/07/23 at 3:49 PM with the DON revealed she was on vacation at the time of the resident's incidents. The DON said Resident #1 required two staff members for incontinence care for safety and to prevent falls and if staff were unsure, they could look in the computer system for confirmation. Review of the facility's Fall Management System policy, revised 01/03/17, reflected the following: Policy It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs

Based on observation, interview, and record review the facility failed to provide treatment and care in accordance with standards of practice and based on the comprehensive assessment for 2 of 14 residents reviewed for quality of care (Residents #3). An unsupervised regular diet meal tray was at the North hall nursing station where Resident #3 had access. Resident #3 who had a diagnosis of dysphagia ,an order for pureed diet, and a behavior of not complying with his diet grabbed the tortilla off of an unattended leftover tray and placed in his mouth. Resident #3 displayed signs of choking while consuming the tortilla and later died . Resident #3 care plan did not address residents' diet or his behavior of being non-compliant with his diet. These failure resulted in an identification of an Immediate Jeopardy (IJ)on [DATE] . While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not Immediate jeopardy with a scope of Isolated due to the facility need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed residents who required mechanically altered diets (advanced dysphagia diets) at risk of aspiration (food or liquid entering the airway), aspiration pneumonia, choking, hospitalization , or death. Findings Included: Resident #3 Record review of Resident #3s Face Sheet dated [DATE], revealed he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnosis included: [CONDITION(S)], Dysphagia, Oropharyngeal phase; Dementia. Record Review of Resident #3's Physician order summary report dated [DATE] reveled an order for Pureed diet, Nectar diet, and Med Plus Supplement QID with no end date. Record Review of Resident #3s 3.0(MDS), dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was empty. Review of a nursing progress note dated [DATE] revealed a BIMS score was a 3 signifying a severe cognitive impairment. Resident #3s diet was not addressed in the MDS. A review of the most recent Nutrition Assessment was completed on [DATE] and stated that Patient is on a NAS/RCS (pureed, nectar diet, med plus supplement 120 mL (milliliters) QID (4 times a day). A review of Resident #3's Care Plan dated [DATE] with a Target Completion date of [DATE] ( this date was significant as the monitoring time may be an error) revealed documentation addressing Resident #3's falls, therefore, leaving current diet unaddressed in the care plan with needed information for monitoring and interventions. Also revealed that another residents' goals and interventions were documented in Resident #3s Care Plan., section Nursing Department. Resident #6 Record review of Resident #6's Face Sheet dated [DATE] revealed she was a [AGE] year-old, female admitted to the facility on [DATE]. Her diagnosis included: Dysphagia and Oropharyngeal Phase. Record Review of Resident #6s Physician orders dated [DATE] with a start date of [DATE], revealed an order for Regular Diet, Regular texture, Moderately Thick-Honey consistency. Record Review of Care Plan of Resident #6 dated [DATE] revealed in part: Problems .nutritional and hydration risk, with a MBSS swallow study was concluded that a recommendation for Nectar Thick Liquids . Provide/serve diet as ordered . RD to evaluate .make diet/supplement change/recommendations PRN. In an interview and record review with the ADM on [DATE] at 2:30 PM, he stated that Resident #3 had been at the facility for many years, and he had a history of behaviors that included frequent incidents of taking regular textured food from unsupervised trays left by other residents . When asked why this was not care planned, he stated that this should be documented in the care plan. When asked interventions that were put in place to keep the resident from accessing food not on his diet. The ADM stated that the staff had implemented a system to supervise and redirect resident, removed all food trays and take them to the kitchen preventing access. Nursing staff reported that Resident #45 s dinner tray was left on the nursing station by 1 of the 4 staff working on the North Hall: LVN-A, CNA-J, CNA-K, or CNA-L. The tray remained until approximately 8:55 PM, approximately two hours after dinner. Resident ambulated down the hall from his room #22/B, grabbed the tortilla off the tray and put in his mouth. At 8:55 PM CNA-J responded to the resident and took some of the food out of his mouth encouraging him to spit the tortilla out of his mouth . Resident #3 was pronounced dead at 10:30 PM on [DATE]. He stated that the incident was reported to him on [DATE] at 7:00 AM. He stated that LVN-A was on duty at the time of the incident, and she was not aware that incidents of this nature must be reported to the ADM, DON, and ADON within 2 hours of significant incidence. Staff was in serviced on proper reporting of incidence on shift in the requirement time frame, which included notifying the ADM, DON, ADON, Family and MD within two hours of the Incident. He stated that LVN-A acted in the best interest of Resident #3 by immediately upon being notified of the incident, she conducted the [MEDICATION(S)] Maneuver and sending the aide to call 911 and get RN-B from the Central hall of the facility. The ADM stated that he and his staff are currently investigating the incident for more information. The EMT's were contacted immediately, and the nursing staff worked on Resident #3 until the EMT's took over. When asked if he was aware that the diet section of resident #3s Care plan was omitted and not addressed? He stated no. A review of review of Resident #3s Care Plan with ADM and RNN revealed that the documentation listed under Resident#3s Dietary Section listed his goal, plan, and interventions for Resident#3s falls not his diet. She would not respond. In an interview on [DATE] at 5:59 PM, LVN A said residents receive dinner trays at 5:00 PM and they are returned to the kitchen at approximately 6:30 PM. LVN A denies knowledge of the tray at the nursing station. She stated that at approximately 8:45 PM CNA J stated that Resident #3 had taken a tortilla off another resident's tray and stuffed a portion of it in his mouth. She stated that the tray was placed in the desk inside of the nursing counter and where CNA J was sitting. As she walked closer to the nursing station, she could hear Resident #3 breathing was obstructed. She stated that she immediately started doing the [MEDICATION(S)], and instructed CNA J. to call 911. Once 911 was called, LVN A instructed CNAJ to bring the Crash cart, while she continued the [MEDICATION(S)]. LVNA stated that she placed Resident #13 on O2. She stated that once Resident #13 lost conscience she and RNB took him to his room to lay him down to assess his vitals. She attempted to find a pulse, but she stated that she was unable to feel one. At that point EMTs arrived and started CPR and placed Resident #3 on an AED/EKG. LVNA informed the EMT's that a DNR . EMT's started CPR until the staff presented the signed DNR. At that time, EMT's pronounced that Resident #3 had expired. LVNA contacted the M.E., notified the MD and Resident #3s RR of the death. M.E. arrived and picked up the body at 10:30 PM. In an interview with ADONS-A on [DATE] at 6:15 PM, revealed that she observed a missed call on [DATE] at approximately 7am from LVNA. She returned LVNA call, when she informed her that Resident #3 was deceased as of [DATE] at 9:00 PM. ADON stated that LVNA reported that Resident #3 had taken a tortilla off another resident's tray that was placed at the nursing station and stuffed a portion in his mouth. LVNA stated that the tray belonged to Resident #45. CNAJ contacted her for help and as LVNA walked closer to Resident #3 she could hear Resident #3 breathing was obstructed. ADON stated that LVNA revealed that she immediately started doing the [MEDICATION(S)], and instructed CNA J. to call 911. Once 911 was called, LVN A instructed CNAJ to bring the Crash cart, while she continued the [MEDICATION(S)], then get RNB for assistance. RNB arrived and took over [MEDICATION(S)], then he appeared unconscious LVNA, RNB, and CNAJ moved Resident #3 to his room to start O2 and assessed Resident #3s vitals. [NAME] revealed that EMTs arrived and started CPR and placed Resident #3 on an AED/EKG. LVNA informed the EMT's that a DNR . EMT's started CPR until the staff presented the signed DNR. At that time, EMT's pronounced that Resident #3 had expired. LVNA contacted the M.E., notified the MD and Resident #3s RR of the death. M.E. arrived and picked up the body at 10:30 PM. At that point she asked LVNA if she had notified the ADM and DON, and she stated that she had only notified [NAME]. She advised her to contact ADM and DON immediately as the protocol was 2 hours after the incident. She arrived at the facility and told the staff that trays should never be left on the hall as their procedure was to issue trays and upon the meals being completed, they should be returned to cart and covered with plastic to prevent residents from accessing food, especially Resident #3 who had a history of taking food, then return the cart to the dining room. In the event a resident has a late tray remaining on the hall, once the resident has completed eating the tray should be taken to the dining room immediately. In an interview with the DON on [DATE] at 8:03 AM, she said a dysphagia advanced diet was a mechanical soft diet. Residents are ordered a dysphagia advanced diet if they had dysphagia, and if a MBSS were documented that's what [the resident] can tolerate safely. When asked what would happen if a resident were to receive food that was not appropriate for their ordered diet texture, the DON said the resident could aspirate or choke, up to death. When asked if residents ordered a mechanical soft diet could eat tortilla's, the DON said, They should have soft foods. The DON further stated that a resident ordered a mechanical soft diet should not have regular diet foods because they could choke or aspirate. When asked what the procedure for trays was left at the nursing station. She stated that the staff know that all trays are to be returned to the cart and covered or take directly to the kitchen if the cart has already left the hall. She further stated that she expects all nurses to know and execute the notification plan for incidents of death and emergencies. She has trained staff over 3 times since accepting the position of DON. The DON stated that she would expect a nurse on duty to respond immediately when a resident is choking. When asked if she had reviewed the diet section of Resident #3s Care Plan, she revealed that the documentation listed under his Dietary Section she observed documentation of Resident#3s falls not his diet. Therefore, omitting Resident #3s goals, interventions, or plans to review for nursing staff. She would not respond. In an interview with MD on [DATE] at 8: 15 AM, he stated that the resident has been his patient for many years. He stated that the resident was prescribed a pureed diet to assist with swallowing. MD stated that he has observed and been notified of resident sneaking and eating solid foods, and that the resident was educated on the consequences of eating solid food. He stated that he has spoken with the RR about Resident #3s behaviors and constant request to remove the pureed diet. He stated that there were instances when he observed other residents passing Resident #3 food on occasion in the dining room. The consequences of eating solid food when a mechanical soft textured diet has been ordered, could lead to aspiration, choking, loss of oxygen, or death. In an interview with RR on [DATE] at 8:30 AM revealed that she was notified last night of the incident with her brother. She was saddened; however, she understands her brother's behavior and he would often ask her for a diet change because he wanted a hamburger. She would explain to him that she wasn't going to change his diet. She stated that she was not aware that her Resident #3 would sneak solid foods and eat them. She denies having a conversation with facility staff or MD about these behaviors. She stated that her Resident #3's mental compacity was consistent with a 5 year and he did not comprehend eating regular texture food could harm him. He just wanted the food. RR stated that Resident #3 was very impulsive and fixed in on what he wanted regardless of education regarding his swallowing condition. In an interview on [DATE] at 8:45 AM, SLP M stated a dysphagia advanced diet was a mechanical soft texture. She said the meats would be chopped; sides would include soft foods. When asked the reason a resident would be ordered a dysphagia advanced diet, SLP stated it would be ordered for someone that had difficulty swallowing or chewing or if they had oral or pharyngeal dysphagia to reduce the risk of food going into their lungs and aspirate. When asked if a resident on an advanced dysphagia diet could eat foods such as a tortilla, SLP stated no because the resident could aspirate and choke. SLP said signs of aspiration included coughing, turning red, nose starts to run. If you had a pulse ox, O2 stats may drop. When asked what she would do if she were notified a resident on a dysphagia advanced diet ate solid foods SLP said, I would assess the resident and educate resident and staff on appropriate diets, and hazards related to eating non-pureed diet. In an interview on [DATE] at 8:55 AM with MDS Nurse, revealed that she was not aware that Resident #3's would sneak and eat food left unattended by staff. She stated that this has not been discussed in his Care Plan meetings with his RR, nor has she reviewed documentation of these behaviors. She was aware that the resident wanted a diet change from pureed texture to regular. She stated that she had updated his Care Plan on [DATE], and she was aware that he was a pureed mechanical soft diet resident. When asked if she could review the diet section of Resident #3s Care Plan, she revealed that the documentation listed under this goal were addressing his falls, and she stated that I know I put diet in the plan, however, she stated that they have been having computer difficulties and possibly deleted information from Resident #3s care plan. In an interview with RN-A on [DATE] at 9:43 AM, he revealed that he was working on the Central hall checking resident's glucose, when CNAJ came and summons him for assistance with a Resident on the North Hall. He arrived and observed LVNA doing the [MEDICATION(S)] on the resident. He took over the [MEDICATION(S)] while she checks vitals. He stated that LVNA and CNAJ revealed that EMT's had already been called and they were in route to the facility. They moved Resident #3 to his room to further asses upon losing consciousness. In an interview with CNAJ on [DATE] at 10:00 AM , revealed that that Resident #3 was on a pureed mechanical soft diet, should not have regular texture foods. She stated a resident may be placed on a mechanical soft diet if they had difficulty swallowing CNA J said the dinner trays are not left at the nursing stations as Resident #3 has a history of taking food that was not on his diet and eating. the tray had been on the counter, and she denies knowledge of who left the tray. She stated that she was preparing snacks for residents at about 8:50PM. She stated that she was near the nursing station observing the food. Resident #3 came down the hall and grabbed the tortilla and stuffed in his mouth. She stated that she pulled a portion of the tortilla out of his mouth and proceeded to pat him on the back and tell him to spit the food out. She stated that Resident #3 proceeded to push her away. She tried to position him for [MEDICATION(S)], however, do due him resisting she had to call for help from LVN A. LVNA came and proceeded to do the [MEDICATION(S)] on the resident and instructed me to call 911. Upon calling 911, she asked for the Crash Cart and started giving him oxygen and instructing me to get the nurse from the Central hall. RNB came to the hall and took her the [MEDICATION(S)] for LVNB. EMTs arrived and started working on the Resident #3, then stated that he had expired. When asked if there were other residents at the facility that sneak food that are on a pureed diet or special diet, she revealed that Resident #6 and Resident # 37 are often ambulating through the building in a wheelchair or walker and will take food off left over plates or pull liquids off med carts and tray carts. She said that she has been trained on residents' special diets and eating regular food could lead to choking. CNAJ stated that Resident #3 has consumed regular diet food previously, as he would wander and search for food left unattended in the facility. When asked if she had documented this behavior or notified leadership, she stated that she had not documented the behaviors of Resident #3, yet all staff knew of this behavior. CNAJ stated that when has observed the tray on the desk, she should have taken it to the dining room per protocol. This was the purpose of the facility training all staff to return meal trays to the kitchen immediately and/o recover carts with plastic when resident meals have been completed. CNAJ stated that trays are not usually left at the station. In an interview on [DATE] at 10 35 AM with CNA K, she stated that a resident ordered a mechanical soft diet has meats that are ground or chopped up, that way they can chew it and swallow, and review meal tickets to assure residents are receiving the correct food diet before serving residents. She stated that she was working on the north hall, however, when the incident with Resident #3 occurred she was doing patient care on the west side of the hall. When asked the reason a resident would be ordered a mechanical soft diet, CNA K stated it would be for a resident who had issues with swallowing or issues with their teeth or chewing. When asked how often trays were left out for residents to access, she stated that trays are returned to the kitchen as soon as the resident completes the meal. She denies knowledge of the tray being left at the nursing station or who could have left the tray. She further stated that residents ordered a pureed diet are given pudding or applesauce, and snacks are kept locked up until issuing to residents. When asked if there were other residents at the facility that sneak food that are on a pureed diet or special diet, she revealed that Resident #6 and Resident # 37 have been observed taking food off trays or water from medical cart, and the staff will retrieve the items from the residents. In an interview on [DATE] at 12:28 PM with RD, he stated that dysphagia advanced diet was a mechanical soft texture. RD stated that a mechanical soft diet contains soft-textured foods that a person has pureed, mashed, or blended. It is ideal for people who find it difficult to swallow solid foods. This will allow resident with special diets to eat and continue to gain the nutrients needed to function daily. He stated when a resident on a pureed or mechanically soft diet eats a solid food, they can aspirate, choke, and die, and this is what occurred with resident #3. He stated that the staff had not conveyed to him nor had he reviewed documentation of the resident sneaking and eating food outside of his diet. This would have been important for him to know as his professional RD that met with him and provided guidance for his care. In an observation of lunch on [DATE] at 12:30 PM revealed in part the staff implementing the plan for supervision and tray access. Staff were observed on their assigned post serving according to the plan from Inservice. A review of this in-service revealed staff supervising the tray areas to prevent residents from grabbing food off the carts that were not consistent with their diet. In an interview on ,d+[DATE] 2022 at 5:35 PM with CNA L, she stated that a mechanical soft diet has meats that are mashed and soft for residents to eat. She stated that at the time of the incident with Resident #3, she was on break, and was told about the incident when she returned. When asked the reason a resident would be ordered a mechanical soft diet, CNA L stated it would be for a resident who had issues with swallowing or chewing food When asked how often trays were left out for residents to access, and she stated that trays are returned to the kitchen as soon as the resident completes the meal or placed on the meal cart and covered with plastic. She denies knowledge of the tray being left at the nursing station or who could have left the tray. When asked if there were other residents at the facility that sneak food that are on a pureed diet or special diet, she revealed that Resident #6 and Resident # 37 have been observed taking food off trays or water from medical cart, and the staff will retrieve the items from the residents. Resident #6 was observed on [DATE] at lunch time taking tea of the tray cart. A review of the facility's policy, Meal supervision and Assistance dated [DATE] reflected in part: The facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff Develop and implement individualized care plan based on .RAI .monitor .supervised .intervene. Check trays for diets before serving .set up and feed resident .report swallowing issues . Review of Optimizing Texture Modified Foods for Oro-pharyngeal Dysphagia: A Difficult but Possible Target?, dated 2018 and accessed on [DATE] at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 51/, reflected the following: Dysphagia is a swallowing disorder characterized by the difficulty in transferring solid foods and/or liquids from the oral cavity to the stomach, impairing autonomous, and safe oral feeding. The main problems deriving from dysphagia are tracheo-[MEDICATION(S)] aspiration, aspiration pneumonia, malnutrition and dehydration . Oropharyngeal dysphagia (OD) is a dysfunction of the digestive system, consisting of a difficulty in swallowing which affects the proper transit of the bolus in the upper digestive tract. The main complications of dysphagia are tracheo-[MEDICATION(S)] aspiration (food transit in the airways with choking), aspiration pneumonia (pneumonia caused by food in the lungs), . Dysphagic patients fail to control food flow, which is fast and turbulent through the oropharynx, with the risk of misdirection through the respiratory tract . Review of Dysphagia in the elderly: management and nutritional considerations, dated 2012 and accessed on [DATE] at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 63/, reflected the following: . Diet modifications: modification of foods/liquids. Modifying the consistency of solid food and/or liquid is a mainstay of compensatory intervention for patients with dysphagia .The goal of diet modification is to improve the safety and/or ease of oral consumption and thus maintain safe and adequate oral intake of food/liquid . The facility Administrator was notified on [DATE] at 3:21 PM . that there was an Immediate Jeopardy (IJ) identified due to the above failures and an IJ template was provided. The Plan of Removal (POR) was accepted on [DATE] at 1:55PM and it included the following: The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or will be corrected by the date indicated below. Removal of Immediacy This Plan of Removal represents the center's allegation of compliance as of [DATE]. The Texas Health and Human Services Commission entered [name of the facility] on a complaint investigation which started on [DATE] The plan of removal serves as [name of the facility] response to the Immediate Jeopardy Notification the center received at 3:30 pm on [DATE] from the Texas Health and Human Services Commission related to 1. Failure to monitor a resident on a pureed diet 2. Failed to ensure prescribed diet was followed, and 3. Comprehensive Care Plan developed Resident # 1 Resident # 1 was a 78 Y/O male who has resided at the center since 2006 with the following diagnosis: [CONDITION(S)], Diabetes, [CONDITION(S)], Dysphagia, [CONDITION(S)] What happened briefly is as follows: On [DATE], Resident # 1 grabbed a regular flour tortilla from a tray at the nurse's station, a C.N.A. was in close proximity, and was able to get half of the tortilla prior to resident putting it in his mouth, the resident ultimately choked and expired in the facility on [DATE]. Resident # 2 Resident # 2 is a 54 Y/O female who has resided at the center since 2012 with the following diagnosis: [CONDITION(S)] Disorder and Dysphagia What happened briefly is as follows: On [DATE], Resident # 2 was observed by a nurse in close proximity to the cart, taking a glass of thin liquids off of a hall cart. The nurse observed this action and intervened immediately resulting in this resident throwing the glass of thin liquid at the nurse, but not ingesting the liquid. . Immediate Action taken 1. On [DATE] rounds were completed by Regional Nurse Consultant to identify other residents who have the potential to be affected by this alleged practice. Six other residents were identified as having the potential for taking food or fluids from meal trays. Care plans were updated, and resident care tools were updated on these residents. 2. On [DATE] Education was provided to the DON by Regional Nurse Consultant on: A. Emergency response to Choking B. Demonstration of [MEDICATION(S)] Maneuver C. Immediate notification to Administrator This education was completed on [DATE] 3. On [DATE] Education was started for all employees by the DON/Designee on: D. Emergency response to Choking E. Demonstration of [MEDICATION(S)] Maneuver F. Immediate notification to Administrator This education will be completed on [DATE], any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employee's. 4. On [DATE] Education was provided to the DON by Regional Nurse Consultant on: G. Resident Care tool used to identify residents on mechanical altered diets H. Minimizing accessibility to thin liquids for residents on thicken liquids This education was completed on [DATE] 5. On [DATE] Education was started for license nurses, C.N.A.'s and department managers by the DON/Designee on: A. Resident Care tool use to Identify residents on mechanical altered diet. B. Minimizing accessibility to thin liquids for residents on thicken liquids. This education will be completed on [DATE], any employee who has not received the education will be required to complete prior to working, and will be completed upon hire for new employee's 6. On [DATE] 100% audit was completed by Registered Dietitian and Regional Reimbursement to validate that all residents' diets match prescribed orders. 7. On [DATE] 100% audit of comprehensive care plans were completed by Regional Reimbursement consultant to validate that resident's nutritional needs are addressed. 8. On [DATE] Speech Therapist will complete a screen and/or evaluation to determine appropriateness of diet and liquids for identified like residents. Findings of screen and or evaluations will be on each resident's chart and in POC binder. System Change On [DATE], a monthly schedule for meal monitoring was completed by Administrator/Designee to ensure all meals are being monitored for: that trays are not left unattended for resident access at meals, that residents receive appropriate diet and liquids that residents have minimal accessibility to thin liquids. This monitoring schedule will be posted in the main dining room and will be updated monthly, a copy will be in the POC binder, this schedule will be discussed in morning meeting daily. This meal monitoring schedule will be done monthly ongoing Monitoring Administrator/DON/Designee will use a QAPI meal monitoring Audit tool 3x day for each meal x 1 month to monitor that: A. Residents are receiving appropriate diet and liquid consistency B. Meal trays are not being left unattended C. Staff is minimizing accessibility to thin liquids The Regional Reimbursement nurse/Designee will use the care plan Audit tool form to monitor all new and/or readmission residents to validate that a care plan is developed for addressing nutritional needs daily x 1 month, this audit tool will be placed in POC binder on a weekly basis QAPI Meeting The DON/Designee will summarize and report findings from QAPI monitoring tools and Care Plan audit tools during the monthly QAA Meeting for 3 months. The QAPI meeting minutes will be reviewed monthly x 3 months by the Regional Director of Operations or the Regional Nurse Consultant. Monitoring of the plan of removal by HHSC Surveyors revealed: In an interview with C.N.A. M [DATE] at 2:19 PM stated that she had received training on ADL forms that they keep in their pocket of the residents diet plan. The tray procedures, the charge nurse check carts, and then the aides deliver to the residents. She stated that two staff should monitor the dining room, and two on the hall with the cart. One staff hand out trays while the other supervised the cart. Each hall will have a bag on the hall to pour the food not eaten in a plastic bag, poor the water and tea out in the sink on the South hall. CNA M stated that if a resident with Dysphagia should not have a regular texture diet. The residents on her hall that If a resident with dysphagia was given a regular diet she could choke. She stated that any type of food outside of the puree diet could result in choking as the individuals have a difficulty swallowing. In an interview on [DATE] at 2:33 PM CMA-A stated she attended an in-service today. The in-service was to teach staff how to distribute resident's trays and know the types of resident diets. Staff have been instructed to wait until the nurse has checked the trays for accuracy, then they can pass out the food trays to the residents. Encourage residents to come to the dining room. We were trained on how to observe residents for choking and cough. They will each have an assignment cart identifying the diets that the residents are ordered. We were trained on the [MEDICATION(S)] if a resident was choking. If a resident was observed choking, they will notify the ADON, DON, and the Administrator. Once the resident was safe. Continue to monitor the resident after incident. In an interview on [DATE] at 2:51PM RN-C stated this morning he was in-serviced to have two aides on the carts one pass trays and one monitor the carts. When the residents are done eating , pick up the trays and dump food in the plastic bag, then put empty trays back on the cart. The speech therapist in serviced on signs of choking how to feed the residents with small bites and upright and time to chew. Each staff will have a shift of the resident's diet, with liquid type. They will have the aides to copy the diet and keep on them to reference. Nurse will check the trays on the carts for safety of diet, then the aides can take the residents their meal. This has been practiced for lunch and breakfast. The reason the plan was put in place was to prevent residents on special diets from choking and dying. Staff should document in PCC resident behaviors related to danger to diet. In an interview on [DATE] with CMA-B at 2:59 PM, she stated

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for three (Residents #1, #2, and #3) of five residents reviewed for neglect. 1. The facility failed to: - properly assess a deep tissue injury (DTI) on Resident #1's left lateral ankle when she re-admitted to the facility on [DATE] from the hospital; - develop an individualized plan of care to address the DTI; and - obtain/implement physician orders [REDACTED]. These failures resulted in an avoidable worsening of the DTI for seventeen days prior to surveyor intervention on 01/04/17. These failures placed the five residents with pressure ulcers at risk for development and/or worsening of pressure ulcers. 2. 1. The facility failed to identify, assess, and treat an arterial wound on Resident #2's right great toe. 3. The facility failed to assess an open shingles lesion on Resident #3's right buttocks. These failures placed the 59 residents, who resident on the South Station, at risk for the development and/or worsening wounds, infection, and delayed healing. Findings included: 1. The facility's current Abuse policy and procedure, dated 12/06/16, reflected the following: The resident has the right to be free from .neglect . 2. Resident #1's hospital discharge orders, dated 12/12/16, reflected the resident had an unstageable pressure ulcer on her lateral left ankle. The discharge orders reflected the resident was to have a wound care consult for the pressure ulcer on her ankle, a foam [MEDICATION NAME] dressing was to be applied to pressure ulcer daily, and she was to wear waffle boots on both feet and have an Envision mattress (used for managing pressure, moisture, friction and shear in residents at high risk of skin breakdown). Review of hospital discharge information, Pressure Ulcer, dated 12/13/16, sent to the facility with Resident #1's discharge orders revealed: .Suspected deep tissue injury - A person's skin can be injured from pressure or pulling on the skin when his or her position is changed. The skin appears purple or maroon. There may not be an opening in the skin .The site may open and become deeper in time. However, early interventions will help the area heal and may prevent the area from opening . The NPUAP issued the following update on 04/13/16, which was retrieved at www.npuap.org: The term pressure injury replaces pressure ulcer in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as pressure ulcers . .Pressure Injury:A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions An interview with Resident #1 on 01/04/17 at 12:35 p.m. revealed her left ankle feels like a burn. She stated, They put some type of ointment on it. They give me pain medicine, but it doesn't help much. Resident #1's MDS assessment, dated 12/20/16, reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had one unstageable pressure ulcer with suspected deep tissue injury in evolution. This unstageable pressure ulcer was present upon reentry to the facility, and treatment included pressure ulcer care and applications of ointments/medications other than to feet. Resident #1's readmission Resident Data Collection Tool completed by LVN F on 12/13/16 reflected the resident had a DTI on her left ankle. There was an x on the body diagram on the left ankle. Under comments was documented Lt (left) ankle deep tissue injury unstageable. There were no measurements or further description of the DTI. Resident #1's Nurse's Notes completed by LVN F, dated 12/13/16 at 12:45 p.m., reflected: .Lt ankle deep tissue injury unstageable observed . Review of Resident #1's Physician's Telephone Orders revealed an order written [REDACTED]. An interview with LVN F on 01/05/17 at 2:19 p.m. revealed she did not measure the DTI on Resident #1's left ankle during her admission, but she had the Wound Care Nurse look at it. LVN F said, It was like a mosquito bite and had a scar on it. It was dark brown. I wasn't sure what it was. She (Resident #1) came with waffle boots. I should have written an order for [REDACTED]. An interview with the Social Worker on 01/06/17 at 1:05 p.m. revealed she remembered seeing a communication form for a wound consultation for Resident #1. The Social Worker said, I don't know what I did with it. Usually I check their insurance and start calling around to make an appointment for the resident. An interview on 01/04/17 with ADON A revealed the Wound Care Nurse would be notified if a resident had an order for [REDACTED].#1's clinical record and revealed she could not find a progress note from the Wound Care Physician. An interview with the DON on 01/04/16 at 3:45 p.m. revealed when a resident was admitted to the facility the nurses were supposed to do a head-to-toe skin assessment, call the physician, obtain orders and initiate treatment. If there was an actual pressure ulcer, the admitting nurse was supposed to measure the pressure ulcer, describe it, and notify the Wound Care Nurse. Resident #1's Care Plan, dated 12/13/16, reflected resident was at risk for alteration in skin integrity. There were no other care plans addressing the care and treatment of [REDACTED].#1's left ankle. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she was responsible for completing the initial wound care plans for the facility's residents. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk, completed on 12/13/16, revealed the resident scored a 16 which indicated she was at mild risk for developing pressure ulcers. There was no further documented evidence reflecting a Braden Scale for Predicting Pressure Sore Risk was completed subsequent to this assessment. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if they had scores on the Braden Scale of 12 or less or when there was a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the Wound Care Nurse. If a resident had a Braden Scale score greater than 12 and did not have a known skin issue, the resident did not have weekly skin assessments. An interview with the DON on 01/04/17 at 3:45 p.m. revealed Braden Scales for Predicating Pressure Sore Risk were completed upon admission to the facility then weekly for three weeks. After that, the assessments for pressure ulcer risk were completed quarterly. Also, if a resident developed a new pressure ulcer, a Braden Scale would also be done at that time. The DON stated the Braden Scale assessment were kept on the computer. If a resident scored a 14 or less on the Braden Scale, the nurses would do weekly skin assessments. The DON stated the Wound Care Nurse was responsible for completing weekly skin assessments on residents with pressure ulcers. A subsequent interview with the DON on 01/05/17 at 8:00 a.m. revealed the only Braden Scale completed for Resident #1 was the admission assessment on 12/13/16. She stated the computer system did not trigger for Resident #1 to have weekly Braden Scale assessments because the resident was not discharged from the system after the resident went to the hospital. The DON revealed she did see the DTI on Resident #1's left ankle when she readmitted to the facility from the hospital, and she confirmed it was a DTI. She stated that the was only time she saw the DTI. The DON stated the following week the Wound Care Nurse told her the DTI was nothing, and they were applying skin prep to the area. The DON stated when a resident had a wound the Wound Care Nurse was supposed to do daily assessments along with weekly measurements and documentation. She stated the Wound Care Nurse should also document when the wound resolved. The DON revealed the Wound Care Nurse should have continued to perform weekly skin assessments for Resident #1 to assess and monitor the wound. She stated the Wound Care Nurse also should have gotten a wound care consultation as ordered on [DATE]. An interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she did not have any documentation regarding Resident #1's skin, and she did not do weekly skin assessments. Review of the Weekly Pressure Ulcer Log, dated 12/14/16, revealed Resident #1 had a DTI on her left ankle that measured 0.5 cm x 0.5 cm. The wound did not have drainage, no eschar, and no slough. The wound was identified as New/Worsening, and the column labeled treatment was left blank. A low air loss mattress and wheel chair cushion were identified as the devices in place for the wound, and the dietary interventions identified included protein powder and multivitamin with minerals. The Weekly Pressure Ulcer Log further reflected there was a care plan. Further review of the Weekly Pressure Ulcer Logs revealed Resident #1 was not listed on the log completed on 12/21/16. Review of Resident #1's clinical record revealed there was no documented evidence of a TAR for December 2016. An interview with the DON, on 01/05/17 at 2:30 p.m. regarding the Weekly Pressure Ulcer Log, revealed she and the Wound Care Nurse decided together what devices and dietary supplements Resident #1 should have then the Wound Care Nurse obtained physician orders [REDACTED]. On 01/06/17 at 2:15 p.m., the Wound Care Nurse nurse was shown the Weekly Pressure Ulcer Log, dated 12/14/16, which reflected the devices and dietary interventions noted for Resident #1. The Wound Care Nurse revealed she did not know anything about those interventions because they were usually already in place for the residents. Review of Resident #1's December 2016 MAR indicated [REDACTED]. This treatment was initialed as completed beginning 12/13/16 at 5:00 p.m. through 12/28/16 at 5:00 p.m. On 12/29/16, STOP was hand written on the MAR. A review of Resident #1's physician orders [REDACTED]. An observation on 01/04/17 at 1:10 p.m. revealed ADON A assessed and measured the DTI on Resident #1's left ankle. ADON A measured the wound as 3.5 cm x 4.0 cm. She stated the wound was discolored. She then measured the center of the wound as 1.0 cm x 1.5 cm. which she described as having a darker, harder center. An interview with Resident #1's charge nurse, LVN E, on 01/04/17 at 1:24 p.m. revealed Resident #1 had a little red area on her left ankle for more than two weeks. LVN E said, It's just a little scar. It's not very deep or down to the bone. She stated she collaborated with the Wound Care Nurse and one of them applied skin prep to the area daily. LVN E was asked if she documented when she applied skin prep on Resident #1's ankle, and she stated she had not documented it. She was asked if Resident #1 had an order for [REDACTED].#1's ankle today, but she had yesterday (01/03/17). An interview with the Wound Care Nurse on 01/04/17 at 12:00 p.m. revealed she had been a nurse at the facility for the past three years and for the past few months had served as the Wound Care Nurse. She stated the facility previously had a Wound Care Physician, who visited the facility weekly, up until December 2016. At that time the facility switched to a new company to provide wound consultations. The Wound Care Nurse stated currently a Wound Nurse Practitioner made rounds at the facility once a month with her, and the other three weeks of the month they performed virtual wound rounds using an electronic tablet. A subsequent interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she assessed the DTI on Resident #1's left ankle when the resident re-admitted to the facility on [DATE]. She said, It didn't look like anything. It looked like maybe there was something there, but it was just a discoloration. I got an order for [REDACTED]. The Wound Care Nurse further stated the DTI on Resident #1's ankle never developed into anything so she had the staff stop applying skin prep to area. She stated she was pretty sure they had gotten an order to discontinue the treatment. An interview with the DON on 01/04/16 at 3:45 p.m. revealed the Wound Consultants started the first part of December 2016. She stated the Wound Nurse Practitioner made rounds once a month in the building, and the other three weekly visits were conducted virtually using an electronic tablet. A review of the facility's Skin Observation Worksheets completed by the CNAs revealed Resident #1 had two Skin Observation Worksheets. The worksheets reflected the following: 12/16/16 - there was a picture of a body and redness was hand written over the resident's left shoulder. A box labeled Change in Skin Color or Condition was checked. 12/23/16 - there was a picture of a body with no markings written on it. Neither Change in Skin Color or Condition nor No Change in skin Color or Condition was checked by the CNA who completed the worksheet. An interview with CNA H on 01/04/17 at 10:40 a.m. revealed she remembered showering Resident #1 on 12/14/16, and the resident had a scab on her left ankle. CNA H stated after she completed the Skin Observation Worksheets she put them on the desk at the nurses' station. CNA H then looked through the Skin Observation Worksheet binder and could not find any worksheets for Resident #1. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs were supposed to complete shower sheets and notify the nurse if they saw a change in a resident's skin. ADON A revealed she was not surprised Resident #1 did not have shower sheets in the binder. She said, They (CNAs) don't have time to keep up with shower sheets. They do as many showers as they can. Review of the virtual Wound Consultation report for Resident #1, dated 01/05/17, revealed the resident had a pressure related DTI on her left lateral malleolus (bony prominence of ankle) that measured 1.0 cm x 0.8 cm. The wound was described as being 100% ecchymotic (subcutaneous discoloration) with no odor, discharge, or tunneling/undermining. The edges of the wound were described as intact and [MEDICAL CONDITION] was noted to the ankle. The report reflected this was the first assessment of this wound. The Wound Consultation report reflected recommendations for treatment included application of skin prep to Resident #1's left lateral malleolus and covering the area with a foam adhesive dressing daily and as needed in the case of dislodgement. There was also a recommendation to consider using a low air loss bed to further reduce risk. A new care plan developed for Resident #1 on 01/05/17 reflected the resident was at risk for skin breakdown related to incontinence, fragile skin and physical impairment. The care plan reflected skin prep was to be applied to the left ankle with a foam dressing daily and as needed. The facility's current Skin Management Policy policy and procedure, dated 03/11/14, reflected the following: Review the discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development . .Licensed Nurses complete the admission data collection tool and Braden Scale for Predicting Pressure Score Risk which guides implementation of interventions to stabilize, reduce or remove underlying risk factors related to pressure ulcer prevention and treatment . .The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to promoting the prevention of pressure ulcer development, promoting and healing of pressure ulcers that are present, prevention of infection of the wound to the extent possible. .An At Risk for Skin Breakdown care plan is implemented by the licensed nurse for patients . that scores 18 or less on the Braden Scale or as clinically indicated. .Based upon the findings of the MDS and other evaluations, the patient's initial plan of care is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on reduction, modification or stabilizations of actors relevant to skin breakdown. .The Braden Scale is completed on admission and then weekly for an additional three (3) weeks (four (4) weeks total, quarterly, with a significant change in condition and as clinically indicated. .A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. .The wound nurse or licensed nurses re assesses/re evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . Interviews were conducted on 01/07/17 starting at 10:43 a.m. and continued through 01/07/17 at 3:45 a.m. with CNAs. CNAs from various shifts were interviewed, they were: CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P and CNA Q. Responses revealed the CNAs were to complete skin observation worksheets while providing resident care, at least three times a week. They were supposed to document on this worksheet anything they saw on the resident's skin, old and new areas. After the worksheet was completed they were supposed to give it to their charge nurse. If a resident refused care, they were supposed to document refused care on the worksheet and notify their charge. If the resident was on hospice, the facility CNAs were still required to complete skin observation worksheets. Interviews were conducted on 01/07/17 starting at 11:45 a.m. and continued through 01/08/17 at 10:03 a.m. with nurses. Nurses from various shifts were interviewed, they were: LVN G, LVN R, LVN S, LVN T, LVN U and LVN V. Responses revealed the CNAs completed Skin Observation Worksheets while they provided care to a resident. Once they completed the worksheet it was given to the charge nurse, who signs and dates the worksheet. The nurses address any skin issues, with assessments, measurements, documentation, obtaining physician orders, initiating treatment and document the treatment in the TAR. The worksheet was then given to the ADON. If there was a physician's orders [REDACTED]. When a resident was admitted , it was the admitting nurse's responsibility to complete a head to toe skin assessment. The nurse was to assess any wounds, including measurements and a description, and document their findings on the Admission Resident Data Collection Tool. Physician orders [REDACTED]. Braden Scales were completed upon admission and then the ADON did them weekly for the following three weeks, then quarterly. The nurses now had a schedule to complete head to toe skin assessments on all residents. If a resident had a known skin issue the Wound Care Nurse completed their weekly skin assessment. Interviews were conducted on 01/07/17 starting at 1:30 p.m. and continued through 01/07/17 at 2:35 p.m. with the ADONs. ADONs interviewed were ADON A, ADON B and ADON C. Responses revealed the ADONs were to ensure the Skin Observation Worksheets were completed by the CNA and charge nurse, and necessary resident skin assessments were completed. They were to maintain the Skin Observation Worksheet binders, which were kept at the nurses' station. The ADONs were responsible to enter into the computer the resident's admission Braden Scale for Predicting Pressure Sore Risk, the admitting nurse completed on paper. The ADON then completed the subsequent three weekly and quarterly Braden scales. The ADONs were to ensure the nurses completed weekly skin assessments as assigned. The ADONs reviewed all new admission paperwork, hospital discharge orders and physician orders [REDACTED]. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she had not had wound care training until 01/06/17. She stated each hall now had a treatment book, and each resident with a wound would be in the book. She stated the book included the treatment, care plan, and Braden Scale. She stated the admitting nurse would conduct a head-to-toe assessment to included obtaining measurements and a description of each wound. The admitting nurse was then supposed to notify the Wound Care Nurse, who would document his/her own skin assessment. The Wound Care Nurse stated she was going to begin attending the morning meetings where they would discuss new wounds and physician orders, including wound consultations. The Wound Care Nurse stated she would obtain a dietary consultation for residents with wounds for the necessary protein/calories intake, and she would also order any necessary devices such as air loss mattresses. An interview with the Medical Director on 01/06/17 at 1:05 p.m. revealed he thought the nurses should be doing resident skin assessments at least every two weeks and planned to speak to about this at the next QA meeting. An interview with the DON on 01/08/17 at 10:41 a.m. revealed the nurses received annual computer training regarding wounds, but it was not hands on training. She stated they did discuss the wound consultation order for Resident #1, but the Wound Care Nurse stated the wound consultation was not needed because the DTI on Resident #1's ankle was healed. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/04/17, reflected four residents had pressure ulcers not including Resident #1. 3. Resident #2's MDS assessment, dated 12/02/16, reflected the Resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was not at risk for pressure ulcers nor did not have any pressure ulcers. The resident did not have pressure reducing devices for her chair or bed, did not receive nutrition or hydration interventions to manage skin problems and was not on a turning/reposition program. Review of Resident #2's Braden Scale completed on 11/17/16 and 12/13/16 reflected the resident was at risk for pressure ulcer development with a score of 15. Per the facility's protocol, Braden Scores of greater than 14 did not warrant a weekly nursing skin assessment. Review of the Skin Observation Worksheet binder reflected Resident #2 did not have any Skin Observation Worksheets. Review of Resident #2's comprehensive care plans revealed there was no documented evidence an individualized plan of care had been developed to address Resident #2's risk for pressure ulcer development or skin related concerns. An observation on 01/05/17 at 1:00 p.m. revealed there was black eschar on the tip of Resident #2's right great toe. The tops of the other four toes on the resident's right foot had areas of redness. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with Resident #2's charge nurse, LVN E, on 01/05/17 at 1:30 p.m. revealed she was not aware Resdient #2 had any skin issues. LVN E revealed the CNAs had not mentioned any skin issues. She stated she was responsible to check the residents' shower sheets on her shift and she had to remind the CNAs to do them. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs completed shower sheets and notified the nurse if they saw a change in the resident's skin. ADON A revealed CNAs did not have time to keep up with shower sheets, and they did as many showers as they could. She stated she was not surprised that there were no sheets for Resident #2. An interview with the DON on 01/04/16 at 3:45 p.m. revealed if a resident's Braden Scale score was 14 or less the nurses would do weekly skin assessments. An observation with LVN E on 01/05/17 at 1:30 p.m. revealed the tip of Resident #2's great toe had an unopen, blackened area that measured 1.0 cm x 1.5 cm lack which was surrounded by reddened tissue. Review of a Wound Consultation report dated 01/05/17 reflected Resident #2 had an arterial wound on the tip of her right great toe that measured 0.7 cm x 1.2 cm with eschar that measured 0.7 cm x 0.9 cm. The wound was described as having full thickness loss with the wound base redness with the center that was 100% eschar. The wound was described as stable and without drainage, odor, or tunneling/undermining. The edges of the wound were described as intact, and the report reflected this was the first assessment of the wound. The Wound Consultation report also reflected Resident #2 had aterial wounds on her right second toe with partial thickness loss measuring 0.5 cm x 0.6 cm; an arterial wound to her right third toe measuring 0.3 cm x 0.5 cm with partial thickness loss; an arterial wound to her right fourth toe measuring 0.3 cm x 0.3 cm with partial thickness loss; and an arterial wound to her fifth right toe measuring 1.2 cm x 1.4 cm with partial thickness loss. The Wound Consultation report reflected the following recommendations for treatment were made: .prep the right great toe eschar area daily; apply A & D ointment to bilateral feet including reddened areas on right phalanges and reddened area on left great toe twice a day. Resident does have a pressure redistribution mattress in place, but due to low body weight recommend a low air loss bed . 4. Resident #3's MDS assessment, dated 12/27/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She required the assistance of two people with ADLs. She was totally dependent on staff for bathing. She relied on a wheelchair for mobility. She was incontinent of both bowel and bladder. She had no documented skin problems. A review of Resident #3's Comprehensive Care Plan dated 12/27/16 revealed the resident had shingles on her right buttocks. The interventions included monitor areas for increase breakdown, reporting signs/symptoms of infection to the physician, and assessing the resident's skin weekly and recording the findings in her clinical record. An observation of Resident #3 on 01/05/17 at 2:00 p.m. with LVN E revealed the resident had three dry, dark pink, circular areas approximately the size of a pencil eraser and one irregularly shaped area approximately two inches by one inch that was bright pink on her right buttocks. The base of the area appeared moist. There was an area of translucent skin noted to approximately one half of an inch of the outer margin of the lesion. An interview with LVN E on 01/05/15 at 1:42 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. shift on the South Hall. She stated on 12/26/16 they discovered blisters on Resident #3's buttocks. She stated she assessed the area and notified the Physician's Assistant; however, she did not complete a skin assessment sheet. An interview with LVN G on 01/05/17 at 4:10 p.m. revealed she worked the 2:00 p.m. to 10:00 p.m. shift on the South Hall. On 12/27/16, LVN G stated Resident #3 was transferred to an isolation room on the North Hall after being diagnosed with [REDACTED]. LVN G stated on 01/03/17, Resident #3 had a red open area on her buttock. She stated she assessed the area as a non-draining, red, unhealed area that was related to the resident's shingles. It was not a new lesion so she did not complete a skin assessment sheet at that time. LVN G stated she had not seen a prior skin assessment sheet to determine if the area was a new lesion but she had seen the resident's shingles prior to the resident being transferred to the North Hall. She stated she had not completed a skin assessment sheet at that time. An interview wi

Based on observation, interview and record review, the facility failed to ensure a resident had the right to be free from neglect for three (Residents #1, #2, #3) of five residents reviewed for neglect. 1. The facility failed to: - properly assess a deep tissue injury (DTI) on Resident #1's left lateral ankle when she re-admitted to the facility on [DATE] from the hospital; - develop an individualized plan of care to address the DTI; and - obtain/implement physician orders [REDACTED]. These failures resulted in an avoidable worsening of the DTI for seventeen days prior to surveyor intervention on 01/04/17. These failures placed the five residents with pressure ulcers at risk for development and/or worsening of pressure ulcers. 2. 1. The facility failed to identify, assess, and treat an arterial wound on Resident #2's right great toe. 3. The facility failed to assess an open shingles lesion on Resident #3's right buttocks. These failures placed the 59 residents, who resident on the South Station, at risk for the development and/or worsening wounds, infection, and delayed healing. Findings included: 1. Resident #1's hospital discharge orders, dated 12/12/16, reflected the resident had an unstageable pressure ulcer on her lateral left ankle. The discharge orders reflected the resident was to have a wound care consult for the pressure ulcer on her ankle, a foam [MEDICATION NAME] dressing was to be applied to pressure ulcer daily, and she was to wear waffle boots on both feet and have an Envision mattress (used for managing pressure, moisture, friction and shear in residents at high risk of skin breakdown). Review of hospital discharge information, Pressure Ulcer, dated 12/13/16, sent to the facility with Resident #1's discharge orders revealed: .Suspected deep tissue injury - A person's skin can be injured from pressure or pulling on the skin when his or her position is changed. The skin appears purple or maroon. There may not be an opening in the skin .The site may open and become deeper in time. However, early interventions will help the area heal and may prevent the area from opening . The NPUAP issued the following update on 04/13/16, which was retrieved at www.npuap.org: The term pressure injury replaces pressure ulcer in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as pressure ulcers . .Pressure Injury:A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions An interview with Resident #1 on 01/04/17 at 12:35 p.m. revealed her left ankle feels like a burn. She stated, They put some type of ointment on it. They give me pain medicine, but it doesn't help much. Resident #1's MDS assessment, dated 12/20/16, reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had one unstageable pressure ulcer with suspected deep tissue injury in evolution. This unstageable pressure ulcer was present upon reentry to the facility, and treatment included pressure ulcer care and applications of ointments/medications other than to feet. Resident #1's readmission Resident Data Collection Tool completed by LVN F on 12/13/16 reflected the resident had a DTI on her left ankle. There was an x on the body diagram on the left ankle. Under comments was documented Lt (left) ankle deep tissue injury unstageable. There were no measurements or further description of the DTI. Resident #1's Nurse's Notes completed by LVN F, dated 12/13/16 at 12:45 p.m., reflected: .Lt ankle deep tissue injury unstageable observed . Review of Resident #1's Physician's Telephone Orders revealed an order written [REDACTED]. An interview with LVN F on 01/05/17 at 2:19 p.m. revealed she did not measure the DTI on Resident #1's left ankle during her admission, but she had the Wound Care Nurse look at it. LVN F said, It was like a mosquito bite and had a scar on it. It was dark brown. I wasn't sure what it was. She (Resident #1) came with waffle boots. I should have written an order for [REDACTED]. An interview with the Social Worker on 01/06/17 at 1:05 p.m. revealed she remembered seeing a communication form for a wound consultation for Resident #1. The Social Worker said, I don't know what I did with it. Usually I check their insurance and start calling around to make an appointment for the resident. An interview on 01/04/17 with ADON A revealed the Wound Care Nurse would be notified if a resident had an order for [REDACTED].#1's clinical record and revealed she could not find a progress note from the Wound Care Physician. An interview with the DON on 01/04/16 at 3:45 p.m. revealed when a resident was admitted to the facility the nurses were supposed to do a head-to-toe skin assessment, call the physician, obtain orders and initiate treatment. If there was an actual pressure ulcer, the admitting nurse was supposed to measure the pressure ulcer, describe it, and notify the Wound Care Nurse. Resident #1's Care Plan, dated 12/13/16, reflected resident was at risk for alteration in skin integrity. There were no other care plans addressing the care and treatment of [REDACTED].#1's left ankle. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she was responsible for completing the initial wound care plans for the facility's residents. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk, completed on 12/13/16, revealed the resident scored a 16 which indicated she was at mild risk for developing pressure ulcers. There was no further documented evidence reflecting a Braden Scale for Predicting Pressure Sore Risk was completed subsequent to this assessment. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if they had scores on the Braden Scale of 12 or less or when there was a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the Wound Care Nurse. If a resident had a Braden Scale score greater than 12 and did not have a known skin issue, the resident did not have weekly skin assessments. An interview with the DON on 01/04/17 at 3:45 p.m. revealed Braden Scales for Predicating Pressure Sore Risk were completed upon admission to the facility then weekly for three weeks. After that, the assessments for pressure ulcer risk were completed quarterly. Also, if a resident developed a new pressure ulcer, a Braden Scale would also be done at that time. The DON stated the Braden Scale assessment were kept on the computer. If a resident scored a 14 or less on the Braden Scale, the nurses would do weekly skin assessments. The DON stated the Wound Care Nurse was responsible for completing weekly skin assessments on residents with pressure ulcers. A subsequent interview with the DON on 01/05/17 at 8:00 a.m. revealed the only Braden Scale completed for Resident #1 was the admission assessment on 12/13/16. She stated the computer system did not trigger for Resident #1 to have weekly Braden Scale assessments because the resident was not discharged from the system after the resident went to the hospital. The DON revealed she did see the DTI on Resident #1's left ankle when she readmitted to the facility from the hospital, and she confirmed it was a DTI. She stated that the was only time she saw the DTI. The DON stated the following week the Wound Care Nurse told her the DTI was nothing, and they were applying skin prep to the area. The DON stated when a resident had a wound the Wound Care Nurse was supposed to do daily assessments along with weekly measurements and documentation. She stated the Wound Care Nurse should also document when the wound resolved. The DON revealed the Wound Care Nurse should have continued to perform weekly skin assessments for Resident #1 to assess and monitor the wound. She stated the Wound Care Nurse also should have gotten a wound care consultation as ordered on [DATE]. An interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she did not have any documentation regarding Resident #1's skin, and she did not do weekly skin assessments. Review of the Weekly Pressure Ulcer Log, dated 12/14/16, revealed Resident #1 had a DTI on her left ankle that measured 0.5 cm x 0.5 cm. The wound did not have drainage, no eschar, and no slough. The wound was identified as New/Worsening, and the column labeled treatment was left blank. A low air loss mattress and wheel chair cushion were identified as the devices in place for the wound, and the dietary interventions identified included protein powder and multivitamin with minerals. The Weekly Pressure Ulcer Log further reflected there was a care plan. Further review of the Weekly Pressure Ulcer Logs revealed Resident #1 was not listed on the log completed on 12/21/16. Review of Resident #1's clinical record revealed there was no documented evidence of a TAR for December 2016. An interview with the DON, on 01/05/17 at 2:30 p.m. regarding the Weekly Pressure Ulcer Log, revealed she and the Wound Care Nurse decided together what devices and dietary supplements Resident #1 should have then the Wound Care Nurse obtained physician orders [REDACTED]. On 01/06/17 at 2:15 p.m., the Wound Care Nurse nurse was shown the Weekly Pressure Ulcer Log, dated 12/14/16, which reflected the devices and dietary interventions noted for Resident #1. The Wound Care Nurse revealed she did not know anything about those interventions because they were usually already in place for the residents. Review of Resident #1's December 2016 MAR indicated [REDACTED]. This treatment was initialed as completed beginning 12/13/16 at 5:00 p.m. through 12/28/16 at 5:00 p.m. On 12/29/16, STOP was hand written on the MAR. A review of Resident #1's physician orders [REDACTED]. An observation on 01/04/17 at 1:10 p.m. revealed ADON A assessed and measured the DTI on Resident #1's left ankle. ADON A measured the wound as 3.5 cm x 4.0 cm. She stated the wound was discolored. She then measured the center of the wound as 1.0 cm x 1.5 cm. which she described as having a darker, harder center. An interview with Resident #1's charge nurse, LVN E, on 01/04/17 at 1:24 p.m. revealed Resident #1 had a little red area on her left ankle for more than two weeks. LVN E said, It's just a little scar. It's not very deep or down to the bone. She stated she collaborated with the Wound Care Nurse and one of them applied skin prep to the area daily. LVN E was asked if she documented when she applied skin prep on Resident #1's ankle, and she stated she had not documented it. She was asked if Resident #1 had an order for [REDACTED].#1's ankle today, but she had yesterday (01/03/17). An interview with the Wound Care Nurse on 01/04/17 at 12:00 p.m. revealed she had been a nurse at the facility for the past three years and for the past few months had served as the Wound Care Nurse. She stated the facility previously had a Wound Care Physician, who visited the facility weekly, up until December 2016. At that time the facility switched to a new company to provide wound consultations. The Wound Care Nurse stated currently a Wound Nurse Practitioner made rounds at the facility once a month with her, and the other three weeks of the month they performed virtual wound rounds using an electronic tablet. A subsequent interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she assessed the DTI on Resident #1's left ankle when the resident re-admitted to the facility on [DATE]. She said, It didn't look like anything. It looked like maybe there was something there, but it was just a discoloration. I got an order for [REDACTED]. The Wound Care Nurse further stated the DTI on Resident #1's ankle never developed into anything so she had the staff stop applying skin prep to area. She stated she was pretty sure they had gotten an order to discontinue the treatment. An interview with the DON on 01/04/16 at 3:45 p.m. revealed the Wound Consultants started the first part of December 2016. She stated the Wound Nurse Practitioner made rounds once a month in the building, and the other three weekly visits were conducted virtually using an electronic tablet. A review of the facility's Skin Observation Worksheets completed by the CNAs revealed Resident #1 had two Skin Observation Worksheets. The worksheets reflected the following: 12/16/16 - there was a picture of a body and redness was hand written over the resident's left shoulder. A box labeled Change in Skin Color or Condition was checked. 12/23/16 - there was a picture of a body with no markings written on it. Neither Change in Skin Color or Condition nor No Change in skin Color or Condition was checked by the CNA who completed the worksheet. An interview with CNA H on 01/04/17 at 10:40 a.m. revealed she remembered showering Resident #1 on 12/14/16, and the resident had a scab on her left ankle. CNA H stated after she completed the Skin Observation Worksheets she put them on the desk at the nurses' station. CNA H then looked through the Skin Observation Worksheet binder and could not find any worksheets for Resident #1. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs were supposed to complete shower sheets and notify the nurse if they saw a change in a resident's skin. ADON A revealed she was not surprised Resident #1 did not have shower sheets in the binder. She said, They (CNAs) don't have time to keep up with shower sheets. They do as many showers as they can. Review of the virtual Wound Consultation report for Resident #1, dated 01/05/17, revealed the resident had a pressure related DTI on her left lateral malleolus (bony prominence of ankle) that measured 1.0 cm x 0.8 cm. The wound was described as being 100% ecchymotic (subcutaneous discoloration) with no odor, discharge, or tunneling/undermining. The edges of the wound were described as intact and [MEDICAL CONDITION] was noted to the ankle. The report reflected this was the first assessment of this wound. The Wound Consultation report reflected recommendations for treatment included application of skin prep to Resident #1's left lateral malleolus and covering the area with a foam adhesive dressing daily and as needed in the case of dislodgement. There was also a recommendation to consider using a low air loss bed to further reduce risk. A new care plan developed for Resident #1 on 01/05/17 reflected the resident was at risk for skin breakdown related to incontinence, fragile skin and physical impairment. The care plan reflected skin prep was to be applied to the left ankle with a foam dressing daily and as needed. The facility's current Skin Management Policy policy and procedure, dated 03/11/14, reflected the following: Review the discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development . .Licensed Nurses complete the admission data collection tool and Braden Scale for Predicting Pressure Score Risk which guides implementation of interventions to stabilize, reduce or remove underlying risk factors related to pressure ulcer prevention and treatment . .The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to promoting the prevention of pressure ulcer development, promoting and healing of pressure ulcers that are present, prevention of infection of the wound to the extent possible. .An At Risk for Skin Breakdown care plan is implemented by the licensed nurse for patients . that scores 18 or less on the Braden Scale or as clinically indicated. .Based upon the findings of the MDS and other evaluations, the patient's initial plan of care is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on reduction, modification or stabilizations of actors relevant to skin breakdown. .The Braden Scale is completed on admission and then weekly for an additional three (3) weeks (four (4) weeks total, quarterly, with a significant change in condition and as clinically indicated. .A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. .The wound nurse or licensed nurses re assesses/re evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . Interviews were conducted on 01/07/17 starting at 10:43 a.m. and continued through 01/07/17 at 3:45 a.m. with CNAs. CNAs from various shifts were interviewed, they were: CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P and CNA Q. Responses revealed the CNAs were to complete skin observation worksheets while providing resident care, at least three times a week. They were supposed to document on this worksheet anything they saw on the resident's skin, old and new areas. After the worksheet was completed they were supposed to give it to their charge nurse. If a resident refused care, they were supposed to document refused care on the worksheet and notify their charge. If the resident was on hospice, the facility CNAs were still required to complete skin observation worksheets. Interviews were conducted on 01/07/17 starting at 11:45 a.m. and continued through 01/08/17 at 10:03 a.m. with nurses. Nurses from various shifts were interviewed, they were: LVN G, LVN R, LVN S, LVN T, LVN U and LVN V. Responses revealed the CNAs completed Skin Observation Worksheets while they provided care to a resident. Once they completed the worksheet it was given to the charge nurse, who signs and dates the worksheet. The nurses address any skin issues, with assessments, measurements, documentation, obtaining physician orders, initiating treatment and document the treatment in the TAR. The worksheet was then given to the ADON. If there was a physician's orders [REDACTED]. When a resident was admitted , it was the admitting nurse's responsibility to complete a head to toe skin assessment. The nurse was to assess any wounds, including measurements and a description, and document their findings on the Admission Resident Data Collection Tool. Physician orders [REDACTED]. Braden Scales were completed upon admission and then the ADON did them weekly for the following three weeks, then quarterly. The nurses now had a schedule to complete head to toe skin assessments on all residents. If a resident had a known skin issue the Wound Care Nurse completed their weekly skin assessment. Interviews were conducted on 01/07/17 starting at 1:30 p.m. and continued through 01/07/17 at 2:35 p.m. with the ADONs. ADONs interviewed were ADON A, ADON B and ADON C. Responses revealed the ADONs were to ensure the Skin Observation Worksheets were completed by the CNA and charge nurse, and necessary resident skin assessments were completed. They were to maintain the Skin Observation Worksheet binders, which were kept at the nurses' station. The ADONs were responsible to enter into the computer the resident's admission Braden Scale for Predicting Pressure Sore Risk, the admitting nurse completed on paper. The ADON then completed the subsequent three weekly and quarterly Braden scales. The ADONs were to ensure the nurses completed weekly skin assessments as assigned. The ADONs reviewed all new admission paperwork, hospital discharge orders and physician orders [REDACTED]. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she had not had wound care training until 01/06/17. She stated each hall now had a treatment book, and each resident with a wound would be in the book. She stated the book included the treatment, care plan, and Braden Scale. She stated the admitting nurse would conduct a head-to-toe assessment to included obtaining measurements and a description of each wound. The admitting nurse was then supposed to notify the Wound Care Nurse, who would document his/her own skin assessment. The Wound Care Nurse stated she was going to begin attending the morning meetings where they would discuss new wounds and physician orders, including wound consultations. The Wound Care Nurse stated she would obtain a dietary consultation for residents with wounds for the necessary protein/calories intake, and she would also order any necessary devices such as air loss mattresses. An interview with the Medical Director on 01/06/17 at 1:05 p.m. revealed he thought the nurses should be doing resident skin assessments at least every two weeks and planned to speak to about this at the next QA meeting. An interview with the DON on 01/08/17 at 10:41 a.m. revealed the nurses received annual computer training regarding wounds, but it was not hands on training. She stated they did discuss the wound consultation order for Resident #1, but the Wound Care Nurse stated the wound consultation was not needed because the DTI on Resident #1's ankle was healed. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/04/17, reflected four residents had pressure ulcers not including Resident #1. 2. Resident #2's MDS assessment, dated 12/02/16, reflected the Resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was not at risk for pressure ulcers nor did not have any pressure ulcers. The resident did not have pressure reducing devices for her chair or bed, did not receive nutrition or hydration interventions to manage skin problems and was not on a turning/reposition program. Review of Resident #2's Braden Scale completed on 11/17/16 and 12/13/16 reflected the resident was at risk for pressure ulcer development with a score of 15. Per the facility's protocol, Braden Scores of greater than 14 did not warrant a weekly nursing skin assessment. Review of the Skin Observation Worksheet binder reflected Resident #2 did not have any Skin Observation Worksheets. Review of Resident #2's comprehensive care plans revealed there was no documented evidence an individualized plan of care had been developed to address Resident #2's risk for pressure ulcer development or skin related concerns. An observation on 01/05/17 at 1:00 p.m. revealed there was black eschar on the tip of Resident #2's right great toe. The tops of the other four toes on the resident's right foot had areas of redness. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with Resident #2's charge nurse, LVN E, on 01/05/17 at 1:30 p.m. revealed she was not aware Resdient #2 had any skin issues. LVN E revealed the CNAs had not mentioned any skin issues. She stated she was responsible to check the residents' shower sheets on her shift and she had to remind the CNAs to do them. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs completed shower sheets and notified the nurse if they saw a change in the resident's skin. ADON A revealed CNAs did not have time to keep up with shower sheets, and they did as many showers as they could. She stated she was not surprised that there were no sheets for Resident #2. An interview with the DON on 01/04/16 at 3:45 p.m. revealed if a resident's Braden Scale score was 14 or less the nurses would do weekly skin assessments. An observation with LVN E on 01/05/17 at 1:30 p.m. revealed the tip of Resident #2's great toe had an unopen, blackened area that measured 1.0 cm x 1.5 cm lack which was surrounded by reddened tissue. Review of a Wound Consultation report dated 01/05/17 reflected Resident #2 had an arterial wound on the tip of her right great toe that measured 0.7 cm x 1.2 cm with eschar that measured 0.7 cm x 0.9 cm. The wound was described as having full thickness loss with the wound base redness with the center that was 100% eschar. The wound was described as stable and without drainage, odor, or tunneling/undermining. The edges of the wound were described as intact, and the report reflected this was the first assessment of the wound. The Wound Consultation report also reflected Resident #2 had aterial wounds on her right second toe with partial thickness loss measuring 0.5 cm x 0.6 cm; an arterial wound to her right third toe measuring 0.3 cm x 0.5 cm with partial thickness loss; an arterial wound to her right fourth toe measuring 0.3 cm x 0.3 cm with partial thickness loss; and an arterial wound to her fifth right toe measuring 1.2 cm x 1.4 cm with partial thickness loss. The Wound Consultation report reflected the following recommendations for treatment were made: .prep the right great toe eschar area daily; apply A & D ointment to bilateral feet including reddened areas on right phalanges and reddened area on left great toe twice a day. Resident does have a pressure redistribution mattress in place, but due to low body weight recommend a low air loss bed . 3. Resident #3's MDS assessment, dated 12/27/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She required the assistance of two people with ADLs. She was totally dependent on staff for bathing. She relied on a wheelchair for mobility. She was incontinent of both bowel and bladder. She had no documented skin problems. A review of Resident #3's Comprehensive Care Plan dated 12/27/16 revealed the resident had shingles on her right buttocks. The interventions included monitor areas for increase breakdown, reporting signs/symptoms of infection to the physician, and assessing the resident's skin weekly and recording the findings in her clinical record. An observation of Resident #3 on 01/05/17 at 2:00 p.m. with LVN E revealed the resident had three dry, dark pink, circular areas approximately the size of a pencil eraser and one irregularly shaped area approximately two inches by one inch that was bright pink on her right buttocks. The base of the area appeared moist. There was an area of translucent skin noted to approximately one half of an inch of the outer margin of the lesion. An interview with LVN E on 01/05/15 at 1:42 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. shift on the South Hall. She stated on 12/26/16 they discovered blisters on Resident #3's buttocks. She stated she assessed the area and notified the Physician's Assistant; however, she did not complete a skin assessment sheet. An interview with LVN G on 01/05/17 at 4:10 p.m. revealed she worked the 2:00 p.m. to 10:00 p.m. shift on the South Hall. On 12/27/16, LVN G stated Resident #3 was transferred to an isolation room on the North Hall after being diagnosed with [REDACTED]. LVN G stated on 01/03/17, Resident #3 had a red open area on her buttock. She stated she assessed the area as a non-draining, red, unhealed area that was related to the resident's shingles. It was not a new lesion so she did not complete a skin assessment sheet at that time. LVN G stated she had not seen a prior skin assessment sheet to determine if the area was a new lesion but she had seen the resident's shingles prior to the resident being transferred to the North Hall. She stated she had not completed a skin assessment sheet at that time. An interview with the DON 01/05/17 at 2:00 p.m. revealed there was an admission skin assessment for Resident #3 that had been performed by an LVN. There were no other nursing skin assessment sheets. Revie

Based on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #1) of five residents reviewed for pressure ulcers (injuries). The facility failed to: - properly assess a deep tissue injury (DTI) on Resident #1's left lateral ankle when she re-admitted to the facility on [DATE] from the hospital; - develop an individualized plan of care to address the DTI; and - obtain/implement physician orders [REDACTED]. These failures resulted in an avoidable worsening of the DTI for seventeen days prior to surveyor intervention on 01/04/17. These failures placed the five residents with pressure ulcers at risk for development and/or worsening of pressure ulcers. Findings included: Resident #1's hospital discharge orders, dated 12/12/16, reflected the resident had an unstageable pressure ulcer on her lateral left ankle. The discharge orders reflected the resident was to have a wound care consult for the pressure ulcer on her ankle, a foam [MEDICATION NAME] dressing was to be applied to pressure ulcer daily, and she was to wear waffle boots on both feet and have an Envision mattress (used for managing pressure, moisture, friction and shear in residents at high risk of skin breakdown). Review of hospital discharge information, Pressure Ulcer, dated 12/13/16, sent to the facility with Resident #1's discharge orders revealed: .Suspected deep tissue injury - A person's skin can be injured from pressure or pulling on the skin when his or her position is changed. The skin appears purple or maroon. There may not be an opening in the skin .The site may open and become deeper in time. However, early interventions will help the area heal and may prevent the area from opening . The NPUAP issued the following update on 04/13/16, which was retrieved at www.npuap.org: The term pressure injury replaces pressure ulcer in the National Pressure Ulcer Advisory Panel Pressure Injury Staging System according to the NPUAP. The change in terminology more accurately describes pressure injuries to both intact and ulcerated skin. In the previous staging system Stage 1 and Deep Tissue Injury described injured intact skin, while the other stages described open ulcers. This led to confusion because the definitions for each of the stages referred to the injuries as pressure ulcers . .Pressure Injury:A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions An interview with Resident #1 on 01/04/17 at 12:35 p.m. revealed her left ankle feels like a burn. She stated, They put some type of ointment on it. They give me pain medicine, but it doesn't help much. Resident #1's MDS assessment, dated 12/20/16, reflected the resident was a [AGE] year-old female, who was initially admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had one unstageable pressure ulcer with suspected deep tissue injury in evolution. This unstageable pressure ulcer was present upon reentry to the facility, and treatment included pressure ulcer care and applications of ointments/medications other than to feet. Resident #1's readmission Resident Data Collection Tool completed by LVN F on 12/13/16 reflected the resident had a DTI on her left ankle. There was an x on the body diagram on the left ankle. Under comments was documented Lt (left) ankle deep tissue injury unstageable. There were no measurements or further description of the DTI. Resident #1's Nurse's Notes completed by LVN F, dated 12/13/16 at 12:45 p.m., reflected: .Lt ankle deep tissue injury unstageable observed . Review of Resident #1's Physician's Telephone Orders revealed an order written [REDACTED]. An interview with LVN F on 01/05/17 at 2:19 p.m. revealed she did not measure the DTI on Resident #1's left ankle during her admission, but she had the Wound Care Nurse look at it. LVN F said, It was like a mosquito bite and had a scar on it. It was dark brown. I wasn't sure what it was. She (Resident #1) came with waffle boots. I should have written an order for [REDACTED]. An interview with the Social Worker on 01/06/17 at 1:05 p.m. revealed she remembered seeing a communication form for a wound consultation for Resident #1. The Social Worker said, I don't know what I did with it. Usually I check their insurance and start calling around to make an appointment for the resident. An interview on 01/04/17 with ADON A revealed the Wound Care Nurse would be notified if a resident had an order for [REDACTED].#1's clinical record and revealed she could not find a progress note from the Wound Care Physician. An interview with the DON on 01/04/16 at 3:45 p.m. revealed when a resident was admitted to the facility the nurses were supposed to do a head-to-toe skin assessment, call the physician, obtain orders and initiate treatment. If there was an actual pressure ulcer, the admitting nurse was supposed to measure the pressure ulcer, describe it, and notify the Wound Care Nurse. Resident #1's Care Plan, dated 12/13/16, reflected resident was at risk for alteration in skin integrity. There were no other care plans addressing the care and treatment of [REDACTED].#1's left ankle. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she was responsible for completing the initial wound care plans for the facility's residents. Review of Resident #1's Braden Scale for Predicting Pressure Sore Risk, completed on 12/13/16, revealed the resident scored a 16 which indicated she was at mild risk for developing pressure ulcers. There was no further documented evidence reflecting a Braden Scale for Predicting Pressure Sore Risk was completed subsequent to this assessment. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if they had scores on the Braden Scale of 12 or less or when there was a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the Wound Care Nurse. If a resident had a Braden Scale score greater than 12 and did not have a known skin issue, the resident did not have weekly skin assessments. An interview with the DON on 01/04/17 at 3:45 p.m. revealed Braden Scales for Predicating Pressure Sore Risk were completed upon admission to the facility then weekly for three weeks. After that, the assessments for pressure ulcer risk were completed quarterly. Also, if a resident developed a new pressure ulcer, a Braden Scale would also be done at that time. The DON stated the Braden Scale assessment were kept on the computer. If a resident scored a 14 or less on the Braden Scale, the nurses would do weekly skin assessments. The DON stated the Wound Care Nurse was responsible for completing weekly skin assessments on residents with pressure ulcers. A subsequent interview with the DON on 01/05/17 at 8:00 a.m. revealed the only Braden Scale completed for Resident #1 was the admission assessment on 12/13/16. She stated the computer system did not trigger for Resident #1 to have weekly Braden Scale assessments because the resident was not discharged from the system after the resident went to the hospital. The DON revealed she did see the DTI on Resident #1's left ankle when she readmitted to the facility from the hospital, and she confirmed it was a DTI. She stated that the was only time she saw the DTI. The DON stated the following week the Wound Care Nurse told her the DTI was nothing, and they were applying skin prep to the area. The DON stated when a resident had a wound the Wound Care Nurse was supposed to do daily assessments along with weekly measurements and documentation. She stated the Wound Care Nurse should also document when the wound resolved. The DON revealed the Wound Care Nurse should have continued to perform weekly skin assessments for Resident #1 to assess and monitor the wound. She stated the Wound Care Nurse also should have gotten a wound care consultation as ordered on [DATE]. An interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she did not have any documentation regarding Resident #1's skin, and she did not do weekly skin assessments. Review of the Weekly Pressure Ulcer Log, dated 12/14/16, revealed Resident #1 had a DTI on her left ankle that measured 0.5 cm x 0.5 cm. The wound did not have drainage, no eschar, and no slough. The wound was identified as New/Worsening, and the column labeled treatment was left blank. A low air loss mattress and wheel chair cushion were identified as the devices in place for the wound, and the dietary interventions identified included protein powder and multivitamin with minerals. The Weekly Pressure Ulcer Log further reflected there was a care plan. Further review of the Weekly Pressure Ulcer Logs revealed Resident #1 was not listed on the log completed on 12/21/16. Review of Resident #1's clinical record revealed there was no documented evidence of a TAR for December 2016. An interview with the DON, on 01/05/17 at 2:30 p.m. regarding the Weekly Pressure Ulcer Log, revealed she and the Wound Care Nurse decided together what devices and dietary supplements Resident #1 should have then the Wound Care Nurse obtained physician orders [REDACTED]. On 01/06/17 at 2:15 p.m., the Wound Care Nurse nurse was shown the Weekly Pressure Ulcer Log, dated 12/14/16, which reflected the devices and dietary interventions noted for Resident #1. The Wound Care Nurse revealed she did not know anything about those interventions because they were usually already in place for the residents. Review of Resident #1's December 2016 MAR indicated [REDACTED]. This treatment was initialed as completed beginning 12/13/16 at 5:00 p.m. through 12/28/16 at 5:00 p.m. On 12/29/16, STOP was hand written on the MAR. A review of Resident #1's physician orders [REDACTED]. An observation on 01/04/17 at 1:10 p.m. revealed ADON A assessed and measured the DTI on Resident #1's left ankle. ADON A measured the wound as 3.5 cm x 4.0 cm. She stated the wound was discolored. She then measured the center of the wound as 1.0 cm x 1.5 cm. which she described as having a darker, harder center. An interview with Resident #1's charge nurse, LVN E, on 01/04/17 at 1:24 p.m. revealed Resident #1 had a little red area on her left ankle for more than two weeks. LVN E said, It's just a little scar. It's not very deep or down to the bone. She stated she collaborated with the Wound Care Nurse and one of them applied skin prep to the area daily. LVN E was asked if she documented when she applied skin prep on Resident #1's ankle, and she stated she had not documented it. She was asked if Resident #1 had an order for [REDACTED].#1's ankle today, but she had yesterday (01/03/17). An interview with the Wound Care Nurse on 01/04/17 at 12:00 p.m. revealed she had been a nurse at the facility for the past three years and for the past few months had served as the Wound Care Nurse. She stated the facility previously had a Wound Care Physician, who visited the facility weekly, up until December 2016. At that time the facility switched to a new company to provide wound consultations. The Wound Care Nurse stated currently a Wound Nurse Practitioner made rounds at the facility once a month with her, and the other three weeks of the month they performed virtual wound rounds using an electronic tablet. A subsequent interview with the Wound Care Nurse on 01/04/17 at 1:45 p.m. revealed she assessed the DTI on Resident #1's left ankle when the resident re-admitted to the facility on [DATE]. She said, It didn't look like anything. It looked like maybe there was something there, but it was just a discoloration. I got an order for [REDACTED]. The Wound Care Nurse further stated the DTI on Resident #1's ankle never developed into anything so she had the staff stop applying skin prep to area. She stated she was pretty sure they had gotten an order to discontinue the treatment. An interview with the DON on 01/04/16 at 3:45 p.m. revealed the Wound Consultants started the first part of December 2016. She stated the Wound Nurse Practitioner made rounds once a month in the building, and the other three weekly visits were conducted virtually using an electronic tablet. A review of the facility's Skin Observation Worksheets completed by the CNAs revealed Resident #1 had two Skin Observation Worksheets. The worksheets reflected the following: 12/16/16 - there was a picture of a body and redness was hand written over the resident's left shoulder. A box labeled Change in Skin Color or Condition was checked. 12/23/16 - there was a picture of a body with no markings written on it. Neither Change in Skin Color or Condition nor No Change in skin Color or Condition was checked by the CNA who completed the worksheet. An interview with CNA H on 01/04/17 at 10:40 a.m. revealed she remembered showering Resident #1 on 12/14/16, and the resident had a scab on her left ankle. CNA H stated after she completed the Skin Observation Worksheets she put them on the desk at the nurses' station. CNA H then looked through the Skin Observation Worksheet binder and could not find any worksheets for Resident #1. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs were supposed to complete shower sheets and notify the nurse if they saw a change in a resident's skin. ADON A revealed she was not surprised Resident #1 did not have shower sheets in the binder. She said, They (CNAs) don't have time to keep up with shower sheets. They do as many showers as they can. Review of the virtual Wound Consultation report for Resident #1, dated 01/05/17, revealed the resident had a pressure related DTI on her left lateral malleolus (bony prominence of ankle) that measured 1.0 cm x 0.8 cm. The wound was described as being 100% ecchymotic (subcutaneous discoloration) with no odor, discharge, or tunneling/undermining. The edges of the wound were described as intact and [MEDICAL CONDITION] was noted to the ankle. The report reflected this was the first assessment of this wound. The Wound Consultation report reflected recommendations for treatment included application of skin prep to Resident #1's left lateral malleolus and covering the area with a foam adhesive dressing daily and as needed in the case of dislodgement. There was also a recommendation to consider using a low air loss bed to further reduce risk. A new care plan developed for Resident #1 on 01/05/17 reflected the resident was at risk for skin breakdown related to incontinence, fragile skin and physical impairment. The care plan reflected skin prep was to be applied to the left ankle with a foam dressing daily and as needed. The facility's current Skin Management Policy policy and procedure, dated 03/11/14, reflected the following: Review the discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development . .Licensed Nurses complete the admission data collection tool and Braden Scale for Predicting Pressure Score Risk which guides implementation of interventions to stabilize, reduce or remove underlying risk factors related to pressure ulcer prevention and treatment . .The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to promoting the prevention of pressure ulcer development, promoting and healing of pressure ulcers that are present, prevention of infection of the wound to the extent possible. .An At Risk for Skin Breakdown care plan is implemented by the licensed nurse for patients . that scores 18 or less on the Braden Scale or as clinically indicated. .Based upon the findings of the MDS and other evaluations, the patient's initial plan of care is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on reduction, modification or stabilizations of actors relevant to skin breakdown. .The Braden Scale is completed on admission and then weekly for an additional three (3) weeks (four (4) weeks total, quarterly, with a significant change in condition and as clinically indicated. .A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. .The wound nurse or licensed nurses re assesses/re evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form. Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . Interviews were conducted on 01/07/17 starting at 10:43 a.m. and continued through 01/07/17 at 3:45 a.m. with CNAs. CNAs from various shifts were interviewed, they were: CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, CNA P and CNA Q. Responses revealed the CNAs were to complete skin observation worksheets while providing resident care, at least three times a week. They were supposed to document on this worksheet anything they saw on the resident's skin, old and new areas. After the worksheet was completed they were supposed to give it to their charge nurse. If a resident refused care, they were supposed to document refused care on the worksheet and notify their charge. If the resident was on hospice, the facility CNAs were still required to complete skin observation worksheets. Interviews were conducted on 01/07/17 starting at 11:45 a.m. and continued through 01/08/17 at 10:03 a.m. with nurses. Nurses from various shifts were interviewed, they were: LVN G, LVN R, LVN S, LVN T, LVN U and LVN V. Responses revealed the CNAs completed Skin Observation Worksheets while they provided care to a resident. Once they completed the worksheet it was given to the charge nurse, who signs and dates the worksheet. The nurses address any skin issues, with assessments, measurements, documentation, obtaining physician orders, initiating treatment and document the treatment in the TAR. The worksheet was then given to the ADON. If there was a physician's orders [REDACTED]. When a resident was admitted , it was the admitting nurse's responsibility to complete a head to toe skin assessment. The nurse was to assess any wounds, including measurements and a description, and document their findings on the Admission Resident Data Collection Tool. Physician orders [REDACTED]. Braden Scales were completed upon admission and then the ADON did them weekly for the following three weeks, then quarterly. The nurses now had a schedule to complete head to toe skin assessments on all residents. If a resident had a known skin issue the Wound Care Nurse completed their weekly skin assessment. Interviews were conducted on 01/07/17 starting at 1:30 p.m. and continued through 01/07/17 at 2:35 p.m. with the ADONs. ADONs interviewed were ADON A, ADON B and ADON C. Responses revealed the ADONs were to ensure the Skin Observation Worksheets were completed by the CNA and charge nurse, and necessary resident skin assessments were completed. They were to maintain the Skin Observation Worksheet binders, which were kept at the nurses' station. The ADONs were responsible to enter into the computer the resident's admission Braden Scale for Predicting Pressure Sore Risk, the admitting nurse completed on paper. The ADON then completed the subsequent three weekly and quarterly Braden scales. The ADONs were to ensure the nurses completed weekly skin assessments as assigned. The ADONs reviewed all new admission paperwork, hospital discharge orders and physician orders [REDACTED]. An interview with the Wound Care Nurse on 01/08/17 at 11:27 a.m. revealed she had not had wound care training until 01/06/17. She stated each hall now had a treatment book, and each resident with a wound would be in the book. She stated the book included the treatment, care plan, and Braden Scale. She stated the admitting nurse would conduct a head-to-toe assessment to included obtaining measurements and a description of each wound. The admitting nurse was then supposed to notify the Wound Care Nurse, who would document his/her own skin assessment. The Wound Care Nurse stated she was going to begin attending the morning meetings where they would discuss new wounds and physician orders, including wound consultations. The Wound Care Nurse stated she would obtain a dietary consultation for residents with wounds for the necessary protein/calories intake, and she would also order any necessary devices such as air loss mattresses. An interview with the Medical Director on 01/06/17 at 1:05 p.m. revealed he thought the nurses should be doing resident skin assessments at least every two weeks and planned to speak to about this at the next QA meeting. An interview with the DON on 01/08/17 at 10:41 a.m. revealed the nurses received annual computer training regarding wounds, but it was not hands on training. She stated they did discuss the wound consultation order for Resident #1, but the Wound Care Nurse stated the wound consultation was not needed because the DTI on Resident #1's ankle was healed. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 01/04/17, reflected four residents had pressure ulcers not including Resident #1.

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being consistent with the resident's comprehensive assessment and plan of care, for two (Residents #2 and #3) of five residents reviewed for skin assessments. 1. The facility failed to identify, assess, and treat an arterial wound on Resident #2's right great toe. 2. The facility failed to assess an open shingles lesion on Resident #3's right buttocks. These failures placed the 59 residents, who resident on the South Station, at risk for the development and/or worsening wounds, infection, and delayed healing. Findings included: 1. Resident #2's MDS assessment, dated 12/02/16, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was not at risk for pressure ulcers nor did not have any pressure ulcers. The resident did not have pressure reducing devices for her chair or bed, did not receive nutrition or hydration interventions to manage skin problems and was not on a turning/reposition program. Review of Resident #2's Braden Scale completed on 11/17/16 and 12/13/16 reflected the resident was at risk for pressure ulcer development with a score of 15. Per the facility's protocol, Braden Scores of greater than 14 did not warrant a weekly nursing skin assessment. Review of the Skin Observation Worksheet binder reflected Resident #2 did not have any Skin Observation Worksheets. Review of Resident #2's comprehensive care plans revealed there was no documented evidence an individualized plan of care had been developed to address Resident #2's risk for pressure ulcer development or skin related concerns. An observation on 01/05/17 at 1:00 p.m. revealed there was black eschar on the tip of Resident #2's right great toe. The tops of the other four toes on the resident's right foot had areas of redness. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with Resident #2's charge nurse, LVN E, on 01/05/17 at 1:30 p.m. revealed she was not aware Resdient #2 had any skin issues. LVN E revealed the CNAs had not mentioned any skin issues. She stated she was responsible to check the residents' shower sheets on her shift and she had to remind the CNAs to do them. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed residents received skin assessments by the charge nurses if their Braden Scale Score was 12 or less or if they had a known skin issue. She stated if the resident had a Stage 2 pressure ulcer or greater, the resident received a daily skin assessment by the treatment nurse. If a resident had a Braden Scale score greater than 12 and they did not have a known skin issue, they did not get weekly skin assessments. An interview with ADON A on 01/04/17 at 11:15 a.m. revealed CNAs completed shower sheets and notified the nurse if they saw a change in the resident's skin. ADON A revealed CNAs did not have time to keep up with shower sheets, and they did as many showers as they could. She stated she was not surprised that there were no sheets for Resident #2. An interview with the DON on 01/04/16 at 3:45 p.m. revealed if a resident's Braden Scale score was 14 or less the nurses would do weekly skin assessments. An observation with LVN E on 01/05/17 at 1:30 p.m. revealed the tip of Resident #2's great toe had an unopen, blackened area that measured 1.0 cm x 1.5 cm lack which was surrounded by reddened tissue. Review of a Wound Consultation report dated 01/05/17 reflected Resident #2 had an arterial wound on the tip of her right great toe that measured 0.7 cm x 1.2 cm with eschar that measured 0.7 cm x 0.9 cm. The wound was described as having full thickness loss with the wound base redness with the center that was 100% eschar. The wound was described as stable and without drainage, odor, or tunneling/undermining. The edges of the wound were described as intact, and the report reflected this was the first assessment of the wound. The Wound Consultation report also reflected Resident #2 had aterial wounds on her right second toe with partial thickness loss measuring 0.5 cm x 0.6 cm; an arterial wound to her right third toe measuring 0.3 cm x 0.5 cm with partial thickness loss; an arterial wound to her right fourth toe measuring 0.3 cm x 0.3 cm with partial thickness loss; and an arterial wound to her fifth right toe measuring 1.2 cm x 1.4 cm with partial thickness loss. The Wound Consultation report reflected the following recommendations for treatment were made: .prep the right great toe eschar area daily; apply A & D ointment to bilateral feet including reddened areas on right phalanges and reddened area on left great toe twice a day. Resident does have a pressure redistribution mattress in place, but due to low body weight recommend a low air loss bed . 2. Resident #3's MDS assessment, dated 12/27/16, reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She required the assistance of two people with ADLs. She was totally dependent on staff for bathing. She relied on a wheelchair for mobility. She was incontinent of both bowel and bladder. She had no documented skin problems. A review of Resident #3's Comprehensive Care Plan dated 12/27/16 revealed the resident had shingles on her right buttocks. The interventions included monitor areas for increase breakdown, reporting signs/symptoms of infection to the physician, and assessing the resident's skin weekly and recording the findings in her clinical record. An observation of Resident #3 on 01/05/17 at 2:00 p.m. with LVN E revealed the resident had three dry, dark pink, circular areas approximately the size of a pencil eraser and one irregularly shaped area approximately two inches by one inch that was bright pink on her right buttocks. The base of the area appeared moist. There was an area of translucent skin noted to approximately one half of an inch of the outer margin of the lesion. An interview with LVN E on 01/05/15 at 1:42 p.m. revealed she worked the 6:00 a.m. to 2:00 p.m. shift on the South Hall. She stated on 12/26/16 they discovered blisters on Resident #3's buttocks. She stated she assessed the area and notified the Physician's Assistant; however, she did not complete a skin assessment sheet. An interview with LVN G on 01/05/17 at 4:10 p.m. revealed she worked the 2:00 p.m. to 10:00 p.m. shift on the South Hall. On 12/27/16, LVN G stated Resident #3 was transferred to an isolation room on the North Hall after being diagnosed with [REDACTED]. LVN G stated on 01/03/17, Resident #3 had a red open area on her buttock. She stated she assessed the area as a non-draining, red, unhealed area that was related to the resident's shingles. It was not a new lesion so she did not complete a skin assessment sheet at that time. LVN G stated she had not seen a prior skin assessment sheet to determine if the area was a new lesion but she had seen the resident's shingles prior to the resident being transferred to the North Hall. She stated she had not completed a skin assessment sheet at that time. An interview with the DON 01/05/17 at 2:00 p.m. revealed there was an admission skin assessment for Resident #3 that had been performed by an LVN. There were no other nursing skin assessment sheets. Review of the Nurses Notes dated 12/26/16 by LVN E reflected Resident #3 was noted to have a cluster of blisters on her right buttock. A review of Nurse's Notes from 12/26/16 through 01/06/17 for Resident #3 revealed no complete assessment of the shingles area had been documented. Review of a skin observation worksheet completed 01/03/17 by a CNA which indicated resident #3 had a red open lesion on her buttock. LVN G signed the worksheet to indicate she had seen the document. 3. Review of the facility's current policy and procedure Skin Management Policy, dated 03/11/14, reflected: Review the discharge records, transfer sheets or other data regarding the patient's history of, or risk factors for skin alterations and pressure ulcer development . .Licensed Nurses complete the admission data collection tool and Braden Scale for Predicting Pressure Score Risk which guides implementation of interventions to stabilize, reduce or remove underlying risk factors related to pressure ulcer prevention and treatment . .The initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to promoting the prevention of pressure ulcer development, promoting and healing of pressure ulcers that are present, prevention of infection of the wound to the extent possible. .An At Risk for Skin Breakdown care plan is implemented by the licensed nurse for patients with a (sic) that scores 18 or less on the Braden Scale or as clinically indicated. .Based upon the findings of the MDS and other evaluations, the patient's initial plan of care is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on reduction, modification or stabilizations of actors relevant to skin breakdown . .The Braden Scale is completed on admission and then weekly for an additional three (3) weeks (four (4) weeks total, quarterly, with a significant change in condition and as clinically indicated . .A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers. Documentation that the skin evaluation was completed is entered on the Treatment Administration Record. .The wound nurse or licensed nurses re assesses/re evaluates pressure ulcers weekly and as clinically indicated. The weekly evaluation/assessment of the pressure ulcer is documented on the Pressure Ulcer Form . .Nursing assistants perform skin observations with routine care. The Skin Worksheet Tool is completed by the nursing assistant at least two times per week. Results are submitted to the licensed nurse for review and follow-up as needed . 4. An interview with the ADON A on 01/04/17 at 11:15 a.m. revealed 59 residents resided on the South Hall.

Based on observation, interview and record review, it was determined the facility failed to implement written policies and procedures to prevent neglect for one (Resident #1) of nine residents reviewed for neglect. On 05/10/14, Resident #1, who had a known history of suicidal attempts, threats and ideations, wrapped her call light cord around her neck. She was transferred to a hospital for evaluation and treatment. The facility, including the Administrator, DON, and LVN A, failed to implement any interventions to prevent Resident #1 from wrapping the call light cord around her neck when she readmitted to the facility. On 05/14/14 (four days later), Resident #1 readmitted to the facility. While alone in her room, she again wrapped the call light cord around her neck. Resident #1 was transferred to a local hospital for further evaluation and treatment. A Past Immediate Jeopardy (IJ) existed on 05/14/14. This Past IJ was identified on 06/05/14 and remained until 06/09/14. While the IJ was removed on 06/09/14, the facility remained out of compliance at a severity level of "potential of more than minimal harm that is not immediate jeopardy" and a scope of "pattern" as the facility was continuing to monitor the effectiveness of their Plan of Removal. Failure to provide Resident #1 appropriate supervision placed the resident at risk of oxygen deprivation, [MEDICAL CONDITION], and death. This failure further placed nine additional residents, who were identified as having self injurious ideations and/or behaviors, at risk of not receiving the appropriate level of supervision to prevent self inflected injury(ies) or death. Findings included: The facility's current Abuse Prohibition Policy and Procedure, revised July 2012, reflected neglect was "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." Resident #1's Face Sheet, dated 05/20/14, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Physician's Telephone Order, dated 04/10/14, reflected psychiatric services to evaluate and treat her Anxiety and Dementia. Resident #1's Care Plan, dated 04/04/14, reflected Suicidal Ideation and reflected, "AT RISK FOR SUICIDE - Make statement about wanting to hurt self - No plan - reported that when she gets upset will make these statements. 5-10-14 Resident attempted to wrap call light around call light (sic). OBJECTIVE No suicide attempts. The approaches were as follows: 1. "Refer resident to (psychological services) for evaluation. 2. Resident is put on 1 hour (sic) monitoring." Then handwritten on the same line: "q (every) 15 mins (minutes). 3. Notify physician of suicidal tendencies. 4. Give meds as ordered. 5. Encourage resident to voice concerns/problems. 6. Provide activities to divert res (sic) attention. 7. Resident's environment will be fully check (sic) and free of any item that may use to injure self." The Care Plan was reviewed by the facility on 04/05/14, 04/09/14, and 05/10/14. The 05/10/14 review date reflected, "Resident attempted to wrap call light cord around neck sent out to (local hospital)." Resident #1's MDS assessment, dated 04/12/14, reflected her cognition was moderately impaired, she had little interest or pleasure in doing things, she felt down, depressed or hopeless, she felt tired or had little energy, and she had trouble concentrating on things. The MDS assessment also reflected she required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review of Resident #1's MDS Assessment revealed she was unable to walk in her room or in the corridor of the facility. She used a wheelchair for mobility and had limited range of motion to one side of her upper and lower extremities. Resident #1's Physician's Telephone Order, dated 04/17/14, reflected to transfer her to a local hospital for further treatment for [REDACTED]. Resident #1's Behavioral Health Intake Assessment, completed at a mental health hospital and dated 04/21/14, reflected: "Pt (sic) has an extensive history of suicidal ideation/gesture. Hears voices that state, 'Kill yourself, no one loves you.'" Resident #1's facility Psychological Services Progress Note, dated 04/21/14, reflected, "...has made suicidal threats and has a history of attempts...has made repeated suicidal threats and is a high risk patient." Resident #1's Psychological Services Progress Note, dated 04/24/14, reflected, "...made a homicidal threat towards another patient due to an exchange resulting in an out of proportion reaction. She (Resident #1) experiences anger and irritability in response to minor slights. (Resident #1) was in an erratic mood yelling at staff, making threats and hitting herself against the wall. She then began to throw various objects at the social worker in the office." Resident #1's Psychological Services Progress Note, dated 05/05/14, reflected, "met (with) sw, mimr (sic) and advocate to discuss changes to her (Resident #1's) group home placement. (Resident #1) became sad and tearful when informed that the planned group home was no longer able to accept her." Resident #1's Psychological Services Progress Note, dated 05/07/14, reflected, "...presents (with) impulsivity and responds to various stressors by making suicidal statements, attempts and/or homicidal statements attempts (sic)." Resident #1's facility's "Social Service Progress Note,"dated 05/10/14 at 11:15 AM, reflected it was a Nurse's Note signed by an LVN, but the signature was illegible. The Note reflected, "Resident to continue ABT (Antibiotic) therapy for [MEDICAL CONDITION] with no adverse reaction noted. Temperature 97.6. Remains afebrile (without fever). Resident noted this morning by Aide that resident was trying to kill herself - putting (sic) by putting a cord over her neck; saying I want to die. SN (Skilled Nurse) assessment done, Vital signs stable. Notify MD and family member. N/O (new order): To send resident to (local) hospital. No acute distress noted at this time. Evaluated for change of condition." Resident #1's Physician's Telephone Order, dated 05/10/14, reflected to transfer her to a local hospital due to the suicide attempt. Resident #1's facility's Nurse's Note, dated 05/14/14 at 10:20 PM and completed by LVN A, the resident's charge nurse, reflected at 8:30 PM, the resident returned to the facility via non-emergency transportation service. The CNAs assisted the resident to bed. LVN A then noted: "...my attention called that she is back. as soon as I was done feeding a [DEVICE] resident, I went to her room to assess her. There I saw her with a power cord around her neck. Immediately I loosened the cord off her neck and she was saying that she wanted to die. I called one of the aides to come stay with her." LVN A then noted the DON, Administrator and physician were notified and the resident was transferred to the hospital for further evaluation. The facility's Incident/Accident Report, dated 05/14/14, reflected, "I walked in to assess this resident and saw her (with) power cord around her neck. Immediately loosened the cord off her neck (with) struggle, she woun't (sic) let go, stating I want to die!" The Report reflected there was not an injury. The facility's Investigation Follow-Up, dated 05/14/14, reflected, "...saw her (with) power cord around her neck. Immediately went and loosened the cord off her neck while she was shouting I want to die." An interview with LVN A on 05/19/14 at 3:40 PM revealed when Resident #1 returned from the hospital on [DATE], he was in another resident's room giving medication via [DEVICE] and could not leave. He stated she was placed in her bed by staff with the non-emergency transportation service. LVN A revealed he finished with the other resident and within five minutes entered Resident #1's room and found her with the cord to the call light around her throat. He stated he heard her say she wanted to die. LVN A said he had not seen this behavior from her before. During a subsequent interview with LVN A on 06/05/14 at 5:28 PM, he stated Resident #1's bed was horizontal against the wall (parallel with the light fixture) and the call light was plugged into the wall and clipped onto the overhead light string. He stated Resident #1 had wrapped the cord around her neck twice. Resident #1's Resident Transfer Form, dated 05/14/14 at 9:15 PM, reflected she was transported back to a local hospital for a second suicide attempt. Resident #1's Social Service Progress Notes, dated 05/15/14, reflected, "...Charge Nure (sic) discovered (Resident #1) had the call light cord wrapped around her neck and was pulling it tight and there was a mark. She was repeatedly saying 'I want to die. I want to die' to the Charge Nurse (LVN A) This was at 8:35 pm (sic) - Charge Nurse untied the cord with a struggle...." An observation on 05/19/14 at 3:45 PM of Resident #1's room revealed the unoccupied bed was pushed laterally against the wall. It was directly underneath the reading light, attached to the wall. A string, approximately two to three feet that was used to turn the light on and off was hanging down from the reading light. The cord to the call light was plugged in and was attached by a clip to the reading light's string. The roommate's call light was in place on the other side of the room, which created a total of two cords for two separate call lights. An interview with SW W on 05/19/14 at 3:45 PM revealed Resident #1's Guardian told (SW W) at the time of Resident #1's admission that if she became upset, she might try to hurt herself. SW W stated when Resident #1 made threats they would provide "one-on-one monitoring, 15 minutes checks, staff with her all the time." Further review of Resident #1's closed clinical record provided no documented evidence of when they provided one-on-one monitoring or conducted 15 minutes checks. An interview with Resident #1 on 05/19/14 at 12:15 PM, at a local hospital, revealed she opened her eyes and answered select questions but would keep her eyes closed. She did not acknowledge this surveyor during other questions. She would not explain how she obtained the call light cord. Resident #1 explained when she was at the nursing facility, she wrapped a call light cord around her neck because her right leg was hurting. An interview with Resident #1's Guardian on 05/19/14 at 4:30 PM revealed the facility informed her that the second suicide attempt occurred because Resident #1 pulled her bed to the other side of the room and obtained the call light used by the roommate. She stated Resident #1 was unable to use her lower extremities and that could not have happened. (Note: Resident #1 was unable to ambulate, used a wheelchair for mobility, and she had limited range of motion to one side of her body.) The Guardian explained that on 02/21/14, Resident #1 was to be transported to see a new group home, and she was excited about this move. During that trip, she was involved in a motor vehicle accident and sustained a fractured left leg. On 03/28/14 she was scheduled to move to the group home but developed a [MEDICAL CONDITION] in her left fractured leg and was sent to the hospital, instead. She was admitted to this nursing facility on 04/04/14. The Guardian believed Resident #1 was frustrated about the chain of events that led her to placement in the nursing facility. During an interview with the DON on 05/19/14 at 4:00 PM, she stated Resident #1 was the only resident with suicidal behavior. She stated Resident #1 had several hospitalization s for having planned to hurt herself. She stated that when Resident #1 made "allegations," they kept someone with her until she was sent to a hospital's emergency room . She added they would have their SW talk with her and they would remove objects that may be present in her room. When asked why no interventions were in place when Resident #1 returned from the hospital on [DATE], the DON responded, "(Resident #1) just got back." No policy was presented related to procedures to follow in the event a resident exhibited suicidal behaviors/ideations. On 06/05/14 at 5:00 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The Administrator stated on 06/05/14 at 5:00 PM Resident #1 was the first resident in [AGE] years to attempt a suicide. She stated the resident was sent to the hospital for an evaluation and returned after she was cleared. The Administrator revealed the first time Resident #1 was sent to the hospital, the hospital said she was stable. The Administrator stated they (facility) did not anticipate another suicide. She stated the facility did not accept residents who were suicidal. The Administrator revealed if a resident had ideations the resident would not be readmitted . On 06/06/14 at 9:05 AM, the Administrator provided a list of nine residents at risk of suicide. (Note: on 05/19/14, the DON stated only Resident #1 was suicidal.) An interview with the Medical Director on 06/06/14 at 1:00 PM revealed of the nine residents identified for suicidal behaviors, three residents were highly susceptible to idea implantation through suicidal questioning. He expressed concern with the facility population (in general, no specific resident identified) acting out behaviors they witnessed from other residents. On 06/06/14 at 4:06 PM, the facility's Plan of Removal was accepted. The Plan of Removal revealed the following regarding the incident on 05/14/14: "...(Resident #1) returned to (facility) on May 13, 2014 (actual date May 14th) at 8:00 pm after a 4 day stay at (local) Hospital Psychiatric Evaluation Unit. Upon arrival to the center (LVN A) observed patient in the room at approximately 8:05 pm, patient displayed no verbal, gestures or attempts to harm self. At 8:20 pm, (LVN A) went back to patient's room for admission assessment and noted that patient was lying in the bed and had her call light cord wrapped around her neck twice...(LVN A) removed call light cord from resident's neck, patient was alert, talking voicing that she wanted to go back to hospital. Her color was good and in no distress...(LVN A) called for (CNA B) who remained with the resident while (LVN A) called physician and 911. Patient remained on 1:1 until she left (facility) at 8:45 pm by (company name) Ambulance. Patient no longer resides at (facility). NOTE: LVN A's Nurse's Notes reflected the resident readmitted at 8:30 PM. LVN A told the surveyor the incident occurred within 5 minutes of Resident #1 being readmitted ; not 20 minutes as reflected in the facility's synopsis of the incident. The Plan of Removal further reflected the following: Education: On June 5, 2014, the DON started all staff(nursing, administration, housekeeping, dietary and therapy) in service on the following: (1) Clinical Practice Guidelines Suicide Protocol (a) Where to locate information to determine residents who might be at risk for self harm (b) Signs and Symptoms of residents that are at risk of harming self and immediate action steps (c) Immediate reporting responsibility to direct supervisor when a patient displays signs, symptoms or gestures of self harm. Education was started on June 5, 2014 and completed on June 6, 2014, by the DON. All facility staff has been notified of mandatory training until the center is 100% compliant. No staff will be allowed to return to work until they have had this training... On 06/05/14, the facility's reviewed all residents' clinical records to identify any resident who have a history of harming self. Nine residents were identified based on prior history. The nine residents were Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident 9 and Resident #10. The nine residents were reviewed and evaluated by the Administrator, DON, and (25 Nursing facility staff members) and were found to have no signs or symptoms harming to self. On 06/05/14, all Nurse Aide Assignment sheets will be updated to identify the nine resident by the (DON), (Regional Nurse Consultant), (LVN C), and (LVN D). On 06/05/14, the DON, Regional Nurse Consultant and LVN C will initiate the review and updating of the nine residents' care plans. On 06/05/14, Resident #3's, Resident #4's, Resident #5's, Resident #6's, Resident #7's, Resident #8's, and Resident #9's care plans reflected they had been updated to reflect Suicidal Ideation and attempts. On 06/06/14, Resident #2's care plan was updated to reflect Suicide Ideation. On 06/07/14, Resident #10's care plan was updated to reflect Self Harm. On 06/06/14, Psychologist X review and evaluate the nine identified patients, document the assessment and follow up intervention, as indicated, will be documented in the clinical record. Patient's with active suicidal ideation, verbalization and/or overt suicidal attempts including gestures and self-mutilation attempts will not be admitted or readmitted to the facility. Prior to admission or re admission to the facility the Admission Coordinator, LVN E, Social Worker V or Charge Nurse will receive verbal report and review transfer paper or referral paper work including but not limited to physician orders, nurses notes and physician progress notes [REDACTED]. Upon admission to the facility the patient is placed one-to-one supervision by staff until consulting practitioner or primary physician completes a psychosocial assessment and deems the patient safe to be independent in the facility. The assessment will be documented in the clinical record. A patient with new or returning verbalizations of attempts to harm self, overt suicidal attempts or gestures, including self-mutilation is placed one-to-one staff supervision. The EMS is notified immediately if the patient is making overt attempts and gestures including self mutilation to harm self. The physician or consulting practitioner is notified immediately after the EMS transfer for the need for further psychosocial and medical assessment for the patient to function independently in the facility. The assigned staff member continually observes the patient for signs and symptoms of attempts to harm self and calls for staff assistance if patient displays, verbalizes and/or makes an overt suicidal attempt, including self-mutilation attempts. Documentation will be done each shift by the charge nurse to reflect that patient is being monitored...The patient's room is checked for hazardous items (to include sharp objects, glass, belts, medications, etc.) when an in house patient has returning or new signs and symptoms of attempts to harm self. Documentation that rooms were checked will be completed in patient's nurse's notes. The care plan identifies the interventions used to render a patient as safe as possible to reduce the risk of self harm... On 06/06/14, in-services will be started and all facility staff (nursing, administration, housekeeping, dietary and therapy) have been notified of mandatory training. Learning is validated through post testing Education is expected to be completed June 11, 2014...Any patient that displays signs or symptoms of presenting a danger to self the staff member will remain with the patient and call for help. Patients with a history of presenting a danger to self are evaluated by Psychologists X, Y, and Z who visit the facility 5 days a week. Staff education will be validated by Regional Nurse Consultant. Resident documentation will be validated by the Assistant Directors of Nursing...." On 06/06/14, Psychologists X, Y, and Z will initiate additional training on the signs and symptoms of suicidal behavior and interventions. On 06/05/14, the Quality Assessment and Performance Improvement (QAPI)committee would meet. On 06/06/14, the QAPI will met to review progress of performance improvement plan. The QAPI would meet weekly to review performance improvement plan. On 06/05/14, the facility's Medical Director was notified of the IJ, system changes and plan to sustain compliance. The following evidence confirmed the facility's Plan of Removal had been implemented: The post test issued, to the staff after the in-service given by the Psychologists, reflected on 06/09/14 at 11:15 AM 117 employees successfully completed the post test. The post test issued, to the staff after the in-service given by the DON, reflected on 06/09/14 at 11:28 AM 130 employees successfully completed the post test. Interviews with LVN F, CNA G, Dietary Aide H, MA I, LVN J, and ADON L conducted on 06/05/14 from 1:30 PM to 1:42 PM and at 4:10 PM revealed they knew to stay with a resident who threatened or made statements regarding suicide and to call for assistance. Interviews with LVN M, CNA N, CNA O, CNA P, CNA Q, MA R, MA S, CNA T, CNA U, Cook AA, and Cook BB conducted on 06/07/14 from 1:00 PM through 2:30 PM revealed they knew what to do if a resident made statements about suicide or threats to harm self. They understood they needed to stay with the resident and call for help. Most knew to check the surrounding environment for potential weapons and what 1:1 supervision was. Most understood the CNA books reflected which residents were at risk for suicidal ideation and/or actions. During an interview on 06/09/14 at 12:23 PM, the Administrator, DON, ADON CC, RDO, Regional Nurse Consultant and ADON DD were informed the IJ was removed, but the facility remained out of compliance at a severity of level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" due to the facility was still monitoring the effectiveness of the Plan of Removal. The Administrator provided a list of nine residents, who were at risk for [MEDICAL CONDITION], attempts and self harm, on 06/06/14 at 9:05 AM.

Based on observation, interview, and record review, it was determined the facility failed to implement policies and procedures that prohibit neglect for one (Resident #1) of 10 residents reviewed for self-injurious ideations/behaviors. On 05/10/14, Resident #1, who had a known history of suicidal attempts, threats and ideations, wrapped her call light cord around her neck. She was transferred to a hospital for evaluation and treatment. The facility, including the Administrator, DON, and LVN A, failed to implement any interventions to prevent Resident #1 from wrapping the call light cord around her neck when she readmitted to the facility. On 05/14/14 (four days later), Resident #1 readmitted to the facility. While alone in her room, she again wrapped the call light cord around her neck. Resident #1 was transferred to a local hospital for further evaluation and treatment. A Past Immediate Jeopardy (IJ) existed on 05/14/14. This Past IJ was identified on 06/05/14 and remained until 06/09/14. While the IJ was removed on 06/09/14, the facility remained out of compliance at a severity level of "potential of more than minimal harm that is not immediate jeopardy" and a scope of "pattern" as the facility was continuing to monitor the effectiveness of their Plan of Removal. Failure to provide Resident #1 appropriate supervision placed the resident at risk of oxygen deprivation, [MEDICAL CONDITION], and death. This failure further placed nine additional residents, who were identified as having self injurious ideations and/or behaviors, at risk of not receiving the appropriate level of supervision to prevent self inflected injury(ies) or death. Findings included: Resident #1's Face Sheet, dated 05/20/14, reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's Physician's Telephone Order, dated 04/10/14, reflected psychiatric services to evaluate and treat her Anxiety and Dementia. Resident #1's Care Plan, dated 04/04/14, reflected Suicidal Ideation and reflected, "AT RISK FOR SUICIDE - Make statement about wanting to hurt self - No plan - reported that when she gets upset will make these statements. 5-10-14 Resident attempted to wrap call light around call light (sic). OBJECTIVE No suicide attempts. The approaches were as follows: 1. "Refer resident to (psychological services) for evaluation. 2. Resident is put on 1 hour (sic) monitoring." Then handwritten on the same line: "q (every) 15 mins (minutes). 3. Notify physician of suicidal tendencies. 4. Give meds as ordered. 5. Encourage resident to voice concerns/problems. 6. Provide activities to divert res (sic) attention. 7. Resident's environment will be fully check (sic) and free of any item that may use to injure self." The Care Plan was reviewed by the facility on 04/05/14, 04/09/14, and 05/10/14. The 05/10/14 review date reflected, "Resident attempted to wrap call light cord around neck sent out to (local hospital)." Resident #1's MDS assessment, dated 04/12/14, reflected her cognition was moderately impaired, she had little interest or pleasure in doing things, she felt down, depressed or hopeless, she felt tired or had little energy, and she had trouble concentrating on things. The MDS assessment also reflected she required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Further review of Resident #1's MDS Assessment revealed she was unable to walk in her room or in the corridor of the facility. She used a wheelchair for mobility and had limited range of motion to one side of her upper and lower extremities. Resident #1's Physician's Telephone Order, dated 04/17/14, reflected to transfer her to a local hospital for further treatment for [REDACTED]. Resident #1's Behavioral Health Intake Assessment, completed at a mental health hospital and dated 04/21/14, reflected: "Pt (sic) has an extensive history of suicidal ideation/gesture. Hears voices that state, 'Kill yourself, no one loves you.'" Resident #1's facility Psychological Services Progress Note, dated 04/21/14, reflected, "...has made suicidal threats and has a history of attempts...has made repeated suicidal threats and is a high risk patient." Resident #1's Psychological Services Progress Note, dated 04/24/14, reflected, "...made a homicidal threat towards another patient due to an exchange resulting in an out of proportion reaction. She (Resident #1) experiences anger and irritability in response to minor slights. (Resident #1) was in an erratic mood yelling at staff, making threats and hitting herself against the wall. She then began to throw various objects at the social worker in the office." Resident #1's Psychological Services Progress Note, dated 05/05/14, reflected, "met (with) sw, mimr (sic) and advocate to discuss changes to her (Resident #1's) group home placement. (Resident #1) became sad and tearful when informed that the planned group home was no longer able to accept her." Resident #1's Psychological Services Progress Note, dated 05/07/14, reflected, "...presents (with) impulsivity and responds to various stressors by making suicidal statements, attempts and/or homicidal statements attempts (sic)." Resident #1's facility's "Social Service Progress Note,"dated 05/10/14 at 11:15 AM, reflected it was a Nurse's Note signed by an LVN, but the signature was illegible. The Note reflected, "Resident to continue ABT (Antibiotic) therapy for [MEDICAL CONDITION] with no adverse reaction noted. Temperature 97.6. Remains afebrile (without fever). Resident noted this morning by Aide that resident was trying to kill herself - putting (sic) by putting a cord over her neck; saying I want to die. SN (Skilled Nurse) assessment done, Vital signs stable. Notify MD and family member. N/O (new order): To send resident to (local) hospital. No acute distress noted at this time. Evaluated for change of condition." Resident #1's Physician's Telephone Order, dated 05/10/14, reflected to transfer her to a local hospital due to the suicide attempt. Resident #1's facility's Nurse's Note, dated 05/14/14 at 10:20 PM and completed by LVN A, the resident's charge nurse, reflected at 8:30 PM, the resident returned to the facility via non-emergency transportation service. The CNAs assisted the resident to bed. LVN A then noted: "...my attention called that she is back. as soon as I was done feeding a [DEVICE] resident, I went to her room to assess her. There I saw her with a power cord around her neck. Immediately I loosened the cord off her neck and she was saying that she wanted to die. I called one of the aides to come stay with her." LVN A then noted the DON, Administrator and physician were notified and the resident was transferred to the hospital for further evaluation. The facility's Incident/Accident Report, dated 05/14/14, reflected, "I walked in to assess this resident and saw her (with) power cord around her neck. Immediately loosened the cord off her neck (with) struggle, she woun't (sic) let go, stating I want to die!" The Report reflected there was not an injury. The facility's Investigation Follow-Up, dated 05/14/14, reflected, "...saw her (with) power cord around her neck. Immediately went and loosened the cord off her neck while she was shouting I want to die." An interview with LVN A on 05/19/14 at 3:40 PM revealed when Resident #1 returned from the hospital on [DATE], he was in another resident's room giving medication via [DEVICE] and could not leave. He stated she was placed in her bed by staff with the non-emergency transportation service. LVN A revealed he finished with the other resident and within five minutes entered Resident #1's room and found her with the cord to the call light around her throat. He stated he heard her say she wanted to die. LVN A said he had not seen this behavior from her before. During a subsequent interview with LVN A on 06/05/14 at 5:28 PM, he stated Resident #1's bed was horizontal against the wall (parallel with the light fixture) and the call light was plugged into the wall and clipped onto the overhead light string. He stated Resident #1 had wrapped the cord around her neck twice. Resident #1's Resident Transfer Form, dated 05/14/14 at 9:15 PM, reflected she was transported back to a local hospital for a second suicide attempt. Resident #1's Social Service Progress Notes, dated 05/15/14, reflected, "...Charge Nure (sic) discovered (Resident #1) had the call light cord wrapped around her neck and was pulling it tight and there was a mark. She was repeatedly saying 'I want to die. I want to die' to the Charge Nurse (LVN A) This was at 8:35 pm (sic) - Charge Nurse untied the cord with a struggle...." An observation on 05/19/14 at 3:45 PM of Resident #1's room revealed the unoccupied bed was pushed laterally against the wall. It was directly underneath the reading light, attached to the wall. A string, approximately two to three feet that was used to turn the light on and off was hanging down from the reading light. The cord to the call light was plugged in and was attached by a clip to the reading light's string. The roommate's call light was in place on the other side of the room, which created a total of two cords for two separate call lights. An interview with SW W on 05/19/14 at 3:45 PM revealed Resident #1's Guardian told (SW W) at the time of Resident #1's admission that if she became upset, she might try to hurt herself. SW W stated when Resident #1 made threats they would provide "one-on-one monitoring, 15 minutes checks, staff with her all the time." Further review of Resident #1's closed clinical record provided no documented evidence of when they provided one-on-one monitoring or conducted 15 minutes checks. An interview with Resident #1 on 05/19/14 at 12:15 PM, at a local hospital, revealed she opened her eyes and answered select questions but would keep her eyes closed. She did not acknowledge this surveyor during other questions. She would not explain how she obtained the call light cord. Resident #1 explained when she was at the nursing facility, she wrapped a call light cord around her neck because her right leg was hurting. An interview with Resident #1's Guardian on 05/19/14 at 4:30 PM revealed the facility informed her that the second suicide attempt occurred because Resident #1 pulled her bed to the other side of the room and obtained the call light used by the roommate. She stated Resident #1 was unable to use her lower extremities and that could not have happened. (Note: Resident #1 was unable to ambulate, used a wheelchair for mobility, and she had limited range of motion to one side of her body.) The Guardian explained that on 02/21/14, Resident #1 was to be transported to see a new group home, and she was excited about this move. During that trip, she was involved in a motor vehicle accident and sustained a fractured left leg. On 03/28/14 she was scheduled to move to the group home but developed a [MEDICAL CONDITION] in her left fractured leg and was sent to the hospital, instead. She was admitted to this nursing facility on 04/04/14. The Guardian believed Resident #1 was frustrated about the chain of events that led her to placement in the nursing facility. During an interview with the DON on 05/19/14 at 4:00 PM, she stated Resident #1 was the only resident with suicidal behavior. She stated Resident #1 had several hospitalization s for having planned to hurt herself. She stated that when Resident #1 made "allegations," they kept someone with her until she was sent to a hospital's emergency room . She added they would have their SW talk with her and they would remove objects that may be present in her room. When asked why no interventions were in place when Resident #1 returned from the hospital on [DATE], the DON responded, "(Resident #1) just got back." The facility's current Abuse Prohibition Policy and Procedure, revised July 2012, reflected neglect was "A deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental anguish/illness or physical injury, or harm or death to the resident." No policy was presented related to procedures to follow in the event a resident exhibited suicidal behaviors/ideations. On 06/05/14 at 5:00 PM, the Administrator and DON were notified of the IJ and a Plan of Removal was requested at that time. The Administrator stated on 06/05/14 at 5:00 PM Resident #1 was the first resident in [AGE] years to attempt a suicide. She stated the resident was sent to the hospital for an evaluation and returned after she was cleared. The Administrator revealed the first time Resident #1 was sent to the hospital, the hospital said she was stable. The Administrator stated they (facility) did not anticipate another suicide. She stated the facility did not accept residents who were suicidal. The Administrator revealed if a resident had ideations the resident would not be readmitted . On 06/06/14 at 9:05 AM, the Administrator provided a list of nine residents at risk of suicide. (Note: on 05/19/14, the DON stated only Resident #1 was suicidal.) An interview with the Medical Director on 06/06/14 at 1:00 PM revealed of the nine residents identified for suicidal behaviors, three residents were highly susceptible to idea implantation through suicidal questioning. He expressed concern with the facility population (in general, no specific resident identified) acting out behaviors they witnessed from other residents. On 06/06/14 at 4:06 PM, the facility's Plan of Removal was accepted. The Plan of Removal revealed the following regarding the incident on 05/14/14: "...(Resident #1) returned to (facility) on May 13, 2014 (actual date May 14th) at 8:00 pm after a 4 day stay at (local) Hospital Psychiatric Evaluation Unit. Upon arrival to the center (LVN A) observed patient in the room at approximately 8:05 pm, patient displayed no verbal, gestures or attempts to harm self. At 8:20 pm, (LVN A) went back to patient's room for admission assessment and noted that patient was lying in the bed and had her call light cord wrapped around her neck twice...(LVN A) removed call light cord from resident's neck, patient was alert, talking voicing that she wanted to go back to hospital. Her color was good and in no distress...(LVN A) called for (CNA B) who remained with the resident while (LVN A) called physician and 911. Patient remained on 1:1 until she left (facility) at 8:45 pm by (company name) Ambulance. Patient no longer resides at (facility). NOTE: LVN A's Nurse's Notes reflected the resident readmitted at 8:30 PM. LVN A told the surveyor the incident occurred within 5 minutes of Resident #1 being readmitted ; not 20 minutes as reflected in the facilty's synopsis of the incident. The Plan of Removal further reflected the following: Education: On June 5, 2014, the DON started all staff(nursing, administration, housekeeping, dietary and therapy) in service on the following: (1) Clinical Practice Guidelines Suicide Protocol (a) Where to locate information to determine residents who might be at risk for self harm (b) Signs and Symptoms of residents that are at risk of harming self and immediate action steps (c) Immediate reporting responsibility to direct supervisor when a patient displays signs, symptoms or gestures of self harm. Education was started on June 5, 2014 and completed on June 6, 2014, by the DON. All facility staff has been notified of mandatory training until the center is 100% compliant. No staff will be allowed to return to work until they have had this training... On 06/05/14, the facilty reviewed all residents' clinical records to identify any resident who have a history of harming self. Nine residents were identified based on prior history. The nine residents were Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident 9 and Resident #10. The nine residents were reviewed and evaluated by the Administrator, DON, and (25 Nursing facility staff members) and were found to have no signs or symptoms harming to self. On 06/05/14, all Nurse Aide Assignment sheets will be updated to identify the nine resident by the (DON), (Regional Nurse Consultant), (LVN C), and (LVN D). On 06/05/14, the DON, Regional Nurse Consultant and LVN C will initiate the review and updating of the nine residents' care plans. On 06/05/14, Resident #3's, Resident #4's, Resident #5's, Resident #6's, Resident #7's, Resident #8's, and Resident #9's care plans reflected they had been updated to reflect Suicidal Ideation and attempts. On 06/06/14, Resident #2's care plan was updated to reflect Suicide Ideation. On 06/07/14, Resident #10's care plan was updated to reflect Self Harm. On 06/06/14, Psychologist X review and evaluate the nine identified patients, document the assessment and follow up intervention, as indicated, will be documented in the clinical record. Patient's with active suicidal ideation, verbalization and/or overt suicidal attempts including gestures and self-mutilation attempts will not be admitted or readmitted to the facility. Prior to admission or re admission to the facility the Admission Coordinator, LVN E, Social Worker V or Charge Nurse will receive verbal report and review transfer paper or referral paper work including but not limited to physician orders, nurses notes and physician progress notes [REDACTED]. Upon admission to the facility the patient is placed one-to-one supervision by staff until consulting practitioner or primary physician completes a psychosocial assessment and deems the patient safe to be independent in the facility. The assessment will be documented in the clinical record. A patient with new or returning verbalizations of attempts to harm self, overt suicidal attempts or gestures, including self-mutilation is placed one-to-one staff supervision. The EMS is notified immediately if the patient is making overt attempts and gestures including self mutilation to harm self. The physician or consulting practitioner is notified immediately after the EMS transfer for the need for further psychosocial and medical assessment for the patient to function independently in the facility. The assigned staff member continually observes the patient for signs and symptoms of attempts to harm self and calls for staff assistance if patient displays, verbalizes and/or makes an overt suicidal attempt, including self-mutilation attempts. Documentation will be done each shift by the charge nurse to reflect that patient is being monitored...The patient's room is checked for hazardous items (to include sharp objects, glass, belts, medications, etc.) when an in house patient has returning or new signs and symptoms of attempts to harm self. Documentation that rooms were checked will be completed in patient's nurse's notes. The care plan identifies the interventions used to render a patient as safe as possible to reduce the risk of self harm... On 06/06/14, in-services will be started and all facility staff (nursing, administration, housekeeping, dietary and therapy) have been notified of mandatory training. Learning is validated through post testing Education is expected to be completed June 11, 2014...Any patient that displays signs or symptoms of presenting a danger to self the staff member will remain with the patient and call for help. Patients with a history of presenting a danger to self are evaluated by Psychologists X, Y, and Z who visit the facility 5 days a week. Staff education will be validated by Regional Nurse Consultant. Resident documentation will be validated by the Assistant Directors of Nursing...." On 06/06/14, Psychologists X, Y, and Z will initiate additional training on the signs and symptoms of suicidal behavior and interventions. On 06/05/14, the Quality Assessment and Performance Improvement (QAPI)committee would meet. On 06/06/14, the QAPI would meet to review progress of performance improvement plan. The QAPI will meet weekly to review peroramce improvement plan. On 06/05/14, the facility's Medical Director was notified of the IJ, system changes and plan to sustain compliance. The following evidence confirmed the facilty's Plan of Removal had been implemented: The post test issued, to the staff after the in-service given by the Psychologists, reflected on 06/09/14 at 11:15 AM 117 employees successfully completed the post test. The post test issued, to the staff after the in-service given by the DON, reflected on 06/09/14 at 11:28 AM 130 employees successfully completed the post test. Interviews with LVN F, CNA G, Dietary Aide H, MA I, LVN J, and ADON L conducted on 06/05/14 from 1:30 PM to 1:42 PM and at 4:10 PM revealed they knew to stay with a resident who threatened or made statements regarding suicide and to call for assistance. Interviews with LVN M, CNA N, CNA O, CNA P, CNA Q, MA R, MA S, CNA T, CNA U, Cook AA, and Cook BB conducted on 06/07/14 from 1:00 PM through 2:30 PM revealed they knew what to do if a resident made statements about suicide or threats to harm self. They understood they needed to stay with the resident and call for help. Most knew to check the surrounding environment for potential weapons and what 1:1 supervision was. Most understood the CNA books reflected which residents were at risk for suicidal ideation and/or actions. During an interview on 06/09/14 at 12:23 PM, the Administrator, DON, ADON CC, RDO, Regional Nurse Consultant and ADON DD were informed the IJ was removed, but the facility remained out of compliance at a severity of level of "potential for more than minimal harm that is not immediate jeopardy," and a scope of "pattern" due to the facility was still monitoring the effectiveness of the Plan of Removal. The Administrator provided a list of nine residents, who were at risk for [MEDICAL CONDITION], attempts and self harm, on 06/06/14 at 9:05 AM.

Based on observation, interview and record review, it was determined 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 three (Residents #1, #2 and #4) of nine residents reviewed for assessments. 1. Resident #1 was observed by staff to have right knee swelling and pain on 09/04/12, and an X-ray was ordered. The X-ray results were not obtained until 09/06/12 at 10:30 AM, and showed a fracture of her right distal femur (the lower part of the thigh bone that ends at the knee cap). Resident #1 was not sent to the hospital until 09/06/12 at 8:00 PM because the facility staff wanted clarification of the X-ray results. Resident #1 had no post pain assessments done when she was medicated for pain in her knee. 2. Resident #2 had a fall documented on 08/30/12 and had pain on both 8/30/12 and 09/02/12, and no interventions were taken for pain relief. Resident #2 was medicated for pain on 09/21/12 following a fall, but no follow-up was done to determine whether her pain was relieved. 3. Resident #4 received five doses of [MEDICATION NAME] 10/325, two (2) tablets during the time period from 09/30/12 and 10/05/12. The resident was not assessed prior to administering the medications (pre) and after the medications were administered (post) to determine effectiveness for five of five doses of [MEDICATION NAME] administered. These failures could affect the 63 residents who resided on the South station placing them at risk for delays in treatment and services, increased and unrelieved pain, possible over-sedation, and inaccurate over-all assessments. Findings included: 1. Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, required "extensive assistance" with "one person physical assist" for transfers, she was receiving scheduled and PRN pain medications, and she had indicated pain by facial expressions three to four days out of the past five days. Resident #1's Nurse's Notes reflected the following entries: 09/04/12 at 11:00 AM: "Resident awake and alert able to voice needs speaks clearly c/o (complains of) knee pain of the Rt. knee. Tylenol 325 mg given knee is a little swollen. P.A. notified, n.o.n. X-ray of Rt. Knee d/t pain/swelling. (Resident's guardian) notified, will cont. to monitor." The entry was signed by LVN D. 09/05/12 at 6:00 AM: "Res. in bed...Pending (R) knee X-ray, facial grimacing with turns, remain swollen...." The entry was signed by LVN B. 09/05/12 at 3:50 PM: "Resident denies pain of Rt. Knee, knee remains swollen, X-ray results still pending, all needs met will cont. to monitor." The entry was signed by LVN D. 09/05/12 at 9:00 PM: "Resident F/U Rt knee swollen, voiced (no) pain or discomfort, will cont to monitor." The entry was signed by LVN E. 09/06/12 at 6:00 AM: "Res. cont F/U pain in (R) knee, remains swollen...pending X-ray results...." The entry was signed by LVN B. 09/06/12 at 10:30 AM: "X-Ray results received, per ____ X-ray company impression: Distal femoral fracture seen at the metaphysis (wider portion of a long bone near the end). The prosthesis appears intact during the study. P.A. notified and originally wanted her to her (sic) transfer out to ER to r/o (rule out) fracture. Whenever DON notified she was instructed by (Corporate Nurse) to send report to be re-read for clarification d/t X-ray was supposed to be for her Rt. Knee and doesn't say anything about it. PA re-notified & stated she would wait patiently for results. (Resident #1's guardian) notified and stated to keep him/her informed of the situation. Resident currently not in any distress and denies pain will continue to monitor. Swelling noted at knee area ? (no) discoloration." The entry was signed by LVN D 09/06/12 at 3:00 PM: "X-ray company called, spoke with...and they are currently waiting on doctor, PA re-notified of situation and stated if by 6 PM no clarification report, send to ER, (resident guardian) re-notified and will be awaiting update...." The entry was signed by LVN D. 09/06/12 at 8:15 PM: "Resident was send (sic) to ___Hospital @ 8:00 PM d/t possible femoral fracture for evaluation. DON was notified and she requested to give her feedback and change of condition from hospital when called. The guardian was notified at 8:10 PM...." The entry was signed by LVN E. 09/04/12 at 3:00 AM: "Late entry- Res in bed resting...CNA reported noted [MEDICAL CONDITION] to (R) knee, Pt grimacing (with) turning and repositioning Pt given Tylenol 325 mg X (times) two, tolerated well, report given to AM nurse to f/u (with) X-ray results to R/O (rule out) fx (fracture) or injury...." The entry was signed by LVN B. 09/10/12 at 11:45 PM: "Resident white female 94-yrs-old readmit to PVCC (Park View Care Center)...@ 9:40 PM...." The entry was signed by LVN E. 09/11/12 at 5:00 PM: "Resident late entry of incident that happen on 9/6/12 @ 4pm, Resident c/o pain on Rt knee and noted swollen, an X-ray ordered and report shows possible distal femoral fracture, PA notified and orders to send her out to ___ ER. Resident sent to ____ hospital @ 8 PM - Guardian notified. Continue to investigate." The entry was signed by LVN E. Review of a facility Triage Nursing assessment dated "Night Shift" facility 09/04/12 and completed by LVN B revealed the following: "Complaints of Pain?" revealed "grimacing (with) movement" "Describe pain if present" revealed "(R) knee-achy" "Swelling/[MEDICAL CONDITION]-location" revealed "(R) knee +2" "Physician Notified?" revealed "Yes" "Comments/Nursing Interventions" revealed: "While performing incont (incontinent) care CNA observed Pt grimacing with pain when attempting to turn resident, (R) knee swollen, Pt. given Tylenol 325 (two) PO PRN for (R) knee pain, notified incoming nurse to f/u for X-ray results...." Review of Resident #1's MAR assessment for the month of September 2012 revealed no Tylenol doses were documented as given all month. Further review of Resident #1's clinical record revealed she had no pain flow sheet for the month of September 2012 for documentation of her pre and post pain medication pain levels. Review of Resident #1's Physician's Telephone Order's dated 09/04/12 revealed an order for [REDACTED]. Review of Resident #1's Physician's Telephone Order's dated 09/06/12 at 4:00 PM revealed send resident to the emergency room at 6:00 PM if X-ray company cannot confirm report per PA due to possible femoral fracture at the metaphysis. Resident #1's X-ray report dated 09/05/12 at 12:23 AM and dictated 09/05/12 at 1:39 AM reflected the following: "R Knee 2V (two views) Pain Limited Movement; History: Pain, limited movement...Impression: 1. Distal femoral fracture is seen at the metaphysis. 2. The prosthesis appears intact during the study." A fax date and time appearing along the top of the report reflected it was sent 09/06/12 at 9:02 AM. Review of another X-ray report with the same dates and findings revealed it was faxed 09/06/12 at 1:58 PM. Review of a third X-ray report of Resident #1's right knee dated 09/05/12 at 12:23 AM revealed a dictation time of 09/06/12 at 3:40 PM and reflected the following impression: "1. Distal femoral fracture is seen at the metaphysis. If there is history or fracture at this location, comparison to prior study would be helpful to evaluate stability. 2. The prosthesis appears intact during the study." During an interview on 10/05/12 at 12:45 PM, LVN D was asked whether Resident #1 had any pain flow sheets. LVN D explained Resident #1 did not have a flow sheet because she was not having pain or requiring medications outside of her scheduled doses. When informed Resident #1 had two nurses' notes entries reflecting she was having pain and required additional medication, LVN D stated if she had a flow sheet it would be with the MARs. Resident #1 was observed in her bed on 10/05/12 at 1:30 PM. Both legs, as well as her left arm, were contracted. When asked if she was in any pain, Resident #1 stated, "My knee is sore." When the surveyor asked if it was her right knee, Resident #1 indicated it was. A Hospice CNA was present and performed incontinent care for the resident. When queried whether Resident #1 ever complained of pain during care, the Hospice CNA stated she hardly ever complained but, "If she does and I tell the staff, they tell me she just had something." When asked about the events surrounding 09/04/12 and her fracture, the Hospice CNA stated she had noticed her knee was swollen a couple of days before she was sent out. When asked to whom she reported it, she replied, "I want to say it was (LVN D)." During an interview on 10/05/12 at 2:20 PM, CNA F stated she could not recall the exact dates but stated, "The first day I noticed she was in pain, the next day it was swollen." "I told (LVN D), she'll tell you too. She was holding her leg saying 'ooohhhh!' (loud moaning sound). At first I thought it was the contracted leg, she said no, the other, that's when I said (LVN D) come look!" CNA F stated she had gotten her up to a chair every day and explained some days the Hospice CNA would get her up and they (facility CNAs) would put her back to bed or vice versa. When asked how Resident #1 had been getting up, CNA F explained they had been using two staff, ..."one at the top and one at the bottom... to lift her, but now that she is back, they would be using a Hoyer lift." When asked if they had been using the Hoyer since her return from the hospital, CNA F stated they had not been getting her up on her shift. During an interview on 10/05/12 at 2:55 PM, LVN D was asked about Resident #1 and the events on 09/04/12. LVN D stated the CNA was getting the resident up and said she was complaining of pain, ..."then I heard her hollering and complaining of knee pain." She stated she called the PA and got an order for [REDACTED]. When asked if the night shift had informed her of the resident's complaints, she stated they had not. She added she informed the oncoming shift to look for an X-ray. "Then the next day, LVN D told me to look for an X-ray." When asked why no one was calling for X-ray reports on 09/05/12, LVN D replied, "I can't explain that." LVN D stated when she received the results on 09/06/12, she called the PA who told her to send Resident #1 to the emergency room , and notify the guardian. LVN D notified the guardian then took the transfer paperwork to the DON, the nurse training the DON, and the Corporate Nurse. She stated the Corporate Nurse told her to wait and call the X-ray company back because they did not have enough information on the report. She then called the PA back to report the instructions received by the Corporate Nurse and stated the PA "wasn't happy." LVN D went on to explain the X-ray company sent a revised version to the facility which she took back to the DON and Corporate Nurse, and was told by the Corporate Nurse the report was still not sufficient. LVN D stated she called the PA again to update her on the situation. Before leaving her shift that day, LVN D told the DON the PA was "fed up" and gave them a time limit to get the report or send the resident out. She stated she then left for the day. During an interview on 10/05/12 at 3:45 PM, the DON stated they did ask the X-ray company to give them a clear explanation of the findings. She went on to explain the facility had had problems with the company before. The DON explained "the young lady brought the X-ray to me and we (she and the nurse training her), looked at it and said okay, they did a two-view of the right knee but the X-ray report was related to the femur." When asked if the X-ray report mentioned the distal femur, the DON replied, "Yes." When asked if it was the policy of the facility to second guess the Physicians' or Physicians Assistants' orders to send a resident out, the DON replied, "No, the PA was okay with waiting on the X-ray clarification." During an interview with the Corporate Nurse on 10/05/12 at 4:40 PM, she revealed she had wanted a clarification of Resident #1's X-ray because, "...everything I read shows we wanted an X-ray on the knee, the X-ray showed femur. We've had problems with the X-ray company before." The Corporate Nurse stated she only wanted them to clarify whether they had X-rayed the knee. The Corporate Nurse denied telling the staff to wait to send Resident #1 to the hospital, and stated she was never told the PA wanted her sent out to the ER. In an interview conducted on 10/11/12 at 5:30 AM, CNA C stated she worked the 11 PM to 7 AM shift. CNA C stated she had been taking care of Resident #1 for a long time. She stated on 09/04/12 when she was changing Resident #1, between the hours of midnight and 2:00 AM, the resident groaned, so she went and told the nurse (LVN B). CNA C stated Resident #1 was still in pain on later rounds during that same shift. CNA C stated the next night Resident #1 was "still grunting, I was more gentle with her because she was in a lot of pain. I could tell she was in a lot of pain when I touched her and turned her." CNA C stated she reported to LVN B every time she observed Resident #1 in pain. CNA C denied seeing any bruising on the resident. In an interview with LVN B on 10/11/12 at 6:00 AM, he revealed he remembered the aide telling him Resident #1 was in pain and he remembered administering Tylenol and following-up with the morning nurse about an X-ray. The surveyor queried LVN B if he had done an assessment and he said he did, and LVN B stated he looked at the resident's knee and it was slightly swollen. "I talked to her (Resident #1), I'm trying to recall. We treat her (Resident #1) like a baby, she is very frail." When asked if he ordered an X-ray, LVN B stated he could not remember. When he was asked how he was supposed to document pain and medications, LVN B stated he was supposed to document on the pain flow sheet, but did not remember documenting anything on Resident #1's pain. When asked if he notified the physician of Resident #1's change in condition, as his were the first nurse's notes on the matter, LVN B stated he was not the first nurse to know about the situation and "I know for a fact an X-ray had already been ordered." The surveyor reviewed with LVN B that he was the first nurse to document the resident was in pain. LVN B stated, "Maybe I got the date wrong." When asked whether he had looked for the X-ray results, he stated he remembered telling the day nurse to get the X-ray results. During an interview on 10/11/12 at 10:21 AM, the PA was asked if she remembered getting notified of Resident #1's X-ray results. The PA stated she did remember and stated "I wanted to send her out, then she (LVN D) told me either the DON or Corporate Nurse wanted it repeated, I didn't, I wanted it done in the ER. When she called me back and told me what they wanted I told her to do it ASAP and call me back." The PA stated she was called back again later and informed they wanted further clarification. She stated she told them she wanted it done as soon as possible to determine the fracture, and gave them the 6:00 PM cut off time. When asked whether she was aware Resident #1 still didn't get sent out until 8:00 PM that night, the PA stated, "I am so sorry about that." During an interview on 10/11/12 at 3:56 PM, when LVN E was asked why Resident #1 was not sent out to the hospital until 8:00 PM on 09/06/12, she stated she was not aware of the order. LVN E stated she was told if the X-ray company could not confirm the results, the resident needed to go out. She added, "I can't really remember, so when I called (PA) again, she said send her out." When asked if she had called the X-ray company the day before to ask for the results, LVN E stated she had not. The facility's current policy for Diagnostic Testing dated September 2009 and revised in August 2012 reflected: "It is the policy of this facility that residents receive diagnostic testing as ordered by their physician(s) and results of the testing are communicated to that physician so that prompt appropriate action can be taken if indicated for the resident's care...Diagnostic testing is any kind of medical test performed to aid in the [DIAGNOSES REDACTED]." Procedure: "1. The physician will provide an order, either verbally or written, for the specific test to be obtained...5. When test results are received the physician will be notified of any abnormal findings on the day the results are received by the facility. Notification may be by phone, fax, or in person...7. Should the physician order [REDACTED]. Review of the __________ Diagnostic Services Agreement signed 04/08/12 and 04/09/12 revealed "...1. Services Provider shall provide portable X-ray, EKG, Holter monitoring and ultrasound services to residents or patients of the Facility, only on the order of a duly licensed and qualified Radiologist (the 'Radiologist'). The Radiologist will dictate a report for each examination. Provider will promptly fax an abbreviated report to the Facility, and transcribe the full written report and fax a copy to the Facility. Provider will perform EKGs and upon request have an interpretive written report issued ...." 2. Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was not receiving any pain medications. Observation on 10/11/12 at 9:06 AM, revealed Resident #2 was sitting in a wheelchair, in the dining room with another resident watching television. Review of Resident #2's monthly consolidated physician's orders [REDACTED]. Review of Resident #2's Nurse's Notes dated 08/30/12 at 8:00 AM revealed "Resident found on the floor in the dining room by (another resident), he notified this nurse but didn't see her fall. Resident c/o pain to rt. shoulder & forearm. PA notified, n.o.n. X-ray of Rt. Forearm and shoulder, pelvis and skull & resident may be transferred to bed. ? bruises noted, ? skin tears. Resident able to move all extremities and is awake and alert X 2. Resident is her own responsible party, neuro vital signs initiated will cont. to monitor." Review of Resident #2's Triage Nursing assessment dated [DATE] at 8:00 AM revealed she had complaints of sharp pain to her right shoulder. The area designated for "Comments/Nursing Interventions" was left blank. Review of Resident #2's SBAR Physician/NP/PA Communication and Progress Note for New Symptoms, Signs and Other Changes of Condition revealed her pain level was "6" out of 10 and the resident appeared "in pain." The entries were made by LVN D. Review of Resident #2's MARs for August 2012 revealed she received no medications administered for pain. She had no pain flow sheet. Resident #2's Nurse's Notes entry dated 09/02/12 at 2:00 PM, reflected: "Resident c/o soreness, probably from the recent falls. Grip strength good, lower extremities strength good. Resident has ? fxs as per X-ray results...WCTM ...." There were no further notes related to Resident #2's soreness. The entry was made by LVN G. Resident #2's Nurse's Notes entry dated 09/21/12 at 12:35 PM reflected: "After assisting another resident I responded to residents bed alarm going off and found Resident lying on the floor on rt side & arm in her bathroom. C/o pain to arm [MEDICATION NAME] given as ordered prn. PA notified...." There were no further entries related to the pain in her arm. The entry was made by LVN D. Review of Resident #2's MARs for September 2012 revealed no pain medications were administered on 09/02/12. [MEDICATION NAME] was initialed as given on 09/21/12. She had no pain flow sheet. During an interview on 10/12/12 at 10:05 AM, LVN D was queried about her nursing entries related to Resident #2 on 08/30/12. LVN D explained she remembered being in a hurry to call the doctor and get X-rays ordered and thought she had asked the medication aide to give her [MEDICATION NAME], but stated she could not be sure. During an interview on 10/12/12 at 11:09 AM, LVN G was asked about Resident #2's "soreness" on 09/02/12 and whether or not he addressed it. LVN G stated, "I didn't give her anything? I don't recall if I overlooked that." When asked how he documents if he gives a prn medication, LVN G explained it should be documented on the pain flow sheet and nurse's notes and added, "Typically I make extensive notes." During an interview on 10/12/12 at 12:28 PM, ADON A was asked how the nurses should document pain medications. ADON A explained if a resident was given a prn medication, it should be documented in the nurse's notes and on the pain flow sheet, and the nurse should follow-up in an hour and document the effectiveness. She added the medication should also be signed out on the MAR. 3. Resident #4, a [AGE] year-old-female was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of this assessment revealed the resident received scheduled pain medication, and had occasional pain that the resident described as moderate. Review of Resident #4's consolidated signed physician's orders [REDACTED]." Note there was no frequency. Review of Resident #4's care plan revealed the resident was at risk for pain due to [MEDICAL CONDITION], Wound, Recent Right Hip Arthroplasty, Arthritis and Decreased Debility. Approaches on this care plan included provide medication per the physician's orders [REDACTED]. Review of Resident #4's MARs dated September 2012 revealed no nurses' initials, which indicated the [MEDICATION NAME] was not administered. Review of Resident #4's MARs dated October 2012 revealed no nurses' initials, which indicated the [MEDICATION NAME] was not administered. Review of Resident #4's "Pain Management Flowsheet" revealed no pre or post pain assessments since 09/25/12. Review of Resident #4's "Controlled Drug Record" revealed [MEDICATION NAME] 10/325 mg, two tablets were administered on 09/30/12 at 5:00 PM, on 10/01/12 at 4:30 PM, on 10/03/12 at 8:00 PM, on 10/04/12 at 3:30 PM, and on 10/05/12 at 3:15 PM. Review of Resident #4's nurses' notes dated 09/30/12, 10/01/12, 10/04/12 and 10/05/12 revealed there were no pre or post pain assessments when the [MEDICATION NAME] was administered. An interview conducted on 10/11/12 at 6:00 AM with LVN B revealed it was protocol to document PRN pain medications in the nurses' notes and on the pain flow sheets. An interview conducted on 10/12/12 at 9:00 AM with the DON confirmed Resident #4 did not have a "Pain Management Flowsheet" for October 2012. An interview conducted on 10/12/12 at 10:30 AM with ADON A, revealed the nurses were to document PRN pain medications in the nurses' notes, the MAR and the pain flow sheet. ADON A further stated the nurses were to monitor the effectiveness of the pain medication an hour to an hour and a half after the pain medication was administered. She further stated it was her responsiblity to monitor and see if the nurses completed the proper documentation. Review of a current facility policy and procedure "Pain Management" dated December 2003 revealed, "Fundamental Information ...2. Documenting pain assessment(s), and evaluation activities in a clear and concise manner is a key to effective pain management ...Procedure ...2. The resident's descriptive words descriptive words describing the quality, duration, and location of pain will be used to evaluate the pain and to identify changes in the pain ...8. The pain will be re-evaluated after one hour for effectiveness of the intervention and documented in the medical record, or on a specified alternate schedule when appropriate. 9. The "Pain Management Flow Sheet" ...will be used to assess pain of residents whose pain is not adequately controlled by occasional prn pain or by a regimen of routine pain medications. 10. The Pain Management Flow Sheet will be completed each time a prn pain medication is administered...." The Midnight Census Form provided by the facility on 10/05/12 reflected there were 63 residents residing on the South station.

Based on record review and interview, it was determined that the facility failed to provide or obtain timely radiology services to meet the needs of one (Resident #1) of five residents on the South station whose records were reviewed for such services. Resident #1 was observed by staff to have knee swelling and pain on 09/04/12 and an X-ray was ordered. The X-ray results were not obtained until 09/06/12 at 10:30 AM and revealed a fracture of her right distal femur (the lower part of the thigh bone that ends at the knee cap). Resident #1 was not sent to the hospital until 09/06/12 at 8:00 PM because the facility staff wanted clarification of the X-ray results. This failure could affect any of the 63 residents who resided on the South station placing them at risk for delay in treatment and services. Findings included: Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed she was severely impaired cognitively, and required "extensive assistance" with "one person physical assist" for transfers. Resident #1's Nurses' Notes reflected the following entries: 09/04/12 at 11:00 AM: "Resident awake and alert able to voice needs speaks clearly c/o (complains of) knee pain of the Rt. knee. Tylenol 325 mg given knee is a little swollen. P.A. notified, n.o.n. X-ray of Rt. Knee d/t pain/swelling. (Resident's guardian) notified, will cont. to monitor." The entry was signed by LVN D. 09/05/12 at 6:00 AM: "Res. in bed...Pending (R) knee X-ray, facial grimacing with turns, remain swollen...." The entry was signed by LVN B. 09/05/12 at 3:50 PM: "Resident denies pain of Rt. Knee, knee remains swollen, X-ray results still pending, all needs met will cont. to monitor." The entry was signed by LVN D. 09/05/12 at 9:00 PM: "Resident F/U Rt knee swollen, voiced (no) pain or discomfort, will cont to monitor." The entry was signed by LVN E. 09/06/12 at 6:00 AM: "Res. cont F/U pain in (R) knee, remains swollen...pending X-ray results...." The entry was signed by LVN B. 09/06/12 at 10:30 AM: "X-Ray results received, per ____ X-ray company impression: Distal femoral fracture seen at the metaphysis (wider portion of a long bone near the end). The prosthesis appears intact during the study. P.A. notified and originally wanted her to her (sic) transfer out to ER to r/o (rule out) fracture. Whenever DON notified she was instructed by (Corporate Nurse) to send report to be re-read for clarification d/t X-ray was supposed to be for her Rt. Knee and doesn't say anything about it. PA re-notified & stated she would wait patiently for results. (Resident #1's guardian) notified and stated to keep him/her informed of the situation. Resident currently not in any distress and denies pain will continue to monitor. Swelling noted at knee area ? (no) discoloration." The entry was signed by LVN D 09/06/12 at 3:00 PM: "X-ray company called, spoke with...and they are currently waiting on doctor, PA re-notified of situation and stated if by 6 PM no clarification report, send to ER, (resident guardian) re-notified and will be awaiting update...." The entry was signed by LVN D. 09/06/12 at 8:15 PM: "Resident was send (sic) to ___Hospital @ 8:00 PM d/t possible femoral fracture for evaluation. DON was notified and she requested to give her feedback and change of condition from hospital when called. The guardian was notified at 8:10 PM...." The entry was signed by LVN E. 09/04/12 at 3:00 AM: "Late entry- Res in bed resting...CNA reported noted [MEDICAL CONDITION] to (R) knee, Pt grimacing (with) turning and repositioning Pt given Tylenol 325 mg X (times) two, tolerated well, report given to AM nurse to f/u (with) X-ray results to R/O (rule out) fx (fracture) or injury...." The entry was signed by LVN B. Nurses' notes dated 09/10/12 at 11:45 PM reflected "Resident white female 94-yrs-old readmit to PVCC (Park View Care Center)...@ 9:40 PM...." The entry was signed by LVN E. Nurses' notes dated 09/11/12 at 5:00 PM reflected "Resident late entry of incident that happen on 9/6/12 @ 4pm, Resident c/o pain on Rt knee and noted swollen, an X-ray ordered and report shows possible distal femoral fracture, PA notified and orders to send her out to ___ ER. Resident sent to ____ hospital @ 8 PM - Guardian notified. Continue to investigate." The entry was signed by LVN E. Review of a facility Triage Nursing assessment dated "Night Shift" 09/04/12 and completed by LVN B revealed the following: "Complaints of Pain?" revealed "grimacing (with) movement" "Describe pain if present" revealed "(R) knee-achy" "Swelling/[MEDICAL CONDITION]-location" revealed "(R) knee +2" "Physician Notified?" revealed "Yes" "Comments/Nursing Interventions" revealed: "While performing incont (incontinent) care CNA observed Pt grimacing with pain when attempting to turn resident, (R) knee swollen, Pt. given Tylenol 325 (two) PO PRN for (R) knee pain, notified incoming nurse to f/u for X-ray results...." Review of Resident #1's Physician Telephone Order's dated 09/04/12 revealed an order for [REDACTED]. Review of Resident #1's Physician's Telephone Orders dated 09/06/12 at 4:00 PM, revealed send resident to the emergency room at 6:00 PM if X-ray company cannot confirm report per PA, due to possible femoral fracture at the metaphysis. Resident #1's X-ray report dated 09/05/12 at 12:23 AM, and dictated 09/05/12 at 1:39 AM reflected the following: "R Knee 2V (two views) Pain Limited Movement; History: Pain, limited movement...Impression: 1. Distal femoral fracture is seen at the metaphysis. 2. The prosthesis appears intact during the study." A fax date and time appearing along the top of the report revealed it was sent 09/06/12 at 9:02 AM. Review of another X-ray report with the same dates and findings revealed it was faxed 09/06/12 at 1:58 PM. Review of a third X-ray report of Resident #1's right knee dated 09/05/12 at 12:23 AM, revealed a dictation time of 09/06/12 at 3:40 PM and reflected the following impression: "1. Distal femoral fracture is seen at the metaphysis. If there is history or fracture at this location, comparison to prior study would be helpful to evaluate stability. 2. The prosthesis appears intact during the study." Resident #1 was observed in her bed on 10/05/12 at 1:30 PM. Both legs, as well as her left arm, were contracted. When asked if she was in any pain, Resident #1 stated, "My knee is sore." When the surveyor asked if it was her right knee, Resident #1 indicated it was. A Hospice CNA was present and performed incontinent care for the resident. When queried whether Resident #1 ever complained of pain during care, the Hospice CNA stated she hardly ever complained but, "If she does and I tell the staff, they tell me she just had something." When asked about the events surrounding 09/04/12 and her fracture, the Hospice CNA stated she had noticed her knee was swollen a couple of days before she was sent out. When asked to whom she reported it, she replied, "I want to say it was (LVN D)." During an interview on 10/05/12 at 2:20 PM, CNA F stated she could not recall the exact dates but stated, "The first day I noticed she was in pain, the next day it was swollen." "I told (LVN D), she'll tell you too. She was holding her leg saying 'ooohhhh!' (loud moaning sound). At first I thought it was the contracted leg, she said no, the other, that's when I said (LVN D) come look!" CNA F stated she had gotten her up to a chair every day and explained some days the Hospice CNA would get her up and they (facility CNAs) would put her back to bed or vice versa. When asked how Resident #1 had been getting up, CNA F explained they had been using two staff, "...one at the top and one at the bottom..." to lift her but now that she is back, they would be using a Hoyer lift. When asked if they had been using the Hoyer since her return from the hospital, CNA F stated they had not been getting her up on her shift. During an interview on 10/05/12 at 2:55 PM, LVN D was asked about Resident #1 and the events on 09/04/12. LVN D stated the CNA was getting the resident up and said she was complaining of pain, "...then I heard her hollering and complaining of knee pain." She stated she called the PA and got an order for [REDACTED]. She added she informed the oncoming shift to look for an X-ray. The next day, LVN B told me to look for the X-ray. When asked what had been happening with the X-ray on 09/05/12, LVN B stated she could not explain that. LVN B went on to explain when she received the results on 09/06/12, she called the PA who told her to send Resident #1 to the emergency room , and notify the guardian which she did. She went on to explain she then took the paperwork to the DON, the nurse training the DON, and the Corporate Nurse. She stated the Corporate Nurse told her to wait, and call the X-ray company back because they did not have enough information on the report. She then called the PA back to explain, and stated the PA "wasn't happy." LVN D went on to explain the X-ray company sent a revised version to the facility which she took back to the DON and Corporate Nurse, and was told by the Corporate Nurse, the report was still not sufficient. LVN D stated that she called the PA again to update her on the situation, and told the DON before she left her shift, that the PA was "fed up," and gave a time limit to get the report or to send the resident out. She stated she then left for the day. During an interview on 10/05/12 at 3:45 PM, the DON stated they did ask the X-ray company to give them a clear explanation of the findings. She went on to explain the facility had had problems with the company before. The DON explained "the young lady brought the X-ray to me and (the nurse training her), we looked at it and said okay, they did a two-view of the right knee but the X-ray report was related to the femur." When asked if the X-ray report mentioned the distal femur, the DON replied, "Yes." When asked if it was the policy of the facility to second guess the Physician's or Physicians Assistants'orders to send a resident out, the DON replied, "No, the PA was okay with waiting on the X-ray clarification." In an interview conducted on 10/11/12 at 5:30 AM, CNA C stated she worked the 11:00 PM to 7:00 AM shift. CNA C stated she had been taking care of Resident #1 for a long time. She stated on 09/04/12 when she was changing Resident #1, between the hours of midnight and 2:00 AM, the resident groaned, so she went and told the nurse (LVN B). CNA C stated Resident #1 was still in pain on later rounds during that same shift. CNA C stated the next night, Resident #1 was "Still grunting, I was more gentle with her because she was in a lot of pain. I could tell she was in a lot of pain when I touched her and turned her." CNA C stated she reportd to LVN B every time she observed Resident #1 in pain. CNA C denied seeing any bruising on the resident. During an interview conducted with LVN B on 10/11/12 at 6:00 AM, revealed he remembered the aide telling him Resident #1 was in pain, and he remembered administering Tylenol and following-up with the morning nurse about an X-ray. The surveyor queried LVN B if had done an assessment, and he said he did, and LVN B stated he looked at the resident's knee, and it was slightly swollen. "I talked to her (Resident #1), I'm trying to recall. We treat her (Resident #1) like a baby, she is very frail." When asked if he ordered an X-ray, LVN B stated he could not remember. When he was asked how he was supposed to document pain and medications, LVN B stated he was supposed to document on the pain flow sheet, but did not remember documenting anything on Resident #1's pain. When asked if he notified the physician of Resident #1's change in condition, as his were the first nurse's notes on the matter. LVN B stated he was not the first nurse to know about the situation, and stated, "I know for a fact an X-ray had already been ordered." The surveyor reviewed with LVN B that he was the first nurse to document the resident was in pain, and LVN B stated, "Maybe I got the date wrong." When asked whether he had looked for the X-ray results, he stated he remembered telling the day nurse to get the X-ray results. During an interview conducted on 10/11/12 at 3:56 PM, when LVN E was asked why Resident #1 was not sent out to the hospital until 8:00 PM on 09/06/12, she stated she was not aware of the order. LVN E stated she was told if the X-ray company could not confirm the results, the resident needed to go out. She added, "I can't really remember, so when I called (PA) again, she said send her out." When asked if she had called the X-ray company the day before to ask for the results, LVN E stated she had not. In an interview conducted with the Corporate Nurse on 10/05/12 at 4:40 PM, she revealed she had wanted a clarification of Resident #1's X-ray because, "...everything I read shows we wanted an X-ray on the knee, the X-ray showed femur. We've had problems with the X-ray company before." The Corporate Nurse stated she only wanted them to clarify whether they had x-rayed the knee. The Corporate Nurse denied telling the staff to wait to send Resident #1 to the hospital, and stated she was never told the PA wanted her sent out to the ER. During an interview on 10/11/12 at 10:21 AM, the PA was asked if she remembered getting notified of Resident #1's X-ray results. The PA stated she did remember, and further stated "I wanted to send her out, then she (LVN D) told me either the DON or Corporate Nurse wanted it repeated, I didn't, I wanted it done in the ER. When she called me back and told me what they wanted, I told her to do it ASAP and call me back." The PA stated she was called back again later, and informed they wanted further clarification. She stated she told them she wanted it done as soon as possible to determine the fracture, and gave them the 6:00 PM cut off time. When asked whether she was aware Resident #1 still didn't get sent out until 8:00 PM that night, the PA stated, "I am so sorry about that." The facility's current policy for Diagnostic Testing dated Septemher 2009 and revised August 2012 reflected: "It is the policy of this facility that residents receive diagnostic testing as ordered by their physician(s) and results of the testing are communicated to that physician so that prompt appropriate action can be taken if indicated for the resident's care...Diagnostic testing is any kind of medical test performed to aid in the [DIAGNOSES REDACTED]." Procedure: "1. The physician will provide an order, either verbally or written, for the specific test to be obtained....5. When test results are received the physician will be notified of any abnormal findings on the day the results are received by the facility. Notification may be by phone, fax, or in person...7. Should the physician order [REDACTED]. Review of the __________ Diagnostic Services Agreement signed August 8, 2012 and April 9, 2012 revealed "...1. Services Provider shall provide portable X-ray, EKG, Holter monitoring and ultrasound services to residents or patients of the Facility, only on the order of a duly licensed and qualified Radiologist (the 'Radiologist'). The Radiologist will dictate a report for each examination. Provider will promptly fax an abbreviated report to the Facility, and transcribe the full written report and fax a copy to the Facility. Provider will perform EKGs and upon request have an interpretive written report issued ..." The Midnight Census Form provided by the facility on 10/05/12 reflected there were 63 residents residing on the South station.

Based on observation, interview and record review, it was determined the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being for eight (Residents #1, #5, #6, #7, #8, #9, #11, and #12) of 21 residents reviewed for elopement. 1. The ADM failed to develop an Elopement/Missing Resident policy specific to the facility, since the facility did not have alarms on the exit doors, which the policy indicated. The ADM failed to implement the Abuse Prohibition Policy and Procedure which included the Neglect policy. The ADM failed to supervise the DON to ensure she carried out her job responsibilities regarding preventing resident elopement. 2. The DON failed to supervise the Administrative Nurses to ensure they were completing Care Plans which addressed all of the residents' needs and were completing Elopement/Wandering Assessments after a resident eloped. The DON failed to train staff regarding exit-seeking behaviors and interventions for the behaviors specific to the facility. These failures resulted in Resident #1's elopement from the facility and her subsequent death. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could have affected the 109 residents, including Residents #5, #6, #7, #8, #9, #11, and #12, by placing them at risk for elopement, injuries, and/or death. Findings included: 1. Review of the facility's Abuse Prohibition Policy and Procedure, which included the Neglect policy, dated February 2012 and identified as current by the ADM, revealed, "The facility will be proactive in identifying events and occurrences that may contribute to abuse or neglect...a committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet as needed to identify, correct and intervene in situation in which abuse, neglect or misappropriation of resident property is more likely to occur. This includes an analysis of features of the physical environment that may make abuse and or neglect more likely to occur, such as secluded areas of the facility." Included with the policy was Attachment A, which reflected neglect was "a deprivation of life's necessities of food, water or shelter, or a failure of an individual to provide services treatment or care to a resident which causes or could cause mental anguish/illness or physical injury or harm or death to the resident." The facility's Elopement/Missing Resident nursing policy and procedure revised [DATE] reflected, "If the resident is assessed as moderate to high risk the monitoring procedure will be implemented." The procedure for monitoring included: "When a door alarm sounds, ALL facility staff will immediately respond. UNDER NO CIRCUMSTANCES should an alarm be treated as a 'FALSE ALARM!' ? Determine which door alarm triggered. ? Immediately go to the door to determine how the alarm was activated and assess the situation. If it is clear who/what set the alarm off, reset the alarm. If a resident was seen opening the door, redirect the resident away from the door. ? If the cause of the alarm cannot be quickly identified, survey the immediate area outside the door. ? If a resident is not seen in the immediate area, return to the facility and initiate a head count." Interview on [DATE] at 2:50 PM with FL L revealed the facility did not have any alarms on the exit doors that would sound if the door was opened. Further review of the facility's Elopement/Missing Resident Policy also reflected, "Formulate an assessment of a resident's potential to elope from the facility and have a plan in place to assure appropriate steps are taken to protect the resident from an elopement...Elopement assessments will be completed on admission, quarterly and as needed. If the resident is assessed as a moderate to high risk the monitoring procedure will be implemented." The monitoring procedure was: "Complete the Elopement Assessment Tool. Within ,[DATE] days of admission the Interdisciplinary Team (IDT) will evaluate the residents risk potential and determine the need for further monitoring. If it is determined that the electronic monitoring device is required: ? The monitoring device will be monitored every shift for placement and documented on the MAR's. ? The monitoring device will be checked every day for functioning and documented on the MAR's. ? The electronic monitoring system will be checked every week for operable functioning. The Care Plan will be initiated for those resident identified at risk by the IDT." Interview with ADM on [DATE] at 4:55 PM revealed she had been the ADM of the facility for the past 5 years. When asked what type of procedures were in place to ensure the nursing needs of the residents were being met, she stated she conducted audits of the clinical records and interviewed residents and their families. The ADM stated she did a random sampling of each station with an average of five residents per day being sampled. She revealed she did not document or make any notes when she conducted these random samplings. The ADM stated if she had a concern, she discussed it with the DON to formulate a plan to address the issues. She revealed she also " checks on the residents using the Care Tracker (computer program to track daily ADLs for residents)." She stated she interviewed the employees randomly to see if they had any concerns about the residents. The ADM stated she did not have any documentation of the employee interviews. She said morning meetings also helped her track the progress of the staff to meet the residents' needs. She revealed the " communication from the family and the resident are my first line of information. " When asked if she checked to see if assignments were completed, the ADM stated in the meeting she asked for reports from staff and she would verify their progress " about 60%" of the time to ensure assignments were completed. In this same interview, the ADM stated she monitored the DON and staff through constant communication. When asked how she thought the IJ occurred, she stated she thought Resident #1 followed someone out the door, but with the reports from the other residents of Resident #1 going over the fence made her wonder what really happened. She stated they missed the exit-seeking behaviors of the resident. The ADM stated they needed to do a better job of training their staff to recognize exit-seeking behaviors, and they needed to look more closely at the security of their facility. She stated the courtyard was not secure. She stated they were going to make changes in the courtyard with new mag locks on the doors, a higher fence and 24 hour monitoring of the courtyard. The ADM stated she felt they did not identify the residents at risk of elopement and notify the staff of the residents who were moderate or high risk for elopement. She stated they now had the "walking man" symbols and would continue to ensure residents were assessed and care plans were completed for residents at risk for elopement. 2. Interview with the DON on [DATE] at 2:45 PM revealed Resident #1 had been in the facility for one and a half years. She stated the resident was a loner, was quiet and did not make friends. The DON stated Resident #1 was always talking about leaving the facility and going home or going to the hospital. She stated she thought the IJ occurred because staff failed to monitor the activities of Resident #1 and she was able to slip out the door without being detected. She revealed Resident #1 had eloped from the building twice previously by following vendors out the front door. The DON also stated the resident wandered all over the facility as a part of her normal routine, so no one really kept track of her whereabouts. She revealed Resident #1 should have been assessed for her wandering behaviors and should have had a care plan to reflect her wandering activities and elopements, but she was not sure those had been done. When asked if she worked with the care plans or the assessments, she revealed they were completed by the ADON and the MDS coordinator and not by her. The DON also stated the corporate nurse assigned the in-services that were to be completed by the staff and she was not in charge of in-servicing the staff. The DON stated she could not recall if there had been an staff inservice recently on elopement or behaviors. 3. The facility's Provider Investigation Report dated [DATE] provided by the ADM reflected an allegation of Death/Missing Resident was investigated involving Resident #1. The Report reflected Resident #1 was a [AGE] year-old female, who required no special supervision, had minimal functional ability and who had a history of [REDACTED]. Resident #1's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was 64.5" (approximately 5'4") tall and weighed 211.6 lbs. on [DATE]. Review of Resident #1's Elopement/Wandering Assessment Tools dated [DATE], [DATE], and [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #1's Care Plan originally dated [DATE] and updated on [DATE], [DATE] and [DATE] did not address her exit-seeking behaviors or her elopement/wandering risk. The facility's Incident/Accident Report dated [DATE] reflected at 6:15 AM Resident #1 followed "the vending man while he was exiting the building, and was asked to come back in the building." The Report also reflected every 15 minute checks were started on the resident. Review of the 15 Minute Surveillance Log for Resident #1 on [DATE] revealed she was in the front lobby from 3:30 PM through 4:15 PM, 5:30 PM through 5:45 PM. On [DATE] the Log reflected she was in the front lobby from 2:00 AM through 5:00 AM, 3:45 PM through 6:30 PM and 8:15 PM through 8:30 PM. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new assessment after her elopement of [DATE]. Her previous [DATE] assessment identified her as a moderate risk for elopement. The tool reflected a question "Is there a current behavior of wandering/exit seeking behavior?" If Resident #1 had been assessed using this tool after the [DATE] elopement from the building her new score would have been a four which identified her as being a high risk for elopement. Review of Resident #1's Care Plan originally dated of [DATE] and updated on [DATE] revealed the resident did not have a care plan for her exit-seeking behaviors, her elopement risk, her actual elopements, or her verbalizations of wanting to leave the facility. Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female and she was assessed as usually being understood and as having the ability to usually understand others. The MDS assessment reflected she was moderately impaired cognitively and had fluctuating behaviors of inattention and disorganized thinking. She had [MEDICAL CONDITION] and was assessed as having wandering behaviors occurring four to six days each week. Further review of the MDS assessment revealed she was able to transfer, walk in her room on and off the unit, dress and toilet herself with supervision and she walked without any assistive devices. The assessment also reflected she took antianxiety and antidepressant medications daily. The facility's Incident/Accident Report dated [DATE] for Resident #1 reflected at 8:00 PM she "ran out of the building behind an x-ray tech who was trying to pull his machine through the door." An attached Statement by Witness dated [DATE] by LVN A reflected Resident #1 "took off behind an x-ray technician out of the front door when he tried to pull his machine through the front door (The) resident was chased down by the receptionist at the time with the tech and brought back to the facility...Physician notified and order received to place resident on Q15 (minute) monitoring x (for) 72 hrs (hours) for exit seeking behavior...will continue to monitor closely." Past Interventions Attempted included "redirected to stay within the facility and refrain from trying to get out of the front door. (The) staff (are) to monitor more frequently." Recommended Interventions were "on 15 minute monitoring for exit seeking behavior." Resident #1's Elopement/Wandering Assessment Tool did not reflect a new elopement assessment was completed after the [DATE] elopement. Resident #1's Care Plan was not updated after the [DATE] elopement from the building. Review of Resident #1's NN dated [DATE] revealed "resident is awake, disorganized with poor judgment, poor insight. (She was) constantly thinking of leaving, bringing her blanket and bag." The Provider Investigation Report dated [DATE] reflected Resident #1 was "unable to be located in the facility at 1:00 pm on [DATE]. A search was conducted inside the facility as well as surrounding grounds and nearby businesses as well as bus stations and hospital districts." Further review of the Provider Investigation Report revealed the local Police Department was notified at 2:15 PM and the search continued on the facility grounds as well as the surrounding community by staff members until approximately 5:10 PM when a female was found deceased who matched the description of Resident #1. The facility's Provider Investigation Report also included witness statements of the elopement from Residents #2, #3, and #4. The Report also included interviews with those residents conducted by the Social Worker and statements from MA H and CNA G. Review of Resident #4's Admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male with the ability to understand others and make himself understood. The assessment reflected he was cognitively intact and he did not have hallucinations or [MEDICAL CONDITION]. Review of a statement written by Resident #4 dated [DATE] revealed he saw the elopement of Resident #1 on [DATE]. He revealed he "saw a person standing on a chair at the back fence off the patio. I called out and said someone is trying to leave the facility, they got off the chair. I went in for a couple of minutes, came back out and saw someone in the process of going over the fence ...The only other people the smoke patio were (Residents #2 and #3)." Review of Resident #2's Admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female who was cognitively intact. Interview on [DATE] at 3:20 PM with Resident #2 revealed she talked to the nurse because she was "upset about the girl that got killed (Resident #1). She went over the back gate." She revealed she was sitting on the smoking patio with Residents #3 and #4 when it happened. She revealed Resident #1 told her the day before she was going home, but she "told everyone that all the time." Resident #2 stated the resident used "one of those padded chairs with arms" on the smoking patio to get over the gate. She revealed the chair was positioned with the chair back against the gate. Resident #2 stated Resident #1 climbed on the seat, and then the arms of the chair and then the back of the chair to get on top of the fence. Resident #2 stated Resident #1 lowered herself to the ground and then walked toward the street. Resident #2 stated she did not say anything, because Resident #3 said not to and the police would bring back Resident #1 in a couple of hours. Resident #2 was able to correctly say her name, the day of the week, the month, the date, the president of the United States, the name of the facility and the location of the facility. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was cognitively intact. Interview on [DATE] at 2:15 PM with Resident #3 revealed he witnessed Resident #1's elopement on [DATE]. He revealed he was sitting on the smoking porch in the courtyard with Residents #2 and #4. He stated he saw a female standing on a chair and climbing the fence. Resident #3 was not able to describe the chair the resident used to climb over the fence. He stated he thought the resident was already out in the courtyard when he came out because he did not see her come out the facility door. He revealed it was night time. When asked the day of the week, he could not respond. Resident #3 stated the resident held on to the top of the fence and then dropped to the other side. Review of CNA G's, the CNA for Resident #1 on [DATE], Statement by Witness dated [DATE] revealed she worked the 7:00 AM to 3:00 PM shift on [DATE]. The statement reflected she "came in about 7:00 AM. I went to my station and went room to room and said good morning to all my patients like I always do and get them ready for breakfast. The med aid gave her her meds. I continued to get my patients ready for breakfast. Approximately 7:15 AM was the last time I saw (Resident #1). It's normal that she is not seen because she walks the halls in and out of (her) room." Interview on [DATE] at 4:45 PM with MA H revealed she had worked in the in facility for the past [AGE] years. She worked on the Central Hall, where Resident #1 resided, on the 7:00 AM to 3:00 PM Monday through Friday shift. She stated on [DATE] she entered the facility using the front door and went into the living room. She revealed she saw a few residents in the living room, including Resident #1, who asked her for a soda. She stated she obtained her medication cart, pushed it to the living room and then went to get a soda from the vending machine for Resident #1. MA H stated she gave Resident #1 her medications, followed by water and then gave her the soda. She revealed she always gave medications to Resident #1 first before her shower, because Resident #1 sometimes got agitated when she showered and MA H wanted to ensure the mediations had time to work before she was showered. When asked if the resident was in pajamas, she stated Resident #1 was always dressed when she arrived in the mornings. She stated she Resident #1 had something rolled up in a black jacket and she asked what was rolled up in the jacket. MA H stated Resident #1 opened the jacket and adult briefs were inside. She stated it was not uncommon for Resident #1 to have her jacket with things rolled up inside, such as food, clothing, or juice. MA H revealed she never asked the resident about the clothing because "She is a psych patient, so to me it was normal behavior." She revealed the resident did not make any comments about leaving, but the resident often said she wanted to go home or someone was coming to pick her up. MA H stated she had not witnessed any exit-seeking behaviors of Resident #1, but she was told the resident had previously eloped. She stated she was told to watch the resident. She revealed Resident #1 did not normally sit in the courtyard area, but when it got cool, she sat out there occasionally. MA H stated on [DATE] Resident #1 was wearing a yellow shirt, orange capris and white and blue tennis shoes. The facility's Investigation Summary dated [DATE] included with the Provider Investigation Report reflected after Resident #1 was found deceased , facility rounds were conducted again to ensure all residents were accounted for and a complete chart audit was done to identify all residents who were at risk for elopement. In-services with staff were started regarding the following: ? System for elopement based on risk assessments, ? Location of the elopement book, ? Correct procedure for completing the elopement assessment, ? How to identify residents who are high, moderate or low risk for elopement and ? Ways to redirect these residents. The Summary also reflected residents in the facility who were identified as high risk for elopement were placed on every 30 minute visual checks and moderate to low risk residents were being monitored every hour. All monitoring was documented on individual surveillance forms. Further review of the Investigation Summary revealed the codes on the exterior doors were changed, would be changed daily, a staff member would be at the front reception desk 24 hours a day, and the courtyard area was being monitored from 7:00 AM to 10:00 PM by a smoke aide. Observation on [DATE] at 3:00 PM of the facility's courtyard revealed a six foot iron gate with a smooth railing on the top. There was a stabilizing bar in the fence approximately 10" from the top of the fence which ran side to side. The fence had a gate with a mag lock (locking device that consists of an electromagnet and an armature plate. By attaching the electromagnet to the door frame and the armature plate to the door, the electromagnet attracts the armature plate, holding the door shut) and was secure when tested . The facility's exterior door to the courtyard was not locked. Three chairs with arms were on the smoking patio in the courtyard. Interview on [DATE] 1:45 PM with the CO revealed he was a Forensic Death Investigator who was sent to the scene on [DATE] where Resident #1's body was located. He revealed he arrived at 6:33 PM and observed the body to be approximately .5 miles off the road in the wooded area of the park adjacent to the facility. The resident was fully dressed with no outward signs of trauma and deceased . He stated the resident was dressed in a yellow shirt, orange pants, tennis shoe and wearing a black jacket. He described the resident as warm to the touch with the first signs of rigor mortis setting in and slight sloughing of the skin on the legs, which he attributed to the heat of the day. An interview with the RD on [DATE] at 10:50 AM revealed they had confirmation the deceased female found in the park adjacent to the facility on [DATE] was Resident #1. She revealed Resident #1 did not appear to be a nursing home resident because she was young and could walk unassisted. She revealed the timeline of events on [DATE] were: ? 7:40 AM - The MA was the last staff member to remember seeing Resident #1 when she gave her morning medications in the front lobby. ? 1:00 PM - The staff realized Resident #1 did not come to lunch and began search. ? 2:00 PM - The DON was notified they could not locate Resident #1 in the facility. A facility wide search was conducted including a perimeter search. The ADM, who was out of the building for a guardian meeting, was notified. ? 2:45 PM - After the search did not locate Resident #1 in the facility or on the grounds; 911, the RD, the Regional Nurse, family and physician were notified. The staff was organized into teams and searched the neighborhood streets, the adjoining park, and the bus station. The ADM went to the shelters on her way back to the facility to check for the resident. ? 4:00 PM - The staff was organized to concentrate on the park area and three teams of four staff went into the park to see if they could locate Resident #1. ? 4:15 PM - A helicopter was spotted over the park area and began to hover over one area and an ambulance and fire trucks were observed traveling to the east end of the park area. The resident was found deceased in the park. Resident #1's family member arrived and identified Resident #1 for the Police. Review of Weatherforyou.com on [DATE] revealed the high temperature for Ft. Worth on [DATE] was 98 degrees. Interview on [DATE] at 11:40 AM with the DON revealed on [DATE] at approximately 2:00 PM HK I came and told her Resident #1 was missing. The HK told her he heard the front office staff discussing the situation and heard someone ask if they had told the DON. She revealed she was not notified by nursing of the situation. The DON revealed Resident #1 had been in the facility for about 18 months. The DON described the resident as "a loner, quiet and did not make friends." The DON stated Resident #1 previously eloped twice in the last two months out the front door of the facility. The DON stated the staff knew the door code and the BOM had a "buzzer" to let people in and out of the door." The DON stated Resident #1 "wanders all over the building." She revealed the police arrived at 3:45 PM after several calls. The DON stated elopement assessments should be conducted quarterly or after a successful elopement. When asked if an elopement assessment was completed after the two previous elopements, the DON stated, "I have to check." She stated they also conduct assessments when there was a change in a resident's condition and identified an elopement as a change in condition. The DON stated Resident #1 "looked like a normal person and you could not tell that she had psychotic episodes." The DON stated Resident #1 normally wandered through the building, going to the front lobby area. She stated staff was to "redirect" the resident away from the front lobby. When asked how they "redirected the resident, " she stated they moved her away from the door. Observation of the front lobby door on [DATE] at 2:10 PM revealed the door opened, without punching in the alarm code, when the door was pushed from the inside. The BOM stated at that time someone had just exited the front door and when the BOM pulled the door shut the mag lock engaged to secure the door. Interview on [DATE] at 2:15 PM with the BOM revealed she had a button by her desk to release the magnetic lock on the front door of the facility. She stated she looked to see who was at the door and made sure a resident was not close to the door and then she pushed the button and watched the door until it relocked to ensure no resident exited the building. She revealed when she was on break the receptionist watched the door, but she did not have a button to release the door. The BOM stated the receptionist had to get up from her desk in the lobby and enter the code on the key pad to open the door. The BOM stated she knew Resident #1 often came up to the front lobby door and wanted to leave. They would see her several times a day. The BOM stated when Resident #1 was in the lobby, the staff would redirect her out of the front lobby by walking her into the adjoining living room. The BOM stated she was not in the facility on [DATE] and the Assistant BOM was answering the front door buzzer and letting people in and out of the front door. Observation on [DATE] at 2:20 PM of the BOM's office revealed the view from her desk was through a half closed Dutch door (a door divided in two horizontally so either part can be opened or closed) to the front lobby door. The door buzzer was at desk height and located on the wall next to the BOM's desk. The view from her desk was the outside lobby door, above the push bar (a mechanism for unlatching a door, consisting of a spring-loaded metal bar fixed horizontally to the front of the door) approximately 24" x 36". Observation revealed it was not possible to observe the occupants in the 16' x 20' lobby area when seated at the BOM's desk. Interview on [DATE] at 2:25 PM with the Assistant BOM revealed she had worked in the facility for three months and she did not know all the residents by sight. She stated she "had to verify with someone who they are before I let them out." She revealed, "It is horrible here, me being new. You don't know who is a visitor and who is a resident." The Assistant BOM stated several vendors were in and out of the building on [DATE]. Observation on [DATE] at 2:39 PM of a delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was observed to the right of the front door. Observation on [DATE] at 2:57 PM of another delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was to the right of the front lobby door and a male resident was in front of the door approximately 20' back from the door. An interview on [DATE] at 6:00 PM with the RD revealed the front door "buzzer" was disconnected. The RD stated staff now had to come to the front door to open it with a code and stand there to monitor the door until it closed and locked. Interview with the Admissions Coordinator on [DATE] at 2:45 PM revealed she normally sat in the front lobby of the facility during the day. She stated she knew Resident #1 and the resident "came up every day to get her money." The Admissions Coordinator stated they the staff would redirect Resident #1 to the adjoining living room. The Admissions Coordinator also stated Resident #1 came up to the lobby two to three times daily. The Admissions Coordinator stated the resident would try to push open the door. She stated she did not see Resident #1 on [DATE]. Observations of the facility on [DATE] beginning at 10:00 AM revealed 13 exterior doors in the facility. An observation at 10:10 AM revealed a service door on the east side of the building was not locked and swung open when pushed. The door opened to the employee smoking area with no visible gates or obstructions to the parking lot of the facility. Staff was observed monitoring the door at that time. The door had a 90 second locking delay after opening. An interview with the Regional Nurse and the RD on [DATE] at 10:50 AM revealed the doors to the facility were on a 90 second delay after opening before the lock would reengage. They stated this was a result of the exit code being reset after Resident #1 eloped on [DATE]. They also stated prior to that time the doors had a seven to 10 second locking delay. The Regional Nurse and RD stated the facility's contracted Fire Alarm Company was in the building and was resetting the doors for a three second delay. They also stated until that was completed, a staff member would be by every door until the doors were reset. The Regional Nurse and RD stated 109 residents were identified as wandering or with exit-seeking behaviors. They stated the facility did not have a wander guard system. There were electronic mag locks on the doors with a required code before anyone could exit. They stated if the fire alarm company did not have the doors reset to the new ,[DATE] second locking delay by 5:00 PM, they would keep staff to monitor the doors. Interview on [DATE] at 10:26 AM with the facility's contracted fire alarm company's FT L and FT M revealed they were called to the facility because of the elopement of Resident #1 to check all the exterior doors to make sure they were functioning properly and to reset the locking delay. They stated the doors had been on a seven to ten second locking delay previously, however when the facility reset the alarm codes on [DATE] the doors reverted to the factory setting with a 90 second locking delay. FT M of the fire alarm company stated, "I did not know it did that (the doors would rest to the factory settings when they were opened to work on them) until today." Interview with the Regional Nurse on [DATE] at 12:05 PM revealed they had determined six of the 13 exterior doors located in resident use areas reset to the 90 second locking delay on the morning on [DATE] when they were working on the alarm system. The six doors were located as follows: one at each end of the South Hall, one at each end of the North Hall and the two service doors of the main dining room. An interview on [DATE] at 4:30 PM with the RD revealed all the outside doors were checked for proper operation and were now reset with a new code and no more than a seven second delay to lock afte

Based on interview and record review, the facility failed to use the results of the assessments to development the resident's comprehensive plan of care for eight (Residents #1, #5, #6, #7, #8, #9, #11, and #12) of 21 residents reviewed for care plans. 1. Resident #1 had a history of [REDACTED]. She was also assessed multiple times as a moderate risk for elopement. Staff failed to Care Plan Resident #1's moderate risk for elopement, her recent history of elopement, her exit-seeking behavior, and her verbalizations of wanting to go home. These failures resulted in Resident #1 eloping on [DATE] and her subsequent death on [DATE]. 2. Staff failed to Care Plan Resident #5's high risk for elopement/wandering until 13 weeks after she was assessed. 3. Staff failed to Care Plan Resident #6's high risk for elopement/wandering until 14 weeks after he was assessed. 4. Staff failed to Care Plan Resident #7's high risk for elopement/wandering until 10 weeks after she was assessed. 5. Staff failed to Care Plan Resident #8's high risk for elopement/wandering until eight weeks after she was assessed. 6. Staff failed to Care Plan Resident #9's high risk for elopement/wandering until eight weeks after she was assessed. 7. Staff failed to Care Plan Resident #11's high risk for elopement/wandering until 23 weeks after she was assessed. 8. Staff failed to Care Plan Resident #12's high risk for elopement/wandering until three weeks after he was assessed. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy," because the facility was still monitoring the Plan of Removal. These failures could have affected the 109 residents, including Residents #5, #6, #7, #8, #9, #11, and #12, by placing them at risk for elopement, injuries, and/or death. Findings included: 1) The facility's Provider Investigation Report dated [DATE] provided by the ADM reflected an allegation of Death/Missing Resident was investigated involving Resident #1. The Report reflected Resident #1 was a [AGE] year-old female, who required no special supervision, had minimal functional ability and who had a history of [REDACTED]. Resident #1's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was 64.5" (approximately 5'4") tall and weighed 211.6 lbs. on [DATE]. Review of Resident #1's Elopement/Wandering Assessment Tools dated [DATE], [DATE], and [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #1's Care Plan originally dated [DATE] and updated on [DATE], [DATE] and [DATE] did not address her exit-seeking behaviors or her elopement/wandering risk. Review of Resident #1's NN dated [DATE] revealed at 6:15 AM the "resident followed vending man outside the building this am and was asked to come back in the building...Resident is placed on Q15 minute monitoring per facility protocol. WCTM." The facility's Incident/Accident Report dated [DATE] reflected at 6:15 AM Resident #1 followed "the vending man while he was exiting the building, and was asked to come back in the building." The Report also reflected every 15 minute checks were started on the resident. Review of the 15 Minute Surveillance Log for Resident #1 on [DATE] revealed she was in the front lobby from 3:30 PM through 4:15 PM, 5:30 PM through 5:45 PM. On [DATE] the Log reflected she was in the front lobby from 2:00 AM through 5:00 AM, 3:45 PM through 6:30 PM and 8:15 PM through 8:30 PM. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new assessment after her elopement of [DATE]. Her previous [DATE] assessment identified her as a moderate risk for elopement. The tool reflected a question "Is there a current behavior of wandering/exit seeking behavior?" If Resident #1 had been assessed using this tool after the [DATE] elopement from the building her new score would have been a four which identified her as being a high risk for elopement. Resident #1's NN dated [DATE] reflected she was "constantly asking to go home. (The) resident informed that this is her home now. She is still requesting to leave." Review of Resident #1's Care Plan originally dated of [DATE] and updated on [DATE] revealed the resident did not have a care plan for her exit-seeking behaviors, her elopement risk, her actual elopements, or her verbalizations of wanting to leave the facility. Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female and she was assessed as usually being understood and as having the ability to usually understand others. The MDS assessment reflected she was moderately impaired cognitively and had fluctuating behaviors of inattention and disorganized thinking. She had [MEDICAL CONDITION] and was assessed as having wandering behaviors occurring four to six days each week. Further review of the MDS assessment revealed she was able to transfer, walk in her room on and off the unit, dress and toilet herself with supervision and she walked without any assistive devices. The assessment also reflected she took antianxiety and antidepressant medications daily. Resident #1's NN dated [DATE] at 7:45 PM reflected, "Resident got out of the front door running behind an x-ray technician who opened to door wide trying to pull his machine through. The receptionist at the time immediately chased her down and brought her back into the unit ...will continue to monitor." The facility's Incident/Accident Report dated [DATE] for Resident #1 reflected at 8:00 PM she "ran out of the building behind an x-ray tech who was trying to pull his machine through the door." An attached Statement by Witness dated [DATE] by LVN A reflected Resident #1 "took off behind an x-ray technician out of the front door when he tried to pull his machine through the front door (The) resident was chased down by the receptionist at the time with the tech and brought back to the facility...Physician notified and order received to place resident on Q15 (minute) monitoring x (for) 72 hrs (hours) for exit seeking behavior...will continue to monitor closely." Past Interventions Attempted included "redirected to stay within the facility and refrain from trying to get out of the front door. (The) staff (are) to monitor more frequently." Recommended Interventions were "on 15 minute monitoring for exit seeking behavior." Resident #1's Elopement/Wandering Assessment Tool did not reflect a new elopement assessment was completed after the [DATE] elopement. Resident #1's Care Plan was not updated after the [DATE] elopement from the building. Review of Resident #1's NN dated [DATE] revealed "resident is awake, disorganized with poor judgment, poor insight. (She was) constantly thinking of leaving, bringing her blanket and bag." The Provider Investigation Report dated [DATE] reflected Resident #1 was "unable to be located in the facility at 1:00 pm on [DATE]. A search was conducted inside the facility as well as surrounding grounds and nearby businesses as well as bus stations and hospital districts." Further review of the Provider Investigation Report revealed the local Police Department was notified at 2:15 PM and the search continued on the facility grounds as well as the surrounding community by staff members until approximately 5:10 PM when a female was found deceased who matched the description of Resident #1. Interview on [DATE] at 4:45 PM with MA H revealed she had worked in the in facility for the past [AGE] years. She worked on the Central Hall, where Resident #1 resided, on the 7:00 AM to 3:00 PM Monday through Friday shift. She revealed the resident did not make any comments about leaving, but the resident often said she wanted to go home or someone was coming to pick her up. MA H stated she had not witnessed any exit-seeking behaviors of Resident #1, but she was told the resident had previously eloped. She stated she was told to watch the resident. The facility's Investigation Summary dated [DATE] included with the Provider Investigation Report reflected after Resident #1 was found deceased , facility rounds were conducted again to ensure all residents were accounted for and a complete chart audit was done to identify all residents who were at risk for elopement. In-services with staff were started regarding the following: ? System for elopement based on risk assessments, ? Location of the elopement book, ? Correct procedure for completing the elopement assessment, ? How to identify residents who are high, moderate or low risk for elopement and ? Ways to redirect these residents. The Summary also reflected residents in the facility who were identified as high risk for elopement were placed on every 30 minute visual checks and moderate to low risk residents were being monitored every hour. All monitoring was documented on individual surveillance forms. Further review of the Investigation Summary revealed the codes on the exterior doors were changed, would be changed daily, a staff member would be at the front reception desk 24 hours a day, and the courtyard area was being monitored from 7:00 AM to 10:00 PM by a smoke aide. Interview on [DATE] 1:45 PM with the CO revealed he was a Forensic Death Investigator who was sent to the scene on [DATE] where Resident #1's body was located. He revealed he arrived at 6:33 PM and observed the body to be approximately .5 miles off the road in the wooded area of the park adjacent to the facility. The resident was fully dressed with no outward signs of trauma and deceased . He stated the resident was dressed in a yellow shirt, orange pants, tennis shoe and wearing a black jacket. He described the resident as warm to the touch with the first signs of rigor mortis setting in and slight sloughing of the skin on the legs, which he attributed to the heat of the day. Review of Weatherforyou.com on [DATE] revealed the high temperature for Ft. Worth on [DATE] was 98 degrees. Interview on [DATE] at 11:40 AM with the DON revealed on [DATE] at approximately 2:00 PM HK I came and told her Resident #1 was missing. The HK told her he heard the front office staff discussing the situation and heard someone ask if they had told the DON. The DON revealed Resident #1 had been in the facility for about 18 months. The DON described the resident as "a loner, quiet and did not make friends." The DON stated Resident #1 previously eloped twice in the last two months out the front door of the facility. The DON stated the staff knew the door code and the BOM had a "buzzer" to let people in and out of the door." The DON stated Resident #1 "wanders all over the building." She revealed the police arrived at 3:45 PM after several calls. The DON stated elopement assessments should be conducted quarterly or after a successful elopement. When asked if an elopement assessment was completed after the two previous elopements, the DON stated, "I have to check." She stated they also conduct assessments when there was a change in a resident's condition and identified an elopement as a change in condition. The DON stated Resident #1 "looked like a normal person and you could not tell that she had psychotic episodes." The DON stated Resident #1 normally wandered through the building, going to the front lobby area. She stated staff was to "redirect" the resident away from the front lobby. When asked how they "redirected the resident," she stated they moved her away from the door. Interview on [DATE] at 2:15 PM with the BOM revealed Resident #1 often came up to the front lobby door and wanted to leave. They would see her several times a day. The BOM stated when Resident #1 was in the lobby, the staff would redirect her out of the front lobby by walking her into the adjoining living room. Interview with the Admissions Coordinator on [DATE] at 2:45 PM revealed she normally sat in the front lobby of the facility during the day. She stated she knew Resident #1 and the resident "came up every day to get her money." The Admissions Coordinator stated they the staff would redirect Resident #1 to the adjoining living room. The Admissions Coordinator also stated Resident #1 came up to the lobby two to three times daily. The Admissions Coordinator stated the resident would try to push open the door. She stated she did not see Resident #1 on [DATE]. Interview on [DATE] at 11:40 AM with the DON revealed the facility staff had not conducted facility specific in-services for identifying residents at risk for elopement, procedures for redirecting exit-seeking behaviors or procedures when a resident eloped from the facility prior to [DATE]. The residents at risk for elopement were not identified for the CNAs or nursing staff, but now they had the "walking man" symbols on every door of residents at risk for elopement and a new list had been created and posted for staff reference. Interview on [DATE] at 6:03 AM with LVN B revealed Resident #1 had exit-seeking behaviors. LVN B stated Resident #1 would get up in the middle of the night and wander back and forth between the front lobby and the dining room. He described the resident as "actively exit-seeking." LVN B stated he was aware the resident had eloped from the building twice and he was told to watch her more closely; however he was not given any specific interventions to use with Resident #1 to address her exit-seeking behaviors. Interview on [DATE] at 6:25 AM with CNA E revealed Resident #1 was often up in the middle of the night and she "always went to the front lobby." When asked how often she would go to the front lobby, CNA E stated, "Oh about 100 (times a day). She just kept going to the front door." She stated she would "redirect" her to the dining room or the living room. When asked what she did to redirect her, CNA E stated she walked her somewhere else. When asked if she was aware of previous elopements by Resident #1, she stated, "No. No one told me anything." CNA E stated she did not report her behavior to the nurse, because it was her normal behavior. Interview on [DATE] at 6:55 AM with CNA F revealed she worked with Resident #1 when she was a resident on the North Hall. CNA F stated the resident "always talked about going home." CNA F stated Resident #1 would stand by the front lobby door with her bag." When asked if she knew the resident had eloped from the building, CNA F stated she did not know and she had not been given any instructions on how to work with Resident #1. Interview with ADON A on [DATE] at 3:30 PM revealed she was responsible for completing the Elopement/Wandering Assessments for Resident #1. She stated the last assessment was a quarterly assessment and was completed on [DATE]. ADON A stated she was aware Resident #1 went to the front lobby daily, went to the front door, and looked out. ADON A stated she was aware of Resident #1's recent elopements out of the building. When asked if an elopement was a change in condition, she stated, "Yes. I should have done another assessment. That is the policy." ADON A stated she learned about resident's changes in condition from the morning meeting and the 24 hour reports. When asked who completed the care plan when there was a change in condition, ADON A stated, "The MDS Coordinator." She stated "maybe the assessments are not being done as often as I should." Interview on [DATE] at 3:55 PM with the MDS Coordinator revealed the most current care plan for Resident #1 was dated [DATE]. When asked if there was a care plan for elopements, she revealed, "There was no care plan until yesterday ([DATE])." When asked why there was no elopement care plan, the MDS Coordinator stated, because it was not "triggered" by the MDS assessment. She stated the ADON was responsible to complete the assessments on the residents quarterly and as needed. The MDS Coordinator stated she used "some of the assessments" to complete the MDS assessments. At that time, the MDS Coordinator and the surveyor reviewed Resident #1's MDS assessment dated [DATE], which revealed the resident had wandering behaviors four to six days a week. When asked why there was no care plan for elopement, she stated, "We did not (have one) and we should have." The MDS Coordinator stated they focused on the problems triggered by the MDS assessment that needed care plans. She stated it was the responsibility of the ADON to complete an acute care plan when a resident had a change in condition. 2) Resident #5's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #5's Elopement/Wandering Assessment tool revealed she was assessed on [DATE] as a high risk for elopement. Resident #5's Care Plan did not address her risk for Elopement/Wandering until [DATE], which was 13 weeks after the Elopement/Wandering Assessment was completed. 3) Resident #6's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #6's Elopement/Wandering Assessment tool revealed he was assessed on [DATE] as a high risk for elopement. Resident #6's Care Plan did not address his risk for Elopement/Wandering until [DATE], which was 14 weeks after the Elopement/Wandering Assessment was completed. 4) Resident #7's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] and readmitted on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #7's Elopement/Wandering Assessment tool revealed she was assessed on [DATE] as a high risk for elopement. Resident #7's Care Plan did not address her risk of Elopement/Wandering until [DATE], which was 10 weeks after the Elopement/Wandering Assessment was completed. 5) Resident #8's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #8's Elopement/Wandering Assessment tool revealed she was assessed on [DATE] as a high risk for elopement. Resident #8's Care Plan did not address her risk for Elopement/Wandering until [DATE], which was eight weeks after the Elopement/Wandering Assessment was completed. 6) Resident #9's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #9's Elopement/Wandering Assessment tool revealed she was assessed on [DATE] as a high risk for elopement. Resident #9's Care Plan did not address her risk for Elopement/Wandering until [DATE], which was eight weeks after the Elopement/Wandering Assessment was completed. 7) Resident #11's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #11's Elopement/Wandering Assessment tool revealed she was assessed on [DATE] as a high risk for elopement. Resident #11's Care Plan did not address her risk for Elopement/Wandering until [DATE], which was 23 weeks after the Elopement/Wandering Assessment was completed. 8) Resident #12's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Review of Resident #12's Elopement/Wandering Assessment tool revealed he was assessed on [DATE] as a high risk for elopement. Resident #12's Care Plan did not address his risk of elopement/wandering until [DATE], which was three weeks after the Elopement/Wandering Assessment was completed. 9) The facility's Elopement/Missing Resident Policy revised [DATE], identified by the RD as the current policy, reflected, "Formulate an assessment of a resident's potential to elope from the facility and have a plan in place to assure appropriate steps are taken to protect the resident from an elopement...Elopement assessments will be completed on admission, quarterly and as needed. If the resident is assessed as a moderate to high risk the monitoring procedure will be implemented." The monitoring procedure was: "Complete the Elopement Assessment Tool. Within ,[DATE] days of admission the Interdisciplinary Team (IDT) will evaluate the residents risk potential and determine the need for further monitoring. If it is determined that the electronic monitoring device is required: ? The monitoring device will be monitored every shift for placement and documented on the MAR's. ? The monitoring device will be checked every day for functioning and documented on the MAR's. ? The electronic monitoring system will be checked every week for operable functioning. The Care Plan will be initiated for those resident identified at risk by the IDT." 10) An IJ was identified on [DATE]. The ADM, DON, RD, and Regional Nurse were informed on [DATE] at 5:15 PM of the IJ and a Plan of Removal was requested at that time. 11) The facility's Plan of Removal provided on [DATE] was accepted at approximately 7:30 PM and reflected "1. A 100% audit was completed on all residents to identify all low, medium and high risk through completion of elopement assessments and care plan. This was completed by the Clinical ADON's and Case Mix Managers on [DATE]...8. An identifier system was put into place on all resident room doors to denote who is at risk for elopement. This was implemented on [DATE]. This will be kept updated by the DON or designee as assessments are completed on admission, significant changes and quarterly...." 12) Interviews on [DATE] from 6:03 AM through 12:17 PM with LVN B, CNA E, CNA F, CNA G, LVN N, CNA O, CNA P, CNA Q, LVN R, MA S, LVN T, CNA U revealed they had received in-services training on [DATE] and [DATE] on elopement risk, what to do in the case of elopement and procedures if a resident could not be found, the new "walking man" elopement symbols, the elopement book, diversional activities and elopement monitoring. They stated they received a list identifying residents who were at risk for elopement and high risk residents were on 30 minute checks and residents at moderate risk were on one hour checks. They were familiar with the new symbols placed on the residents' doors which identified the resident's level of risk. They stated the green symbol was for high risk residents and orange was for moderate risk residents. The CNAs were checking on the residents and recording their locations. The nurses stated they were to ensure the CNAs were completing the surveillance logs and checking on the residents. They were able to identify exit-seeking behaviors. They stated residents who were exhibiting exit-seeking behaviors were to be redirected with diversional activities, assessed for toileting, provided snacks, and/or visited with and all exit-seeking behaviors were to be reported to the nurses. They stated any resident who was actively exit-seeking was to be put on every 15 minute checks for at least 72 hours or more depending on their behaviors and the family was to be notified of the behaviors. 13) The IJ was removed on [DATE]. The ADM, DON, RD, and Regional Nurse were notified on [DATE] at 12:40 PM that the IJ was removed. While the IJ was removed, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because they were still monitoring the Plan of Removal. 11) An interview with the Regional Nurse and the RD on [DATE] at 10:50 AM revealed 109 residents were at risk for elopement.

Based on observation, interview and record review, it was determined the facility failed to implement its Abuse Prohibition Policy and Procedure for one (Resident #1) of 21 residents reviewed for elopement. The facility failed to Care Plan or implement intervention strategies, other than redirection, for Resident #1 who had a history of [REDACTED]. Nursing staff failed to inform the DON when Resident #1 eloped. The facility failed to have an Elopement/Missing Persons policy that indicated the facility's capabilities. The policy indicated when staff heard door alarms sounding, they should respond, but the facility did not have door alarms. The facility failed to train staff regarding facility specific exit-seeking behaviors, interventions for exit-seeking behaviors, and procedures for resident elopement prior to [DATE]. These failures resulted in Resident #1's elopement and subsequent death on [DATE]. 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 "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the Plan of Removal. These failures could affect the 109 residents, who were elopement risks, by placing them at risk for elopement, injuries, and/or death. Findings included: Review of the facility's Abuse Prohibition Policy and Procedure, which included the Neglect policy, dated February 2012 and identified as current by the ADM, revealed, "The facility will be proactive in identifying events and occurrences that may contribute to abuse or neglect...a committee selected and chaired by the Administrator or designated representative will function under the Quality Assurance and Assessment committee and meet as needed to identify, correct and intervene in situation in which abuse, neglect or misappropriation of resident property is more likely to occur. This includes an analysis of features of the physical environment that may make abuse and or neglect more likely to occur, such as secluded areas of the facility." Included with the policy was Attachment A, which reflected neglect was "a deprivation of life's necessities of food, water or shelter, or a failure of an individual to provide services treatment or care to a resident which causes or could cause mental anguish/illness or physical injury or harm or death to the resident." The facility's Provider Investigation Report dated [DATE] provided by the ADM reflected an allegation of Death/Missing Resident was investigated involving Resident #1. The Report reflected Resident #1 was a [AGE] year-old female, who required no special supervision, had minimal functional ability and who had a history of [REDACTED]. Resident #1's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was 64.5" (approximately 5'4") tall and weighed 211.6 lbs. on [DATE]. Review of Resident #1's Elopement/Wandering Assessment Tools dated [DATE], [DATE], and [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #1's Care Plan originally dated [DATE] and updated on [DATE], [DATE] and [DATE] did not address her exit-seeking behaviors or her elopement/wandering risk. Review of Resident #1's NN dated [DATE] revealed at 6:15 AM the "resident followed vending man outside the building this am and was asked to come back in the building...Resident is placed on Q15 minute monitoring per facility protocol. WCTM." The facility's Incident/Accident Report dated [DATE] reflected at 6:15 AM Resident #1 followed "the vending man while he was exiting the building, and was asked to come back in the building." The Report also reflected every 15 minute checks were started on the resident. Review of the 15 Minute Surveillance Log for Resident #1 on [DATE] revealed she was in the front lobby from 3:30 PM through 4:15 PM, 5:30 PM through 5:45 PM. On [DATE] the Log reflected she was in the front lobby from 2:00 AM through 5:00 AM, 3:45 PM through 6:30 PM and 8:15 PM through 8:30 PM. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new assessment after her elopement of [DATE]. Her previous [DATE] assessment identified her as a moderate risk for elopement. The tool reflected a question "Is there a current behavior of wandering/exit seeking behavior?" If Resident #1 had been assessed using this tool after the [DATE] elopement from the building her new score would have been a four which identified her as being a high risk for elopement. Resident #1's NN dated [DATE] reflected she was "constantly asking to go home. (The) resident informed that this is her home now. She is still requesting to leave." Review of Resident #1's Care Plan originally dated of [DATE] and updated on [DATE] revealed the resident did not have a care plan for her exit-seeking behaviors, her elopement risk, her actual elopements, or her verbalizations of wanting to leave the facility. Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female and she was assessed as usually being understood and as having the ability to usually understand others. The MDS assessment reflected she was moderately impaired cognitively and had fluctuating behaviors of inattention and disorganized thinking. She had [MEDICAL CONDITION] and was assessed as having wandering behaviors occurring four to six days each week. Further review of the MDS assessment revealed she was able to transfer, walk in her room on and off the unit, dress and toilet herself with supervision and she walked without any assistive devices. The assessment also reflected she took antianxiety and antidepressant medications daily. Resident #1's NN dated [DATE] at 7:45 PM reflected, "Resident got out of the front door running behind an x-ray technician who opened to door wide trying to pull his machine through. The receptionist at the time immediately chased her down and brought her back into the unit ...will continue to monitor." The facility's Incident/Accident Report dated [DATE] for Resident #1 reflected at 8:00 PM she "ran out of the building behind an x-ray tech who was trying to pull his machine through the door." An attached Statement by Witness dated [DATE] by LVN A reflected Resident #1 "took off behind an x-ray technician out of the front door when he tried to pull his machine through the front door (The) resident was chased down by the receptionist at the time with the tech and brought back to the facility...Physician notified and order received to place resident on Q15 (minute) monitoring x (for) 72 hrs (hours) for exit seeking behavior...will continue to monitor closely." Past Interventions Attempted included "redirected to stay within the facility and refrain from trying to get out of the front door. (The) staff (are) to monitor more frequently." Recommended Interventions were "on 15 minute monitoring for exit seeking behavior." Statement by Witness dated [DATE] by CNA D reflected Resident #1 "ran out of the front door behind the x-ray man. She waited until he was clear from the door and ran and caught it before it closed. I had to run down the resident to return her to the building. She only made it to the van before I caught her with the x-ray man's help we brought her back to the building and notified the nurse on duty." Review of the 15 minute Surveillance Program for Resident #1 revealed 15 minute checks were started on [DATE] at 8:00 PM and continued until 11:00 PM on [DATE]. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new elopement assessment was completed after the [DATE] elopement. Resident #1's Care Plan was not updated after the [DATE] elopement from the building. Review of Resident #1's NN dated [DATE] revealed "resident is awake, disorganized with poor judgment, poor insight. (She was) constantly thinking of leaving, bringing her blanket and bag." The Provider Investigation Report dated [DATE] reflected Resident #1 was "unable to be located in the facility at 1:00 pm on [DATE]. A search was conducted inside the facility as well as surrounding grounds and nearby businesses as well as bus stations and hospital districts." Further review of the Provider Investigation Report revealed the local Police Department was notified at 2:15 PM and the search continued on the facility grounds as well as the surrounding community by staff members until approximately 5:10 PM when a female was found deceased who matched the description of Resident #1. The facility's Provider Investigation Report also included witness statements of the elopement from Residents #2, #3, and #4. The Report also included interviews with those residents conducted by the Social Worker and statements from MA H and CNA G. Review of Resident #4's Admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male with the ability to understand others and make himself understood. The assessment reflected he was cognitively intact and he did not have hallucinations or [MEDICAL CONDITION]. Review of a statement written by Resident #4 dated [DATE] revealed he saw the elopement of Resident #1 on [DATE]. He revealed he "saw a person standing on a chair at the back fence off the patio. I called out and said someone is trying to leave the facility, they got off the chair. I went in for a couple of minutes, came back out and saw someone in the process of going over the fence ...The only other people the smoke patio were (Residents #2 and #3)." Review of Resident #2's Admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female who was cognitively intact. Review of Resident #2's Witness Statement, included with the facility's Provider Investigation Report, dated [DATE] revealed she "stated to the nurse that (Resident #1) jumped the gate with ,[DATE] chairs. Stated that (Resident #3) told her not to tell because the police would bring her (Resident #1) back within a couple of hours." Interview on [DATE] at 3:20 PM with Resident #2 revealed she talked to the nurse because she was "upset about the girl that got killed (Resident #1). She went over the back gate." She revealed she was sitting on the smoking patio with Residents #3 and #4 when it happened. She revealed Resident #1 told her the day before she was going home, but she "told everyone that all the time." Resident #2 stated the resident used "one of those padded chairs with arms" on the smoking patio to get over the gate. She revealed the chair was positioned with the chair back against the gate. Resident #2 stated Resident #1 climbed on the seat, and then the arms of the chair and then the back of the chair to get on top of the fence. Resident #2 stated Resident #1 lowered herself to the ground and then walked toward the street. Resident #2 stated she did not say anything, because Resident #3 said not to and the police would bring back Resident #1 in a couple of hours. Resident #2 was able to correctly say her name, the day of the week, the month, the date, the president of the United States, the name of the facility and the location of the facility. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was cognitively intact. Review of Resident #3's interview with the SW, dated [DATE], revealed he was on the smoking patio with Residents #2 and #4 sometime after the last smoke break and "he saw a female resident (Resident #1) climb on a chair and go over the back fence." The interview reflected Resident #3 thought the police would pick her up and bring her back. He said he told "(Residents #2 and #4) not to tell anyone." Interview on [DATE] at 2:15 PM with Resident #3 revealed he witnessed Resident #1's elopement on [DATE]. He revealed he was sitting on the smoking porch in the courtyard with Residents #2 and #4. He stated he saw a female standing on a chair and climbing the fence. Resident #3 was not able to describe the chair the resident used to climb over the fence. He stated he thought the resident was already out in the courtyard when he came out because he did not see her come out the facility door. He revealed it was night time. When asked the day of the week, he could not respond. Resident #3 stated the resident held on to the top of the fence and then dropped to the other side. Review of CNA G's, the CNA for Resident #1 on [DATE], Statement by Witness dated [DATE] revealed she worked the 7:00 AM to 3:00 PM shift on [DATE]. The statement reflected she "came in about 7:00 AM. I went to my station and went room to room and said good morning to all my patients like I always do and get them ready for breakfast. The med aid gave her her meds. I continued to get my patients ready for breakfast. Approximately 7:15 AM was the last time I saw (Resident #1). It's normal that she is not seen because she walks the halls in and out of (her) room." Review of Statement by Witness dated [DATE] by MA H revealed "on the day of [DATE] Resident (#1) was seen by me approximately 7:40 AM in the morning sitting in the front lobby. I went over to the resident and asked her how her morning was and what she had wrapped up in her black jacket. The resident stated pull-ups and asked me for a soda. I went to the central station got my med cart and pulled it to the corner of the main lobby, gave the resident her morning meds, a cup of water and then the soda." The statement reflected the MA revealed the resident was wearing a yellow shirt, orange capris and white and blue tennis shoes and holding the black jacket in her arms. Interview on [DATE] at 4:45 PM with MA H revealed she had worked in the in facility for the past [AGE] years. She worked on the Central Hall, where Resident #1 resided, on the 7:00 AM to 3:00 PM Monday through Friday shift. She stated on [DATE] she entered the facility using the front door and went into the living room. She revealed she saw a few residents in the living room, including Resident #1, who asked her for a soda. She stated she obtained her medication cart, pushed it to the living room and then went to get a soda from the vending machine for Resident #1. MA H stated she gave Resident #1 her medications, followed by water and then gave her the soda. She revealed she always gave medications to Resident #1 first before her shower, because Resident #1 sometimes got agitated when she showered and MA H wanted to ensure the mediations had time to work before she was showered. When asked if the resident was in pajamas, she stated Resident #1 was always dressed when she arrived in the mornings. She stated she Resident #1 had something rolled up in a black jacket and she asked what was rolled up in the jacket. MA H stated Resident #1 opened the jacket and adult briefs were inside. She stated it was not uncommon for Resident #1 to have her jacket with things rolled up inside, such as food, clothing, or juice. MA H revealed she never asked the resident about the clothing because "She is a psych patient, so to me it was normal behavior." She revealed the resident did not make any comments about leaving, but the resident often said she wanted to go home or someone was coming to pick her up. MA H stated she had not witnessed any exit-seeking behaviors of Resident #1, but she was told the resident had previously eloped. She stated she was told to watch the resident. She revealed Resident #1 did not normally sit in the courtyard area, but when it got cool, she sat out there occasionally. MA H stated on [DATE] Resident #1 was wearing a yellow shirt, orange capris and white and blue tennis shoes. The facility's Investigation Summary dated [DATE] included with the Provider Investigation Report reflected after Resident #1 was found deceased , facility rounds were conducted again to ensure all residents were accounted for and a complete chart audit was done to identify all residents who were at risk for elopement. In-services with staff were started regarding the following: ? System for elopement based on risk assessments, ? Location of the elopement book, ? Correct procedure for completing the elopement assessment, ? How to identify residents who are high, moderate or low risk for elopement and ? Ways to redirect these residents. The Summary also reflected residents in the facility who were identified as high risk for elopement were placed on every 30 minute visual checks and moderate to low risk residents were being monitored every hour. All monitoring was documented on individual surveillance forms. Further review of the Investigation Summary revealed the codes on the exterior doors were changed, would be changed daily, a staff member would be at the front reception desk 24 hours a day, and the courtyard area was being monitored from 7:00 AM to 10:00 PM by a smoke aide. Observation on [DATE] at 3:00 PM of the facility's courtyard revealed a six foot iron gate with a smooth railing on the top. There was a stabilizing bar in the fence approximately 10" from the top of the fence which ran side to side. The fence had a gate with a mag lock (locking device that consists of an electromagnet and an armature plate. By attaching the electromagnet to the door frame and the armature plate to the door, the electromagnet attracts the armature plate, holding the door shut) and was secure when tested . The facility's exterior door to the courtyard was not locked. Three chairs with arms were on the smoking patio in the courtyard. Interview on [DATE] 1:45 PM with the CO revealed he was a Forensic Death Investigator who was sent to the scene on [DATE] where Resident #1's body was located. He revealed he arrived at 6:33 PM and observed the body to be approximately .5 miles off the road in the wooded area of the park adjacent to the facility. The resident was fully dressed with no outward signs of trauma and deceased . He stated the resident was dressed in a yellow shirt, orange pants, tennis shoe and wearing a black jacket. He described the resident as warm to the touch with the first signs of rigor mortis setting in and slight sloughing of the skin on the legs, which he attributed to the heat of the day. An interview with the RD on [DATE] at 10:50 AM revealed they had confirmation the deceased female found in the park adjacent to the facility on [DATE] was Resident #1. She revealed Resident #1 did not appear to be a nursing home resident because she was young and could walk unassisted. She revealed the timeline of events on [DATE] were: ? 7:40 AM - The MA was the last staff member to remember seeing Resident #1 when she gave her morning medications in the front lobby. ? 1:00 PM - The staff realized Resident #1 did not come to lunch and began search. ? 2:00 PM - The DON was notified they could not locate Resident #1 in the facility. A facility wide search was conducted including a perimeter search. The ADM, who was out of the building for a guardian meeting, was notified. ? 2:45 PM - After the search did not locate Resident #1 in the facility or on the grounds; 911, the RD, the Regional Nurse, family and physician were notified. The staff was organized into teams and searched the neighborhood streets, the adjoining park, and the bus station. The ADM went to the shelters on her way back to the facility to check for the resident. ? 4:00 PM - The staff was organized to concentrate on the park area and three teams of four staff went into the park to see if they could locate Resident #1. ? 4:15 PM - A helicopter was spotted over the park area and began to hover over one area and an ambulance and fire trucks were observed traveling to the east end of the park area. The resident was found deceased in the park. Resident #1's family member arrived and identified Resident #1 for the Police. Review of Weatherforyou.com on [DATE] revealed the high temperature for Ft. Worth on [DATE] was 98 degrees. Interview on [DATE] at 11:40 AM with the DON revealed on [DATE] at approximately 2:00 PM HK I came and told her Resident #1 was missing. The HK told her he heard the front office staff discussing the situation and heard someone ask if they had told the DON. She revealed she was not notified by nursing of the situation. The DON revealed Resident #1 had been in the facility for about 18 months. The DON described the resident as "a loner, quiet and did not make friends." The DON stated Resident #1 previously eloped twice in the last two months out the front door of the facility. The DON stated the staff knew the door code and the BOM had a "buzzer" to let people in and out of the door." The DON stated Resident #1 "wanders all over the building." She revealed the police arrived at 3:45 PM after several calls. The DON stated elopement assessments should be conducted quarterly or after a successful elopement. When asked if an elopement assessment was completed after the two previous elopements, the DON stated, "I have to check." She stated they also conduct assessments when there was a change in a resident's condition and identified an elopement as a change in condition. The DON stated Resident #1 "looked like a normal person and you could not tell that she had psychotic episodes." The DON stated Resident #1 normally wandered through the building, going to the front lobby area. She stated staff was to "redirect" the resident away from the front lobby. When asked how they "redirected the resident," she stated they moved her away from the door. Observation of the front lobby door on [DATE] at 2:10 PM revealed the door opened, without punching in the alarm code, when the door was pushed from the inside. The BOM stated at that time someone had just exited the front door and when the BOM pulled the door shut the mag lock engaged to secure the door. Interview on [DATE] at 2:15 PM with the BOM revealed she had a button by her desk to release the magnetic lock on the front door of the facility. She stated she looked to see who was at the door and made sure a resident was not close to the door and then she pushed the button and watched the door until it relocked to ensure no resident exited the building. She revealed when she was on break the receptionist watched the door, but she did not have a button to release the door. The BOM stated the receptionist had to get up from her desk in the lobby and enter the code on the key pad to open the door. The BOM stated she knew Resident #1 often came up to the front lobby door and wanted to leave. They would see her several times a day. The BOM stated when Resident #1 was in the lobby, the staff would redirect her out of the front lobby by walking her into the adjoining living room. The BOM stated she was not in the facility on [DATE] and the Assistant BOM was answering the front door buzzer and letting people in and out of the front door. Observation on [DATE] at 2:20 PM of the BOM's office revealed the view from her desk was through a half closed Dutch door (a door divided in two horizontally so either part can be opened or closed) to the front lobby door. The door buzzer was at desk height and located on the wall next to the BOM's desk. The view from her desk was the outside lobby door, above the push bar (a mechanism for unlatching a door, consisting of a spring-loaded metal bar fixed horizontally to the front of the door) approximately 24" x 36". Observation revealed it was not possible to observe the occupants in the 16' x 20' lobby area when seated at the BOM's desk. Interview on [DATE] at 2:25 PM with the Assistant BOM revealed she had worked in the facility for three months and she did not know all the residents by sight. She stated she "had to verify with someone who they are before I let them out." She revealed, "It is horrible here, me being new. You don't know who is a visitor and who is a resident." The Assistant BOM stated several vendors were in and out of the building on [DATE]. Observation on [DATE] at 2:39 PM of a delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was observed to the right of the front door. Observation on [DATE] at 2:57 PM of another delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was to the right of the front lobby door and a male resident was in front of the door approximately 20' back from the door. An interview on [DATE] at 6:00 PM with the RD revealed the front door "buzzer" was disconnected. The RD stated staff now had to come to the front door to open it with a code and stand there to monitor the door until it closed and locked. Interview with the Admissions Coordinator on [DATE] at 2:45 PM revealed she normally sat in the front lobby of the facility during the day. She stated she knew Resident #1 and the resident "came up every day to get her money." The Admissions Coordinator stated they the staff would redirect Resident #1 to the adjoining living room. The Admissions Coordinator also stated Resident #1 came up to the lobby two to three times daily. The Admissions Coordinator stated the resident would try to push open the door. She stated she did not see Resident #1 on [DATE]. Observations of the facility on [DATE] beginning at 10:00 AM revealed 13 exterior doors in the facility. An observation at 10:10 AM revealed a service door on the east side of the building was not locked and swung open when pushed. The door opened to the employee smoking area with no visible gates or obstructions to the parking lot of the facility. Staff was observed monitoring the door at that time. The door had a 90 second locking delay after opening. An interview with the Regional Nurse and the RD on [DATE] at 10:50 AM revealed the doors to the facility were on a 90 second delay after opening before the lock would reengage. They stated this was a result of the exit code being reset after Resident #1 eloped on [DATE]. They also stated prior to that time the doors had a seven to 10 second locking delay. The Regional Nurse and RD stated the facility's contracted Fire Alarm Company was in the building and was resetting the doors for a three second delay. They also stated until that was completed, a staff member would be by every door until the doors were reset. The Regional Nurse and RD stated 109 residents were identified as wandering or with exit-seeking behaviors. They stated the facility did not have a wander guard system. There were electronic mag locks on the doors with a required code before anyone could exit. They stated if the fire alarm company did not have the doors reset to the new ,[DATE] second locking delay by 5:00 PM, they would keep staff to monitor the doors. Interview on [DATE] at 10:26 AM with the facility's contracted fire alarm company's FT L and FT M revealed they were called to the facility because of the elopement of Resident #1 to check all the exterior doors to make sure they were functioning properly and to reset the locking delay. They stated the doors had been on a seven to ten second locking delay previously, however when the facility reset the alarm codes on [DATE] the doors reverted to the factory setting with a 90 second locking delay. FT M of the fire alarm company stated, "I did not know it did that (the doors would rest to the factory settings when they were opened to work on them) until today." Interview with the Regional Nurse on [DATE] at 12:05 PM revealed they had determined six of the 13 exterior doors located in resident use areas reset to the 90 second locking delay on the morning on [DATE] when they were working on the alarm system. The six doors were located as follows: one at each end of the South Hall, one at each end of the North Hall and the two service doors of the main dining room. An interview on [DATE] at 4:30 PM with the RD revealed all the outside doors were checked for proper operation and were now reset with a new code and no more than a seven second delay to lock after the code unlocks the door. Observation on [DATE] of all exterior doors of the facility from 1:30 PM through 1:47 PM revealed all doors had a ,[DATE] second locking delay time. The facility's Elopement/Missing Resident nursing policy and procedure revised [DATE] reflected, "If the resident is assessed as moderate to high risk the monitoring procedure will be implemented." The procedure for monitoring included: "When a door alarm sounds, ALL facility staff will immediately respond. UNDER NO CIRCUMSTANCES should an alarm be treated as a 'FALSE ALARM!' ? Determine which door alarm triggered. ? Immediately go to the door to determine how the alarm was activated and assess the situation. If it is clear who/what set the alarm off, reset the alarm. If a resident was seen opening the door, redirect the resident away from the door. ? If the cause of the alarm cannot be quickly identified, survey the immediate area outside the door. ? If a resident is not seen in the immediate area, return to the facility and initiate a head count." Interview on [DATE] at 2:50 PM with FL L revealed the facility did not have any alarms on the exit doors that would sound if the doors were opened. Review of the log for the "Upstairs Solution" (computerized staff training with generalized training) revealed the last elopement training assigned for the staff was on [DATE]. Interview on [DATE] at 11:40 AM with the DON revealed the facility staff had not conducted facility specific in-services for identifying residents at risk for elopement, procedures for redirecting exit-seeking behaviors or procedures when a resident eloped from the facility prior to [DATE]. The residents at risk for elopement were not identified for the CNAs or nursing staff, but now they had the "walking man" symbols on every door of residents at risk for elopement and a new list had been created and posted for staff reference. Interview on [DATE] at 6:03 AM with LVN B revealed Resident #1 had exit-seeking behaviors. LVN B stated Resident #1 would get up in the middle of the night and wander back and forth between the front lobby and the dining room. He described the resident as "actively exit-seeking." LVN B stated he was aware the resident had eloped from the building twice and he was told to watch her more closely; however he was not given any specific interventions to use with Resident #1 to address her exit-seeking behaviors. Interview on [DATE] at 6:25 AM with CNA E revealed Resident #1 was often up in the middle of the night and she "always went to the front lobby." When asked how often she would go to the front lobby, CNA E stated, "Oh about 100 (times a day). She just kept going to the front door." She stated she would "redirect" her to the dining room or the living room. When asked what she did to redirect her, CNA E stated she walked her somewhere else. When asked if she was aware of previous elopements by Resident #1, she stated, "No. No one told me anything." CNA E stated she did not report her behavior to the nurse, because it was her normal behavior. Interview on [DATE] at 6:55 AM with CNA F revealed she worked with Resident #1 when she was a resident on the North Hall. CNA F stated the resident "always talked about going home." CNA F stated Resident #1 would stand by the front lobby door with her bag." When asked if she knew the resident had eloped from the building, CNA F stated she did

Based on observation, interview, and record review, the facility failed to implement its written policies and procedures that prohibit the neglect of residents for one (Resident #1) of eight residents reviewed for elopement. The facility failed to Care Plan or implement intervention strategies, other than redirection, for Resident #1 who had a history of [REDACTED]. Nursing staff failed to inform the DON when Resident #1 eloped. The facility failed to have an Elopement/Missing Persons policy that indicated the facility's capabilities. The policy indicated when staff heard door alarms sounding, they should respond, but the facility did not have door alarms. The facility failed to train staff regarding facility specific exit-seeking behaviors, interventions for exit-seeking behaviors, and procedures for resident elopement prior to [DATE]. These failures resulted in Resident #1's elopement and subsequent death on [DATE]. 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 "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained, and the facility was still monitoring the Plan of Removal. These failures could affect the 109 residents, who were elopement risks, by placing them at risk for elopement, injuries, and/or death. Findings included: The facility's Provider Investigation Report dated [DATE] provided by the ADM reflected an allegation of Death/Missing Resident was investigated involving Resident #1. The Report reflected Resident #1 was a [AGE] year-old female, who required no special supervision, had minimal functional ability and who had a history of [REDACTED]. Resident #1's Admission Record, dated [DATE], reflected the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was 64.5" (approximately 5'4") tall and weighed 211.6 lbs. on [DATE]. Review of Resident #1's Elopement/Wandering Assessment Tools dated [DATE], [DATE], and [DATE] revealed the resident was assessed with [REDACTED]. Review of Resident #1's Care Plan originally dated [DATE] and updated on [DATE], [DATE] and [DATE] did not address her exit-seeking behaviors or her elopement/wandering risk. Review of Resident #1's NN dated [DATE] revealed at 6:15 AM the "resident followed vending man outside the building this am and was asked to come back in the building...Resident is placed on Q15 minute monitoring per facility protocol. WCTM." The facility's Incident/Accident Report dated [DATE] reflected at 6:15 AM Resident #1 followed "the vending man while he was exiting the building, and was asked to come back in the building." The Report also reflected every 15 minute checks were started on the resident. Review of the 15 Minute Surveillance Log for Resident #1 on [DATE] revealed she was in the front lobby from 3:30 PM through 4:15 PM, 5:30 PM through 5:45 PM. On [DATE] the Log reflected she was in the front lobby from 2:00 AM through 5:00 AM, 3:45 PM through 6:30 PM and 8:15 PM through 8:30 PM. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new assessment after her elopement of [DATE]. Her previous [DATE] assessment identified her as a moderate risk for elopement. The tool reflected a question "Is there a current behavior of wandering/exit seeking behavior?" If Resident #1 had been assessed using this tool after the [DATE] elopement from the building her new score would have been a four which identified her as being a high risk for elopement. Resident #1's NN dated [DATE] reflected she was "constantly asking to go home. (The) resident informed that this is her home now. She is still requesting to leave." Review of Resident #1's Care Plan originally dated of [DATE] and updated on [DATE] revealed the resident did not have a care plan for her exit-seeking behaviors, her elopement risk, her actual elopements, or her verbalizations of wanting to leave the facility. Resident #1's Quarterly MDS assessment dated [DATE] reflected the resident was a [AGE] year-old female and she was assessed as usually being understood and as having the ability to usually understand others. The MDS assessment reflected she was moderately impaired cognitively and had fluctuating behaviors of inattention and disorganized thinking. She had [MEDICAL CONDITION] and was assessed as having wandering behaviors occurring four to six days each week. Further review of the MDS assessment revealed she was able to transfer, walk in her room on and off the unit, dress and toilet herself with supervision and she walked without any assistive devices. The assessment also reflected she took antianxiety and antidepressant medications daily. Resident #1's NN dated [DATE] at 7:45 PM reflected, "Resident got out of the front door running behind an x-ray technician who opened to door wide trying to pull his machine through. The receptionist at the time immediately chased her down and brought her back into the unit ...will continue to monitor." The facility's Incident/Accident Report dated [DATE] for Resident #1 reflected at 8:00 PM she "ran out of the building behind an x-ray tech who was trying to pull his machine through the door." An attached Statement by Witness dated [DATE] by LVN A reflected Resident #1 "took off behind an x-ray technician out of the front door when he tried to pull his machine through the front door (The) resident was chased down by the receptionist at the time with the tech and brought back to the facility...Physician notified and order received to place resident on Q15 (minute) monitoring x (for) 72 hrs (hours) for exit seeking behavior...will continue to monitor closely." Past Interventions Attempted included "redirected to stay within the facility and refrain from trying to get out of the front door. (The) staff (are) to monitor more frequently." Recommended Interventions were "on 15 minute monitoring for exit seeking behavior." Statement by Witness dated [DATE] by CNA D reflected Resident #1 "ran out of the front door behind the x-ray man. She waited until he was clear from the door and ran and caught it before it closed. I had to run down the resident to return her to the building. She only made it to the van before I caught her with the x-ray man's help we brought her back to the building and notified the nurse on duty." Review of the 15 minute Surveillance Program for Resident #1 revealed 15 minute checks were started on [DATE] at 8:00 PM and continued until 11:00 PM on [DATE]. Resident #1's Elopement/Wandering Assessment Tool did not reflect a new elopement assessment was completed after the [DATE] elopement. Resident #1's Care Plan was not updated after the [DATE] elopement from the building. Review of Resident #1's NN dated [DATE] revealed "resident is awake, disorganized with poor judgment, poor insight. (She was) constantly thinking of leaving, bringing her blanket and bag." The Provider Investigation Report dated [DATE] reflected Resident #1 was "unable to be located in the facility at 1:00 pm on [DATE]. A search was conducted inside the facility as well as surrounding grounds and nearby businesses as well as bus stations and hospital districts." Further review of the Provider Investigation Report revealed the local Police Department was notified at 2:15 PM and the search continued on the facility grounds as well as the surrounding community by staff members until approximately 5:10 PM when a female was found deceased who matched the description of Resident #1. The facility's Provider Investigation Report also included witness statements of the elopement from Residents #2, #3, and #4. The Report also included interviews with those residents conducted by the Social Worker and statements from MA H and CNA G. Review of Resident #4's Admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male with the ability to understand others and make himself understood. The assessment reflected he was cognitively intact and he did not have hallucinations or [MEDICAL CONDITION]. Review of a statement written by Resident #4 dated [DATE] revealed he saw the elopement of Resident #1 on [DATE]. He revealed he "saw a person standing on a chair at the back fence off the patio. I called out and said someone is trying to leave the facility, they got off the chair. I went in for a couple of minutes, came back out and saw someone in the process of going over the fence ...The only other people the smoke patio were (Residents #2 and #3)." Review of Resident #2's Admission MDS assessment dated [DATE] revealed she was a [AGE] year-old female who was cognitively intact. Review of Resident #2's Witness Statement, included with the facility's Provider Investigation Report, dated [DATE] revealed she "stated to the nurse that (Resident #1) jumped the gate with ,[DATE] chairs. Stated that (Resident #3) told her not to tell because the police would bring her (Resident #1) back within a couple of hours." Interview on [DATE] at 3:20 PM with Resident #2 revealed she talked to the nurse because she was "upset about the girl that got killed (Resident #1). She went over the back gate." She revealed she was sitting on the smoking patio with Residents #3 and #4 when it happened. She revealed Resident #1 told her the day before she was going home, but she "told everyone that all the time." Resident #2 stated the resident used "one of those padded chairs with arms" on the smoking patio to get over the gate. She revealed the chair was positioned with the chair back against the gate. Resident #2 stated Resident #1 climbed on the seat, and then the arms of the chair and then the back of the chair to get on top of the fence. Resident #2 stated Resident #1 lowered herself to the ground and then walked toward the street. Resident #2 stated she did not say anything, because Resident #3 said not to and the police would bring back Resident #1 in a couple of hours. Resident #2 was able to correctly say her name, the day of the week, the month, the date, the president of the United States, the name of the facility and the location of the facility. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed he was a [AGE] year-old male who was cognitively intact. Review of Resident #3's interview with the SW, dated [DATE], revealed he was on the smoking patio with Residents #2 and #4 sometime after the last smoke break and "he saw a female resident (Resident #1) climb on a chair and go over the back fence." The interview reflected Resident #3 thought the police would pick her up and bring her back. He said he told "(Residents #2 and #4) not to tell anyone." Interview on [DATE] at 2:15 PM with Resident #3 revealed he witnessed Resident #1's elopement on [DATE]. He revealed he was sitting on the smoking porch in the courtyard with Residents #2 and #4. He stated he saw a female standing on a chair and climbing the fence. Resident #3 was not able to describe the chair the resident used to climb over the fence. He stated he thought the resident was already out in the courtyard when he came out because he did not see her come out the facility door. He revealed it was night time. When asked the day of the week, he could not respond. Resident #3 stated the resident held on to the top of the fence and then dropped to the other side. Review of CNA G's, the CNA for Resident #1 on [DATE], Statement by Witness dated [DATE] revealed she worked the 7:00 AM to 3:00 PM shift on [DATE]. The statement reflected she "came in about 7:00 AM. I went to my station and went room to room and said good morning to all my patients like I always do and get them ready for breakfast. The med aid gave her her meds. I continued to get my patients ready for breakfast. Approximately 7:15 AM was the last time I saw (Resident #1). It's normal that she is not seen because she walks the halls in and out of (her) room." Review of Statement by Witness dated [DATE] by MA H revealed "on the day of [DATE] Resident (#1) was seen by me approximately 7:40 AM in the morning sitting in the front lobby. I went over to the resident and asked her how her morning was and what she had wrapped up in her black jacket. The resident stated pull-ups and asked me for a soda. I went to the central station got my med cart and pulled it to the corner of the main lobby, gave the resident her morning meds, a cup of water and then the soda." The statement reflected the MA revealed the resident was wearing a yellow shirt, orange capris and white and blue tennis shoes and holding the black jacket in her arms. Interview on [DATE] at 4:45 PM with MA H revealed she had worked in the in facility for the past [AGE] years. She worked on the Central Hall, where Resident #1 resided, on the 7:00 AM to 3:00 PM Monday through Friday shift. She stated on [DATE] she entered the facility using the front door and went into the living room. She revealed she saw a few residents in the living room, including Resident #1, who asked her for a soda. She stated she obtained her medication cart, pushed it to the living room and then went to get a soda from the vending machine for Resident #1. MA H stated she gave Resident #1 her medications, followed by water and then gave her the soda. She revealed she always gave medications to Resident #1 first before her shower, because Resident #1 sometimes got agitated when she showered and MA H wanted to ensure the mediations had time to work before she was showered. When asked if the resident was in pajamas, she stated Resident #1 was always dressed when she arrived in the mornings. She stated she Resident #1 had something rolled up in a black jacket and she asked what was rolled up in the jacket. MA H stated Resident #1 opened the jacket and adult briefs were inside. She stated it was not uncommon for Resident #1 to have her jacket with things rolled up inside, such as food, clothing, or juice. MA H revealed she never asked the resident about the clothing because "She is a psych patient, so to me it was normal behavior." She revealed the resident did not make any comments about leaving, but the resident often said she wanted to go home or someone was coming to pick her up. MA H stated she had not witnessed any exit-seeking behaviors of Resident #1, but she was told the resident had previously eloped. She stated she was told to watch the resident. She revealed Resident #1 did not normally sit in the courtyard area, but when it got cool, she sat out there occasionally. MA H stated on [DATE] Resident #1 was wearing a yellow shirt, orange capris and white and blue tennis shoes. The facility's Investigation Summary dated [DATE] included with the Provider Investigation Report reflected after Resident #1 was found deceased , facility rounds were conducted again to ensure all residents were accounted for and a complete chart audit was done to identify all residents who were at risk for elopement. In-services with staff were started regarding the following: ? System for elopement based on risk assessments, ? Location of the elopement book, ? Correct procedure for completing the elopement assessment, ? How to identify residents who are high, moderate or low risk for elopement and ? Ways to redirect these residents. The Summary also reflected residents in the facility who were identified as high risk for elopement were placed on every 30 minute visual checks and moderate to low risk residents were being monitored every hour. All monitoring was documented on individual surveillance forms. Further review of the Investigation Summary revealed the codes on the exterior doors were changed, would be changed daily, a staff member would be at the front reception desk 24 hours a day, and the courtyard area was being monitored from 7:00 AM to 10:00 PM by a smoke aide. Observation on [DATE] at 3:00 PM of the facility's courtyard revealed a six foot iron gate with a smooth railing on the top. There was a stabilizing bar in the fence approximately 10" from the top of the fence which ran side to side. The fence had a gate with a mag lock (locking device that consists of an electromagnet and an armature plate. By attaching the electromagnet to the door frame and the armature plate to the door, the electromagnet attracts the armature plate, holding the door shut) and was secure when tested . The facility's exterior door to the courtyard was not locked. Three chairs with arms were on the smoking patio in the courtyard. Interview on [DATE] 1:45 PM with the CO revealed he was a Forensic Death Investigator who was sent to the scene on [DATE] where Resident #1's body was located. He revealed he arrived at 6:33 PM and observed the body to be approximately .5 miles off the road in the wooded area of the park adjacent to the facility. The resident was fully dressed with no outward signs of trauma and deceased . He stated the resident was dressed in a yellow shirt, orange pants, tennis shoe and wearing a black jacket. He described the resident as warm to the touch with the first signs of rigor mortis setting in and slight sloughing of the skin on the legs, which he attributed to the heat of the day. An interview with the RD on [DATE] at 10:50 AM revealed they had confirmation the deceased female found in the park adjacent to the facility on [DATE] was Resident #1. She revealed Resident #1 did not appear to be a nursing home resident because she was young and could walk unassisted. She revealed the timeline of events on [DATE] were: ? 7:40 AM - The MA was the last staff member to remember seeing Resident #1 when she gave her morning medications in the front lobby. ? 1:00 PM - The staff realized Resident #1 did not come to lunch and began search. ? 2:00 PM - The DON was notified they could not locate Resident #1 in the facility. A facility wide search was conducted including a perimeter search. The ADM, who was out of the building for a guardian meeting, was notified. ? 2:45 PM - After the search did not locate Resident #1 in the facility or on the grounds; 911, the RD, the Regional Nurse, family and physician were notified. The staff was organized into teams and searched the neighborhood streets, the adjoining park, and the bus station. The ADM went to the shelters on her way back to the facility to check for the resident. ? 4:00 PM - The staff was organized to concentrate on the park area and three teams of four staff went into the park to see if they could locate Resident #1. ? 4:15 PM - A helicopter was spotted over the park area and began to hover over one area and an ambulance and fire trucks were observed traveling to the east end of the park area. The resident was found deceased in the park. Resident #1's family member arrived and identified Resident #1 for the Police. Review of Weatherforyou.com on [DATE] revealed the high temperature for Ft. Worth on [DATE] was 98 degrees. Interview on [DATE] at 11:40 AM with the DON revealed on [DATE] at approximately 2:00 PM HK I came and told her Resident #1 was missing. The HK told her he heard the front office staff discussing the situation and heard someone ask if they had told the DON. She revealed she was not notified by nursing of the situation. The DON revealed Resident #1 had been in the facility for about 18 months. The DON described the resident as "a loner, quiet and did not make friends." The DON stated Resident #1 previously eloped twice in the last two months out the front door of the facility. The DON stated the staff knew the door code and the BOM had a "buzzer" to let people in and out of the door." The DON stated Resident #1 "wanders all over the building." She revealed the police arrived at 3:45 PM after several calls. The DON stated elopement assessments should be conducted quarterly or after a successful elopement. When asked if an elopement assessment was completed after the two previous elopements, the DON stated, "I have to check." She stated they also conduct assessments when there was a change in a resident's condition and identified an elopement as a change in condition. The DON stated Resident #1 "looked like a normal person and you could not tell that she had psychotic episodes." The DON stated Resident #1 normally wandered through the building, going to the front lobby area. She stated staff was to "redirect" the resident away from the front lobby. When asked how they "redirected the resident, " she stated they moved her away from the door. Observation of the front lobby door on [DATE] at 2:10 PM revealed the door opened, without punching in the alarm code, when the door was pushed from the inside. The BOM stated at that time someone had just exited the front door and when the BOM pulled the door shut the mag lock engaged to secure the door. Interview on [DATE] at 2:15 PM with the BOM revealed she had a button by her desk to release the magnetic lock on the front door of the facility. She stated she looked to see who was at the door and made sure a resident was not close to the door and then she pushed the button and watched the door until it relocked to ensure no resident exited the building. She revealed when she was on break the receptionist watched the door, but she did not have a button to release the door. The BOM stated the receptionist had to get up from her desk in the lobby and enter the code on the key pad to open the door. The BOM stated she knew Resident #1 often came up to the front lobby door and wanted to leave. They would see her several times a day. The BOM stated when Resident #1 was in the lobby, the staff would redirect her out of the front lobby by walking her into the adjoining living room. The BOM stated she was not in the facility on [DATE] and the Assistant BOM was answering the front door buzzer and letting people in and out of the front door. Observation on [DATE] at 2:20 PM of the BOM's office revealed the view from her desk was through a half closed Dutch door (a door divided in two horizontally so either part can be opened or closed) to the front lobby door. The door buzzer was at desk height and located on the wall next to the BOM's desk. The view from her desk was the outside lobby door, above the push bar (a mechanism for unlatching a door, consisting of a spring-loaded metal bar fixed horizontally to the front of the door) approximately 24" x 36". Observation revealed it was not possible to observe the occupants in the 16' x 20' lobby area when seated at the BOM's desk. Interview on [DATE] at 2:25 PM with the Assistant BOM revealed she had worked in the facility for three months and she did not know all the residents by sight. She stated she "had to verify with someone who they are before I let them out." She revealed, "It is horrible here, me being new. You don't know who is a visitor and who is a resident." The Assistant BOM stated several vendors were in and out of the building on [DATE]. Observation on [DATE] at 2:39 PM of a delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was observed to the right of the front door. Observation on [DATE] at 2:57 PM of another delivery man at the front door revealed the BOM, sitting at her desk, "buzzed" the door open for the delivery man without coming to the door of the office to make an observation of the lobby. A female resident was to the right of the front lobby door and a male resident was in front of the door approximately 20' back from the door. An interview on [DATE] at 6:00 PM with the RD revealed the front door "buzzer" was disconnected. The RD stated staff now had to come to the front door to open it with a code and stand there to monitor the door until it closed and locked. Interview with the Admissions Coordinator on [DATE] at 2:45 PM revealed she normally sat in the front lobby of the facility during the day. She stated she knew Resident #1 and the resident "came up every day to get her money." The Admissions Coordinator stated they the staff would redirect Resident #1 to the adjoining living room. The Admissions Coordinator also stated Resident #1 came up to the lobby two to three times daily. The Admissions Coordinator stated the resident would try to push open the door. She stated she did not see Resident #1 on [DATE]. Observations of the facility on [DATE] beginning at 10:00 AM revealed 13 exterior doors in the facility. An observation at 10:10 AM revealed a service door on the east side of the building was not locked and swung open when pushed. The door opened to the employee smoking area with no visible gates or obstructions to the parking lot of the facility. Staff was observed monitoring the door at that time. The door had a 90 second locking delay after opening. An interview with the Regional Nurse and the RD on [DATE] at 10:50 AM revealed the doors to the facility were on a 90 second delay after opening before the lock would reengage. They stated this was a result of the exit code being reset after Resident #1 eloped on [DATE]. They also stated prior to that time the doors had a seven to 10 second locking delay. The Regional Nurse and RD stated the facility's contracted Fire Alarm Company was in the building and was resetting the doors for a three second delay. They also stated until that was completed, a staff member would be by every door until the doors were reset. The Regional Nurse and RD stated 109 residents were identified as wandering or with exit-seeking behaviors. They stated the facility did not have a wander guard system. There were electronic mag locks on the doors with a required code before anyone could exit. They stated if the fire alarm company did not have the doors reset to the new ,[DATE] second locking delay by 5:00 PM, they would keep staff to monitor the doors. Interview on [DATE] at 10:26 AM with the facility's contracted fire alarm company's FT L and FT M revealed they were called to the facility because of the elopement of Resident #1 to check all the exterior doors to make sure they were functioning properly and to reset the locking delay. They stated the doors had been on a seven to ten second locking delay previously, however when the facility reset the alarm codes on [DATE] the doors reverted to the factory setting with a 90 second locking delay. FT M of the fire alarm company stated, "I did not know it did that (the doors would rest to the factory settings when they were opened to work on them) until today." Interview with the Regional Nurse on [DATE] at 12:05 PM revealed they had determined six of the 13 exterior doors located in resident use areas reset to the 90 second locking delay on the morning on [DATE] when they were working on the alarm system. The six doors were located as follows: one at each end of the South Hall, one at each end of the North Hall and the two service doors of the main dining room. An interview on [DATE] at 4:30 PM with the RD revealed all the outside doors were checked for proper operation and were now reset with a new code and no more than a seven second delay to lock after the code unlocks the door. Observation on [DATE] of all exterior doors of the facility from 1:30 PM through 1:47 PM revealed all doors had a ,[DATE] second locking delay time. The facility's Elopement/Missing Resident nursing policy and procedure revised [DATE] reflected, "If the resident is assessed as moderate to high risk the monitoring procedure will be implemented." The procedure for monitoring included: "When a door alarm sounds, ALL facility staff will immediately respond. UNDER NO CIRCUMSTANCES should an alarm be treated as a 'FALSE ALARM!' ? Determine which door alarm triggered. ? Immediately go to the door to determine how the alarm was activated and assess the situation. If it is clear who/what set the alarm off, reset the alarm. If a resident was seen opening the door, redirect the resident away from the door. ? If the cause of the alarm cannot be quickly identified, survey the immediate area outside the door. ? If a resident is not seen in the immediate area, return to the facility and initiate a head count." Interview on [DATE] at 2:50 PM with FL L revealed the facility did not have any alarms on the exit doors that would sound if the doors were opened. Review of the log for the "Upstairs Solution" (computerized staff training with generalized training) revealed the last elopement training assigned for the staff was on [DATE]. Interview on [DATE] at 11:40 AM with the DON revealed the facility staff had not conducted facility specific in-services for identifying residents at risk for elopement, procedures for redirecting exit-seeking behaviors or procedures when a resident eloped from the facility prior to [DATE]. The residents at risk for elopement were not identified for the CNAs or nursing staff, but now they had the "walking man" symbols on every door of residents at risk for elopement and a new list had been created and posted for staff reference. Interview on [DATE] at 6:03 AM with LVN B revealed Resident #1 had exit-seeking behaviors. LVN B stated Resident #1 would get up in the middle of the night and wander back and forth between the front lobby and the dining room. He described the resident as "actively exit-seeking." LVN B stated he was aware the resident had eloped from the building twice and he was told to watch her more closely; however he was not given any specific interventions to use with Resident #1 to address her exit-seeking behaviors. Interview on [DATE] at 6:25 AM with CNA E revealed Resident #1 was often up in the middle of the night and she "always went to the front lobby." When asked how often she would go to the front lobby, CNA E stated, "Oh about 100 (times a day). She just kept going to the front door." She stated she would "redirect" her to the dining room or the living room. When asked what she did to redirect her, CNA E stated she walked her somewhere else. When asked if she was aware of previous elopements by Resident #1, she stated, "No. No one told me anything." CNA E stated she did not report her behavior to the nurse, because it was her normal behavior. Interview on [DATE] at 6:55 AM with CNA F revealed she worked with Resident #1 when she was a resident on the North Hall. CNA F stated the resident "always talked about going home." CNA F stated Resident #1 would stand by the front lobby door with her bag." When asked if she knew the resident had eloped from the building, CNA F stated she did not know and she had not been given any instructions on how to work with Resident #1. Interview with ADON A on [DATE] at 3:30 PM revealed she was responsible for completing the Elopement/Wandering Assessments for Resident #1. She stated the last assessment was a quarterly assessment and was completed on [DATE]. ADON A stated she was aware Resident #1 went to the front lobby daily, went to the front door, and looked out. ADON A stated she was aware of Resident #1's recent elopements out of the building. When asked if an elopement was a change in condition, she stated, "Yes. I should have done another assessment. That is the policy." ADON A stated she learned about resident's changes in condition from the morning meeting and the 24 hour reports. When asked who completed the care plan when there was a change in condition, ADON A stated, "The MDS Coordinator." She stated "maybe the assessments are not being done as often as I should." Interview on [DATE] at 3:55 PM with the MDS Coordinator revealed the most current care plan for Res